In fact, it’s possible to see America’s astronomical health costs as a bill coming due from our reluctance to pay for everything else. “We spend so much on health care because we’re mopping up for our lack of investment in education, housing and other areas,” says Corey Rhyan, an analyst at the Center for Sustainable Health Spending at health care think tank Altarum.

One of the most closely watched programs has been that run by Minneapolis-based Hennepin Health, an accountable care organization for patients on Medicaid run by the surrounding county. Minnesota sharply expanded Medicaid eligibility in the state in 2011 and again in 2014, bringing in about 10,000 new enrollees under Hennepin’s care, representing well over $300 million in new health care costs. These enrollees, all of whom were poor and many of whom didn’t have permanent housing, were being admitted to the hospital at three times the rate of other nonelderly adults, and were visiting the emergency department an astonishing 13 times as often, according to Ross Owen, the health strategy director for Hennepin County. Each such admission or visit can easily rack up thousands of dollars in costs, making reducing them good targets for a program. “Those are the low-hanging fruits of these kinds of interventions,” says Owen.

IT’S ONE THING if this and many other projects together succeed in building a clear-cut, hard-dollars case for the big health payback of social-service spending. Having those results matter is another thing. There’s no guarantee that, even in the face of strong proof to the contrary, politicians won’t keep on with business as usual, continuing to throw the bigger bucks at health care—which has big, well-funded lobbies and enjoys broad public support—rather than the social conditions that make the care necessary. After all, they’ve done a pretty good job of shrugging off the evidence so far. “It’s been making less and less sense to look at medical diagnoses when you want make health-related spending decisions, and more and more sense to look at demographics,” says Hennepin’s Owen. “The way we distribute resources in this country ignores that reality.”

For those reasons, program sponsors and researchers are now focusing on the shorter term, trying to prove that social spending can pay off quickly in reduced health care costs. One sweet spot is in subsidized housing, where benefits often accrue right away, especially for the most challenging patients.

Looming over the American conversation about public health is a growing suspicion that there’s a bigger reason for our uniquely poor showing, one that has been staring us in the face for years. It’s an explanation rooted in one simple statistic: While we pay more for health care than any other country in the world, when it comes to spending on social services—education, subsidized housing, food assistance and more—we rank in the bottom 10 among developed countries.

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