“James House has written a powerful book that shows a recent erosion of the health status of Americans that cannot be fixed by increased medical care but requires new public policies aimed at achieving greater fairness and justice in employment, income levels, and housing markets as well as educational systems of higher quality. Beyond Obamacare is a masterwork!”

—ALVIN R. TARLOV, emeritus professor of medicine, University of Chicago, and former president, Henry J. Kaiser Family Foundation

“Beyond Obamacare maintains that both improving population health and constraining growth in health care costs requires shifting our focus from more narrow medical concerns to social and other non-medical determinants including income, education, work and social relations. Drawing on his distinguished research in these areas over several decades, and with broad interdisciplinary scope, James House's data-driven, provocative, and compelling presentation provides the basis for a new health policy paradigm. Presented in a clear and accessible way, it will be invaluable to health professionals, policy scholars, and students.”

—DAVID MECHANIC, Rene Dubos University Professor, Institute for Health, Health Care Policy, and Aging Research, Rutgers, The State University of New Jersey

“In this beautifully written book, James House provides a carefully reasoned, empirically grounded analysis of why universal health care, though long overdue, is still insufficient to move Americans closer to the health profile enjoyed by citizens of other wealthy nations. Beyond Obamacare is must reading for everyone who wants to see a healthier, more socially just America.”

—SHERMAN A. JAMES, Susan B. King Emeritus Professor of Public Policy, Duke University

Health care spending in the United States today is approaching 20 percent of GDP, yet levels of U.S. population health have been declining for decades relative to other wealthy—and even some developing—nations. How is it possible that the United States, which spends more than any other nation on health care and insurance, now has a population markedly less healthy than those of many other nations? Sociologist and public health expert James S. House analyzes this paradoxical crisis, offering surprising new explanations for how and why the United States has fallen into this trap. In Beyond Obamacare, House shows that health care reforms, including the Affordable Care Act, cannot resolve this crisis because they do not focus on the underlying causes for the nation’s poor health outcomes, which are largely social, economic, environmental, psychological, and behavioral.

House demonstrates that the problems of our broken health care and insurance system are interconnected with our large and growing social disparities in education, income, and other conditions of life and work. House calls for a complete reorientation of how we think about health. He concludes that we need to move away from our misguided and almost exclusive focus on biomedical determinants of health, and to place more emphasis on addressing social, economic,and other inequalities.

House’s review of the evidence suggests that the landmark Affordable Care Act of 2010, and even universal access to health care, are likely to yield only marginal improvements in population health or in reducing health care expenditures. In order to rein in spending and improve population health, we need to refocus health policy from the supply side—which makes more and presumably better health care available to more citizens—to the demand side—which would improve population health though means other than health care and insurance, thereby reducing need and spending for health care. House shows how policies that provide expanded educational opportunities, more and better jobs and income, reduced racial/ethnic discrimination and segregation, and improved neighborhood quality enhance population health and quality of life as well as help curb health spending. He recommends redirecting funds from inefficient supply-side health care measures toward broader social initiatives focused on education, income support, civil rights, housing and neighborhoods, and other reforms, which can be paid for from savings in expenditures for health care and insurance.

A provocative reconceptualization of health in America, Beyond Obamacare looks past partisan debates to show how cost-efficient and effective health policies begin with more comprehensive social policy reforms.

JAMES S. HOUSE is Angus Campbell Distinguished University Professor Emeritus of Survey Research, Public Policy, and Sociology at the University of Michigan, Ann Arbor.

“This carefully researched book documents that family background matters more in accounting for the academic success of children in the United States than for those in Canada, the United Kingdom, or Australia—all countries that have experienced similar economic shocks and have large immigrant populations. The authors make a compelling case that differences among the countries in social supports for families, labor market policies, and education policies all play roles in explaining this pattern. Too Many Children Left Behind will be sobering to readers in the United States, but it provides a source of hope that public policies matter in leveling the playing field and improving the life chances of children from low-income families.”

—RICHARD J. MURNANE, Thompson Research Professor, Harvard Graduate School of Education

“A devastating dismantling of the American Dream drawn from the most compelling data yet on children’s achievement during their early and formative years.”

—LEE ELLIOT MAJOR, chief executive, The Sutton Trust, and trustee, The Education Endowment Foundation

“It’s easy to think that the large achievement gap between rich and poor students in the United States is an immutable pattern, but the careful cross-national analysis in Too Many Children Left Behind suggests the opposite. The book’s detailed comparison of patterns of educational inequality in four countries demonstrates clearly that social and educational policies can help to equalize children’s opportunities for educational success.”

—SEAN F. REARDON, professor of poverty and inequality in education, Stanford University

The belief that with hard work and determination, all children have the opportunity to succeed in life is a cherished part of the American Dream. Yet, increased inequality in America has made that dream more difficult for many to obtain. In Too Many Children Left Behind, an international team of social scientists assesses how social mobility varies in the United States compared with Australia, Canada, and the United Kingdom. Bruce Bradbury, Miles Corak, Jane Waldfogel, and Elizabeth Washbrook show that the academic achievement gap between disadvantaged American children and their more advantaged peers is far greater than in other wealthy countries, with serious consequences for their future life outcomes. With education the key to expanding opportunities for those born into low socioeconomic status families, Too Many Children Left Behind helps us better understand educational disparities and how to reduce them.

Analyzing data on 8,000 school children in the United States, the authors demonstrate that disadvantages that begin early in life have long lasting effects on academic performance. The social inequalities that children experience before they start school contribute to a large gap in test scores between low- and high-SES students later in life. Many children from low-SES backgrounds lack critical resources, including books, high-quality child care, and other goods and services that foster the stimulating environment necessary for cognitive development. The authors find that not only is a child’s academic success deeply tied to his or her family background, but that this class-based achievement gap does not narrow as the child proceeds through school.

The authors compare test score gaps from the United States with those from three other countries and find smaller achievement gaps and greater social mobility in all three, particularly in Canada. The wider availability of public resources for disadvantaged children in those countries facilitates the early child development that is fundamental for academic success. All three countries provide stronger social services than the United States, including universal health insurance, universal preschool, paid parental leave, and other supports. The authors conclude that the United States could narrow its achievement gap by adopting public policies that expand support for children in the form of tax credits, parenting programs, and pre-K.

With economic inequalities limiting the futures of millions of children, Too Many Children Left Behind is a timely study that uses global evidence to show how the United States can do more to level the playing field.

BRUCE BRADBURY is associate professor at the Social Policy Research Centre at the University of New South Wales, Australia.

MILES CORAK is professor of economics at the Graduate School of Public and International Affairs at the University of Ottawa.

JANE WALDFOGEL is professor of social work and public affairs at the Columbia University School of Social Work and visiting professor at the Centre for Analysis of Social Exclusion at the London School of Economics and Political Science.

ELIZABETH WASHBROOK is lecturer in Quantitative Methods for Education at the Graduate School of Education and a member of the Centre for Multilevel Modelling at the University of Bristol, United Kingdom.