Why is the rich US 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 healthcare. That was the startling conclusion of a major report released earlier this year by the US National Research Council (NRC) and the Institute of Medicine (IOM).

It 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.”

What it revealed was the extent of the US’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 UK – generally do much better, although the UK isn’t far behind the US.

The poorer outcomes in the US 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 non-partisan 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 US 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 US, and the cost to the healthcare system is estimated to top $26 billion a year.

“The rate of premature births in the US more closely resembles those of sub-Saharan Africa”

As distressing as all this is, much less attention has been given to the obvious question: why is the US 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. Behaviours 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 US 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 US consume more calories, are more sedentary, abuse more drugs and shoot one another more often. The US 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, raises 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 US, which emphasises self-reliance, individualism and free markets, is resistant to anything that even appears to hint at socialism. Interestingly, as a group, classically liberal nations like the US and the UK – 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 emphasises 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 “cut-throat” US 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 US spends plenty on social welfare. It may tax less and spend less on social programmes than most rich democracies, but when you add in tax-based subsidies and private social spending, it ranks as the fifth highest in the world, just after Sweden. What distinguishes the US is how that money is spent. More goes on healthcare – while still leaving many without health insurance or access to care – and less on 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 Finland, Australia and Canada 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 US these ideas have yet to gain much traction.

Moving beyond the dismal headlines generated by the NRC/IOM report, we can hope that the evidence of a health disadvantage in the US is now so compelling that the terms of the conversation and even the political calculus will begin to change. Then, perhaps, we can start addressing that disadvantage and stop paying for it with our lives.

This article appeared in print under the headline “Paying with our lives?”