America’s unhealthy obsession with health care over public health costs us dearly amid COVID-19

Elena Marks

By Elena Marks
CEO, Episcopal Health Foundation

This essay first appeared in the Milken Institute’s Power of Ideas collection focused on navigating the new health, financial, and social uncertainties wrought by the ongoing pandemic and a reckoning of racial injustice. The essay series features insights from thought leaders across industries. Read their contributions and share your thoughts using #PowerofIdeas. Find more coverage on the Milken Institute LinkedIn page.

Americans are obsessed with health care. We can’t get enough of it. We believe more is better; the latest technology, drug, or procedure is the best. And we put our money where our mouth is: We spend more money on health care than any other country on the planet. We use the words “health care” and “health” interchangeably as if they were one and the same. We’re so smitten with health care that we have forgotten that it is only a means to an end—being in good health—and not the only pathway to achieve good health.

Yet, for all our money, US health outcomes lag behind those of most developed countries. We have higher rates of obesity and infant mortality and lower life expectancy than other countries that spend less on health care. One of the reasons our health-care investments haven’t translated into better health outcomes is that health care only accounts for 20 percent of health outcomes. Social and economic factors, health behaviors, and environmental factors account for 80 percent of health outcomes. And yet of our $3.6 trillion National Health Expenditures, less than 3 percent is devoted to public health activities that address these non-medical factors.

Medical care isn’t a substitute for adequate public health infrastructure, especially when a pandemic hits.

As a country, we are over-investing in medical services and under-investing in the social, economic, behavioral, and environmental factors that have a greater impact on health outcomes. This lopsided investment left us particularly vulnerable to the COVID-19 pandemic.

Our response to COVID-19 reflects our belief that health care is the answer to all health problems, and that has greatly hurt us. Initial efforts focused on making sure there would be sufficient critical care capacity for people sick with the virus, going to great pains to ensure we’d have enough ICU beds, ventilators, doctors, nurses, and personal protective equipment. If we maintained enough hospital capacity, we believed, we were responding well. While it was—and still is—important to treat infected patients, viewing the crisis through just a health-care lens missed the larger point: Medical care isn’t a substitute for adequate public health infrastructure, especially when a pandemic hits.

The decades-long underinvestment in public health left us without the funding, workforce, or surveillance systems necessary to address a pandemic. Across the country, public health funding has declined over the past decade. And because of those years of chronic neglect, we were unable to quickly implement effective strategies, including wide-scale testing and contact tracing, the primary tools of containment.

This neglect set the stage for the nationwide, disproportionate health outcomes experienced by low-income communities, and especially communities of color. The non-health-care factors, including the social and economic conditions in which these communities often live, made them more likely to get COVID-19. These individuals are more likely to work in “essential” frontline roles, and they are also more likely to continue to go into work even if sick. It can also be difficult for them to remain socially distanced in their home and their community, thereby increasing their risk for contracting COVID-19. These factors are also the root cause of higher rates of preexisting conditions such as obesity, heart and lung disease, and cancer in these communities, meaning individuals on average are more likely to become gravely ill and to die if infected. The Episcopal Health Foundation has been working to mend these disparities in Texas by providing funding to nonprofits and community clinics to help them continue to address these non-health-care factors in at-risk communities across the state and supporting research to identify where to focus efforts in recovery. Working to implement community-based approaches nationwide would make great strides towards creating a better, more equitable system.

The status quo is the result of the choices we made as a country over decades. We’ve built a system overly reliant on health care as a means for achieving health, one that underinvests in the non-health-care factors that have the biggest impact on health outcomes. That was the norm. As we rebuild post-COVID-19, we need to look for value in our $3.6 trillion national health investment. Value should be measured by health outcomes, not health-care services delivered. A value-oriented approach would shift dollars upstream, into prevention and public health programs that address the non-health-care factors that influence health outcomes. With so much talk about a “new normal” post-pandemic, let’s make this the new normal in how we deliver health, not just health care.