The pharmaceutical industry is a behemoth in the United States. In 2023, the 20 largest pharmaceutical companies had a market capitalization of $3.78 trillion dollars. Pharma companies spent more than $15 million dollars in contributions through political action committees during the 2020 election cycle. Analysts constantly see new avenues of generating revenues and profits for the industry including, most recently, obesity drugs which are predicted to become a $ 44 billion market by 2030, according to Bloomberg Intelligence. Private equity has targeted elder and primary care for a quick investment return leaving long-term in-equities with significant public and health policy implications.
Public health and healthcare in the United States is dismal. Compared to the average healthcare per capita expenditure of all other OECD countries ($6,414), the U.S. spends almost double the amount ($12,555) per person, without any visible benefits. In a group of 11 comparable developed countries, the U.S. ranks last on outcomes such as infant mortality, maternal mortality, preventable mortality, and life expectancy. The diabetes admission rate per 100k people is the second highest[pdf] among the 38 OECD countries, and much higher than the remaining 36 countries on the list.
A tale of two fortunes?
This divergence in fortunes between a few pharmaceutical companies on one side and the public on the other, is stark. But we argue that it is also a choice that our society is collectively making. There are glaring omissions in our care system that could help alleviate some of these stark inequities.
Social Care and In-equity
Social care is an important determinant of healthcare expenditure. “Multivisit patients,” for example, are individuals who have acute social needs along with medical care needs. More generally, social care could target individuals needing assistance to avoid more serious – and expensive – healthcare needs downstream, months or years later.
Data on social care, however, is frustratingly limited. A sense for the numbers involved can be gleaned from homelessness, an area where some data is available. The Department of Housing and Urban Development (HUD) counts more than 650,000 homeless people in the United States, a number considered by some to be an underestimate. Mortality risk rises 3.5 times when someone experiences a loss in housing. This risk increases 10 times for those experiencing street homelessness. Estimates about the cost that each chronically homeless person puts on taxpayers ranges between $ 30,000-35,000 per year.
But more importantly, outside of eventual consequences for healthcare expenditure, social care poses a fundamental challenge for our society. That challenge is how best to address in-equities while giving individuals a chance to live with basic freedoms, basic capabilities, and without the threat and violence of poverty, deprivation and isolation.
A fast-exacerbating climate crisis will heighten the importance of social care. Climate justice problems stem from the impact of heat, climate disasters, forced displacement on mental health and well-being. An estimated 250,000 excess deaths are expected from the climate crisis in the U.S. annually between 2030 and 2050, and this figure only accounts for a subset of all expected channels of harm.
Social care, therefore, is necessary. The question is, why haven’t we done it yet? Perhaps relatedly, why don’t we see more debates on social care rather than just healthcare?
The need for coordination of services
Like healthcare but worse, social care is extremely fragmented. There is no coordination between the different agencies, often local, undertaking different aspects of social care. Inefficiencies abound. There is also fragmentation in funding, so that many organizations depend on the largesse of philanthropical foundations.
A more subtle point is the inertia in maintaining the system as it is. There are fewer studies on the effect of social care; moreover there is often a demand to assign a dollar value to the benefits of the providing social care.
However, this demand misses some compelling facts. First, social care is as inefficient as it is inequitable, so that only a fraction of every dollar contributes to its intended recipient. There is a clear need for coordination. Lack of coordination results in silos of care that maintain poverty and homelessness.
The intersections of poverty, training needed for employment with livable wages, criminal justice system, affordable housing, integrated behavioral health and primary care (to name but a few) each represent silos with a chasm in between. Those in great need can never overcome the barriers of each silo or system to succeed. Second, there are compelling reasons to intervene more systematically in upstream social care, and medicalizing social ills does not seem to be the most efficient way to do it.
Third, measuring the effect of an intervention requires a window of time that proves its efficacy. For example, statin therapy effects are often measured in terms of added years of life or a ten-year CVD mortality risk. Lastly, comparable “developed” countries with social care such as Sweden, France and Germany have a total spend on care (health and social) that is roughly equivalent to the U.S. but with much better outcomes and equity in the system.
Whose interests are being served?
Beyond questions of money, equity, and efficiency, the fundamental issue reflects a misunderstanding of the true purpose of social welfare. Do we want to merely provide minimum support to people so that they continue to survive? Or do we want to support them living better and more productive lives? And whose welfare do we privilege? The people or corporations?
Social care requires a fundamental reimagining of how care is provided. The agency of recipients is crucial[pdf], and they will often be the people deciding how to implement improvements to their lives. Concerns may be raised here. For example, critics worry that giving transfers to recipients to alleviate their social care concerns needs to be closely monitored.
Disabling programs or missed opportunities?
Existing evidence on cash transfers elsewhere show that the conditionality of transfers provides no added benefit over simple unconditional transfers. If anything, giving people the freedom to spend the money they receive is a better strategy, and may reduce homelessness. Once people are out of the traps of poverty and scarcity, they tend to make better decisions for themselves. Agency, rather than being a liability, empowers participants.
Another worry is if the money used for social care is directed to the more deserving recipient taking into account, for example, equity concerns. We subscribe to the idea of “proportionate universalism” as introduced by Benach et al. This system proposes a universal investment approach, giving aid to all groups but proportionally increasing targeted aid to groups that have higher rates of social care issues. In this way, both absolute burden of social needs and disparate rates of social care issues are addressed.
To reduce in-equity, we have a choice to sate the appetite of large corporations’ shareholders or meet basic human needs. We call for a new American social care system.
Haaris Mateen
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David Buck