- Review of Beyond Obamacare: Life, Death, and Social Policy by James S. House
By James S. House
Russell Sage Foundation, 2015. 234 Pages. https://www.russellsage.org/publications/beyond-obamacare
In "Beyond Obamacare: Life, Death, and Social Policy" (Russell Sage Foundation, 2015) James S. House makes the conservative case for investment in progressive social policies that will improve population health. He argues that reducing social disparities by race, ethnicity, and gender, but particularly by income and education, is the only way to significantly reduce spending on "health care and insurance." Social justice, according to House, is an "important" reason to address health disparities, but he is more interested in a rational, efficient health policy and reducing the nation's debt. Investment in the social determinants of health will make patients healthier and reduce the "demand" for costly medical care, according to House. He knows the Affordable Care Act won't control costs but has little to say about more fundamental health reform. This is a serious flaw, because without the cost control tools provided by a single payer national health program, the for-profit health industry will continue to consume more of the nation's gross domestic product.
House is one of the pioneers in rediscovering the social determinants of health during the late twentieth century. His influential research at the University of Michigan, the decades long Americans' Changing Lives study, revealed that socioeconomic factors were the strongest predictors of health and mortality. He notes that population health in the United States is actually deteriorating: "between 1990 and 2008 life expectancy ...for white women... without a high school diploma... actually decreased by five years in less than two decades". His overview of the evidence on how social inequalities affect health is the focus and the highlight of this well-written volume. House's digest would make a useful introduction to the subject for medical and public health students, as well as students in the social sciences and policymakers.
House argues that investments in the social determinants of health "could be financed at first through more progressive taxation and ultimately with the savings from reducing expenditures on health." Among other evidence, he cites a RAND study showing that the United States could reduce health care costs substantially by raising the health of people aged 50 and older to the same average level of health as their counterparts in eight European nations.
On the other hand, House is skeptical that the Affordable Care Act (ACA) will reduce medical costs or improve the population health of the United States, but not for the typical reasons. Many people believe the ACA doesn't go far enough, because it leaves tens of millions of people uninsured and millions more underinsured, and there are an estimated 29,000 deaths annually due to lack of access to health care, according to researchers with Physicians for a National Health Program. House's critique is based on his general view that medical care is neither effective nor cost-effective at improving the health of populations. He cites research on the historic rise in life-expectancy in the 20th century, which shows that perhaps only 15–20 percent of the gain may be attributed to medical care.
The 19th century German physician Rudolf Virchow observed the large impact of poverty on health while studying the spread of typhus. Although House approvingly quotes Virchow's 1848 dictum that "Medicine is a social science and politics is nothing but medicine on a grand scale," he steers clear of a political analysis. House creates a new term, "medical-biotechnology complex," inspired by the term "medical industrial complex." But House otherwise remains curiously silent on the political forces that have created the U.S. health care crisis, aside from noting that its origins are "bipartisan." The word "profits," for example, does not appear in the index, and neither do the terms "market," "capitalism," "privatization," or "neoliberalism." In addition, mental health, arguably the area with the most unmet health needs, is relegated to a footnote.
Although House's book appeared before Senator Bernie Sanders' 2016 Presidential campaign, House presumably would have...