Canadian Study Suggests Spending on Social Programs Can Improve Overall Health—Public Health Watch

After a week during which members of Congress were unable to reach agreement on a short-term spending bill, expecting a wholesale shift in the philosophy with regard to health care spending seems like a pipe dream—at best.

However, after reading the findings of a study published by the Canadian Medical Association Journal (CMAJ), in an article described to Contagion^® as a “manifesto” by a leading health care spending expert, such a change in thinking might make fiscal sense for a country, that being the United States, facing a cost crunch within the medical sphere. Frankly, there’s no other way to characterize a scenario in which the country spends roughly $3.3 trillion (17.9% of its gross domestic product)—or $10,348 per person—on health care, per Centers for Medicare and Medicaid Services figures, for a system that ranks 37th globally, according to World Health Organization (WHO) methodology, which assesses spending against outcomes.

Not surprisingly, American taxpayers are paying for this dollar disconnect in health care—one way or another. An analysis published in JAMA Internal Medicine on January 22nd found that although Americans’ out-of-pocket costs have declined 11.9% since the implementation of the Affordable Care Act, health care insurance premiums have increased by 12.1% over the same period.

Is there a solution? The authors of the CMAJ paper think so. Although Canada has a “universal” health care system, in which a government-run plan provides baseline coverage to all citizens, the neighbors to the north of the US border have seen a similar increase in medical-related spending (some 25% between 1981 and 2011, according to data included in the report), while spending on social programs (think: public housing, education, welfare programs) has remained flat over the same period. The study found that if Canadian provinces increased spending on social programs by 1 cent for every dollar spent on health care, they would see a 0.1% reduction in “potentially avoidable mortality” and 0.01% increase in overall life expectancy.

“Our analysis showed that increased social spending was positively associated with population health measures in Canada at the provincial level… [and] that health spending did not have the same association,” the authors wrote. “The ratio of social to health spending is a potential avenue through which the government can affect population health outcomes. The ratio of social to health spending is low, so redistributing money from health to social spending represents a small relative change in health spending.”

Douglas E. Hough, PhD, health economist at the Johns Hopkins Bloomberg School of Public Health and author of Irrationality in Healthcare, an analysis of the US healthcare system from a behavioral economics perspective, thinks there are lessons to be learned in the United States from the Canadian analysis, and he would love to see a similar assessment here—one that would obviously take into account the differences between the 2 countries in terms of how health care is delivered and covered.

“Authors before me have pointed out that we can improve outcomes a little bit, but it costs a lot of money to do—yet that’s the lever we keep on pushing,” he told Contagion^®. “One of the curious things about policymakers in the United States is that they don’t seem to connect health care spending and social spending—spending on housing, education, crime—when spending on these programs can lead to improvements in overall health. Poor housing can be linked with asthma, for example. In fact, I suspect we’d see the same impact of social spending in the United States as the authors in Canada found.”

“One of the most powerful forces in behavioral economics is framing,” he added. “For decades, if not hundreds of years, we’ve framed social spending as helping the poor, and the debate centers around whether or not the poor are deserving of assistance.” Dr. Hough suggested that instead of seeing issues such as poverty and crime as “social problems” they should—and could—be re-framed as “public health problems.”

“Think about it: Is gun violence a public health problem? It certainly results in mortality and added health care costs. The opioid epidemic is a perfect example of this. We are already investing a lot in health care for those who become addicted, just to treat their addiction and related health problems. But what if we spent the money on training, education, and jobs programs—programs that could help people get out of a pattern that brings them to opioid addiction?”

Makes sense, of course. However, given the ongoing dysfunction in Washington, getting legislators to reach consensus on such complex issues may, unfortunately, be impossible.

Brian P. Dunleavy is a medical writer and editor based in New York. His work has appeared in numerous health care-related publications. He is the former editor of Infectious Disease Special Edition.