Too Much Spending on Healthcare, Not Enough on Social Services

Here's a remarkable op-ed by my colleagues Betsy Bradley and Lauren Taylor. (Among many other things, Betsy runs Yale's Global Health Leadership Institute and Lauren is an alum of our Bioethics Summer Program.) Their piece summarizes data from a study that ran in BMJ Quality and Safety earlier this year.

The US famously spends very much more on healthcare than other countries. But the study looked at social spending more broadly, counting expenditures not only on health, but also on social services such as rent subsidies, employment-training programs, unemployment benefits, old-age pensions, family support, and so on. When those expenditures are added up, the US comes in 10th in world spending. And we're one of only three industrialized countries which spends more on health care than on those other social services. This failure to spend on social services, the op-ed claims, explains why our huge expenditures on health care don't give us good health outcomes. We'd get more health for our dollars if we offered people more social support.

A striking example from the op-ed: 119 chronically homeless people in Boston logged 18,884 emergency room visits in just five years, at a cost of $12.7 million. Perhaps if those people had had better social services, we wouldn't have had to pay for so many costly ER visits.

Obese Child Seized by State

Ohio officials have taken an eight-year-old child away from his mother and placed him into foster care because they believe his mother has been unable to help the child control his weight. (The boy weighs 200 pounds, while normal weight for an 8-year-old is 60.) State authorities had been working with the mother to reduce the boy's weight for 20 months. The boy has been diagnosed with sleep apnea. In this interview, Art Caplan offers several reasons why the state's move was wrong: the removal from his mother will cause emotional turmoil; there's no proof that foster care will help control the boy's weight; the foster-care system is already overwhelmed and there are too many morbidly obese kids to make this a viable policy; the boy will eventually return home, where bad habits and social conditions may not have changed during his absence; and, finally, while the boy's weight places him at high risk for future disease, his obesity does not put him in the kind of imminent danger normally needed to justify removal from the home. On this last point, bioethicist Norm Fost disagrees; he's quoted in the first article linked above as saying that the boy's sleep apnea could be placing him in imminent danger.

Removing the child from home can't be the right approach. It may be true that his mother is incapable of taking basic steps to control his weight. But even on that assumption, his obesity is likely to have social, emotional and physical origins that even very fine foster care will be ill-equipped to address. Perhaps he'll lose weight when he's away from his home--or perhaps the emotional turmoil will make it harder for him to lose weight. In any case, he'll eventually return home, and what will happen then? Meantime, his mother is surely learning the wrong lesson about the benevolence of state interventions on her son's behalf.