Each week it seems, more evidence emerges regarding the poor health of Americans. We [Woolf and Aron] first documented a “U.S. health disadvantage” as chair and study director of the panel on understanding cross-national health differences among high-income countries at the National Academies in 2013.
Our panel’s report Shorter Lives, Poorer Health showed that, as long ago as 1980, the United States began to take a different path in terms of the health and survival of its population. We found evidence that the U.S health disadvantage compared to other countries existed among Americans at every age below 75, among all races/ethnicities, and among both men and women—but especially among women. We even found evidence of a health disadvantage among white, college-educated, non-obese, non-smoking, and health-insured Americans.
Why Is This Happening?
Our panel considered the obvious explanations — deficiencies in the U.S. health care system, such as the lack of universal health insurance, and higher rates of unhealthy behaviors, such as those responsible for obesity. We also considered the physical and social environments in which Americans live, conditions that too often are not conducive to good health or longer lives. We documented the adverse socioeconomic conditions in the United States, such as inadequate education, higher poverty, especially child poverty, and greater income inequality than in other countries. We understood that all of these factors are powerful contributors to poor health and wellbeing, but we also recognized that these conditions exist because of the policies and spending priorities of our nation, our states, and our communities. The decisions we make as a society shape socioeconomic conditions, the design of our communities, our health behaviors, our access to health care, and how all of these are distributed across people and places.
An intriguing study featured in our report was a 2011 study by Elizabeth Bradley and her colleagues at Yale University, who compared the ratio of social spending to health care spending in various countries and found that countries that spent proportionately more on social services had longer life expectancy. The Bradley study, along with other work by Kimberly Morgan of George Washington University, showed that the U.S. is an outlier when it comes to spending on health and social welfare.
Bradley’s study showed that the U.S. spends $2 on health care for every $1 spent on social services, while Morgan’s showed that U.S. spending per capita on health and social welfare, including tax-based subsidies and private social spending, ranks fifth highest in the world (just behind Sweden). What distinguishes the U.S. is how that that money is spent: more goes to health care, while still leaving many without health insurance or access to care. Fewer dollars are spent on children, families, and the disadvantaged. Both studies conveyed a powerful message: Meaningful change in our nation’s health may come less from investing in medical care than in addressing the social determinants of health. It’s a timely message for the United States, given weekly confirmation of our poor state of health, as well as current debates about growing inequality and what to do about it.
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