Farley calls for health reform in the United States to pay increased attention to social and behavioral determinants of health, rather than the typical single-minded pursuit of health care system reform.1 He convincingly argues that addressing underlying causes or disruptions of well-being is the most effective strategy for improving population health. Outcomes from nations emphasizing social investments over medical ones strengthen that assertion, and suggest that if better health is the goal, the United States is investing too much in the wrong place. Among nations of the Organization of Economic Cooperation and Development (OECD), increased social spending is linked to lower infant mortality and longer life expectancy.2 Compared with fellow OECD countries, the United States spends little on social investments (Table 1) while simultaneously hemorrhaging disproportionately large sums from a health care system that provides below-average results.3 Spending more on health care does not increase health, and increased health care spending does not necessarily correlate with higher social spending (Table 1).
TABLE 1 Relative rankings of OECD countries for select expenditures and health outcomes: 2003–2005
| Health Care Spending, % GDP | Social Spending, % GDP | Infant Mortality, Rate Per 1000 Births | Life Expectancy, Mean Years at Birth | |
| Australia | 9.5 | 17.9 | 5.0 | 80.9 |
| Austria | 10.2 | 26.1 | 4.2 | 79.5 |
| Belgium | 10.3 | 26.5 | 3.7 | 78.7 |
| Canada | 9.8 | 17.3 | 5.4 | 80.2 |
| Czech Republic | 7.2 | 21.2 | 3.4 | 76.0 |
| Denmark | 9.1 | 27.6 | 4.4 | 77.9 |
| Finland | 7.5 | 22.5 | 3.0 | 78.9 |
| France | 11.1 | 28.7 | 3.6 | 80.3 |
| Germany | 10.7 | 27.3 | 3.9 | 79.0 |
| Greece | 10.1 | 21.3 | 3.8 | 79.3 |
| Hungary | 8.1 | 22.7 | 6.2 | 72.8 |
| Iceland | 9.5 | 18.7 | 2.3 | 81.2 |
| Ireland | 7.5 | 15.9 | 4.0 | 79.5 |
| Italy | 8.9 | 24.2 | 4.7 | 80.4 |
| Japan | 8.0 | 17.7 | 2.8 | 82.1 |
| Luxembourg | 7.9 | 22.2 | 2.6 | 79.3 |
| Mexico | 6.4 | 6.8 | 18.8 | 75.5 |
| Netherlands | 9.2 | 20.7 | 4.9 | 79.4 |
| New Zealand | 9.0 | 18.0 | 5.1 | 79.6 |
| Norway | 9.1 | 25.1 | 3.1 | 80.1 |
| Poland | 6.2 | 22.9 | 6.4 | 75.1 |
| Portugal | 10.2 | 23.5 | 3.5 | 78.2 |
| Slovak Republic | 7.1 | 17.3 | 7.2 | 74.0 |
| Spain | 8.3 | 20.3 | 4.1 | 80.7 |
| Sweden | 9.1 | 31.3 | 2.4 | 80.6 |
| Switzerland | 11.6 | 20.5 | 4.2 | 81.3 |
| United Kingdom | 8.3 | 20.6 | 5.1 | 79.0 |
| United States | 15.3 | 16.3 | 6.8 | 77.8 |
| OECD average | 9.0 | 20.7 | 5.5 | 78.6 |
Note. GDP = gross domestic product; OECD = Organization for Economic Cooperation and Development. Data exhibit a high degree of stability over years, so for years where data were missing, adjacent years’ data were used to create a complete set.
Source. http://www.sourceoecd.org/factbook.
Universal access to health care is a worthy goal, but it may do little to improve overall health in the United States. Even the wealthiest Americans who currently enjoy such access, 50 to 74 year-olds earning equal to or greater than $496 000 per year, appear to manifest the effects of neglected social priorities with poorer health than do their European counterparts.4 Furthermore, although Scotland provides universal health care access, social inequities still cause the wealthiest Scots to live an average of 28 years longer than do the poorest.5 As we can see, more of the same health care is not necessarily the answer.
Although the tendency for Europeans to be generally healthier than Americans despite spending fewer health care dollars is well established,3,4,6 it should not be assumed that more efficient use and equitable distribution of health care is the principle contributor to their well-being. Those better outcomes are more likely a result of a greater emphasis on social policy. Correspondingly, the assumption that poor population health in the United States is primarily attributable to health care that is wasteful, inefficient, and not available to all citizens deserves reconsideration. Reforms in US health care delivery, access, and funding are certainly needed, and spending the OECD average of 9% of gross domestic product on health care should be sufficient to manage the burden of illness we face. But meaningful improvements in population health may require us to invest as heavily in social programs as the healthiest OECD nations (between 20-30% of gross domestic product; Table 1). Evidence increasingly indicates that social policies that care for people are the best investments for health.
