“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.

• About the Book
• Table of Contents
• Resources

1

Introduction

Douglas Wolf

In this overview of the volume, Wolf outlines recent developments in long-term care policy and how research can help lead to a truly universal long-term care system in America.

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2

Long-Term Care and Long-Term Family Caregivers: Outdated Assumptions, Future Opportunities

Carol Levine

Blending insights from her personal life and policy analysis, Carol Levine asks: How can public policy best support long-term family care?

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3

The Rise and Fall of the Class Act: What Lessons Can We Learn?

Howard Gleckman

In an engaging history of the CLASS Act, Howard Gleckman examines why the landmark legislation failed and if it can be improved.

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4

The CLASS Promise in the Context of American Long-Term Care Policy

Robert Hudson

Robert Hudson looks at the history of long-term care policy in America and why the issue has remained only marginally acknowledged or addressed.

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5

Free Personal Care in Scotland, (Almost) 10 Years On

David Bell and Alison Bowes

After reviewing recent policy shifts in the United Kingdom, David Bell and Alison Bowes describe the costs and benefits of the provision of free personal care in Scotland.

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6

Population Aging and Long-Term Care: The Scandinavian Case

Svein Olav Daatland

Svein Olav Daatland analyzes the Scandinavian approach to long-term care, with a particular emphasis on the Norwegian model.

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7

Lessons on Long-Term Care from Germany and Japan

Mary Jo Gibson

Germany and Japan have both implemented mandatory social insurance programs to help provide long-term care. Mary Jo Gibson provides an in-depth analysis, along with possible lessons for American policymakers.

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8

The Long-Term Care Workforce: From Accidental to Valued Profession

Robyn Stone

In her overview of the formal, paid long-term care workforce, Robyn I. Stone discusses current challenges and potential solutions to increase supply and quality.

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9

The Perverse Public and Private Finances of Long-Term Care

Leonard Burman

How do Americans pay for long-term care? Leonard Burman explains the long-term care financing system, which he calls "dysfunctional."

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10

It Takes Two to Tango: A Perspective on Public and Private Coverage for Long-Term Care

David Stevenson, Marc A. Cohen, Brian Burwell, and Eileen J. Tell

David Stevenson, Marc A. Cohen, Brian Burwell and Eileen J. Tell look at the private long-term care insurance market and ask: Why don’t more Americans purchase such insurance?

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11

Long-Term Care Coverage for All: Getting There from Here

Nancy Folbre and Douglas Wolf

Editors Nancy Folbre and Douglas Wolf conclude the volume by discussing potential pathways to more comprehensive long-term care insurance.

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Winner of the 2016 American Sociological Association’s Asia and Asian America Section Book Award

“In this well written and wide ranging book, Dina Okamoto puts forward a new theory describing the relationship between race, ethnicity, and assimilation among Asian Americans. This provocative racial boundary approach to understanding the identities and the incorporation of Asian Americans is a sophisticated and welcome contribution to the field. Using the case of Asian Americans it contributes to our understanding of the concepts and changing nature of race and ethnicity in general.”

—MARY C. WATERS, M.E. Zukerman Professor of Sociology, Harvard University

“Redefining Race redefines our understanding of the making of Asian America. By carefully articulating a theory of panethnicity as a process of shaping and shifting group boundaries, collecting data apposite to that theory, and designing demanding empirical tests, Okamoto expertly shows that Americans of diverse Asian backgrounds did not become panethnic overnight and ex nihilo as a passive response to state- constructed racial categories. Rather, Okamoto presents a vivid account of the accidents, opportunities, and contexts that fire up panethnic moments of collective action and douse them back into quiescence. Redefining Race is a major advancement and original contribution to the fields of immigrant incorporation, racial and ethnic formation, and Asian American studies.”

—TAEKU LEE, professor of political science and professor of law, University of California, Berkeley

“Through a sophisticated marshaling of theory and evidence from historical archives, interviews and social surveys, Dina Okamoto demonstrates how Americans of Japanese, Filipino, Korean, Chinese, Indian, Vietnamese, and other origins created an Asian American identity and Asian American institutions in the last quarter of the twentieth century. Despite disparate languages and conflicting histories, leaders of ethnic organizations defined by their nation of origin and others would strategically organize along panethnic lines when they found common interests rather than simply respond to the wider American society’s imposition of race. Okamoto’s Redefining Race is a new benchmark for understanding the social construction of ethnicity and ethnic identity.”

—EDWARD TELLES, professor of sociology, Princeton University

In 2012, the Pew Research Center issued a report that named Asian Americans as the “highest-income, best-educated, and fastest-growing racial group in the United States.” Despite this optimistic conclusion, over thirty Asian American advocacy groups challenged the findings, noting that the term “Asian American” is complicated. It includes a wide range of ethnicities, national origins, and languages, and encompasses groups that differ greatly in their economic and social status. In Redefining Race, sociologist Dina G. Okamoto traces the complex evolution of “Asian American” as a panethnic label and identity, emphasizing how it is a deliberate social achievement negotiated by group members, rather than an organic and inevitable process.

Drawing on original research and a series of interviews, Okamoto investigates how different Asian ethnic groups created this collective identity in the wake of the Civil Rights movement in the 1960s. Okamoto documents the social forces that encouraged the development of this panethnic identity. The racial segregation of Asians in similar occupations and industries, for example, produced a shared experience of racial discrimination, which led Asians of different national origins to develop shared interests and identities. By constructing a panethnic label and identity, ethnic group members created their own collective histories, and in the process challenged and redefined current notions of race.

The emergence of a panethnic racial identity also depended, somewhat paradoxically, on different groups organizing along distinct ethnic lines to gain recognition and rights from the larger society. According to Okamoto, ethnic organizations provided the foundation necessary to build solidarity within different Asian-origin communities. Leaders and community members who created inclusive narratives and advocated policies that benefited groups beyond their own moved their discrete ethnic organizations toward a panethnic model. For example, a number of ethnic-specific organizations in San Francisco expanded their services and programs to include other ethnic group members after their original constituencies dwindled in size or assimilated. A Laotian organization included refugees from different parts of Asia, a Japanese organization began to advocate for South Asian populations, and a Chinese organization opened its doors to Filipinos and Vietnamese. As Okamoto shows, the process of building ties between ethnic communities while also recognizing ethnic diversity is the hallmark of panethnicity.

Redefining Race is a groundbreaking analysis of the processes through which group boundaries are drawn and contested. In mapping the genesis of a panethnic Asian American identity, Okamoto illustrates the ways in which concepts of race continue to shape how ethnic and immigrant groups view themselves and organize for representation in the public arena.

DINA G. OKAMOTO is an associate professor of sociology and director of the Center for Research on Race and Ethnicity in Society at Indiana University.