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2
Poorer Health Throughout Life
T
he previous chapter documented that life expectancy in the United
States is shorter than in other high-income countries and identified
the principal causes of death that account for this difference. How-
ever, health involves much more than staying alive. The goal of a healthy
life is freedom from illness and injury: “Health is a state of complete physi-
cal, mental, and social well-being and not merely the absence of disease or
infirmity” (World Health Organization, 1948). Thus, health is measured
not only by mortality, but also morbidity and quality of life.
This chapter looks at cross-national comparisons of physical and
psy hological illnesses, injuries, and biological risk factors across the life
c
course, from infancy to old age, with a special focus on childhood and
adolescence. The panel chose to focus on youth for four reasons:
1. Previous research has concentrated on understanding the U.S.
health disadvantage after age 50 (the age group for which most
data are available), not on the question of whether there is a similar
disadvantage for younger Americans. This is hardly an academic
question. Young adults are among the most productive members
of modern economies, and children and young adults will lead the
next generation and determine the future strength and well-being
of the nation. A health disadvantage early in life has profound
implications for everyone.
2. The health problems facing children, adolescents, and young adults
are often quite different from those affecting other age groups. As
documented in Chapter 1, the U.S. mortality disadvantage is driven
57
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58 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE
by different causes at different ages: before age 50, these causes
include conditions in infancy, nonintentional injuries, violence, and
diseases of the heart and circulatory system at ages 30-50 (Palloni
and Yonker, 2012).
3. The health and well-being of young people may help explain health
disadvantages that emerge later in life. For example, approximately
80 percent of adults who are regular users of cigarettes or alcohol
start these behaviors as adolescents (Kalaydjian et al., 2009; Oh
et al., 2010; Viner, 2012). High rates of obesity among children
and adolescents can track into adulthood and shed light on pat-
terns of heart disease and diabetes among older people (Tirosh et
al., 2011). Exposure to these risk factors, among others, and the
pathophysiological damage they inflict generally occurs over many
years before the disease processes they induce reach the point of
producing clinical symptoms, yet they may play a vital role in
understanding disease outcomes later in life.
4. The causal pathways that link early life health risks with subse-
quent diseases may involve many aspects of development that are
seemingly unrelated. For example, health challenges in early life
can disrupt intellectual and emotional development, impede physi-
cal growth, and limit education and employment opportunities
(Fletcher and Richards, 2012), which in turn may set up a lifetime
of socioeconomic disadvantage (see Chapter 6). Conditions of aus-
terity may restrict access to health care (see Chapter 4) and limit
opportunities to pursue healthy behaviors (see Chapter 5) or live
in neighborhoods that promote good health (see Chapter 7).
This chapter compares, for each age group, a set of health indicators in
the United States with those in a comparable group of other high-income
or “peer” countries. The chapter focuses on illnesses and injuries, not
unhealthy behaviors or other modifiable risk factors (health behaviors such
as smoking and unhealthy diets are examined in Chapter 5). Unlike the
previous chapter, which examined a relatively precise outcome, death, this
chapter investigates a more general one, health. Health is more challenging
to measure and quantify because it is multidimensional, and it reflects the
culmination of a complex set of factors that include exposure to risk (or
protective) factors and susceptibility (or resistance) to illness and injury. It
is especially difficult to assess cross-national differences in health because of
inconsistent data and metrics, conflicting findings, and in many cases, the
absence of comparable data. This chapter critically examines the data that
are currently available, and Chapter 9 outlines research priorities that will
produce a stronger empirical basis for future work on this topic.
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POORER HEALTH THROUGHOUT LIFE 59
HEALTH ACROSS THE LIFE COURSE
The panel commissioned two special analyses of health under age 50.
For the first analysis, Palloni and Yonker (2012) collated data for the same
17 peer countries discussed in Chapter 1 and examined the results across
four age groups: infancy and early childhood (ages 0 to 4), late childhood
and adolescence (ages 5-19), early adulthood (ages 20-34), and middle
adulthood (ages 35-49).1 The analysis drew on data from the World Health
Organization (WHO), the Global Burden of Diseases, Injuries, and Risk
Factors Study (GBD 2010 Study), UNICEF, and statistics that OECD has
compiled from various national sources and household surveys conducted
in its member countries. The second analysis, by Viner (2012), examined
mortality rates by cause in the United States and 26 other high-income
countries2 for five age groups—1-4, 5-9, 10-14, 15-19, and 20-24—and
then reanalyzed the data for the 17 peer countries of interest to the panel.
These data were drawn from the WHO World Mortality Database.
The panel also commissioned a third analysis of data from the National
Health and Nutrition Examination Survey in the United States (NHANES)
and the Survey of Health, Ageing and Retirement in Europe (SHARE),
in which Crimmins and Solé-Auró (2011) compared the cardiovascular
risk profile of adults at age 50 in the United States and other high-income
countries.
The data presented in this chapter are subject to important limitations.
As already noted, there is no single measure of health status across the life
course, and comparable data on many important health measures are not
available across all countries. The available data often cover a very narrow
(recent) time period and do not extend far enough back in time to capture
health determinants that may explain current patterns. Ideally, longitudinal
data would be used to examine changes in health conditions over time.
Comparisons of national indicators also mask important within-country
health disparities: a country’s low ranking on any indicator may be a reflec-
tion of a health disadvantage in certain segments of the population or some
geographic regions. Finally, despite any adjustments or harmonization,
most data were not originally collected for the purposes of this report. The
1
Age groups cannot always be defined consistently across data sources. Dividing the life
course into age groups is largely a matter of convenience, although each phase of life pre
sents different health challenges and opportunities, developmental milestones, and crucial
transitions.
2
These 27 countries are Australia, Austria, Canada, Chile, Denmark, Estonia, Finland,
France, Greece, Hungary, Iceland, Ireland, Israel, Italy, Japan, Luxembourg, Mexico, the
Netherlands, New Zealand, Norway, Poland, Portugal, Spain, Sweden, Switzerland, the United
Kingdom, and the United States.
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60 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE
inferences we draw are dependent on the validity of the ranking methodol-
ogy and the quality of the source data on which they are based.
Table 2-1 presents data on health outcomes from the analysis by Palloni
and Yonker (2012). For each indicator, the table presents the range (and
average) of peer country values, along with the U.S. value and ranking3
relative to the other countries. The final column presents a composite rank-
ing for the United States that standardizes and combines the distributions
of each age-specific measure.4
CHILDREN AND ADOLESCENTS
Between 2001 and 2006, mortality rates for children aged 1-19 were
higher in the United States than in all peer countries except Portugal. Most
OECD countries had mortality rates between 15 and 25 deaths per 100,000
children; the U.S. rate was 32.7 (National Center for Health Statistics,
2011). For decades, the mortality disadvantage experienced by U.S. youth
relative to their peers in other countries has followed a U-shaped pattern:
the United States has exhibited higher infant mortality rates than the OECD
average, comparable mortality rates at ages 1-9, and higher mortality rates
at older ages, especially after age 15 (Viner, 2012).
Two recent international reports have also found that the overall well-
being of U.S. children is quite low relative to other rich nations, at least
according to the composite measures used in the studies. In a report by
OECD (2009a), the United States ranked 24 out of 30 countries on chil-
dren’s well-being for health and safety.5 A UNICEF (2007) report also
found that children in the United States ranked poorly (21st out of 21
countries) based on selected indicators of child well-being.6
3
Rankings are calculated from a standardized distribution that includes all OECD countries
in the comparison set. The principal unit of analysis is the individual in the designated age
group.
4
The “composite rank” is the rank order of the averaged z-scores across indicators: see
footnotes in Table 2-1 for details on how this was calculated.
5
The OECD report examined six areas of child well-being: material well-being, housing
and environment, educational well-being, health and safety, risk behaviors, and quality of the
school day (OECD, 2009a).
6
The UNICEF score was based on country statistics for low birth weight, infant mortality,
breastfeeding, vaccinations, physical activity, mortality, and suicides (UNICEF, 2007).
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POORER HEALTH THROUGHOUT LIFE 61
TABLE 2-1 Health Indicators by Age Group, Range, and Rank of the
United States Among 17 Peer Countries
U.S. Ranka
Age Composite
Group U.S. By for Age
(years) Measure Range (average) Data Indicator Group
0-4 Stillbirthsb 2.0-3.9 (2.9) 3.0 11 17
Low birth weightc 4.2-9.6 (6.6) 8.2 16
Perinatal mortalityd 3.0-11.9 (5.7) 6.6 13
Neonatal mortalitye 1.3-4.4 (2.7) 4.4 17
Infant mortalityf 2.5-6.7 (3.9) 6.7 17
Days of life lost,g 0.05-0.12 (0.07) 0.12 17
females
Days of life lost,g males 0.05-0.15 (0.09) 0.15 17
5-19 Overweight,h girls 13.1-35.9 (22.6) 35.9 17 17
Overweight,h boys 12.9-35.0 (22.4) 35.0 16
Dental cariesi 0.7-2.1 (1.1) 1.2 11
Good health,j females 45.3-96.6 (86.4) 96.6 1
Good health,j males 49.8-97.1 (89.8) 97.1 1
Youth HIV,k females 0.0-0.5 (0.2) 0.3 14
Youth HIV,k males 0.1-0.7 (0.3) 0.7 16
Adolescent birthsl 5-41 (12) 41 17
Adolescent suicidesm 2.4-12.2 (6.5) 7.7 11
Days of life lost,g 0.10-0.21 (0.12) 0.21 17
females
Days of life lost,g males 0.16-0.37 (0.21) 0.37 17
20-34 Good health,j females 41.1-93.4 (80.5) 92.6 2 17
Good health,j males 42.8-93.9 (83.4) 93.9 1
Average BMI,n females 20.1-25.6 (22.9) 25.6 17
aged 20-24
Average BMI,n males 22.2-26.3 (24.1) 26.3 17
aged 20-24
Average BMI,n females 20.9-27.1 (24.0) 27.1 17
aged 25-34
Average BMI,n males 23.3-27.8 (25.8) 27.8 17
aged 25-34
Diabetes,o females 0.9-2.3 (1.6) 2.3 17
Diabetes,o males 1.6-4.1 (2.9) 4.1 17
Average FPG,p females 4.6-5.1 (4.9) 5.1 17
Average FPG,p males 4.9-5.4 (5.2) 5.4 17
continued
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62 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE
TABLE 2-1 Continued
U.S. Ranka
Age Composite
Group U.S. By for Age
(years) Measure Range (average) Data Indicator Group
20-34 Average BP,q females 106.5-115.9 (111.3) 107.9 3
Average BP,q males 118.8-129.8 (124.0) 118.8 1
Average cholesterol,r 4.4-4.8 (4.7) 4.8 11
females
Average cholesterol,r 4.7-5.1 (4.9) 4.8 6
males
Maternal mortalitys 2.0-14.9 (6.0) 13.7 16
Days of life lost,g 0.20-0.43 (0.26) 0.43 17
females
Days of life lost,g males 0.34-0.77 (0.47) 0.77 17
35-49 Average BMI,n females 21.9-28.8 (25.6) 28.8 17 17
aged 35-44
Average BMI,n males 24.0-29.0 (27.0) 29.0 17 17
aged 35-44
Average BMI,n females 22.7-29.9 (26.9) 29.9 17
aged 45-54
Average BMI,n males 24.1-29.5 (27.7) 29.5 17
aged 45-54
Diabetes,o females aged 1.7-4.7 (3.1) 4.5 16
35-44
Diabetes,o males aged 3.2-7.1 (5.1) 7.1 17
35-44
Diabetes,o females aged 3.6-9.7 (6.2) 9.3 16
45-54
Diabetes,o males aged 6.4-14.1 (9.9) 14.1 17
45-54
Average FPG,p females 4.8-5.4 (5.1) 5.4 16
aged 35-44
Average FPG,p males 5.1-5.7 (5.4) 5.7 17
aged 35-44
Average FPG,p females 5.0-5.7 (5.4) 5.7 16
aged 45-54
Average FPG,p males 5.4-6.0 (5.7) 6.0 17
aged 45-54
Average BP,q females 110.7-120.5 (115.9) 112.4 2
aged 35-44
Average BP,q males aged 119.7-130.9 (126.1) 119.7 1
35-44
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POORER HEALTH THROUGHOUT LIFE 63
TABLE 2-1 Continued
U.S. Ranka
Age Composite
Group U.S. By for Age
(years) Measure Range (average) Data Indicator Group
35-49 Average BP,q females 119.0-129.7 (124.1) 120.3 3
aged 45-54
Average BP,q males aged 123.3-135.7 (131.1) 123.3 1
45-54
Average cholesterol,r 4.7-5.2 (5.0) 5.0 7
females aged 35-44
Average cholesterol,r 5.1-5.6 (5.3) 5.2 4
males aged 35-44
Average cholesterol,r 5.2-5.7 (5.5) 5.4 3
females aged 45-54
Average cholesterol,r 5.3-5.8 (5.5) 5.3 1
males aged 45-54
Days of life lost,g 0.01-0.04 (0.02) 0.04 17
females
Days of life lost,g males 0.37-0.80 (0.47) 0.80 17
NOTE: Data are for the most recent year available.
aRankings are calculated from a standardized distribution that includes all 16 OECD countries
in the comparison set. Rankings are from best (1) to worst (17), and all comparisons are for the
17 peer countries listed in the text. The “composite rank” is the rank order of the averaged
z-scores across indicators. It was calculated in two stages: (1) the value of each indicator was
converted into a z-score based on observed means and standard deviations and (2) the z-scores
were averaged across indicators and then rank ordered. For consistency, some z-scores were
reverse coded to preserve the meaning of high and low ranks across all indicators. Data were
not always available to rank all 17 countries.
bStillbirths are rate per 1,000 total births (2009). Stillbirth rates and numbers use the WHO
definition of birth weight of at least 1,000 grams or a gestational age of at least 28 weeks
(third-trimester stillbirth). Data from WHO at http://www.who.int/reproductivehealth/topics/
maternal_perinatal/stillbirth/en/.
cLow birth weight is the number of live births weighing less than 2,500 grams as a percent-
age of the total number of live births. Values (if present) averaged over 2005-2009. Data from
OECD at http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT.
dPerinatal mortality is the ratio of deaths of children within 1 week of birth (early neonatal
deaths) plus fetal deaths with a minimum gestation period of 28 weeks or a minimum fetal
weight of 1,000 grams, expressed per 1,000 births. Values (if present) averaged over 2005-
2009. Data from OECD at OECD_Health_MaternalAndInfantMortality_2653d1a3-bb42-
4768-9cfb-d405eb5050a1.xls.
eNeonatal mortality is the number of deaths of children under 28 days of age in a given
year, expressed per 1,000 live births. Values (if present) averaged over 2005-2009. Data from
OECD_Health_MaternalAndInfantMortality_2653d1a3-bb42-4768-9cfb-d405eb5050a1.xls.
fInfant mortality is the number of deaths of children under 1 year of age that occurred in
a given year, expressed per 1,000 live births. Values (if present) averaged over 2005-2009.
continued
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64 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE
TABLE 2-1 Continued
Data from OECD at OECD_Health_MaternalAndInfantMortality_2653d1a3-bb42-4768-
9cfb-d405eb5050a1.xls.
gDays of life lost is the number of potential days of life lost due to mortality in the desig-
nated age range. Calculated for 2009 from life tables. Data from WHO at http://www.who.
int/whosis/whostat/2011/en/.
hOverweight is defined variously by country. Source years also vary by country. Data from In-
ternational Association for the Study of Obesity at http://www.iaso.org/resources/world-map-
obesity/?map=children.
i Dental caries is the weighted average of the number of decayed, missing, or filled teeth
(DMFT) among 12-year-olds (2004). Data from WHO at http://apps.who.int/ghodata/.
jGood health is the percentage of the population who report their health as “good” or “bet-
ter.” Values (if present) averaged over 2005-2009. Data available for ages 15-24 are provided
here for ages 5-19, and data available for ages 25-44 are provided here for ages 20-34. Data
from OECD at http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT.
kYouth HIV is the percentage of the population infected with HIV (2007). Data available for
ages 15-24 are provided here for ages 5-19. Data from United Nations Human Development
Report 2010 at http://hdr.undp.org/en/statistics/.
lAdolescent births is the number of births to women ages 15-19 per 1,000 women (2010).
Data from United Nations Human Development Report 2010 at http://hdrstats.undp.org/en/
indicators/36806.html.
mAdolescent suicides is suicides per 100,000 people ages 15-19. Three-year averages
of data from most recent years available. Data from OECD at http://stats.oecd.org/index.
aspx?DataSetCode=HEALTH_STAT.
nAverage BMI is average body mass index (kg/m2) (2008). Obesity is a BMI above 30 kg/m2.
Data available for ages 20-24 and ages 25-34 are provided here for ages 20-34 and data for
ages 35-44 and ages 45-54 are provided for ages 35-49. Data from Global Burden of Meta-
bolic Risk Factors of Chronic Diseases Collaborating Group at http://www1.imperial.ac.uk/
publichealth/departments/ebs/projects/eresh/majidezzati/healthmetrics/metabolicriskfactors/.
oDiabetes is the percentage of the population diagnosed with diabetes (2008). Data available
for ages 25-34 are provided here for ages 20-34, and data for ages 35-44 and ages 45-54 are
provided here for ages 35-49. Data from Global Burden of Metabolic Risk Factors of Chronic
Diseases Collaborating Group at http://www1.imperial.ac.uk/publichealth/departments/ebs/
projects/eresh/majidezzati/healthmetrics/metabolicriskfactors/.
pAverage FPG is average fasting plasma glucose (mmol/L) (2008). Data available for ages
2
0-24 and ages 25-34 are provided here for ages 20-34, and data for ages 35-44 and ages 45-54
are provided for ages 35-49. Data from Global Burden of Metabolic Risk Factors of Chronic
Diseases Collaborating Group at http://www1.imperial.ac.uk/publichealth/departments/ebs/
projects/eresh/majidezzati/healthmetrics/metabolicriskfactors/.
qAverage BP is average systolic blood pressure (mm Hg) (2008). Data available for ages
2
0-24 and ages 25-34 are provided here for ages 20-34, and data for ages 35-44 and ages
45-54 are provided here for ages 35-49. Data from Global Burden of Metabolic Risk Fac-
tors of Chronic Diseases Collaborating Group at http://www1.imperial.ac.uk/publichealth/
departments/ebs/projects/eresh/majidezzati/healthmetrics/metabolicriskfactors/.
rAverage cholesterol is average total serum cholesterol (mmol/L) (2008). Data available for
ages 20-24 and ages 25-34 are provided here for ages 20-34, and data for ages 35-44 and
ages 45-54 are provided here for ages 35-49. Data from Global Burden of Metabolic Risk
Factors of Chronic Diseases Collaborating Group at http://www1.imperial.ac.uk/publichealth/
departments/ebs/projects/eresh/majidezzati/healthmetrics/metabolicriskfactors/.
sMaternal mortality is the ratio of maternal deaths from all causes per 100 000 live births.
Values (if present) averaged over 2005-2009. Data from OECD at http://stats.oecd.org/index.
aspx?DataSetCode=HEALTH_STAT.
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POORER HEALTH THROUGHOUT LIFE 65
Sweden 2.5
Japan 2.6
Finland 2.7
Norway 3.0
Portugal 3.4
Spain 3.5
Italy 3.6
Germany 3.7
Austria 3.8
Denmark 3.8
France 3.8
Switzerland 4.2
Netherlands 4.2
Australia 4.5
United Kingdom 4.8
Canada 5.2
United States 6.7
0 1 2 3 4 5 6 7
Deaths per 1,000 Live Births
FIGURE 2-1 Infant mortality rates in 17 peer countries, 2005-2009.
Fig2-1.eps
NOTE: Rates averaged over 2005-2009.
SOURCE: Data from OECD (2012c).
Infancy and Early Childhood: Ages 0-4
Birth Outcomes
Infant mortality rates in the United States have been stagnant in the
past decade and are now higher than in most high-income countries (Con-
gressional Budget Office, 1992; MacDorman and Mathews, 2009; OECD,
2011b). From 2005-2009, the United States had the highest infant mortality
rate (6.7 per 1,000 live births) of the 17 peer countries and the 31st highest
in the OECD (OECD, 2011b) (see Figure 2-1).7 The U.S. ranking on birth
outcomes—including stillbirths, infant mortality, and low birth weight—
can be seen in Table 2-1. Across these indicators, the United States has the
lowest composite rank. The U.S. rate for stillbirths and perinatal mortality
7
Among 40 OECD countries in 2009, the only countries with a higher infant mortality rate
than the United States were Brazil, Chile, China, India, Indonesia, Mexico, the Russian Federa-
tion, South Africa, and Turkey (OECD, 2011b). Cross-national variation in infant mortality
rates is partly affected by differences in how countries register preterm births. In the United
States, Canada, and Nordic countries, preterm neonates who often have low probabilities of
survival are registered as live births, thereby increasing the mortality rate relative to countries
that do not include preterm neonates among live births.
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66 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE
ranks among the highest in the peer countries, but the most glaring differ-
ence is low birth weight and neonatal and infant mortality.
The United States ranks poorly on low birth weight, prematurity, and
maternal health. Figure 2-2 shows that the proportion of low-birth-weight
babies in the United States (8.2 percent for 2005-2009) is the second high-
est among the peer countries. Among the 17 peer countries examined in
Chapter 1, the United States had the 14th highest rate of preterm deaths
before age 5 in 2008 (World Health Organization, 2010). Figure 2-3 shows
the results of a recent analysis of data from 184 countries (Blencowe et al.,
2012), which found that the rate of preterm births in the United States (12
percent) was comparable to that of sub-Saharan Africa. Two important
antecedents of infant and child health—adolescent pregnancies and mater-
nal health—also show a clear U.S. disadvantage (see Figure 2-2). Taken
together, these measures indicate that U.S. children often enter life under
unfavorable health conditions.
The high rate of adverse birth outcomes in the United States does not
appear to be a statistical artifact, such as a difference in coding practices
for very small infants who die soon after birth (MacDorman and Mathews,
Sweden 4.2
Finland 4.2
Norway 5.0
Canada 6.0
Denmark 6.2
Australia 6.3
Switzerland 6.4
Netherlands 6.5
France 6.7
Italy 6.8
Germany 6.8
Austria 7.1
United Kingdom 7.3
Spain 7.5
Portugal 7.8
United States 8.2
Japan 9.6
0 2 4 6 8 10
Percentage of Live Newborns Weighing Less Than 2,500 g
FIGURE 2-2 Low birth weight in 17 peer countries, 2005-2009.
Fig2-2.eps
NOTE: Values (if present) averaged over 2005-2009.
SOURCE: Data from OECD (2012l), OECD.StatExtracts: Health Status (database).
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POORER HEALTH THROUGHOUT LIFE 67
Preterm Birth Rate, Year 2010
<10%
10≤15%
15% or More
Data Not Available
Not Applicable
FIGURE 2-3 Global prevalence of preterm births, 2010.
SOURCE: Blencowe et al. (2012, Figure 3).
Fig2-3.eps
2009). Indeed, countrywith mask and new legend type Palloni and
bitmap rankings remained identical even when
Yonker (2012) recalculated the rates to exclude preterm births (less than
22 weeks of gestation).
Infant mortality and low birth weight are both markers of unhealth-
ful in utero and postnatal conditions, findings that are also supported by
related indicators. From birth through age 4, U.S. children lose more years
of life than children in the other 16 peer countries (Palloni and Yonker,
2012). Infants who die during the first year of life, particularly preterm
infants, are those at the lower tail of the distribution of newborns by health
status, and low-birth-weight babies are at the extreme end of this tail. Both
infant mortality and low birth weight are, in turn, influenced by maternal
characteristics, including health-related behaviors (e.g., smoking, drink-
ing, diet, and breastfeeding practices), marital and family status, maternal
education, access to health care, and household and family conditions.
The U.S. excess in infant mortality and the prevalence of low-birth-weight
babies probably reflect both individual and societal contextual factors. For
example, the United States fares poorly with respect to adolescent preg-
nancy and child poverty (see Chapter 6), which are, respectively, proximate
and distal determinants of low birth weight and infant mortality.
Data are available to track trends over time in U.S. infant mortality
and birth weight relative to other countries. By the early 1960s, the aver-
age infant mortality rate among peer countries had dropped to the U.S.
rate, and by the 1970s the United States began to develop a disadvantage
in infant mortality (Viner, 2012) (see Figure 2-4). Although U.S. infant
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80 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE
c 21.9 Japan 24.0
24.0 Switzerland 26.5
24.7 Sweden 26.5
24.7 Italy 26.9
24.5 France 26.2
25.1 Netherlands 26.3
25.3 Austria 27.0
25.3 Denmark 26.5
25.4 Finland 27.2
25.4 Germany 27.5
25.6 Norway 27.3
26.2 Spain 28.0
26.4 Portugal 27.3
26.5 Canada 27.9
27.0 United Kingdom 27.8
27.0 Australia 28.0
28.8 United States 29.0
30 25 20 15 10 5 0 0 5 10 15 20 25 30
Females Males
Ages 35-44
FIGURE 2-9 Continued.
Figure 2-9c
the 1950s, deaths at these ages from transportation-related and non-
transportation-related injuries have been markedly higher in the United
States than in other OECD countries (Viner, 2012). In the United States,
the second and third leading causes of death in this age group are, respec-
tively, suicide and homicide (Karch et al., 2011). For U.S. males aged
20-24, the risk of dying from violence is nearly seven times higher than
in other OECD countries, a trend that dates back to the 1950s.
Middle Adulthood: Ages 35-49
The symptoms of chronic illnesses often first appear between ages 35
and 49. At this age, cardiovascular diseases claim the largest fraction of
years lost to disability (Palloni and Yonker, 2012). Continuing the pattern
observed at younger ages, Americans who reach middle adulthood rank
poorly on measures of obesity and diabetes (see Figures 2-9a-c and 2-10a-c)
and have relatively high fasting plasma glucose levels. However, uninten-
tional injuries remain the leading cause of death at this age (National Cen-
ter for Health Statistics, 2012).
Health at Age 50
On average, Americans reach age 50 in significantly poorer health
than their peers in other high-income countries. The panel commissioned
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POORER HEALTH THROUGHOUT LIFE 81
a 0.9 Italy 2.8
0.9 Netherlands 1.6
1.1 Austria 2.2
1.1 Portugal 1.9
1.4 Denmark 2.8
1.5 Switzerland 2.9
1.5 Germany 3.0
1.5 Japan 2.3
1.5 Sweden 2.9
1.7 France 2.8
1.8 United Kingdom 2.8
1.9 Finland 3.3
1.9 Norway 3.6
2.1 Australia 3.6
2.2 Canada 3.7
2.2 Spain 2.8
2.3 United States 4.1
5 0 0 5
Females Males
Ages 15-24
b 1.7 Netherlands 3.2
2.1 Austria 3.5
2.3 Italy
Figure 2-10a 4.9
2.5 Portugal 4.2
2.6 Germany 5.2
2.6 Japan 4.3
2.8 France 4.9
2.9 Switzerland 5.3
3.0 Denmark 5.1
3.0 United Kingdom 4.4
3.0 Sweden 5.0
3.5 Finland 5.5
3.7 Australia 5.7
3.8 Norway 6.0
4.4 Canada 6.4
4.5 United States 7.1
4.7 Spain 6.3
10 5 0 0 5 10
Females Males
Ages 25-34
FIGURE 2-10 Self-reported prevalence of diabetes, by age and sex, in 17 peer
countries, 2008.
SOURCE: Data from the Global Burden of Metabolic Risk Factors of Chronic
Diseases Collaborating Group (2012), diabetes by country.
Figure 2-10b continued
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82 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE
c 3.6 Netherlands 6.4
4.4 Austria 7.5
4.5 Italy 8.3
4.6 Portugal 7.7
5.2 Germany 9.4
5.2 Japan 9.9
5.3 France 7.7
5.6 Switzerland 8.9
5.6 Denmark 10.4
6.1 United Kingdom 9.9
6.1 Sweden 9.1
6.8 Finland 10.3
6.8 Australia 10.4
7.7 Norway 11.6
9.1 Canada 12.5
9.3 United States 14.1
9.7 Spain 13.5
15 10 5 0 0 5 10 15
Females Males
Ages 35-44
FIGURE 2-10 Continued.
an analysis of cardiovascular risk factors among adults aged 50-54 in the
United States and 10 European countries. This c
Figure 2-10 age group was selected
because it is the beginning of the age range when cardiovascular mortality,
the leading cause of death, begins to be important, but mortality has not
yet affected the population through selection.
Data obtained from NHANES and SHARE indicate that U.S. adults
aged 50-54 report a higher prevalence of heart disease, stroke, diabe-
tes, hypertension, and obesity than do their counterparts in 10 European
countries. Crimmins and Solé-Auró (2012) calculated a cardiovascular risk
score by adapting the method of Gaziano et al. (2008), which includes
the above-mentioned risk factors along with smoking. The proportion of
U.S. adults aged 50-54 with at least a 20 percent risk of having a fatal or
nonfatal cardiac event within 5 years was higher in the United States than
in the European countries (see Table 2-2). The percentage of U.S. adults at
high risk exceeded the European percentage by 34 percent for men and by
more than 159 percent for women (Crimmins and Solé-Auró, 2012). That
is, Americans reach age 50 with significantly higher levels of cardiovascular
risk than their European counterparts.
Maturity: Age 50 and Older
As noted in Chapter 1, a previous National Research Council (2011)
report documented that life expectancy at age 50 is lower in the United
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POORER HEALTH THROUGHOUT LIFE 83
TABLE 2-2 Distribution of Cardiovascular Risk for Adults Aged 50-54
Among 11 High-Income Countries
Level of Risk
Males Country Very High High Moderate Low
Austria 0.70 11.37 38.55 49.38
Belgium 0.25 13.35 42.06 44.33
Denmark 2.41 10.24 39.76 47.59
France 0.00 12.48 34.19 53.32
Germany 0.52 14.30 37.73 47.45
Greece 0.43 10.40 50.14 39.04
Italy 0.00 12.28 41.56 46.16
Netherlands 1.89 8.43 42.23 47.46
Spain 2.37 15.58 42.84 39.21
Sweden 0.33 7.88 29.46 62.33
Pooled values (10 countries) 0.68 12.93 38.98 47.40
United States 1.86 16.37 38.68 43.09
Females
Austria 0.00 3.90 26.42 69.68
Belgium 0.00 5.65 22.86 71.49
Denmark 0.00 5.70 26.58 67.72
France 0.00 5.10 17.58 77.32
Germany 0.29 3.60 24.79 71.32
Greece 0.00 4.66 29.29 66.06
Italy 0.60 4.08 22.64 72.68
Netherlands 1.85 4.34 24.83 68.98
Spain 0.00 3.29 19.52 77.19
Sweden 1.08 6.65 22.71 69.57
Pooled values (10 countries) 0.32 4.22 22.41 73.05
United States 1.34 10.37 30.69 57.60
NOTES: Data for European countries are from the Survey of Health, Ageing and Retirement
in Europe (SHARE) and data for the United States are from the National Health and Nutrition
Examination Survey (NHANES). Data reflect estimated probability of a cardiovascular event
(fatal or nonfatal) within 5 years, including low risk (10 percent or less), moderate risk (10-20
percent), high risk (20-30 percent), and very high risk (greater than 30 percent). Probabilities
were determined by applying the risk charts in Gaziano et al. (2008) to data from NHANES
for 2001-2006 and from the first wave of SHARE in 2004. SHARE data include 10 countries
included in the first wave (Switzerland is omitted because of a low response rate). Samples are
weighted in the analyses to be representative of national populations. People with disease are
automatically categorized as high risk. For those without disease, age- and sex-specific risk
is based on having indicators of high blood pressure, diabetes, body mass index, and current
smoking.
SOURCE: Crimmins and Solé-Auró (2011, Table 3).
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84 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE
States than in other high-income countries. Research also shows that U.S.
adults aged 50 and older have a higher prevalence of cardiovascular and
other chronic diseases. Comparing the results of national population sur-
veys in the United States and England, one of the first studies of this issue
found that U.S. adults aged 55-64 reported higher rates of diabetes, hyper-
tension, heart disease, myocardial infarction, stroke, lung disease, and
cancer (Banks et al., 2006). To account for reporting biases, the researchers
also compared the prevalence of biomarkers, and the biomarker data fol-
lowed the same pattern. Controlling for health behaviors, such as smoking
and alcohol use, did not explain the disparity. Health disparities between
the United States and England were largest among individuals at the lowest
socioeconomic levels, but the U.S. health disadvantage persisted even at the
highest socioeconomic levels (Banks et al., 2006). Similarly, Reynolds et al.
(2008) found that U.S. adults age 65 and older were more likely than their
Japanese counterparts to report being overweight or obese and having heart
disease, diabetes, arthritis, and activity limitations.
Other studies have demonstrated that older Americans have higher
rates of disease than Europeans. In one study that compared U.S. adults
age 50 and older with those in 10 European countries, the United States
had a higher prevalence of heart disease, hypertension, high cholesterol,
cerebrovascular disease, diabetes, chronic lung disease, asthma, arthritis,
and cancer (Thorpe et al., 2007). Similarly, another study that compared
the health of U.S. adults aged 50-74 with those in England and 10 European
countries reported that Americans had higher rates of heart disease, stroke,
hypertension, diabetes, cancer, lung disease, and limited activity than their
European counterparts (Avendano et al., 2009). This study also found that
Americans at all socioeconomic levels were less healthy, but the disparity
was greatest among low-income groups. Oral disease is an important public
health problem in older adults (Griffin et al., 2012; Institute of Medicine,
2011a), but there is no evidence of a U.S. disadvantage: one study found
that older U.S. adults did not appear to have a greater prevalence of dental
disease than Europeans (Crocombe et al., 2009).
A study that compared adults age 50 and older in Canada, Denmark,
England, France, Italy, Japan, the Netherlands, Spain, and the United States
found that Americans had the highest prevalence of heart attacks, strokes,
diabetes, cancer, and activity limitations, and twice the risk of multiple
comorbidities (Crimmins et al., 2010). The U.S. health disadvantage was
generally larger among those aged 50-64 than among older adults, per-
haps because Americans experienced the onset of disease at earlier ages.
Nonobese Americans were less healthy than non-obese people in other
countries, suggesting that obesity alone did not explain the U.S. health
disadvantage (Crimmins et al., 2010). Still another study that compared
the health of adults aged 50-53 in the United States and eight European
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POORER HEALTH THROUGHOUT LIFE 85
countries found a higher prevalence of heart disease, diabetes, stroke,
lung, disease, cancer, hypertension, and limited activity among Americans
(Michaud et al., 2011). In a study that compared the health of adults aged
55-64 in the United States and 12 European countries, Banks and Smith
(2011) found that the United States had the highest rates of cancer, diabetes,
lung disease, and stroke.
Mental Health
Reports about the health of populations often ignore mental health,
yet mental illness may act as both a cause and a manifestation of the U.S.
health disadvantage. People’s emotional and neuropsychiatric health can
affect diseases and injurious behavior that claim lives, and of course mental
illness is itself an important health outcome (U.S. Department of Health and
Human Services, 2001a). Depression, alcohol-use disorders, schizophrenia,
and bipolar disorders are among the six leading causes of years lived with
disability in the United States (World Health Organization, 2003). The
years of life affected by mental illness can be substantial because these
disorders often first appear in adolescence and young adulthood (Kessler
et al., 2007).
In an analysis commissioned by the panel, Palloni and Yonker (2012)
calculated the per capita years of life before age 60 that were afflicted by
disability (or incapacitation) in 2002-2006. In terms of the number of years
lived with a disability, the United States ranked in the bottom quartile of peer
countries (i.e., living more years with a disability), and mental illness and
other neuropsychiatric disorders accounted for a large proportion of these
years, especially among youth. Neuropsychiatric disorders claimed approxi-
mately 75 percent of days lost to disability at ages 15-29 and approximately
50 percent of days lost at ages 30-44 (Palloni and Yonker, 2012).
Individuals with serious mental illnesses, such as depression, face a
higher risk of physical illnesses such as diabetes, hypertension, and heart
disease (Newcomer, 2007) and, in the United States at least, may die many
years earlier than the general population (Felker et al., 1996; Parks et al.
2006). The higher mortality rates of people with mental illness (Thornicroft,
2011; Wahlbeck et al., 2011) could contribute to the U.S. health disadvan-
tage through multiple causal pathways. For example, people with mental
illness may turn to cigarettes, alcohol, or drugs to cope with their condi-
tion. Schroeder and Morris (2010) found that people with mental illness
consume 44 percent of all cigarettes in the United States. Fully 45 percent
of U.S. suicides are precipitated by mental illness (e.g., depression, dysthy-
mia, bipolar disorder) (Karch et al., 2011). Although people with mental
illness are more likely to be victims rather than perpetrators of violence
(Eisenberg, 2005; McNally, 2011), it is also the case that people struggling
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86 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE
with antisocial behavior, paranoid schizophrenia, or bipolar disorders may
commit homicide or other violent acts. People with serious mental illness,
especially those being treated with second-generation anti sychotics, are
p
known to have higher rates of cardiovascular, pulmonary, and infectious
diseases (Parks et al., 2006). Anxiety and stress may affect the brain and
the endocrine system, alter the behavior of the immune system, and dam-
age end organs (McEwen and Gianaros, 2010). Finally, by affecting work
productivity, absenteeism, employability, and social roles (e.g., social isola-
tion, interpersonal tensions, marital disruptions) (Kessler, 2007), mental
health can also influence social and economic determinants of health (see
Chapter 6).
Whether mental illness (in its various forms) is more prevalent in the
United States than in other high-income countries is still unclear. Cross-
national studies of mental illness are limited because of inconsistencies
in diagnostic criteria and disease classifications,19 survey administration
methods, and measured covariables (e.g., demographic characteristics, risk
factors, treatment) (Kessler, 2007).20 Differences in the prevalence of men-
tal illnesses may be confounded by differences in awareness, detection,
diagnosis, treatment approaches, and comorbidities. With all these cave-
ats, however, several studies suggest that the prevalence of mental illness
may be higher in the United States than in other countries. For example, a
WHO study (Demyttenaere et al., 2004) conducted in 14 countries found
the highest prevalence of mental illness in the United States: 26 percent of
Americans reported having a mental health disorder in the past 12 months.
The United States had the highest rates of depression (18 percent) and of
mood (10 percent) and impulse-control (7 percent) disorders, and only
Ukraine exceeded the U.S. prevalence rate for substance abuse disorders
(Demyttenaere et al., 2004). Other studies from the same project, involving
a longer list of countries, also found a high prevalence of depression in the
United States relative to other high-income countries (Andrade et al., 2003;
Bromet et al., 2011). Further research is needed, however, to conclude that
mental illness is more prevalent in the United States than in peer countries.
19
Mental illnesses are classified differently under different editions of the Diagnostic and
Statistical Manual of Mental Disorders (DSM)—editions III, IIIR, IV—and under the Interna-
tional Classification of Diseases (ICD).
20
Over time, such changes as the development of the Diagnostic Interview Schedule in the
early 1980s and the WHO Composite International Diagnostic Interview in 1990 and its trans-
lation into multiple languages, have helped stimulate more comparable cross-national data on
mental illness. The WHO International Consortium in Psychiatric Epidemiology helped launch
the World Mental Health Survey Initiative, which will continue to yield rich data on mental
health (see Demyttenaere et al., 2004).
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POORER HEALTH THROUGHOUT LIFE 87
CONCLUSIONS
The evidence reviewed in this chapter, together with the findings in
Chapter 1, clearly point to a pervasive pattern of poorer health, more
injuries, and shorter lives in the United States than in other high-income
countries. These data show that Americans have shorter life expectancy
than people in almost all other high-income countries—at birth and at age
50—and they are less likely to survive to age 50. This mortality disadvan-
tage has been growing for the past three decades, especially among females.
The U.S. health disadvantage is pervasive: it affects all age groups up
to age 75 and is observed for multiple diseases, biological and behavioral
risk factors, and injuries. More specifically, when compared with the aver-
age for other high-income countries, the United States fares worse in nine
health domains: adverse birth outcomes; injuries, accidents, and homicides;
adolescent pregnancy and sexually transmitted infections; HIV and AIDS;
drug-related mortality; obesity and diabetes; heart disease; chronic lung
disease; and disability.
1. Adverse birth outcomes: For decades, the United States has experi-
enced the highest infant mortality rate of high-income countries. It
also ranks poorly on other birth outcomes (e.g., low birth weight)
and measures of child health. American children are less likely to
live to age 5 than children in other peer countries.
2. Injuries, accidents, and homicides: Injuries are a major cause of
premature death in the United States, claiming 53 and 37 per-
cent, respectively, of the excess years of life lost before age 50
by U.S. males and females. Deaths from motor vehicle crashes,
nontransportation-related injuries, and violence occur at much
higher rates in the United States than in other countries and are a
leading cause of death in children, adolescents, and young adults.
Since the 1950s, U.S. adolescents and young adults have died at
higher rates from traffic accidents and homicide than their coun-
terparts in other countries.
3. Adolescent pregnancy and sexually transmitted infections: Among
high-income countries, U.S. adolescents have the highest rate of
pregnancies and are more likely to acquire sexually transmitted
infections, such as gonorrhea, syphilis, and chlamydia.
4. HIV and AIDS: HIV and other communicable diseases claim
ap roximately 5 percent of the excess years of life lost in the United
p
States before age 50. The United States has the second highest
prevalence of HIV infection among the 17 peer countries and the
highest incidence of AIDS. The United States has a high prevalence
of HIV infection beginning at age 5.
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88 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE
5. Drug-related mortality: Americans lose more years of life to alcohol
and other drugs than people in peer countries, even when deaths
from drunk driving are excluded.
6. Obesity and diabetes: For decades, the United States has had the
highest obesity rate among high-income countries. High prevalence
rates for obesity are seen in U.S. children and in every age group
thereafter. Beginning at age 20, Americans have among the highest
prevalence rates of diabetes (and high plasma glucose levels) among
people in all OECD countries.
7. Heart disease: The U.S. death rate from ischemic heart disease is
the second highest among the 17 peer countries. Americans reach
age 50 with a less favorable cardiovascular risk profile than their
peers in Europe, and adults over age 50 are more likely to experi-
ence and die from cardiovascular disease than are older adults in
other high-income countries.
8. Chronic lung disease: Lung disease is more prevalent and associ-
ated with higher mortality in the United States than in the United
Kingdom and several other European countries.
9. Disability: Older U.S. adults report a higher prevalence of arthritis
and activity limitations than their counterparts in Europe, Japan,
and the United Kingdom.
The evidence for some other health indicators is less clear or mixed.
Some studies suggest that the United States may also have higher rates of
mental illnesses and asthma than comparable countries. The prevalence of
cancer is also higher in the United States than in other countries, but this
finding may reflect more intensive cancer screening practices. The United
States also has a higher prevalence of strokes, which may reflect better
survival rates with treatment.
The first half of the above list occurs disproportionately among young
Americans. Deaths that occur before age 50 are responsible for about two-
thirds of the difference in life expectancy between males in the United States
and other high-income countries and about one-third of the difference for
females. Americans reach age 50 in poorer health than their counterparts in
other high-income countries, and as older adults they face greater morbid-
ity and mortality from chronic diseases that arise from risk factors (e.g.,
smoking, obesity, diabetes) that are often established earlier in life. These
findings underscore the importance of early life interventions, but there is
also considerable evidence to support the importance of mid- and late-life
interventions (such as smoking cessation) in addressing the U.S. health
disadvantage.
The U.S. health disadvantage is more pronounced among socioeconom-
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POORER HEALTH THROUGHOUT LIFE 89
ically disadvantaged groups, but several studies have found that even the
most advantaged Americans may be faring worse than their counterparts
in other countries. In comparisons with England and some other countries,
Americans with healthy behaviors or those who are white, insured, college-
educated, or in upper-income brackets are in worse health than similar
groups in other countries.
The United States enjoys some health advantages, including a suicide
rate that is at or below the OECD average, low cancer mortality rates, and
possibly greater control of blood pressure and serum lipids. And despite
objective measures to the contrary, American adults are more likely than
others to rate their health as good.
The disappointing U.S. rankings across the life course suggest the
existence of “tracking” between early life behaviors and risk factors: that
is, patterns related to obesity, self-reported diabetes, and mental disorders
appear to carry forward into successive age groups. Furthermore, the condi-
tions that affect one generation may affect the next, as when poor maternal
health or adolescent pregnancy leads to low-birth-weight newborns and
infant mortality. Current research is attempting to delineate and quantify
the interaction variables in these relationships (see, e.g., Gavin et al., 2011).
Although statistical associations may represent an artifact of the available
data, a more likely explanation is that they reflect the influence of common
underlying conditions on all stages of the life course or causal connections
across ages.
The health disadvantages that exist in the United States relative to other
countries are all the more remarkable given the size and relative wealth
of the U.S. economy and the nation’s enormous spending on health care.
National health expenditures in the United States have grown from an
annual $256 billion (9.2 percent of gross domestic product [GDP]) in 1980
to $2.6 trillion (17.9 percent of GDP) in 2010 (Martin et al., 2012). No
other country in the world spends as much on health care, and per capita
spending on health care is also much higher in the United States than in any
other country (Squires, 2011).
Although this report focuses on health and not economics, it bears
noting that the health disadvantage of the United States does have implica-
tions for other domains, such as the economy and national security. For
example, military and national security experts have warned that rising
rates of obesity and illness in young adults are making it harder to recruit
healthy soldiers (Cawley and Maclean, 2010). Major corporations are
also concerned about the effects of obesity on workforce productivity and
competitiveness in the international marketplace (see, e.g., Heinen, 2006).
The economic costs of higher rates of illness and premature death may
be substantial. As LaVeist and colleagues (2009, p. 2) explain:
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90 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE
[D]isparities in health and health care impose costs on many parts of soci-
ety, including individuals, families, communities, health care organizations,
employers, health plans, and government agencies, including, of course,
Medicare and Medicaid. These costs include direct expenses associated
with the provision of care to a sicker and more disadvantaged population
as well as indirect costs such as lost productivity, lost wages, absenteeism,
family leave to deal with avoidable illnesses, and lower quality of life.
Premature death imposes significant costs on society in the form of lower
wages, lost tax revenues, additional services and benefits for families of
the deceased, and lower quality of life for survivors.
Estimating direct medical costs and indirect costs to the economy and
to individuals is methodologically complex (Russell, 2011) and beyond
the focus of this report, but the existing literature hints at its scale (Cutler
et al., 1997; Gold et al., 1996; LaVeist et al., 2009; Waidmann, 2009).
For example, one analysis that focused only on the health disadvantage
experienced by U.S. blacks, Asians, and Hispanics relative to non-Hispanic
whites found that the combined costs of health inequalities and premature
death between 2003 and 2006 was $1.24 trillion (LaVeist et al., 2009). This
estimate relies on certain assumptions, but it suggests that the costs associ-
ated with the entire population having a health disadvantage relative to
other high-income countries are also very high. Although current thinking
on this topic is still evolving (e.g., see Acemoglu and Johnson, 2007), some
economists have found a strong positive correlation between life expectancy
and economic growth (Bloom et al., 2004). Quantifying the net effects of
longevity and illness on economic growth and productivity is an area of
ongoing research, but it seems likely that the economic costs of the U.S.
health disadvantage are substantial.
The pervasive U.S. health disadvantage documented in this and the
preceding chapter could arise from problems with health care, individual
behaviors, social factors, the environment, or various policies. In Part II of
the report, we explore these issues in an effort to explain why, compared
with their counterparts elsewhere, Americans face shorter lives and greater
illness at almost all ages.
