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Last year, Americans borrowed approximately $88 billion to pay for health care. One in four of us skipped medical appointments because of concern about costs. Such statistics reflect a trend that has been going on for decades. In 1970, the U.S. spent $74.6 billion on health. By 2000, this figure had risen to around $1.4 trillion and by 2017 it was $3.5 trillion. Not incidentally, medical debt is now the number one cause of personal bankruptcy in the U.S.

This question — Are we paying too much for health? — has defined much of the health conversation in the U.S. over the years. Unfortunately, it is the wrong question. Here’s the right one: Is our spending making us healthier?


The answer, sadly, is no.

Compared to the world’s wealthiest countries, we rank near the bottom on a range of key health indicators, from adverse birth outcomes to heart disease and sexually transmitted infections. At the same time, epidemics like opioids, gun violence, and obesity are further undermining health, contributing to declines in U.S. life expectancy. All of this has occurred as we have doubled down on our investment in doctors, medicines, and cutting-edge treatments.

Why has our spending been so ineffective at actually delivering health? The reason is that we aren’t actually spending on health. We are spending on health care. The difference between the two is simple, yet fundamental. Health care — doctors, hospitals, medicines, treatments, and the like — takes care of us when we are sick. Health is about not getting sick in the first place.


Doctors and medicines are important, of course. When you get sick, you want the best health care you can find. But ask yourself this: Would you rather live in a world where a disease like HIV is curable, or would you rather live in a world where HIV no longer exists? Creating the latter cannot be accomplished by drugs alone.

We currently have excellent treatments for HIV, and better ones are being developed all the time. Yet around the world, HIV continues to devastate families and communities. It persists not because the medicines to treat it are inadequate, but because stigma, poverty, political negligence, and the marginalization of at-risk populations have allowed the disease to remain a threat.

Pouring money into health care while ignoring these social determinants means health will continue to elude us.

The outsize importance of the conditions that shape health has not translated into nationwide conversations about them. To be sure, we talk about the socioeconomic forces that shape American life, but rarely in the context of health. When we talk about health, we still primarily talk about health care. This has created a strange situation in which Americans regularly show how much they value health — through their spending and their passionate engagement with the issue of health care — while neglecting what actually produces it.

It would be easy to think that we just lack the political vocabulary to discuss what we should be talking about when it comes to our collective wellbeing. But we actually do have words for talking about these issues. They come from this country’s rich tradition of investing in public goods as a matter of core national values. Public goods are common resources that are available to all, supported by our collective investment. Libraries are public goods. So are parks, clean air, public education, and national security.

Many Americans, from Franklin Roosevelt to Woody Guthrie, have made the case for common investment in the public goods that improve our lives and health. Yet the most compelling argument for this investment may be the words of the Constitution, where our obligation to “promote the general Welfare” is spelled out in the document’s very first line.

This obligation has given rise to large-scale programs like the New Deal and the Great Society, which addressed the foundational issues of equity and justice that underlie the structures that shape health — from housing and economic inequality to the ongoing challenge of racism and the quality of public schools. But we have allowed the legacy of these programs to fade over time, embracing instead a belief in unfettered individualism, where no one need look out for anyone else as long as everyone can look out for themselves.

Politically, this has led to a disinvestment in the policies and institutions that, in a prior era, created the conditions for better health. This initially occurred during the administration of Ronald Reagan, whose deregulatory agenda became a template for succeeding administrations, Democratic and Republican alike, and has been embraced with particular zeal by Donald Trump. At nearly every turn, his administration has shown itself to be no friend to health, from its attempted rollback of environmental standards to its dim view of public schools and its unwillingness to make affordable housing available to the many Americans who need it.

Taken together, these moves represent an attack on health that is, in my view, even more harmful than the administration’s ongoing efforts to undermine the Affordable Care Act. Yet in attacking the conditions that shape health, the Trump administration has, perhaps paradoxically, highlighted their importance by placing them at the center of our political conversation. As I describe in my new book, “Well,” this has overlapped with a shift in what we talk about when we talk about health. The conversation now includes broader issues like climate change, gun violence, and economic inequality.

Consider, for example, how I earlier referred to opioids, obesity, and gun violence as “epidemics.” A lot of work went into making that characterization sound natural. Neither opioids nor obesity nor gun violence are infectious threats, like the flu or Ebola, yet public health experts have shown how they spread through populations like a disease. Just as important, we can now see that they are most effectively addressed using public health methods — namely a focus on the underlying socioeconomic conditions that allow diseases to emerge and spread.

It is too early to say definitively how changes in the way we talk about health will affect our politics. Yet there are early signs they have begun to move our political priorities in a healthier direction. The midterm elections saw many candidates win by running on policies that speak to the foundational drivers of health. Since the election, high-profile initiatives like the Green New Deal have linked these conditions with questions of justice and equity that are central to ensuring the health of the many, not just the few.

These are first steps towards a renewal of the public goods that support health in the U.S. Getting all the way there requires us to look beyond health care to see the core socioeconomic forces that shape health, and to see that health itself is a public good. This means starting health conversations that embrace the full range of conditions that make us sick or keep us healthy. When we lose sight of these, we lose our health, no matter how much we spend on doctors and medicines.

Instead of investing primarily in treatments for illness, we should also be investing in what shapes health and create the conditions for all to be well.

Sandro Galea, M.D., is professor and dean at the Boston University School of Public Health. His latest book is Well: What We Need to Talk About When We Talk About Health” (Oxford University Press, May 2019).

  • Very nice article, but you haven’t mentioned the epidemic I’ve been preoccupied with for decades. I became interested in psychotherapy before psychiatry became addicted to drugs, and when we ran psychiatric units in a mental hospital, in Denver, and a general hospital, in Edmonton, psychiatry shut them down because they thought drugs would be cheaper and faster.
    This began the revolving door of modern psychiatry and of our streets, prisons and cemeteries filling with the poor souls with emotional problems.
    Since I’d lost work I returned to private practice in Ottawa, where I could get paid for seeing anyone in need, and discovered that several psychotic patients became the most interesting, challenging, and rewarding of my 50 year career.
    Unfortunately the psychiatric and psychoanalytic associations to which I belonged weren’t interested in our work.
    I could send you articles I’ve written about this.

  • Nicely written, but you’re missing the big fat elephant in the room when it comes to health vs. health care.

    Taking shots at Trump and lauding the tragic Great Society program of LBJ leads you down the path of political quaqmire.

    As the prior commenters suggest, we are eating ourselves to death. Our own behaviour at the table, not the behaviour of politicians in D.C., must change.

    What we typically eat is driving us straight down the path towards the chronic diseases that will ultimately kill most of us. And doctors trying to fix us along the way accounts for the epidemic in health care spending.

    There is a level playing field of opportunity for all of us to get on a better path towards healthy eating, but few of us have any idea what that path is.

    Train your guns on the task of educating the public on how what they eat drives how and when they die, and you will have a bullseye.

    Leave taking down Trump to the maddening crowd.

    • Excellent point! I developed type 1 diabetes at age 37 due to terrible nutrition and lack of proper exercise. Since we had 1 and 1/2 babies, and little money, we had to focus on keeping me alive. Fortunately my wife was very smart, and had survived wartime Scotland mainly on the fruit and vegetables that they could grow, so I rapidly learned to eat nutritious food.
      It seems to have worked. I’m now 90, and still enjoy golf and tennis.
      And none of our children or grandchildren are obese, or have diabetes.

  • A good point taking care of Health is more important than spending on healthcare. My parents used to say a proverb in Tamil language which translates that if you wisely spend money on buying healthy food choices we will spend less on healthcare. A policy change should come to invest on promoting healthy life style, mental health and other social determinants. A persons kitchen is the best medical shop to prevent many types of illnesses.

  • Thank you. A great piece, plain truths on public health. For health, we need to pay more attention to diet, and dental. As anyone with pets knows, disease and mortality starts in the mouth. Until the US gets serious about biocompatible, biological dental care – and fully integrates dental into medical care, insurance, records and Big Data – we will be battling against the current and tide on chronic illness, and for health.

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