Wealth but not health in the USA
Last
week, American people, health-care workers, and policy makers
received shocking news. Despite spending more on health care per
person than other high-income countries, Americans die sooner, are
least likely to reach the age of 50 years, and have higher rates of
disease or injury. When judged by health alone, Americans are less
healthy from birth to 75 years of age than people in 16 other
economically wealthy countries, and this health disadvantage has been
getting worse for 30 years, especially among women.
In
a report released on Jan 9 from the US National Research Council and
Institute of Medicine, U.S. Health in International Perspective:
Shorter Lives, Poorer Health, comprehensive mortality and
morbidity data are presented, comparing the USA with affluent
democratic countries including Australia, Canada, France, Italy, most
of the Nordic countries, Spain, and the UK. Life expectancy is
shorter at birth for American men than for men in any of the other 16
countries, and American women fare little better—Denmark is the
only country that has a lower life expectancy for women at birth. In
nine key areas of health, Americans fare least well, or are near the
bottom of the tables. These areas are: infant mortality and low
birth-weight; injuries and homicides; teenage pregnancies and
sexually transmitted infections; HIV/AIDS prevalence; drug-related
deaths; obesity and diabetes; heart disease; chronic lung disease;
and disability. This health disadvantage applies to those with health
insurance, a college education, higher incomes, and healthy behaviors
as well as to those without.
Some
good news in the report is that those Americans who reach 75 years
live longer than their peers in other countries, and that Americans
have low death rates from stroke and cancer. Moreover, current
smoking rates are low, which should lead to future health benefits,
and household income is relatively high.
US
health spending was US$2·7 trillion in 2011, which is $8700 for
every person in the country, and represents 17·9% of the economy—far
greater than any other economically advanced country. But spending on
health care bears little relation to good health.
Why
are Americans at a health disadvantage compared with those in other
countries? The fragmented US health-care system, and, in particular,
poor access to health care and to primary care, are partly to blame.
Lack of insurance, or inadequate insurance, restricts access to
health care for many Americans. But the system is not the only
problem. Unhealthy behaviours abound in the USA, particularly
overeating, drug abuse, and other risk-taking activities such as not
wearing motorcycle helmets, drinking and driving, and using firearms.
Social and economic conditions in the USA contribute to high incomes
for some, but to high poverty and income inequality for others, and
to low standards of education. Welfare safety nets are not as robust
as they are in other countries. Moreover, cities in the USA are often
built around car use, which discourages physical activity and
contributes to obesity.
Change
is needed. The first step is to implement the National Prevention
Strategy: America's Plan for Better Health and Wellness, which
was published in June, 2011. Next, two dominant causes of the US
health disadvantage deserve special mention. For people over 50
years, preventing cardiovascular disease through, for example, the
Million Hearts campaign is key. For those under 50 years, preventing
injury and deaths in road traffic accidents or by guns, and HIV
prevention and treatment, are important targets. Considering and
adapting health-promoting policies from other countries is
recommended, as is further research to work out why, for example,
Japan, Switzerland, and Italy have relatively good health outcomes in
many areas overall.
In
addition to improving access to health care, it will take social,
economic, health, and environmental policies to increase job
availability, education, healthy eating, and physical activity, in
order to reduce the US health disadvantage.
To
promote and inform continuing debate, health in the USA will be the
theme of a Series in a special issue of The Lancet in 2014. In
conjunction with Tom Frieden and Harold Jaffe at the Centers for
Disease Control and Prevention, we will publish papers reviewing new
opportunities to substantially improve health in the era of the
Affordable Care Act. Planned topics include more on premature
mortality in the USA, the impact of violence and injury, the
challenges of non-communicable diseases and infections, public health
and biosecurity, and the role of the USA in global health.
The
USA is one of the world's wealthiest countries; it should be one of
the world's healthiest.
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