U.S. Health Disadvantage is Not Inevitable

Two major research studies in the last year compare health indicators in the United States with other major upper-income countries. Both exhaustively review government statistics and published articles. The first study, from the Institute of Medicine, draws on a panel of luminary demographers and epidemiologists to explore the causes of U.S. health disadvantage (editors Laudan Aron and Steven Woolf). The second study, from the Global Burden of Disease Group (led by Christopher Murray), applies complex modeling to assess the relative consequences of different diseases and their sequelae on premature death and disability.

The two reports reach the same conclusion: the United States fares worse than virtually every other rich country across a broad set of outcomes – babies in the United States are more likely to die at birth; teenagers are more likely to have unintended pregnancies, to be the victims of homicide, and to die in a car accident; and adults are more likely to experience diabetes, hypertension, heart disease, drug overdoses, and HIV.

Both reports note that although life expectancy is increasing in the United States, disability is not decreasing as people live longer – adults are living slightly longer, but those additional years are lived with a lower quality of life.  Moreover, life expectancy gains in other countries have been much more impressive over recent decades, leading to a widening health life expectancy gap between the United States and its counterparts.

Some figures that help to tell the story:

 In 1980, the United States was in the middle of the OECD pack in life expectancy, but all other countries have raced ahead, while the United States has increased only slightly.

The gap is most dramatic when considering the probability of survival up to age 50 for women:

Here’s a figure from the Murray et al. paper that illustrates the relative weakness of the United States across multiple different causes of death and disability:

Areas of red indicate conditions where each country fares significantly worse than other countries, areas of green indicate where they fare significantly better.

With poor health outcomes spanning so many different domains (communicable, chronic, etc.) and age groups, it is not surprising that there is not a single causal factor that completely accounts for the disadvantage of the United States – it’s not just a lack of universal health care, greater economic inequality, higher child poverty, differences in lifestyle factors, racial diversity, a more libertarian culture, or weaker public health regulations – it’s probably a little bit of all of these things. It is notable for instance, that Americans are relatively disadvantaged even when considering non-minority whites with upper incomes and better education.

Should we despair? “American health disadvantage: it’s everything” is not a particularly good bumper sticker slogan, nor an apt slogan for a political campaign. As overwhelming as the problem seems, there are clearly several factors that are modifiable and politically feasible. To their credit, both reports single out particular areas of social and health policy that could be altered in order to substantially improve population health.

Here are some examples of concrete policies that could make a big impact on population health:

• Road injuries: road injuries declined 33% in 20 years, but they have gone down much more in some countries – like Spain and Sweden – that implemented comprehensive road safety programs. We know what works – motorcycle helmets, anti drunk-driving laws, seatbelt laws.
• Diabetes management programs: diabetes can be identified and managed early, substantially reducing the onset of kidney disease and reducing future complications. As obesity has increased, so has diabetes, but there are promising interventions – such as peer support groups – to encourage weight loss and adherence to medications.
• Sexual risk behaviors: youth in the United States are much more susceptible to teenage pregnancy and sexually transmitted infections. This is another area in which the social norms trump scientific consensus. We can begin to solve this problem by increasing awareness of risk factors for STIs, offering access to contraceptives, and encouraging engagement in school are all factors likely to reduce teenage pregnancy.

American health disadvantage is not inevitable and it’s not excusable. There are other roads that the United States could have taken over the last thirty years that would have led to very different outcomes, and there are still opportunities to get back onto a healthier path. We have made a huge dent in tobacco, reduced motor vehicles deaths, and dramatically improved survival of heart attack victims – we have chances to learn from and replicate those successes, and other countries point the direction forward.