American Crossroads

More Than Health Care

By Shannon Monnat

Politicians and voters have a chance to embrace what social science shows: health depends on a broader conception of well-being.

Special Series: American Crossroads
Eight faculty experts bring context and historical perspective to this year’s election.

In the presidential campaign, most health care debate has been about the benefits of private insurance versus socialized medicine. Many voters are focused on this question.

But, as someone who researches the social determinants of health and health disparities, I offer a broader lens than the "private-vs-socialized" question. What’s often lost is a more important discussion, about supporting societal well-being rather than relying on a treatment-and-cure approach.

If the coronavirus pandemic has made anything clear, it’s that the United States relies on a health-care system to fix what ails us rather than investing in institutions that build strong societies and keep us healthy to begin with—education, families, communities, and social and physical infrastructure. I would encourage voters to think about those policies, too, as they head to a voting booth.

It’s a long-standing tension. After World War II, government social welfare policies created opportunities for families to achieve upward mobility, which positively impacted well-being. But starting in the 1970s, and particularly in the 1980s, government policies increasingly emphasized the market and maximizing shareholder value at the expense of investment in collective societal well-being. Our policies began emphasizing profits over people.

We need to think about how our economic and social policies create the conditions in which we spend our everyday lives.

We see the impact of those choices reflected in our national mortality rate. In the 1980s, the pace of life expectancy improvements in the U.S. began to slow relative to our peer countries. By the late 1990s, U.S. life expectancy had fallen below the average of our peer countries, and, starting in 2014, it actually declined for three consecutive years. Most of that decline is seen in the working class, particularly among people without a four-year college degree. That’s a change that can be directly correlated to shifts in policy over the past 30 to 40 years.

Americans without a four-year college degree have seen themselves becoming less and less valued in our economy. Their efforts provide smaller rewards in the form of wages and benefits and they suffer longer periods of unemployment than ever before. These are all things that affect health at both the individual and the population level.

The coronavirus pandemic has made the weaknesses in our safety net evident. As layoffs skyrocket in the midst of this emergency, it’s this same population that is most vulnerable. With businesses closed, hourly wage earners are forced to stay home and lose their income. The government bailout to support struggling Americans wouldn’t be necessary if we had an economic system that protected workers with mandated paid sick and family leave and unemployment coverage during times of job loss.

As Americans prepare to vote, it’s important to think about policies beyond what we typically term "health care." Instead of focusing on health insurance, we need to think about how our various economic and social policies create the conditions in which we spend our everyday lives.

No one chooses to be born into a household that is contaminated with lead-based paint. No one chooses to be born into poverty or to have a parent who is incarcerated. And while our health-care system can’t fix any of those things, research makes clear that each of them has profound impacts on individual and population health.

The U.S. spends an astronomical amount of money on health care—more than any of its peer countries. But that investment has produced very little return on health. Instead, our social, economic, and environmental context are the main drivers of both our individual and larger public health, and we have disinvested in the institutions that keep us healthy to begin with.

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