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Facing the Facts on Health Care

by Stephen C. Schoenbaum, MD, MPH

Wednesday, February 5th, 2014

Stephen Schoenbaum is a physician, former executive director of the Commonwealth Fund Commission on a High Performance Health System, and a special advisor to the president of the Josiah Macy Jr. Foundation.

Passage and implementation of the Affordable Care Act raises questions about how to achieve cost control, including how best to replace the current fee-for-service payment system and how to rethink what exactly our health insurance plans cover.

But beyond these important policy questions, this research raises concerns about some Americans’ values related to health care. Persons in most developed countries are used to the idea that every member of society should have coverage and is entitled to access to health care. They do not understand, and frankly neither do I, why in the United States a sizeable minority of the population feels that health care is a privilege.

However, I believe that framing healthcare coverage and access as an issue of right vs. privilege is misguided since it is clear that we do not all agree on that issue and will not easily resolve the debate. But, when presented with the data, I hope we can all agree that our performance on outcomes such as life expectancy is not as good as in many other countries. Try as many have in the past to say that our population is different, good data now show that that is not the explanation.

Most people in the United States do not realize that there is tremendous variation in health outcomes across the country; and in fact, where you live makes a difference. There is wider variation in health outcomes within the United States than across about 18 other developed countries. Our best states perform as well as the best countries but our worst states perform more poorly than the poorest performing developed countries. When presented information on variation on health outcomes and spending within the United States and internationally, participants in Public Agenda’s focus groups indeed reacted with surprise. But they also reacted with great interest, and began thinking and deliberating over why outcomes and costs vary so widely. This indicates that Americans are ready to engage not only with the issue of rising health care costs but also with questions about quality and outcomes.

It turns out that there is a strong relationship between state health outcomes and measures of social capital. This was pointed out by Robert Putnam nearly 15 years ago in his book, Bowling Alone. In states with high levels of social capital, as measured by responses to various survey questions and memberships in various organizations, people are more likely to trust and work with their neighbors. Those states may also be more likely to have a variety of state and local programs that benefit their entire populations. Putnam demonstrated not only that measures of social capital vary by state but also that the overall level of social capital in this country has been decreasing steadily for a few decades.

I would love to see public discourse begin to focus on how we might increase our levels of social capital. Indeed, more public discourse in general is likely to have a salubrious effect on our national and local levels of social capital. While this may seem distant from controlling health care costs, I suspect there will ultimately be a strong relationship.


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