Beyond Obamacare

Beyond Obamacare: Life, Death, and Social Policy

James S. House
Copyright Date: 2015
Published by: Russell Sage Foundation
Pages: 236
https://www.jstor.org/stable/10.7758/9781610448499
  • Cite this Item
  • Book Info
    Beyond Obamacare
    Book Description:

    Health care spending in the United States today is approaching 20 percent of GDP, yet levels of U.S. population health have been declining for decades relative to other wealthy and even some developing nations. How is it possible that the United States, which spends more than any other nation on health care and insurance, now has a population markedly less healthy than those of many other nations? Sociologist and public health expert James S. House analyzes this paradoxical crisis, offering surprising new explanations for how and why the United States has fallen into this trap. InBeyond Obamacare, House shows that health care reforms, including the Affordable Care Act, cannot resolve this crisis because they do not focus on the underlying causes for the nation's poor health outcomes, which are largely social, economic, environmental, psychological, and behavioral.

    House demonstrates that the problems of our broken health care and insurance system are interconnected with our large and growing social disparities in education, income, and other conditions of life and work, and calls for a complete reorientation of how we think about health. He concludes that we need to move away from our misguided and almost exclusive focus on biomedical determinants of health, and to place more emphasis on addressing social, economic, and other inequalities.

    House's review of the evidence suggests that the landmark Affordable Care Act of 2010, and even universal access to health care, are likely to yield only marginal improvements in population health or in reducing health care expenditures. In order to rein in spending and improve population health, we need to refocus health policy from the supply side-which makes more and presumably better health care available to more citizens-to the demand side-which would improve population health though means other than health care and insurance, thereby reducing need and spending for health care. House shows how policies that provide expanded educational opportunities, more and better jobs and income, reduced racial-ethnic discrimination and segregation, and improved neighborhood quality enhance population health and quality of life as well as help curb health spending. He recommends redirecting funds from inefficient supply-side health care measures toward broader social initiatives focused on education, income support, civil rights, housing and neighborhoods, and other reforms, which can be paid for from savings in expenditures for health care and insurance.

    A provocative reconceptualization of health in America,Beyond Obamacarelooks past partisan debates to show how cost-efficient and effective health policies begin with more comprehensive social policy reforms.

    eISBN: 978-1-61044-849-9
    Subjects: Sociology, Health Sciences

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
  3. List of Illustrations
    (pp. ix-xii)
  4. About the Author
    (pp. xiii-xiv)
  5. Preface
    (pp. xv-xviii)
  6. Acknowledgments
    (pp. xix-xxiv)
  7. Part I Historical and Scientific Foundations
    • Chapter 2 Health Care Reform: Necessary but Not Nearly Sufficient
      (pp. 19-28)

      The Patient Protection and Affordable Care Act of 2010 (hereafter ACA) is the most significant health care and insurance legislation since the establishment of Medicare and Medicaid almost fifty years ago. The overarching goal of this health care reform could be seen as resolving America’s paradoxical crisis of health care and health, obviating the need for further major health policy legislation—and perhaps also the need for this book. However, the impact of this broad and dramatic legislation was significantly diminished by the negotiations and compromises necessary to its passage and is being further weakened in the continuing struggles over...

    • Chapter 3 Health Care ≠ Health: From Biomedical to Social Determinants of Health
      (pp. 29-47)

      We have remained fixated for a century or more on the notion that health policy is essentially health care and insurance policy, and hence that reform or improvement of health policy can only be addressed via health care and insurance reform. This fixation derives from an underlying belief that health care is the predominant determinant of health and therefore the way to maintain and improve individual and population health is to provide more universal access to more and better health care. Thus, all major health policy legislation, from Medicare and Medicaid in the mid-1960s to the Affordable Care Act (ACA)...

    • Chapter 4 The Lives, Deaths, and Health of Individuals and Populations over Time and Social Strata
      (pp. 48-70)

      Any discussion of health science and policy must recognize that health is not like most things that we seek to increase—most noticeably economic ones, which have no inherent limits. In theory at least, there is no cap on how much income or wealth, or how many goods and services, an individual, organization, or society can achieve. Health, in contrast, has real limits established by the evolutionary development of the human organism over millennia. These limits in turn pose some challenges for purely economic ways of thinking about the many major issues in America’s paradoxical crisis of health care and...

    • Chapter 5 Racial-Ethnic, Gender, and Age Disparities in Health and Their Relation to Socioeconomic Position
      (pp. 71-86)

      Social disparities in health are not just socioeconomic. They also occur by race-ethnicity, gender, and even age. Indeed, in the popular mind, and perhaps even more in political and governmental arenas, the term “social disparities in health” is as likely to connote racial-ethnic, gender, or age disparities as socioeconomic ones, if not more so. For example, the newest institute of the National Institutes of Health (NIH), charged with doing research and training on social disparities in health, is the National Institute of Minority Health and Health Disparities, which prioritizes, at least in name, racial-ethnic disparities in health. Since 1991, NIH...

  8. Part II Policy Implications
    • Chapter 6 A New Demand-Side Health Policy: Implications for Research, Education, Policy, and Practice
      (pp. 89-102)

      What would a demand-side health policy, grounded in the science of social determinants and disparities in health, look like? And how different would it be from current supplyside approaches? Any answer to the first question must necessarily be both comprehensive and complex. The answer to the second question is “very,” though a demand-side policy would strongly complement supply-side approaches, not supplant them.

      Our current supply-side health policy developed via the initially sequential, now multiple and simultaneous, operation of three foundational elements: research, education, and policy and practice. A new demand-side approach will require the same foundational elements and a similar...

    • Chapter 7 Socioeconomic Policies That Affect Health and Health Disparities
      (pp. 103-128)

      Historically, demand-side health policies have been largely grounded in biomedical science. The demand-side approach we need now, however, must focus far more heavily on social determinants and disparities in health. It must identify and prioritize socioeconomic and other public policies that significantly improve individual and population health, reduce health disparities, and feasibly and costeffectively reduce health care and insurance expenditures.

      The health consequences of socioeconomic policies are often not obvious, and typically they are neither anticipated nor recognized at the policymaking stage. In addition, some people have other reasons to resist changes in socioeconomic policies that affect health. Throughout this...

    • Chapter 8 The Economic Value and Impact of a New Demand-Side Health Policy
      (pp. 129-140)

      Part I of this book indicated that population health and health disparities are determined by social, environmental, behavioral, and psychological factors more than by health care and insurance. Chapters 6 and 7 showed why we have been able to improve population health and reduce health disparities more effectively through socioeconomic and other non health policies than by just providing more and better health care. Our spending on health care and insurance is outstripping all other nations, however, approaching 20 percent of our gross domestic product (GDP) and creating fiscal crises for all levels of government, private-sector organizations, and many individuals,...

    • Chapter 9 Understanding and Resolving America’s Paradoxical Crisis of Health Care and Health
      (pp. 141-158)

      Political struggles over Obamacare and the challenges in implementing it continue to preoccupy health policy in our nation. Yet, as seen in chapter 1, we face a more fundamental crisis in health policy, and in public policy more generally. We are spending more every year on health care and insurance, both absolutely and relative to all other nations, at levels that are increasingly burdening, and sometimes bankrupting, households, private organizations, and all levels of government. Yet the health of our population is declining relative to all comparably wealthy nations, and some less wealthy ones as well, and recently has even...

  9. Notes
    (pp. 159-180)
  10. References
    (pp. 181-198)
  11. Index
    (pp. 199-210)