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Why Don’t Food And Housing Count As Health Care?

The federal program that provides food and other services to low-income mothers, pregnant women and young children, known as WIC, can have a big impact on participants’ health. It has been shown to reduce premature births, increase vaccination rates in children and lower obesity rates. Yet as far as the government is concerned, WIC doesn’t count as health care spending.

It isn’t just WIC. There are numerous government programs at the federal, state and local levels — school lunch programs, food stamps, housing choice vouchers — that have an impact on Americans’ health but don’t count as part of the health care system. Some experts argue those omissions are a mistake — that our definition of “health care” is too narrow, and that it skews our understanding of how the U.S. stacks up against the rest of the world.

The U.S. famously spends more than any other rich country on health care while getting results that are, at best, middle of the pack. According to a study by the Organization for Economic Co-operation and Development, the U.S. spent 16.4 percent of its gross domestic product on health care in 2012; the Netherlands, which came in second place in spending, spent just 11.1 percent.

Spending on social programs such as WIC, however, looks very different. The U.S. lands 25th in the OECD’s rankings of social services spending, below the median. The U.S. spends 9 percent of GDP on social services such as disability benefits, employment programs and WIC, and is the only rich country where health care spending accounts for a greater share of GDP than social services. In contrast, France and Sweden spent 21 percent of GDP on social services and around 11 percent of GDP on health care.

Many experts say that the line between health care and social services is blurry. Helping people afford food or housing is just as important for their well-being as getting them into the doctor’s office, said Elizabeth Bradley and Lauren Taylor, health policy researchers who wrote a book on U.S. health care spending.

“The total spending on health care plus social services; that’s what we’re spending on health. That’s critical,” Bradley said. “That’s the great American mistake … separating in our brains the difference between health care and health.”

Bradley said it makes more sense to think of health care and social services spending together. By that measure, the U.S. ranks roughly in the middle of OECD countries.1 That is more in line with U.S. life expectancy and other measures of health.

But while combining health care and social services makes the disparity between U.S. spending and health outcomes look less severe, it also highlights how differently the U.S. spends its money than other rich nations. The U.S. spends much less than many European countries on social services, which mostly benefit the poor, and much more on health care, a disproportionate amount of which is spent on the rich.

“In our country, about two-thirds of health care spending is government money, but a lot of that is going for the care of wealthy people,” said David U. Himmelstein, a doctor and professor at the City University of New York’s Hunter College. “And as a result, wealthy people pay very, very little and poor people don’t get as much.”

Other experts, of course, don’t share the view that the U.S. should spend more on social programs. But there is widespread agreement that the conventional narrative on U.S. health spending is too simplistic: The problem isn’t necessarily that we spend too much on health care, many experts argue. It’s that we spend it in the wrong places. “Investing in social services could make people healthier,” said Taylor. And that, after all, is the goal of health care.


  1. Simply adding health care and social-service spending isn’t a perfect measure. Health care costs gathered by the OECD include a combination of both public and private health care spending, while social services figures include only public expenditures. Focusing only on public spending is problematic, however, because different countries fund health care differently — most health care spending in the U.S. is private, for example, while the Netherlands’ system is almost entirely publicly funded. Bradley said she has looked at total U.S. social-services spending — including public and private spending — across the states and found that the states with higher social service spending had better health. Because of this, she decided that we could compare the U.S. to other countries, since the basic patterns will stay the same.

Christianna Silva was FiveThirtyEight’s fall 2016 politics intern.