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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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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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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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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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• 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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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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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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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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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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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.
