Health reform has been one of the most prominent and contentious issues in US politics during the last decade, with all six of the election cycles between 2008 and 2018 intensely focused on whether the Affordable Care Act (ACA) should be enacted, extended, altered, or repealed. The legislative and judicial fights over the ACA are just the latest battles in a struggle over health policy going back at least fifty years.
In Beyond Obamacare: Life, Death, and Social Policy, James S. House argues that policy makers have been tackling the wrong questions. Our energy has been disproportionately spent trying to expand insurance coverage rather than solve the deeper systemic issues that serve as a fundamental barrier to maximal health for all populations. His core argument is that “we must get beyond the view of Obamacare as all that we can or should do to deal with the serious health policy problems of our nation.” Our focus on coverage misses “the essential, and truly paradoxical, nature of the serious health policy crisis in which we are ever more deeply enmeshed and which is increasingly exceptional among all similarly developed or wealthy nations” (xv). Health care is important, but it is only one element of a broader set of factors affecting health rather than the solution deserving the disproportionate level of attention it has been given.
Anticipating readers' potential objections, early on House acknowledges that his argument is not particularly novel (xviii)—public health leaders have for many years called for greater attention to the social determinants of health. The paradox he describes, that we spend more than any other nation in the world on health care and insurance yet have far from the best health outcomes, has been dissected by others (e.g., Bradley and Taylor 2013). His book is a valuable contribution nonetheless, bringing together a wide variety of data to comprehensively and convincingly argue that the most effective way to improve the health of populations is to reduce social, environmental, psychological, and behavioral disparities. He builds on a conceptual framework from his widely cited paper (House 2002) that considers health outcomes as the product of a variety of explanatory variables, which are themselves mediated by factors such as race, ethnicity, gender, and age. His framework is consistent with the current leading models in public health but does not break much conceptual ground at this point.
A fundamental strength of this text is its comprehensive overview of the history of nonhealth policies in the United States, the rise of biomedical research, and detailed analysis of changes in mortality and morbidity as a by-product of policy and/or social changes. This is important because so many discussions about public health or health in all policies are ahistorical. His strong historical analysis in the first part of the book supports House's argument for social policies as a method of health reform. These chapters are particularly compelling given that House says they are the evidence base that motivated his own conversion to recognizing the foundational determinants of health.
The second half of the book discusses potential policy approaches to addressing what he refers to as the demand-side issues shaping health (using the language of economics and public policy) known in public health as the social determinants of health. He contrasts this approach with health reform efforts heavily focused on supply-side solutions concerned with medical care and insurance coverage. To support his argument for a demand-side approach, House highlights a number of public health successes, including the decline of infectious diseases and reductions in cigarette smoking, as evidence that policy change can be a driver for improvements in population health. He mentions some initiatives that sparked considerable controversy, such as adding fluoride to city water supplies to promote dental health. However, he does not explore these policies in depth or closely examine why they were successfully implemented despite the prominence of solutions prioritizing medical care.
In Beyond Obamacare, House does not propose a specific set of policies that would accomplish the goals for which he has convincingly argued, leaving the reader thirsty for more guidance on what should be done next. To be fair, this is in line with the expectations House established at the start of the book, which is to shift our focus to broader and deeper problems. One of the most compelling concrete changes he articulates is that funders should fix the imbalance in research dollars going to medical care and diseases rather than demand-side solutions. The core insight in the latter chapters is that a paradigm shift is needed such that all policies are viewed in terms of their health implications, including and perhaps especially issues not containing the word health in their name. In other words, policy makers wanting to improve the health of their population should look to experts on education and housing for policy ideas, for example.
House considers whether success on the demand side is likely to reduce supply-side costs, and whether a healthier population will spend less on medical care. He concludes that the evidence is not yet clear one way or another. However, the lesson from the first half of his book is that improving population health should be done not simply to lower health care costs. Those who want to make a business case for improving population health should frame the issue in terms of achieving value. Spending more on health and health care would be worth it if the United States had better overall health and fewer inequities.
As said above, House does not deeply grapple with the political constraints that have stymied those who have worked on population health and health equity. What nonhealth policies with deep health implications could be politically and financially feasible? He sidesteps the question using John W. Kingdon's (1995) policy windows to suggest it would be a mistake to focus only on what is politically feasible: it is academia's role to clarify what the most important problems are and to develop consensus on the most effective solutions. He is correct that politics can change quickly, so it would be a mistake to limit what we say should be done because of assumptions about what is and is not possible. At the same time, the field of public health would benefit from more guidance by political scientists about how to successfully use the policy-making process to improve population health. Though not the focus of House's book, he raises a perennial and important question: does political science have a role in informing estimates of likely reform feasibility, or are such calculations best left to practitioners and pollsters? An analytic and rigorous take on the feasibility of encouraging health in all policies would be a ripe question for those sponsoring and doing health policy research. Political scientists could also explore, debate, and, ultimately, articulate the conditions under which political scientists can (and cannot) provide analysis relevant to policy reform feasibility.
Overall, this book is a pleasure to read. It would be especially valuable as a text for students coming into public health and for scholars of the fields House suggests should more fully appreciate the impact they have on health, such as education. It is energizing to see greater attention to the important role that social and environmental factors play in shaping both an individual's health and a population's health. His call to move beyond the ACA is even more refreshing in 2018 than when he published this book in 2015, given the election and congressional fracas over health reform that he could not have foreseen at the time. Although many of the ideas in this book are familiar to scholars of public health, the primacy of nonmedical factors for shaping health is not yet in the mainstream of US politics and policy. Beyond Obamacare is an important step toward helping change the terms of this conversation.