10

Next Steps

The United States and many other nations should take pride in the dramatic gains in life expectancy and disease survival rates that they have achieved in the past century, a credit to major advances in medicine and public health. However, as documented throughout this report, advances in the United States have generally not kept pace with those of many other high-income countries. Using data from a wide range of sources, Part I details these elements of the U.S. health disadvantage:

•   Americans have shorter life expectancy than people in almost all other high-income countries.

•   This disadvantage has been growing for the past three decades, especially among women.

•   This disadvantage is pervasive—it affects all age groups up to the oldest ages and is observed for multiple diseases, biological and behavioral risk factors, and injuries.

•   More specifically, when compared with the average of other high-income countries, the United States fares worse in nine health domains:

o   adverse birth outcomes (e.g., low birth weight and infant mortality);

o   injuries, accidents, and homicides;

o   adolescent pregnancy and sexually transmitted infections;

o   HIV and AIDS;

o   drug-related mortality;



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10 Next Steps T he United States and many other nations should take pride in the dramatic gains in life expectancy and disease survival rates that they have achieved in the past century, a credit to major advances in medicine and public health. However, as documented throughout this report, advances in the United States have generally not kept pace with those of many other high-income countries. Using data from a wide range of sources, Part I details these elements of the U.S. health disadvantage: • Americans have shorter life expectancy than people in almost all other high-income countries. • This disadvantage has been growing for the past three decades, especially among women. • This disadvantage is pervasive—it affects all age groups up to the oldest ages and is observed for multiple diseases, biological and behavioral risk factors, and injuries. • More specifically, when compared with the average of other high- income countries, the United States fares worse in nine health domains: o adverse birth outcomes (e.g., low birth weight and infant mortality); o  injuries, accidents, and homicides; o adolescent pregnancy and sexually transmitted infections; o  HIV and AIDS; o  drug-related mortality; 273

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274 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE o  obesity and diabetes; o  heart disease; o  chronic lung disease; and o disability. Part II considers potential explanations for this disadvantage and docu- ments that important antecedents of good health are also frequently prob- lematic in the United States: • The U.S. health system is highly fragmented, with weak public health and primary care components and a large uninsured popu- lation. Compared with people in other high-income countries, Americans are more likely to find care inaccessible or unafford- able and to report lapses in the quality and safety of ambulatory care. • Americans are less likely to smoke and may drink less heavily than their counterparts in other countries; however, they consume the most calories per capita, abuse more prescription and illicit drugs, are less likely to use seatbelts, have more traffic accidents involving alcohol, and own more firearms. U.S. adolescents seem to become sexually active at an earlier age, have more sexual partners, and are more likely to engage in riskier sexual practices than adolescents in other high-income countries. • The United States has higher rates of poverty and income inequality than do most rich democracies. U.S. children, especially, are more likely than children in many other affluent countries to grow up in poverty, and they are less likely to surpass their parents socio- economically. In addition, although the United States was once the world leader in education, it has not kept pace with many other countries for several decades. • There are stark differences in land use patterns and transporta- tion systems between the United States and other high-income countries. Americans are less likely than people in other high- income countries to live close to sources of healthy foods. There is also some evidence that residential segregation by socioeconomic position is greater in the United States than in some European countries. In this chapter we turn to the question of what else the nation should do about the U.S. health disadvantage. We believe that there is sufficient evi- dence for the country to act now, without waiting for additional research. The pervasiveness of the U.S. health disadvantage and the fact that it

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NEXT STEPS 275 has been worsening for decades leads us to recommend that the nation and its leaders act now in three areas: (1) intensify efforts to pursue existing national health objectives that already target the specific areas in which the United States is lagging behind other high-income countries, (2) alert the public about the problem and stimulate a national discussion about inher- ent tradeoffs in a range of actions to begin to match the achievements of other high-income nations, and (3) undertake analyses of policy options by studying the policies used by other high-income countries with better health outcomes and their adaptability to the United States. PURSUE NATIONAL HEALTH OBJECTIVES RECOMMENDATION 4: The nation should intensify efforts to achieve established national health objectives that are directed at the specific disadvantages documented in this report and that use strate- gies and approaches that reputable review bodies have identified as effective. Although the panel was not tasked with evaluating specific policies or programs that could address the U.S. health disadvantage we document in this report, the broad outlines are clear enough. The list of factors that may be responsible for the U.S. health disadvantage is daunting, but it is also very familiar to experts in public health and social policy. The list of specific health problems have been long-standing concerns: infant mortality, injuries, violence, adolescent pregnancy, sexually transmitted infections and HIV, drug abuse, obesity, diabetes, heart and lung disease, and disability. Similarly, the underlying contributors are familiar explanations: smoking and other unhealthy behaviors, education, poverty, and the physical and social environment. Many evidence-based strategies to address these specific public health challenges have been identified, and the United States has set national objectives to address them. Indeed, the very areas in which the United States is deficient relative to other high-income countries are outlined in Healthy People 2020 (U.S. Department of Health and Human Services, 2012a) (see Table 10-1). The problem areas identified in this report align fully with the 12 priority areas in that report that were subsequently singled out as “critical to the nation’s health needs” (Institute of Medicine, 2011g, p. 2). For example, high U.S. transportation-related injury or violent deaths could be ameliorated by efforts that reduce traffic fatalities or homicides. The U.S. ranking as world leader in obesity and the high prevalence of diseases related to obesity (e.g., diabetes) could be helped by initiatives that succeed in lowering the average body mass index of the population. Similarly, the national prevention strategy of the Surgeon General’s

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276 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE TABLE 10-1  National Health Objectives That Address Specific U.S. Health Disadvantages Disadvantages Relative to Other High-Income Countries Examples of Relevant Healthy People 2020 Objectives Chapters 1-2: Shorter Lives, Poorer Health Higher prevalence and death rates HDS-2: Reduce coronary heart disease deaths. from cardiovascular disease HDS-16: Increase the proportion of adults age 20 and older who are aware of, and respond to, early warning symptoms and signs of a heart attack. Higher prevalence and death rates D-1: Reduce the annual number of new cases of from diabetes diagnosed diabetes in the population. D-3: Reduce the diabetes death rate. Higher prevalence and death rates RD-10: Reduce deaths from chronic obstructive from chronic lung diseases pulmonary disease (COPD) among adults. Higher homicide rates IVP-29: Reduce homicides. Higher transportation injury SA-17: Decrease the rate of alcohol-impaired driving fatality rates (.08 + blood alcohol content [BAC]) fatalities. Higher transportation and non- IVP-1: Reduce fatal and nonfatal injuries. transportation injury fatality rates Higher rate of drug-related deaths SA-12: Reduce drug-induced deaths. Higher death rates from communicable diseases Higher death rates from AIDS HIV-3: Reduce the rate of HIV transmission among adolescents and adults. HIV-4: Reduce the number of new AIDS cases among adolescents and adults. HIV-12: Reduce deaths from HIV infection. Higher prevalence of obesity NWS-9: Reduce the proportion of adults who are obese. NWS-10: Reduce the proportion of children and adolescents who are considered obese. Higher prevalence of hypertension HDS-5: Reduce the proportion of persons in the population with hypertension. Higher prevalence of asthma RD-1: Reduce asthma deaths. RD-2: Reduce hospitalizations for asthma. Higher infant mortality rate MICH-1: Reduce the rate of fetal and infant deaths. Higher prevalence of low birth MICH-8: Reduce low birth weight (LBW) and very weight and prematurity low birth weight (VLBW). MICH-9: Reduce preterm births. Higher maternal mortality ratio MICH-5: Reduce the rate of maternal mortality.

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NEXT STEPS 277 TABLE 10-1 Continued Disadvantages Relative to Other High-Income Countries Examples of Relevant Healthy People 2020 Objectives Higher adolescent pregnancy rates FP-1: Increase the proportion of pregnancies that are intended. FP-8: Reduce pregnancy rates among adolescent females. Higher prevalence of sexually STD-1: Reduce the proportion of adolescents and transmitted diseases young adults with chlamydia trachomatis infections. STD-6: Reduce gonorrhea rates. Higher prevalence of mental MHMD-4: Reduce the proportion of persons who illness experience major depressive episodes (MDE). Chapter 4: Public Health and Medical Care Systems Low childhood immunization IID-7: Achieve and maintain effective vaccination rates coverage levels for universally recommended vaccines among young children. Lower health insurance coverage AHS-1: Increase the proportion of persons with health insurance. Greater difficulties with AHS-6: Reduce the proportion of individuals who affordability are unable to obtain or delay in obtaining necessary medical care, dental care, or prescription medicines. Less access to primary care/ AHS-3: Increase the proportion of persons with a regular physician usual primary care provider. AHS-5: Increase the proportion of persons who have a specific source of ongoing care. Greater deficiencies in ambulatory HDS-24: Reduce hospitalizations of older adults with care, such as care of diabetes heart failure as the principal diagnosis. D-5: Improve glycemic control among the population with diagnosed diabetes. D-9: Increase the proportion of adults with diabetes who have at least an annual foot examination. D-10: Increase the proportion of adults with diabetes who have an annual dilated eye examination. D-11: Increase the proportion of adults with diabetes who have a glycosylated hemoglobin measurement at least twice a year. D-12: Increase the proportion of persons with diagnosed diabetes who obtain an annual urinary microalbumin measurement. Fewer electronic medical records HC/HIT-10: Increase the proportion of medical practices that use electronic health records. continued

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278 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE Disadvantages Relative to Other High-Income Countries Examples of Relevant Healthy People 2020 Objectives Fewer registry capacities C-12: Increase the number of central, population- based registries from the 50 states and the District of Columbia that capture case information on at least 95 percent of the expected number of reportable cancers. Chapter 5: Individual Behaviors Higher consumption of calories NWS-17: Reduce consumption of calories from and dietary fat solid fats and added sugars in the population age 2 and older. Higher prevalence of sedentary PA-1: Reduce the proportion of adults who engage in activity no leisure-time physical activity. Higher rates of screen time PA-8: Increase the proportion of children and adolescents who do not exceed recommended limits for screen time. Higher use of drugs SA-2: Increase the proportion of adolescents never using substances. SA-19: Reduce the past-year nonmedical use of prescription drugs. Earlier initiation of adolescent FP-9: Increase the proportion of adolescents age 17 sexual activity and more sexual and under who have never had sexual intercourse. partners Less use of oral contraceptives FP-6: Increase the proportion of females or their and condoms, especially among partners at risk of unintended pregnancy who used adolescents contraception at most recent sexual intercourse. FP-10: Increase the proportion of sexually active persons aged 15-19 who use condoms to both effectively prevent pregnancy and provide barrier protection against disease. FP-11: Increase the proportion of sexually active persons aged 15 to 19 years who use condoms and hormonal or intrauterine contraception to both effectively prevent pregnancy and provide barrier protection against disease. Less use of front seatbelts IVP-15: Increase use of safety belts. Less use of motorcycle helmets More traffic deaths attributable SA-1: Reduce the proportion of adolescents who to alcohol report that they rode, during the past 30 days, with a driver who had been drinking alcohol. continued

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NEXT STEPS 279 TABLE 10-1 Continued Disadvantages Relative to Other High-Income Countries Examples of Relevant Healthy People 2020 Objectives Greater access to firearms IVP-34: Reduce physical fighting among adolescents. IVP-36: Reduce weapon carrying by adolescents on school property. AH-11: Reduce adolescent and young adult perpetration of, as well as victimization by, crimes. Chapter 6: Social Factors Higher poverty Higher social inequality Lower educational performance AH-5: Increase educational achievement of adolescents and young adults. ECBP-6: Increase the proportion of the population that completes high school education. Lower social mobility Chapter 7: Physical and Social Environmental Factors Heavier reliance on automobiles EH-2: Increase use of alternative modes of transportation for work. Lower public transit and non- motorized travel mode shares Longer work hours and less employment protection Greater residential segregation Higher prevalence of food deserts NWS-3: Increase the number of states that have state-level policies that incentivize food retail outlets to provide foods that are encouraged by the dietary guidelines. NOTES: Examples of the objectives are from the U.S. Department of Health and Human Services (2012). The codes in the table refer to theme areas identified by Healthy People 2020. National Prevention Council targets the same issues responsible for the U.S. health disadvantage (see Box 10-1). Appendix A catalogues the specific policy solutions to address these problems and the supporting evidence and citations provided by the National Prevention Council. Although further research (as outlined in Chapter 9) can help prioritize this list, the largest obstacle to addressing the U.S. health disadvantage is not a lack of evidence

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280 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE BOX 10-1 Recommendations of U.S. Surgeon General’s National Prevention Council HEALTHY AND SAFE COMMUNITY ENVIRONMENTS • Improve quality of air, land, and water. • Design and promote affordable, accessible, safe, and healthy housing. •  trengthen state, tribal, local, and territorial public health departments S to provide essential services. • ntegrate health criteria into decision making, where appropriate, I across multiple sectors. •  nhance cross-sector collaboration in community planning and design E to promote health and safety. •  xpand and increase access to information technology and integrated E data systems to promote cross-sector information exchange. • dentify and implement strategies that are proven to work and conduct I research where evidence is lacking. •  aintain a skilled, cross-trained, and diverse prevention workforce. M CLINICAL AND COMMUNITY PREVENTIVE SERVICES •  upport the National Quality Strategy’s focus on improving cardiovas- S cular health. •  se payment and reimbursement mechanisms to encourage delivery U of clinical preventive services. •  xpand use of interoperable health information technology. E •  upport implementation of community-based preventive services and S enhance linkages with clinical care. •  educe barriers to accessing clinical and community preventive ser- R vices, especially among populations at greatest risk. •  nhance coordination and integration of clinical, behavioral, and com- E plementary health strategies. EMPOWERED PEOPLE •  rovide people with tools and information to make healthy choices. P •  romote positive social interactions and support healthy decision P making. •  ngage and empower people and communities to plan and implement E prevention policies and programs. • mprove education and employment opportunities. I ELIMINATION OF HEALTH DISPARITIES •  nsure a strategic focus on communities at greatest risk. E •  educe disparities in access to quality health care. R

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NEXT STEPS 281 • ncrease the capacity of the prevention workforce to identify and I ad­dress disparities. •  upport research to identify effective strategies to eliminate health S disparities. •  tandardize and collect data to better identify and address disparities. S TOBACCO-FREE LIVING •  upport comprehensive tobacco-free policies and other evidence- S based tobacco control policies. •  upport full implementation of the 2009 Family Smoking Prevention S and Tobacco Control Act (Tobacco Control Act). •  xpand use of tobacco cessation services. E •  se media to educate and encourage people to live tobacco free. U PREVENTING DRUG ABUSE AND EXCESSIVE ALCOHOL USE •  upport state, tribal local, and territorial implementation and enforce- S ment of alcohol control policies. •  reate environments that empower young people not to drink or use C other drugs. • dentify alcohol and other drug abuse disorders early and provide brief I intervention, referral, and treatment. •  educe inappropriate access to, and use of, prescription drugs. R HEALTHY EATING • ncrease access to healthy and affordable foods in communities. I • mplement organizational and programmatic nutrition standards and I policies. • mprove nutritional quality of the food supply. I •  elp people recognize and make healthy food and beverage choices. H •  upport policies and programs that promote breastfeeding. S •  nhance food safety. E ACTIVE LIVING •  ncourage community design and development that supports physical E activity. •  romote and strengthen school and early learning policies and pro- P grams that increase physical activity. •  acilitate access to safe, accessible, and affordable places for physi- F cal activity. •  upport workplace policies and programs that increase physical activity. S •  ssess physical activity levels and provide education, counseling, and A referrals. continued

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282 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE BOX 10-1  Continued INJURY AND VIOLENCE FREE LIVING • mplement and strengthen policies and programs to enhance trans- I portation safety. •  upport community and streetscape design that promotes safety and S prevents injuries. •  romote and strengthen policies and programs to prevent falls, espe- P cially among older adults. •  romote and enhance policies and programs to increase safety and P prevent injury in the workplace. •  trengthen policies and programs to prevent violence. S •  rovide individuals and families with the knowledge, skills, and tools P to make safe choices that prevent violence and injuries. REPRODUCTIVE AND SEXUAL HEALTH • ncrease utilization of preconception and prenatal care. I •  upport reproductive and sexual health services and support services S for pregnant and parenting women. •  rovide effective sexual health education, especially for adolescents. P •  nhance early detection of HIV, viral hepatitis, and other sexually E transmitted infections and improve linkage to care. MENTAL AND EMOTIONAL WELL-BEING •  romote positive early childhood development, including positive par- P enting and violence-free homes. •  acilitate social connectedness and community engagement across F the lifespan. •  rovide individuals and families with the support necessary to main- P tain positive mental well-being. •  romote early identification of mental health needs and access to P quality services. NOTE: See Appendix A for specific policy recommendations and supporting evidence cited by the National Prevention Council. SOURCE: Adapted from Appendix 5, National Prevention Council (2011).

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NEXT STEPS 283 or uncertainty about effective interventions1 but limited political support among both the public and policy makers to enact the policies and commit the necessary resources to implement them. As this report is being written, the major debate relevant to this issue is whether to reduce or eliminate discretionary spending on public health and social policy initiatives in an effort to balance budgets and limit the size of government. Setting aside ideological arguments about whether such curtailments are right or wrong, the evidence reviewed in this report suggests that reduced attention to public health priorities will exacerbate the U.S. health disadvantage, resulting in both the human and economic consequences of excess loss of life. The disturbing findings in this report about the relative disadvantages affecting American youth suggest that inattention to these problems will claim the lives of infants, children, and adolescents and shape the health trajectories of those who survive to adulthood. Evidence from tobacco control efforts and other examples in this report (e.g., German unification; see Chapter 8) underscore that interventions with middle-aged and older adults can also be very instrumental in improving the health of a nation. Thus, all age groups—young and old—are important in revers- ing the U.S. health disadvantage. It is important to add that the solutions are not to be found solely at the national level. As the discussion in Box 10-2 emphasizes, meaningful solutions to the nation’s health disadvantage requires the involvement of states and local communities. ALERT THE PUBLIC RECOMMENDATION 5: The philanthropy and advocacy communi- ties should organize a comprehensive media and outreach campaign to inform the general public about the U.S. health disadvantage and to stimulate a national discussion about its implications for the nation. 1  The panel acknowledges that the quality of supporting evidence for the listed interven- tions varies. Some of the policy solutions have been the subject of randomized trials and other useful scientific study designs that document their effectiveness in improving outcomes. Both U.S. and international review groups have conducted numerous systematic reviews and rated the strength of evidence for these strategies: see, especially, Campbell Collaboration (2012), Cochrane Library (2012), and Community Preventive Services Task Force (2012). However, the evidence that other policy solutions are effective is less developed. Some evidence is circumstantial or ecological: health outcomes may have improved in a country after the introduction of a policy, but evidence of a causal relationship may be lacking. And debates continue about proper outcomes for measuring health: for example, some critics argue that mortality rates or life expectancy are less meaningful than measures of health- related quality of life, such as quality-adjusted life years (Institute of Medicine, 2011e), and they fault national health objectives that lack such metrics and do not set specific goals for reducing disparities.

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284 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE BOX 10-2 Roles for Governments and Nongovernment Actors at All Levels The steps advocated by the panel to meet the health objectives that address areas of the U.S. health disadvantage and to stimulate a national discussion on these issues are not activities for the federal gov- ernment alone. Quite to the contrary, productive discussion, design, and implementation of on-the-ground strategies to address the U.S. health disadvantage often require action at the regional, state, and local levels and involvement of local employers, health care institutions, public health officials, school boards, park authorities, civic groups, retailers, restau- rants, developers, media, and other such stakeholders (see Institute of Medicine, 2009b). In the United States, the statutory authority for government to address a variety of contributing factors, from motor vehicle safety to education policy, rests with state and local governments. For some years, in fact, states and localities throughout North America have emerged as labo- ratories for devising and testing solutions within a “health in all policies” framework. For example, important efforts are under way in the Bay Area of California, Denver, Seattle, Vancouver, New York City, Somerville (MA), and Atlanta, where health officials are collaborating with community partners to address a range of social and economic factors that affect health. The federal government is recognizing this work with Community Transformation Grants and Communities Putting Prevention to Work grants, funded by the Centers for Disease Control and Prevention (CDC) to encourage pursuit and testing of creative solutions to health problems. At the same time, the federal government is making its own inroads by forging cross-Cabinet collaborations aimed at achieving these vital goals, such as healthy housing and combating childhood obesity. Of particular concern to the panel is whether the public is fully aware of the U.S. health disadvantage. The depth and breadth of the problem, as documented in this report, came as a surprise to many of us. Although we do not know of survey or poll data that gauge Americans’ awareness of their poor health rankings relative to other high-income countries, we suspect that the information detailed in this report is not widely known. Although people are increasingly aware that the U.S. health care system is costly, inefficient, and out of reach for many Americans (Pew Research Center, 2009), many people may still believe that their own health—if not their health care—is the best in the world. The public likely has little aware-

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NEXT STEPS 285 ness that the United States ranks unfavorably on so many antecedents of disease. For example, the average American may not realize that the coun- try has one of the highest child poverty rates of developed countries and has less success in promoting social mobility (see Chapter 6). Many people may also mistakenly attribute unfavorable health statistics to the conditions of poor, unemployed, or uninsured Americans, when several studies now suggest that even advantaged Americans are in poorer health than their counterparts in other countries. In short, we believe that most Americans do not realize that their expensive, world-class health care system—and the very large economy that supports it—has not enabled them to keep pace with the health gains achieved by people in other high-income countries. With this in mind, the panel believes it is critically important to share our findings not only with relevant professional audiences, but also with the public at large. We believe that doing so will serve to build knowledge of the facts, correct misperceptions, and raise awareness of the health and economic consequences of the nation’s current course. To that end, although this publication will be widely distributed and made available online, a broader, concerted effort will also be needed to reach the general public and policy makers. Such an effort could include a comprehensive communications strategy2 that identifies a broad range of target audiences and packages the report’s key messages in formats that are appropriate and accessible. To broadly spread the word, it could focus on traditional media (e.g., newspaper articles and television and radio coverage), as well as new media (e.g., social networking sites, community listservs, and information-sharing vehicles, such as blogs, Facebook, and Twitter). The panel believes that a national discussion on the implications of the U.S. health disadvantage is an important step, and one that is long overdue. U.S. rankings on many health indicators have been deteriorating 2  Although the government has considerable resources that could be devoted to a commu- nication effort on this scale, the panel believes that it may be more appropriate and effective for independent, objective, nonpartisan organizations to organize a communications effort on this topic. For example, this topic speaks to deficiencies the United States faces relative to other countries, a message that may be politically awkward for an administration to dis- seminate to a domestic or international audience. Yet the public deserves the facts. Thus, the panel believes an independent scientific body, with support from one or more foundations or advocacy organizations concerned with public health (perhaps collaborating as a consortium to share resources), should spearhead a communications campaign. We also think the National Institutes of Health (NIH) would be an ideal entity to take responsibility for disseminating the findings of this report to colleagues and leaders on the NIH campus, to other agencies in the U.S. Department of Health and Human Services, and to the scientific community more broadly. We hope this effort would spur discussion of how to revise solicitations for future research and the composition of study sections to advance scholarship in this field. The Na- tional Institute on Aging has been a leader at NIH in studying cross-national health differences.

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286 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE for decades. As shown by the morbidity and mortality data in this report, this information has not yet been sufficient to arrest or reverse the decline. The panel believes that a national discussion aimed at building consensus is a critical step. Because the factors and determinants underlying the U.S. health disadvantage are far reaching and complex, they raise important questions about national strategies, governance, and policies. A concerted effort is needed to present the evidence to the public and policy makers in a way that is accurate, engaging, and convincing and that stimulates thought- ful discussion of the implications. The goal of a national discussion would be to publicly consider a wide range of tradeoffs. For example, making meaningful progress on our health rankings might require the adoption of policies and practices that give greater priority to public health but impose restrictions on indi- viduals or businesses. As described in Chapter 8, such steps—which some other countries have used successfully—may be at odds with traditional American beliefs (e.g., limited government, free enterprise, individual rights and freedoms); they might be seen as undermining constitutional protections (e.g., the right to bear arms), or as contravening religious and moral beliefs (e.g., the use of birth control). A national discussion could help determine whether the American people deem such tradeoffs acceptable. It could explore whether this poses a false choice, whether models and practices used overseas could be adapted (“Americanized”) or, better yet, whether new solutions could be devised that better conform to American sensibilities. In situations where individual liberties or societal values are in conflict with policies that can produce bet- ter health outcomes, a thoughtful national discussion could help Americans consider what investments and compromises they are willing to make to begin to overcome the U.S. health disadvantage. EXPLORE INNOVATIVE POLICY OPTIONS RECOMMENDATION 6: The National Institutes of Health or another appropriate entity should commission an analytic review of the available evidence on (1) the effects of policies (including social, eco- nomic, educational, urban and rural development and transportation, health care financing and delivery) on the areas in which the United States has an established health disadvantage, (2) how these policies have varied over time across high-income countries, and (3) the extent to which those policy differences may explain cross-national health differences in one or more health domains. This report should be fol- lowed by a series of issue-focused investigative studies to explore why the United States experiences poorer outcomes than other countries in the specific areas documented in this report.

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NEXT STEPS 287 As noted throughout this report, the areas in which the United States has a health disadvantage are familiar challenges that the nation has been trying to address for decades. There is no shortage of good ideas on how to address the obesity epidemic and control diabetes, to control violent crime and homicides, to create jobs and enhance the economic stability of American families, and to improve the quality of education in the United States. There have been many blue-ribbon reports, strategic plans, and even international charters that list best practices and policy recommendations— too many to cite here. Yet the panel believes that the United States can learn more by studying the policies that have been used by those countries that have been outpac- ing the United States on both health outcomes and social factors related to health. Chapter 8 engaged in “informed speculation” about whether the health advantages enjoyed by these countries can be traced to styles of governance or policies adopted in those countries and offered supposi- tions about dominant values in those societies and their potential links to observed outcomes. However, the panel lacked the time and was not charged to undertake a systematic examination of the nature and history of the policies that exist in the 16 peer countries with which the United States was compared. Nor did this panel have the appropriate qualifications for such a study. This panel was composed primarily of demographers, epidemiologists, physicians, and social scientists. Although it did include several European and foreign-born experts, its members did not include authorities from outside the United States with extensive knowledge of the policy landscape in comparable countries.3 The panel therefore recommends that an appropriate organization or federal or international agency undertake a follow-up effort that involves appropriate experts from many of the high-income countries considered in this report.4 In some ways, what we envision would amount to the third report in a trilogy. The first report by the National Research Council (2011) drew attention to the growing U.S. mortality disadvantage among adults age 50 and older. This second report documents the significant health disadvantage for Americans under age 50 and offers a systematic examination of some of the potential causes. It moves “upstream” and highlights the potential importance of policy influences on health, but the panel was unable to examine in any detail whether specific cross-national 3  For example, the panel did not include officials from health ministries or political scientists from Japan or Europe. 4  The effort should also include U.S. experts who understand the opportunities and challenges that come with translating policies from one place to another—whether cross-nationally, across states, or from one local area to another.

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288 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE policy differences might help explain the cross-national health differences documented in Part I of this report. A third report could complete this analysis by evaluating the evidence for health-promoting policies that other top performing countries have adopted and identifying strategies that offer promise in the United States. These strategies could then be assessed for their feasibility or adaptability to the U.S. context. The research community can also adapt and test the effec- tiveness of these strategies in U.S. settings, through demonstration projects, policy research, and intervention studies. The panel notes that the scope of the proposed exercise would not be trivial if it is to cover policies from a life-course perspective. Besides health, the report would need to examine specific policies related to education, family support, workplace benefits, and other social factors that affect health outcomes, as well as contextual factors and other secular trends that bear on all countries’ health patterns (e.g., globalization, population aging). Whereas the proposed report would focus on cross-cutting policies that appear to improve a country’s health outcomes (across multiple dis- eases and conditions), we believe it would also be of great value to launch a series of issue-focused reports on the specific conditions (diseases and injuries) for which the United States has a health disadvantage to identify useful policies to address those health conditions. The panel was impressed with the value of the 2011 report issued by the Transportation Research Board (TRB), Achieving Traffic Safety Goals in the United States: Lessons from Other Nations (discussed in Chapter 8). For one of the prime areas of U.S. health disadvantage—traffic fatalities—the TRB study considered how other countries have achieved lower death rates. The TRB authoring committee included experts in safety research, public policy, evaluation, and public administration, as well as members of state legislatures. That committee included a transportation specialist from the World Bank, cur- rent and former officials of federal and state transportation agencies in the United States, a state police commissioner, economists, and others with special knowledge of how other countries achieve lower traffic fatalities. As noted in Chapter 8, the TRB report’s analytic approach and findings mirror those of this panel, but the report also provides specific guidance that the U.S. transportation community, policy makers, and traffic safety advocates can use to improve conditions in the United States. Thus, the panel recommends a series of similar issue-focused investiga- tive studies to seek explanations for the nine specific health disadvantages identified in this report: (1) adverse birth outcomes; (2) injuries, accidents, and homicides; (3) adolescent pregnancy and sexually transmitted infec- tions; (4) HIV and AIDS; (5) drug-related mortality; (6) obesity and diabe- tes; (7) cardiovascular disease; (8) chronic lung disease; and (9) disability. The panels commissioned for each report would be composed of experts

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NEXT STEPS 289 on the topic, with knowledge of relevant data sources, clinical practices, and policy strategies for addressing the conditions in other rich nations (or knowledgeable contacts in each country for obtaining this information). Like the TRB report, such studies would seek to find discrete explanations for how and why other high-income countries are achieving lower morbid- ity and mortality rates for the specific conditions under study and perhaps model or estimate the predicted health and economic effects of alternative policy strategies that target different components of the causal chain. These issue-focused inquiries are likely to uncover many of the same general themes raised in this report. For example, it is likely that social factors or the lack of universal health insurance in the United States will be found to interfere with access to health care for many of the above condi- tions. But these focused inquiries will also be able to “unpack” the specifics. They can examine, for example, whether strategies for treating drug abuse or controlling access to prescription opioids account for lower drug-related deaths in other countries. The inquiry into adverse birth outcomes can attempt to tease out the specific reasons that U.S. infant mortality rates have not kept pace with other countries for decades by examining differences in not only prenatal or newborn care, but also preconception and prenatal efforts in public health or social policy to lessen maternal risks for adverse birth outcomes. Our vision is a published series of issue-specific reports that would be released over several years, with each study building on the findings and insights of those coming before it. The first report could be commissioned immediately. The series would support a critical ongoing cycle of evidence production, guidance regarding effective policies and practices, implemen- tation and evaluation, and learning from practice. The rollout of these reports over time will not only deliver practical solutions to enable the United States to begin to turn the tide in specific domains in which there is a disadvantage, but it will also provide a basis for steady and continued public attention on this issue. It is important to this panel that the public and the nation’s leaders maintain awareness of the U.S. health disadvantage and not lose momentum in efforts to find solutions. LOOKING AHEAD Although the evidence reviewed in this report documents a U.S. health disadvantage that spans decades and continues to trend downward, no one knows for certain what will come next. The health trajectory of the United States and many other countries will be affected by known global trends— such as climate change, dwindling sources of energy, military conflicts, and overcrowding—but also by unforeseen influences yet to emerge. However, almost all trend lines indicate that, in the absence of corrective action, the

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290 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE U.S. health disadvantage relative to other high-income countries will con- tinue to worsen, as it has for years. A number of factors support the prediction that the health of Ameri- cans will continue to slip behind that of people in other countries. For example, to the extent that education of today’s youth predicts the health of tomorrow’s adults, the failure of the United States to keep pace with the educational advances occurring in other countries is a discouraging sign. So is the continuing rise of income inequality in the United States, the persis- tence of poverty (especially child poverty) at rates that exceed those of most other rich nations, and the relative lack of social mobility. The increasing prevalence of obesity and diabetes among U.S. children at rates that exceed those of other countries is certainly an ominous trend in a country whose adults already suffer from high rates of cardiovascular disease. Other factors, however, could mitigate these trends and perhaps improve the rankings of the United States relative to other countries. For example, there is some evidence that the obesity epidemic is beginning to stabilize in the United States (Ogden et al., 2012a) while it is continuing to spread globally (Finucane et al., 2011). The prevalence of smoking in the United States has fallen considerably while rates in other countries continue to increase (OECD, 2011b).5 These trends might temper the excessive burden of chronic disease in the United States relative to other countries, especially as today’s middle-aged adults (the beneficiaries of lower smoking rates) become older adults.6 And as these behaviors begin to affect morbid- ity and mortality in other countries, it is possible that they may “catch up” with the United States, in a negative sense, and so improve the country’s relative ranking. However, such an “improvement” would mean only that progress in safeguarding public health is faltering globally, and that would hardly be good news for the United States. Indeed, the important point about the U.S. health disadvantage is not that the United States is losing a competition with other countries, but that Americans are dying and suffering at rates that are demonstrably unneces- sary. The fact that other high-income countries have better health outcomes 5  The rate of decrease in tobacco use among young adults has decreased in recent years in the United States, and smokeless tobacco use has increased (U.S. Department of Health and Human Services, 2012b). These trends could diminish the salutary effects of tobacco control on the U.S. health disadvantage of the next generation. Nonetheless, it bears noting that smoking rates among U.S. youth are generally lower than rates among their peers in other high-income countries. 6  As noted in Chapter 5, Wang and Preston (2009) predicted that deaths attributable to smok- ing among men would decline relatively soon but that improvements for women would come later. Other authors, however, have questioned whether the obesity epidemic will outweigh any gains in life expectancy achieved by lower smoking rates (Stewart et al., 2009). Furthermore, specific aspects of the U.S. health disadvantage, such as the high prevalence of low-birth-weight babies, may persist if smoking rates remain high for women of childbearing age.

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NEXT STEPS 291 is evidence that better health is achievable for Americans. The same lesson will apply to other countries if epidemiologic trends cause health improve- ments in their societies to falter, because they too will know that they are capable of achieving better health outcomes for their populations. That the health of Americans does not meet the standard that now exists in other rich nations is a tragedy for all age groups, but especially for children. Behind the statistics detailed in this report are the faces of young people—infants, children, and adolescents—who are unwell and dying early because conditions in this country are not as favorable as those in other countries. Overall, young Americans are entering adulthood in poorer health than their counterparts in other countries and therefore face a future with greater risks of disease and the other life challenges they bring than did their parents. This alone is reason enough for concern, but the nation’s leaders—in government and business—also understand what the nation can expect from a future generation of workers, executives, and military recruits whose illnesses and socioeconomic disadvantages compromise their productivity and require more intensive health care. This forecast has obvious implica- tions for national security and for the economy—the price tag of the U.S. health disadvantage is unlikely to be small. With this many lives and dollars at stake, we believe the U.S. health disadvantage is a problem the country can no longer afford to ignore.