Our health care discussion, for all its political content an social consequences, has essentially been about managing the expense of providing insurance, rather than about investing in the appropriate elements of a health care safety net and affecting the outcomes of a comprehensive strategy. John Maurice Clark, a prominent social economists during the mid 20th century, agreed that our national health should be considered a paramount resource. Well before these issues surfaced during our current debate, he wrote: "It is clear that health is a national asset, and it is worth conserving, more or less regardless of whether it can be done on purely commercial principles." ("Economic means - to what ends?," American Economic Review, 1950). Many of us know that, as a country, we spend much more on health care than any other country in the world. Few of us realize that the health of Americans, by many different measures, is actually worse than the health of citizens in other wealthy countries.
Our health care system is expensive. In 1960 we spent 5.2% of GDP on health care. In 2009 this number had shot up to 17.6%. (Kaiser Foundation, "National Health Expenditures, 1960-2009," published April 6, 2012). While the increase in expenditure did help us improve our overall life expectancy, as well as our "healthy" life expectancy, our improvement has been considerably slower than what most other wealthy countries experienced. The Journal of the American Medical Association, in "The State of U.S. Health, 1990-2010," documented trends in mortality and morbidity (the rate of disease in a population) across 34 OECD countries. It concluded that life expectancy in the U.S. dropped from #20 to #27 , while our healthy life expectancy ranking dropped from #14 to #26. Another study, conducted by the National Research Council and Institute of Medicine, produced a report by a panel of experts examining health indicators in 17 high-income countries. It discovered that American men ranked dead last, while women did only slightly better, ranking second lowest.
The World Health Organization produced a chart showing life expectancy by country across the globe. The U.S. ranked # 31. A list produced by our own C.I.A. ranked us even lower, #43. This is well below countries like Japan, Switzerland, Singapore, Australia or Spain. The contrast between our significant health care expenditure and our disappointingly low healthy outcomes result, especially when compared to much of the developed world, seems paradoxical, and begs for an explanation. Fortunately, studies explaining why we rank as we do are readily available. Unfortunately, our representatives appear less interested in digging below the surface of complex challenges when they are not easily translated into simplistic sound bites.
Kristen Beckman, a senior editor on LifeHealthPro.com, serving the insurance industry, compiled a list of nine factors affecting longevity. A number of these suggest answers that could help us solve our paradox. "Gender," "genetics" and "marital status" are considered important factors. However, they won't help explain the discrepancy. "Pre-natal and childhood conditions" is significant, however. The U.S. has the highest rate of infant mortality among high-income countries. Children born in the U.S. have a lower chance of surviving to the age of five than children born in any other wealthy nation. "Socio-economic status" contributes to life expectancy as well. Poverty has an adverse affect on access to medical care and participation in healthier lifestyle habits. In the U.S. 17% of the population lives in poverty. The median for OECD countries is almost half that, 9%. (Steven Schroeder, past president of Robert Wood Johnson Foundation). "Education" also contributes. According to the Center for Disease Control, a 25 year old man without a high school diploma has a life expectancy 9.3 years less than a man with a bachelor's or higher degree. (A study published in the Washington Post in 2008 concluded that life expectancy in the U.S. was on the increase, but only among people with more than 12 years of education.} Ms. Beckman completes her list with "ethnicity," "lifestyle," and "medical technology." Not all of these explain why our outcomes are lower than those in other countries. Other researchers observed that we invest less than other wealthy countries in social programs like parental leave and early-childhood education. While we rank 1st among OECD countries in heath care expenditures, we are 25th in spending on social services. And, perhaps consequentially, among 17 wealthy democracies included in another report, the U.S. has the highest rate of adolescent pregnancy and sexual disease.
The research suggests that pouring money into health care is not the only answer. Experts estimate that, during the last century, modern medical care treatment delivered to individual patients, thru physician and hospital treatment covered by health insurance, has only been responsible for 10-25% of the improvements in life expectancy. The remainder came from changes in the social determinants of health, especially in early childhood. While other countries use governments to improve health, including, but not limited to, the development of universal health insurance, the U.S. has consistently invested less than other wealthy countries in social programs. Medical care can prolong survival and improve prognosis after some serious diseases. However, the social and economic conditions that make people ill and in need of medical care in the first place appear more important. Perhaps we should re-focus our health care discussion on the overall objective and rethink where our investments will do the most good. There are healthy outcomes in many countries that can serve as examples of how to do this.
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