Why is the rich United States in such poor health?
Americans die younger and experience more injury and illness than people in other rich nations, despite spending almost twice as much per person on health care. That was the startling conclusion of a major report released in 2013 by the US National Research Council (NRC) and the Institute of Medicine (IOM).
Since then, evidence supporting a US “health disadvantage” has only grown, with both the Journal of the American Medical Association and the Centers for Disease Control and Prevention releasing new data in just the last several weeks. Headlines emphasizing Americans’ rising mortality rates are now common.
At the time of its release, the groundbreaking NRC-IOM report received widespread attention. The New York Times concluded: “It is now shockingly clear that poor health is a much broader and deeper problem than past studies have suggested.”
The report revealed the extent of the United States’s large and growing health disadvantage, which shows up as higher rates of disease and injury from birth to age 75 for men and women, rich and poor, across all races and ethnicities. The comparison countries—Australia, Austria, Canada, Denmark, Finland, France, Germany, Italy, Japan, Norway, Portugal, Spain, Sweden, Switzerland, the Netherlands, and the United Kingdom—generally do much better, although the United Kingdom isn’t far behind the United States.
The poorer outcomes in the United States are reflected in measures as varied as infant mortality, the rate of teen pregnancy, traffic fatalities, and heart disease. Even those with health insurance, high incomes, college educations, and healthy lifestyles appear to be sicker than their counterparts in other wealthy countries. The US Council on Foreign Relations, a nonpartisan think tank, described the report as “a catalog of horrors.”
Findings that prompted this reaction include the fact that the rate of premature births in the United States is the highest among the comparison countries and more closely resembles those of sub-Saharan Africa. Premature birth is the most frequent cause of infant death in the United States, and the cost to the health care system is estimated to top $26 billion a year.
As distressing as all this is, much less attention has been given to the obvious question: why is the United States so unwell? The answer, it turns out, is simple and yet deceptively complex: it’s almost everything.
Our health depends on much more than just medical care. Behaviors such as diet, physical activity, and even how fast we drive all have profound effects. So do the environments that expose us to health risks or discourage healthy living, as well as social determinants of health, such as education, income, and poverty.
The United States fares poorly in almost all of these. In addition to many millions of people lacking health insurance, financial barriers to care, and a lack of primary care providers compared with other rich countries, people in the United States consume more calories, are more sedentary, abuse more drugs, and shoot one another more often. The United States also lags behind on many measures of education, has higher child poverty and income inequality, and lower social mobility than most other advanced democracies.
The breadth of these causal factors and the scope of the US health disadvantage they produce raise some fundamental questions about US society. As the NRC-IOM report noted, solutions exist for many of these health problems, but there is “limited political support among both the public and policymakers to enact the policies and commit the necessary resources.”
One major impediment is that the United States, which emphasizes self-reliance, individualism, and free markets, is resistant to anything that even appears to hint at socialism. Interestingly, classically liberal nations like the United States and the United Kingdom—free market–oriented with less regulation, tax, and government services—are the least healthy among wealthy democracies.
By contrast, social democratic countries such as Sweden—in which the state emphasizes full employment, income protection, housing, education, health, and social insurance—enjoy better overall health, although health inequalities within these nations are not always the smallest.
Debates about the relative merits of “cutthroat” American versus “cuddly” Swedish capitalism contend that there are important trade-offs between economic growth and innovation on the one hand, and growing inequality, high poverty, and a weak social safety net on the other. Unfortunately, these debates often fail to factor in our health. That needs to change.
And, as it turns out, the United States spends plenty on social welfare. It may tax less and spend less on social programs than most rich democracies, but when you add tax-based subsidies and private social spending, it ranks fifth-highest in the world, just after Sweden. What distinguishes the United States is how that money is spent. More goes toward health care—while still leaving many without health insurance or access to care—than toward children, families, and the disadvantaged.
Digging into the social determinants of health can be tricky. Social scientists and other researchers are rightly trained not to confuse correlation with causation. But the evidence on the biology of disadvantage—how social and economic conditions affect our health and survival—is rapidly building.
Following the World Health Organization’s 2008 Commission on Social Determinants of Health, countries such as Australia, Canada, and Finland are taking a “health-in-all-policies” approach that promotes health through public policies in areas as diverse as transportation, housing, and agriculture. In the United States, these ideas have yet to gain much traction.
Moving beyond the dismal headlines generated by the NRC-IOM report and others, we can hope that the evidence of a health disadvantage in the United States is now so compelling that the terms of the conversation and even the political calculus will begin to change. Then, perhaps, we can address that disadvantage and stop paying for it with our lives.
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