Everyday people might understandably fear West Nile Virus or Ebola, but a new report in the Annual Review of Public Health journal says it may be smarter to fret about policymakers’ decisions and wasteful health-care spending – which haven’t meant better health.
High levels of health-care spending don’t ensure a healthy society, according to the report “Why Do Americans Have Shorter Life Expectancy and Worse Health than Do People in Other High-Income Countries?” The United States spends more than any country on health care: 17.9 percent of its Gross Domestic Product (GDP). In contrast, Canada’s health spending is 10.9 percent of its GDP, and Britain less: 9.4 percent.
Despite that spending, says the report – which compares the United States to 16 “high-income” nations – U.S. life spans are shorter, infant mortality rates higher, obesity more common, and mental health poorer.
Other factors influence the rates of disease, injury and death that countries experience. These are “conditions in which people are born, grow, live, work and age shaped by the distribution of money, power and resources at global, national and local levels,” according to the World Health Organization. Policies regulating air pollution, income distributions, and discriminatory laws, or the presence or absence of green space in neighborhoods are examples.
The report assesses various explanations for the U.S. health disadvantage, focusing on life expectancy. Authors Ichiro Kawachi of Harvard University and Mauricio Avendano of the London School of Economics compare mortality in the United States with Australia, Japan, Canada and 13 Western European nations.
“The American health disadvantage begins at birth and extends across the life course, and it is particularly marked for American women and for regions in the U.S. South and Midwest,” say Kawachi and Avendano, who work at Harvard’s School of Public Health.
Greg Chance, Public Health Administrator at the Peoria City/County Health Department, agrees.
“The U.S. health disadvantage has many causes,” he says. “What remains unclear is how the combination of these factors influences the magnitude or ‘span’ of the poor health outcomes. What is obvious is that the U.S. has for far too long attempted to make this debate simply about the health-care system performance as well access to health care.”
The report says that social-policy differences may play a role in shortening U.S. lives: “Social policies and programs affecting Americans across the entire life course are less comprehensive in the United States.”
In particular, a higher level of income inequality in the United States, weaker labor laws, and less investment in programs that address housing, poverty, education and child care may be responsible, they say.
“While multiple causes are implicated, crucial differences in social policy might underlie an important part of the U.S. health disadvantage,” they note.
Researchers found that the United States has the lowest life expectancy at birth for both women (80.6 years) and men (75.6 years) compared to the other 16 nations. Also there are wide disparities in U.S. life expectancy by geography, race and socioeconomic status. An analysis in PLOS Medicine found that black men living in urban areas die 21 years earlier than the national average for Asian women. Life expectancy also varies by U.S. region – people in the Midwest and South have the shortest lives. Among low-income Americans, rates of homicide and AIDS-related deaths are high, but another study found that white, middle-class Americans (a relatively healthy group by U.S. standards) also experience poorer health than their European counterparts.
Differences in physical infrastructure may contribute to differences in life expectancies. U.S. communities tend to be planned around cars, which limits opportunities for physical activity. Also, people in the United States drive longer distances and, as a result, they are more likely to die in automobile accidents.
Dr. Jerry McShane, CEO of the OSF Medical Group in Peoria, says inactivity has multiple causes.
“Car driving is one,” he says. “TV viewing versus playing sports is significant for children.”
As far as costs, differences in health insurance and the health-care system may explain some, but not most, of the U.S. disadvantage in mortality, according to the report. While lack of universal health care coverage may be detrimental to health, even Americans with insurance have poorer health than Europeans.
“Multiple differences in western society account for the differences in cost,” Dr. McShane says. “First, wages for all health care workers are higher in America than elsewhere. Next, the U.S. system is incentivized to provide too much care versus the right care. The lack of a strong primary-care base is an essential difference between the American system versus other western countries. Also, Americans have become consumers. In the past, first-dollar costs were paid by insurance companies. Patients are not discerning when the bill is paid by others. New insurance products will introduce high-deductible plans. This will reduce demand for unnecessary services. There are factors at work in America which will decrease the cost of care.”
Chance says people need to look within and without – at their lifestyles and at government policies.
“Health goes beyond what physicians and health departments can do,” Chance says. “In the U.S., we exhibit very poor health behaviors and over-rely on the health care system to improve our health status.”
Public health is a result of many behaviors and policies, he adds.
“In the U.S., we have undervalued the influence of social and environmental factors that influence health status,” he says. “We need to place a larger emphasis on the social determinants of health as well as individual behaviors if we want to improve health outcomes. This will require a complete change in how we think about community health. Because population health improvement requires action on multiple determinants, we need to develop multisectoral community health business partnership models to drive action.”
Research can be tantalizing, but it can require study to clarify next steps, and more involvement by regular people to be more accountable for their health and more demanding of policymakers.