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Panel on Understanding Cross-National Health Differences
Among High-Income Countries
Steven H. Woolf and Laudan Aron, Editors
Committee on Population
Division of Behavioral and Social Sciences and Education
Board on Population Health and Public Health Practice
Institute of Medicine
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Govern-
ing Board of the National Research Council, whose members are drawn from the
councils of the National Academy of Sciences, the National Academy of Engineer-
ing, and the Institute of Medicine. The members of the panel responsible for the
report were chosen for their special competences and with regard for appropriate
balance.
This study was supported by the John E. Fogarty International Center, the National
Center for Complementary and Alternative Medicine, the National Institute on
Aging, and the Office of Behavioral and Social Sciences Research, all within the
National Institutes of Health, and the Office of Women’s Health within the U.S.
Department of Health and Human Services through Contract No. N01-OD-4-2139
Task Orders # 237 and 271 and Contract No. HHSN26300011 between the
National Academy of Sciences and the U.S. Department of Health and Human Ser-
vices. Any opinions, findings, conclusions, or recommendations expressed in this
publication are those of the author(s) and do not necessarily reflect the views of the
organizations or agencies that provided support for the project.
International Standard Book Number-13: 978-0-309-26414-3
International Standard Book Number-10: 0-309-26414-6
Library of Congress Cataloging-in-Publication data are available from the Library
of Congress.
Additional copies of this report are available from the National Academies Press, 500
Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313;
http://www.nap.edu.
Copyright 2013 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
Suggested citation: National Research Council and Institute of Medicine. (2013).
U.S. Health in International Perspective: Shorter Lives, Poorer Health. Panel on
Understanding Cross-National Health Differences Among High-Income Countries,
Steven H. Woolf and Laudan Aron, Eds. Committee on Population, Division of
Behavioral and Social Sciences and Education, and Board on Population Health
and Public Health Practice, Institute of Medicine. Washington, DC: The National
Academies Press.
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The National Academy of Sciences is a private, nonprofit, self-perpetuating society
of distinguished scholars engaged in scientific and engineering research, dedicated to
the furtherance of science and technology and to their use for the general welfare.
Upon the authority of the charter granted to it by the Congress in 1863, the Acad-
emy has a mandate that requires it to advise the federal government on scientific
and technical matters. Dr. Ralph J. Cicerone is president of the National Academy
of Sciences.
The National Academy of Engineering was established in 1964, under the charter
of the National Academy of Sciences, as a parallel organization of outstanding
engineers. It is autonomous in its administration and in the selection of its members,
sharing with the National Academy of Sciences the responsibility for advising the
federal government. The National Academy of Engineering also sponsors engineer-
ing programs aimed at meeting national needs, encourages education and research,
and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi-
dent of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of
Sciences to secure the services of eminent members of appropriate professions in
the examination of policy matters pertaining to the health of the public. The Insti-
tute acts under the responsibility given to the National Academy of Sciences by its
congressional charter to be an adviser to the federal government and, upon its own
initiative, to identify issues of medical care, research, and education. Dr. Harvey V.
Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sci-
ences in 1916 to associate the broad community of science and technology with the
Academy’s purposes of furthering knowledge and advising the federal government.
Functioning in accordance with general policies determined by the Academy, the
Council has become the principal operating agency of both the National Academy
of Sciences and the National Academy of Engineering in providing services to the
government, the public, and the scientific and engineering communities. The Coun-
cil is administered jointly by both Academies and the Institute of Medicine. Dr.
Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of
the National Research Council.
www.national-academies.org
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PANEL ON UNDERSTANDING CROSS-NATIONAL HEALTH
DIFFERENCES AMONG HIGH-INCOME COUNTRIES
STEVEN H. WOOLF (Chair of Panel), Department of Family Medicine,
Virginia Commonwealth University
PAULA A. BRAVEMAN, School of Medicine, University of California,
San Francisco
KAARE CHRISTENSEN, Institute of Public Health, University of
Southern Denmark
EILEEN M. CRIMMINS, Davis School of Gerontology, University of
Southern California
ANA V. DIEZ ROUX, School of Public Health, University of Michigan
DEAN T. JAMISON, Department of Global Health, University of
Washington
JOHAN P. MACKENBACH, Department of Public Health,
Erasmus University, Rotterdam, The Netherlands
DAVID V. McQUEEN, Global Consultant, Atlanta, GA
ALBERTO PALLONI, Department of Sociology, University of
Wisconsin–Madison
SAMUEL H. PRESTON, Department of Sociology, University of
Pennsylvania
LAUDAN ARON, Study Director
DANIELLE JOHNSON, Senior Program Assistant
v
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COMMITTEE ON POPULATION
2012
LINDA J. WAITE (Chair), Department of Sociology, University of
Chicago
CHRISTINE BACHRACH, School of Behavioral and Social Sciences,
University of Maryland
JERE BEHRMAN, Department of Economics, University of Pennsylvania
PETER J. DONALDSON, Population Council, New York, NY
KATHLEEN HARRIS, Carolina Population Center, University of North
Carolina at Chapel Hill
MARK HAYWARD, Population Research Center, University of Texas,
Austin
CHARLES HIRSCHMAN, Department of Sociology, University of
Washington
WOLFGANG LUTZ, World Population Program, International Institute
for Applied Systems Analysis, Laxenburg, Austria
ROBERT MARE, Department of Sociology, University of California,
Los Angeles
SARA McLANAHAN, Center for Research on Child Wellbeing,
Princeton University
BARBARA B. TORREY, Independent Consultant, Washington, DC
MAXINE WEINSTEIN, Center for Population and Health, Georgetown
University
DAVID WEIR, Survey Research Center, Institute for Social Research,
University of Michigan
JOHN R. WILMOTH, Department of Demography, University of
California, Berkeley
BARNEY COHEN, Director (until August 2012)
THOMAS PLEWES, Director (after August 2012)
vi
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BOARD ON POPULATION HEALTH
AND PUBLIC HEALTH PRACTICE
2012
ELLEN WRIGHT CLAYTON (Chair), Center for Biomedical Ethics and
Society, Vanderbilt University
MARGARITA ALEGRÍA, Cambridge Health Alliance, Somerville, MA
SUSAN M. ALLAN, Northwest Center for Public Health Practice,
University of Washington
GEORGES C. BENJAMIN, American Public Health Association,
Washington, DC
BOBBIE A. BERKOWITZ, School of Nursing, Columbia University
DAVID R. CHALLONER, Vice President for Health Affairs, Emeritus,
University of Florida
R. ALTA CHARO, University of Wisconsin Law School
JOSE JULIO ESCARCE, Department of General Internal Medicine and
Health Services Research, Department of Medicine, University of
California, Los Angeles
ALVIN D. JACKSON, Ohio Department of Health, Fremont, OH
MATTHEW W. KREUTER, George Warren Brown School of Social
Work, Washington University in Saint Louis
HOWARD MARKEL, University of Michigan Medical School
MARGARET E. O’KANE, National Committee for Quality Assurance,
Washington, DC
SUSAN L. SANTOS, School of Public Health, University of Medicine and
Dentistry of New Jersey
MARTIN JOSE SEPÚLVEDA, Integrated Health Services, International
Business Machines Corporation, Somers, NY
SAMUEL SO, School of Medicine, Stanford University
ANTONIA M. VILLARRUEL, School of Nursing, University of
Michigan
PAUL J. WALLACE, The Lewin Group, Falls Church, VA
ROSE MARIE MARTINEZ, Director
vii
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Foreword
T
he United States spends much more money on health care than any
other country. Yet Americans die sooner and experience more illness
than residents in many other countries. While the length of life has
improved in the United States, other countries have gained life years even
faster, and our relative standing in the world has fallen over the past half
century.
What accounts for the paradoxical combination in the United States
of relatively great wealth and high spending on health care with relatively
poor health status and lower life expectancy? That is the question posed to
the panel that produced this report, U.S. Health in International Perspec-
tive: Shorter Lives, Poorer Health. The group included experts in medicine,
epidemiology, and demography and other fields in the social sciences. They
scrutinized the relevant data and studies to discern the nature and scope of
the U.S. disadvantage, to explore potential explanations, and to point the
way toward improving the nation’s health performance.
The report identifies a number of misconceptions about the causes of
the nation’s relatively poor performance. The problem is not simply a mat-
ter of a large uninsured population or even of social and economic disad-
vantage. It cannot be explained away by the racial and ethnic diversity of
the U.S. population. The report shows that even relatively well-off Ameri-
cans who do not smoke and are not overweight may experience inferior
health in comparison with their counterparts in other wealthy countries.
The U.S. health disadvantage is expressed in higher rates of chronic disease
and mortality among adults and in higher rates of untimely death and inju-
ries among adolescents and small children. The American health-wealth
ix
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x FOREWORD
paradox is a pervasive disadvantage that affects everyone, and it has not
been improving.
The report describes multiple, plausible explanations for the U.S.
health disadvantage, from deficiencies in the health system to high rates
of unhealthy behaviors and from adverse social conditions to unhealthy
environments. The panel painstakingly reviews the quality and limitations
of evidence about all of the factors that may contribute to poor U.S. health
outcomes. In this, and in earlier work the panel cites, many remediable
shortcomings have been identified. Thus, the report advances an agenda
for both research and action.
The report was made possible by the dedicated work of the panel and
staff who conducted this study and by the generous support of the Office
of Behavioral and Social Sciences Research and other units of the National
Institutes of Health. The National Research Council and the Institute of
Medicine are very much indebted to all who contributed.
The nation’s current health trajectory is lower in success and higher
in cost than it should be. The cost of inaction is high. We hope this report
deepens understanding and resolve to put America on an economically
sustainable path to better health.
Harvey V. Fineberg Robert M. Hauser
President, Institute of Medicine Executive Director, Division of
B
ehavioral and Social Sciences and
Education, National Research Council
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Preface
I
n 2011 the Office of Behavioral and Social Sciences Research (OBSSR)
of the National Institutes of Health (NIH) asked the National Research
Council (NRC) and the Institute of Medicine (IOM) to undertake a
study on understanding cross-national health differences among high-
income countries. The NRC’s Committee on Population and the IOM’s
Board on Population Health and Public Health Practice established our
panel for this task.
The impetus for this project came from a recently released NRC report
that documented that life expectancy at age 50 had been increasing at a
slower pace in the United States than in other high-income countries. The
charge to our panel was to probe further and to determine whether the same
worrying pattern existed among younger Americans, to explore potential
causes, and to recommend future research priorities.
As readers who know this issue can appreciate, this is a daunting
and complex charge. The questions put to the panel involve many fields,
including medicine and public health, demography, social science, political
science, economics, behavioral science, and epidemiology. They require the
examination of data from many countries, drawn from disparate sources.
The panel was given 18 months for the task, enough time to pull back the
curtain on this issue but not to conduct a systematic review of every con-
tributory factor and every relevant study or database. This report serves
only to open the inquiry, with the invitation to others to probe deeper and
with the disclaimer that the evidence cited here can only skim the surface
of highly complex issues.
xi
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Contents
Summary 1
Introduction 11
PART I: DOCUMENTING THE U.S. HEALTH DISADVANTAGE 21
1 Shorter Lives 25
Mortality Rates, 26
Cross-National Differences in Life Expectancy, 35
Survival to Age 50, 41
Years of Life Lost Before Age 50, 46
Causes of Premature Death, 48
Influence of Early Deaths on Life Expectancy at Birth, 54
Conclusions, 56
2 Poorer Health Throughout Life 57
Health Across the Life Course, 59
Children and Adolescents, 60
Adults, 78
Conclusions, 87
xvii
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xviii CONTENTS
PART II: EXPLAINING THE U.S. HEALTH DISADVANTAGE 91
3 Framing the Question 95
The Determinants of Health, 96
The Social-Ecological Framework, 97
A Life-Course Perspective, 99
Conclusions, 104
4 Public Health and Medical Care Systems 106
Defining Systems of Care, 107
Question 1: Do Public Health and Medical Care Systems
Affect Health Outcomes?, 109
Question 2: Are U.S. Health Systems Worse Than
Those in Other High-Income Countries?, 110
Question 3: Do U.S. Health Systems Explain the
U.S. Health Disadvantage?, 132
What U.S. Health Systems Cannot Explain, 133
Conclusions, 135
5 Individual Behaviors 138
Tobacco Use, 140
Diet, 144
Physical Inactivity, 147
Alcohol and Other Drug Use, 149
Sexual Practices, 152
Injurious Behaviors, 154
Conclusions, 159
6 Social Factors 161
Question 1: Do Social Factors Matter to Health?, 163
Question 2: Are Adverse Social Factors More
Prevalent in the United States Than in Other High-Income
Countries?, 170
Question 3: Do Differences in Social Factors Explain the
U.S. Health Disadvantage?, 185
Conclusions, 190
7 Physical and Social Environmental Factors 192
Question 1: Do Environmental Factors Matter to Health?, 193
Question 2: Are Environmental Factors Worse in the
United States Than in Other High-Income Countries?, 199
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CONTENTS xix
Question 3: Do Environmental Factors Explain the
U.S. Health Disadvantage?, 203
Conclusions, 205
8 Policies and Social Values 207
The Role of Public- and Private-Sector Policies, 209
The Role of Institutional Arrangements on
Policies and Programs, 211
Societal Values, 219
Policies for Children and Families, 225
Spending Priorities, 233
Conclusions, 236
PART III: FUTURE DIRECTIONS FOR UNDERSTANDING
THE U.S. HEALTH DISADVANTAGE 239
9 Research Agenda 241
Background, 242
Data Needs, 249
Analytic Methods Development, 262
New Lines of Inquiry, 267
Conclusions, 270
10 Next Steps 273
Pursue National Health Objectives, 275
Alert the Public, 283
Explore Innovative Policy Options, 286
Looking Ahead, 289
References and Bibliography 292
Appendixes
A Recommendations of the National Prevention
Council and Evidence Cited in Its Report 347
B Biographical Sketches of Panel Members and Staff 375
Index 379
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Figures, Tables, and Boxes
FIGURES
1-1 Mortality from noncommunicable diseases in 17 peer countries,
2008, 27
1-2 Mortality from communicable diseases in 17 peer countries,
2008, 27
1-3 Mortality from injuries in 17 peer countries, 2008, 32
1-3a Box 1-3) Number of years behind the leading peer country for
(in
the probability of dying between ages 15 and 50 among females,
1958-2007, 44
1-3b Box 1-3) Number of years behind the leading peer country for
(in
female mortality by 5-year age group, 2007, 45
1-4 Motor vehicle fatalities in the United States and 15 other
high-income countries, 1975-2008, 33
1-5 U.S. male life expectancy at birth relative to 21 other high-income
countries, 1980-2006, 42
1-6 U.S. female life expectancy at birth relative to 21 other
high-income countries, 1980-2006, 43
1-7 Probability of survival to age 50 for males in 21 high-income
countries, 1980-2006, 46
1-8 Probability of survival to age 50 for females in 21 high-income
countries, 1980-2006, 47
1-9 Ranking of U.S. mortality rates, by age group, among 17 peer
countries, 2006-2008, 48
xxi
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xxii FIGURES, TABLES, AND BOXES
1-10 Ranking of U.S mortality rates for non-Hispanic whites only, by
age group, among 17 peer countries, 2006-2008, 49
1-11 Years of life lost before age 50 by males in 17 peer countries,
2006-2008, 50
1-12 Years of life lost before age 50 by females in 17 peer countries,
2006-2008, 51
1-13 Years of life lost before age 50 due to specific causes of death
among males in 17 peer countries, 2006-2008, 52
1-14 Years of life lost before age 50 due to specific causes of death
among females in 17 peer countries, 2006-2008, 53
1-15 Contribution of cause-of-death categories to difference in years of
life lost before age 50 between the United States and the mean of
16 peer countries, males, 2006-2008, 54
1-16 Contribution of cause-of-death categories to difference in years of
life lost before age 50 between the United States and the mean of
16 peer countries, females, 2006-2008, 55
2-1 Infant mortality rates in 17 peer countries, 2005-2009, 65
2-2 Low birth weight in 17 peer countries, 2005-2009, 66
2-3 Global prevalence of preterm births, 2010, 67
2-4 Infant mortality rates in the United States and average of 16 peer
countries, 1960-2009, 68
2-5 Prevalence of overweight (including obesity) among children in
17 peer countries, latest available estimates, 72
2-6 Adolescent birth rate in 17 peer countries, 2010, 73
2-7 Transportation-related mortality among adolescent and young
adult males in the United States and average of 16 peer countries,
1955-2004, 76
(a) Males Aged 15-19
(b) Males Aged 20-24
2-8 Violent mortality among adolescent and young adult males in the
United States and average of 16 peer countries, 1955-2004, 77
(a) Males Aged 15-19
(b) Males Aged 20-24
2-9 Average body mass index (BMI), by age and sex, in 17 peer
c
ountries, 2008, 79
(a) Ages 15-24
(b) Ages 25-34
(c) Ages 35-44
2-10 Self-reported prevalence of diabetes, by age and sex, in 17 peer
countries, 2008, 81
(a) Ages 15-24
(b) Ages 25-34
(c) Ages 35-44
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FIGURES, TABLES, AND BOXES xxiii
3-1 Model to achieve Healthy People 2020 overarching goals, 98
3-2 Panel’s analytic framework for Part II, 104
4-1a Box 4-1) Access to health care independent of personal
(in
resources, 113
4-1 General practitioners as a proportion of total doctors in 15 peer
countries, 2009, 116
4-2 In-hospital case-fatality rates for acute myocardial infarction in
16 peer countries, 123
4-3 Hospital admissions for asthma in 16 peer countries, 125
4-4 Hospital admissions for uncontrolled diabetes in 14 peer
countries, 126
4-5 Frequency of complaints among insured and uninsured U.S.
patients with chronic conditions, 131
5-1 Percentage of U.S. adults age 18 and older who were current
smokers, by sex and race/ethnicity, 1965-2008, 141
5-2 Prevalence of daily smoking in 17 peer countries, 142
5-3 Four stages of the U.S. tobacco epidemic, 143
5-4 Global map of per capita caloric intake, 146
5-5 Civilian firearm ownership in 16 peer countries, 158
6-1 Poverty rates in 17 peer countries, 173
6-2 Child poverty in 17 peer countries, 174
6-3 Enrollment of children aged 0-2 in formal child care in 16 peer
countries, 2008, 177
6-4 Enrollment of children aged 3-5 in preschool in 17 peer countries,
2008, 178
6-5 Upper secondary education rates in 13 peer countries, 2009, 179
6-6 Percentage of adults aged 25-34 with a tertiary education in
17 peer countries, 2009, 181
8-1 model of structural and political influences on population
A
health, 212
8-2 Infant mortality rate for the United States and 30 other countries,
classified by welfare regime type, 214
8-3 Infant mortality rates by welfare regime type, 1960-1992, 216
8-4 A life-course perspective on childhood obesity, 232
8-5 Social benefits and transfers, 17 peer countries, 2000, 235
9-1 Social-ecologic influences on children’s health over time, 254
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xxiv FIGURES, TABLES, AND BOXES
TABLES
1-1 Mortality Rates in 17 Peer Countries, 2008, 28
1-2 U.S. Death Rates Relative to 16 Peer Countries, 2008, 38
1-3 Life Expectancy at Birth in 17 Peer Countries, 2007, 39
2-1 Health Indicators by Age Group, Range, and Rank of the United
States Among 17 Peer Countries, 61
2-2 Distribution of Cardiovascular Risk for Adults Aged 50-54
Among 11 High-Income Countries, 83
4-1 Cost-Related Access Problems in the Past Year Among U.S.
Patients with Complex Chronic Conditions, 2011, 114
5-1 Driving Practices in 16 Peer Countries, 155
6-1 Comparative Ranking of 15-Year-Old Students in High-Income
Countries, 2006, 182
8-1 The Association Between Political Themes and Health Outcomes:
Findings of 73 Empirical Studies, 211
8-2 Macro-Level Conditions That Affect Work-Family Policy, by
Country, Mid-1990s, 218
9-1 Publicly Available Databases for Aging-Related Secondary
A
nalyses in the Behavioral and Social Sciences, 243
10-1
National Health Objectives That Address Specific U.S. Health
Disadvantages, 276
BOXES
S-1 Recommendations Relating to Research, 7
S-2 Recommendations Relating to Policy, 8
1-1 The U.S. Morbidity Disadvantage, 36
1-2 Disparities in Life Expectancy in the United States, 40
1-3 How Many Years Behind Is the United States?, 44
4-1 Health Care Decommodification, 113
4-2 Case Study: Trauma Care in the United States, 120
4-3 Quality of Care: Survey Findings from Commonwealth Fund
Surveys, 128
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FIGURES, TABLES, AND BOXES xxv
6-1 Social Factors That Affect Health Outcomes, 164
8-1 Explanations for the Scandinavian Welfare Paradox, 220
8-2 The Role of Public Policies on U.S. Traffic Fatalities, 226
9-1 International Health Studies of the Population Age 50 and
Older, 248
9-2 International Efforts to Harmonize Data, 256
10-1 Recommendations of U.S. Surgeon General’s National Prevention
Council, 280
10-2 Roles for Governments and Nongovernment Actors at All
Levels, 284
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