Beyond Obamacare: Life, Death, and Social Policy (2015), a new book by sociologist and public health expert James S. House, advances a provocative new analysis of America’s health care crisis. How is it possible that the United States spends more than any other nation on health care and insurance, yet has simultaneously witnessed a decline in population health relative to other wealthy—and even some developing—nations? 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. And it is these poor health outcomes that drive America’s unparalleled spending on health care, now approaching 20% of GDP.

As House notes, socioeconomic determinants such as education and income have significant consequences for individuals’ health outcomes. For example, though mortality rates declined for the population as a whole between 1960 and 1986, they declined more rapidly among the highly educated. As the figure below shows, educational differences in death rates grew for both men and women during this time period. And, House points outs, “Analyses in Canada found much the same, even after a quarter-century of national health insurance.”

In 1986, House and his colleagues launched the Americans’ Changing Lives (ACL) study, a 26-year survey of adult Americans over the age of 25 that measured differences in the way health changes with age across subgroups of the population, including men versus women, blacks versus whites, smokers versus nonsmokers, and higher versus lower income, among other factors. House found that the strongest predictors of successful health maintenance and effective functioning over one’s life course were education and income. As the graph below shows, the survey respondents with the lowest education (less than high school) showed an almost linear decline in functional health from early adulthood to old age. By contrast, the most highly educated group (college degree or higher) showed notable rectangularization and compression—or, in other words, maintained good health for a longer period of their lives. The less educated showed delinces in health by their 30s not seen in the higher educated until their 60s. And this was evident when the study began in 1986, and observed over time as the sample became 25 to 26 years older by 2011-12.

Beyond Obamacare demonstrates that the problems of our struggling 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, concluding that we need to move away from our near-exclusive focus on biomedical determinants of health, and instead place more emphasis on addressing social, economic, and other inequalities. He argues that policies which provide expanded educational opportunities, more and better jobs and income, reduced racial/ethnic discrimination and segregation, and improved neighborhood quality will enhance population health and quality of life, and thus help curb health spending. As House states, “Evidence increasingly indicates that almost all forms of public policy have health effects and thus should be considered in relation to, and even as part of, health policy.”

Click here to read more about Beyond Obamacare and preorder a copy of the book.