25 January 2013
Jon Lidén
(Former Chatham House Expert)


In the good-natured but self-satisfied sniping between Europe and the United States, the dismal US health record is a favorite European subject. Last week, Europe received a new box of ammunition. 

In the most thorough and comprehensive comparison of US health data with that of other industrial countries in decades, the National Research Council and Institute of Medicines of the National Academy of Sciences largely reconfirmed that compared to 16 other countries (13 in Europe plus Australia, Canada and Japan), people in the US lead significantly shorter lives and have poorer health.  

But wait a minute. Hold your fire! A closer look at the findings will see that there is little room for smugness. Instead, the analysis harbors plenty of lessons that the people – and the health authorities – of other wealthy and newly industrialized countries should take seriously.

What emerges from the report is a considerably more complex reality than the one many Europeans (and some Americans) love to describe when explaining the troubling mismatch between health expenditures and health outcomes in the US:

'The problem is not simply a matter of a large uninsured population or even of social and economic disadvantage,’ writes Harvey Finberg in the foreword. ‘It cannot be explained away by the racial and ethnic diversity of the US population. The report shows that even relatively well-off Americans who do not smoke and are not overweight may experience inferior health in comparison with their counterparts in other wealthy countries.'

The report finds that many of the reasons the US lags behind other countries in life expectancy and health outcomes are found in younger populations: higher infant mortality rates and higher under-5 death rates than any other wealthy country; higher levels of injuries and homicides which predominantly affects adolescents and young adults; a higher rate of adolescent pregnancies and sexually transmitted diseases (including HIV and AIDS); and a higher death rate to alcohol and drugs. In addition are the well-known ailments of middle-age: higher obesity and diabetes rates and higher heart disease rates than most other countries; and higher rates of chronic lung disease and disabilities.

But it is when the report asks 'Why?' that things get really interesting. Americans smoke and drink less than their counterparts in other wealthy countries. (Yet their alcohol and substance abuse has more deadly consequences than in other countries.) The US spends more money on keeping the over-75 alive than any other country, and as a result, once you have survived middle age, Americans are no less likely to grow very old than their fellow septuagenarians in other countries.

The highly fragmented nature of the US health system and its nearly exclusive prioritizing of treatment over prevention and specialized, high-tech solutions at the expense of widely available primary health care get some of the blame. But, the authors reflect, most of the reasons for the negative health outcomes seem to lie outside the field of health – in the individual lifestyle choices and in the social, economic and cultural value-based decisions of American society.

Given that in Washington D.C science – from global warming and evolution theory to economics – has over the past decade become the victim of vicious partisan politics, the report’s authors are understandably cautious. But they don’t shrink away from some observations that President Obama could have lifted straight into his recent inauguration speech: Poorer health and shorter lives, the report finds, may simply be the price Americans pay for a society with higher inequality than most other wealthy countries; a society designed for automobiles rather than people; a society with a declining level of education and public services; and a society with higher insecurity and stress linked to more job mobility and fewer safety nets than other wealthy countries.

Herein lies the lesson of this report. Health outcomes are ultimately the consequences of political choices. Therefore, a national debate about health must be about more than what kind of insurance is the most effective and where the caps on expenditure must be placed: at the end of the day, a health debate is about what kind of society we want.

And one more thing: In their attempt at understanding the many and complex patterns that together shape US health outcomes, the report's authors reflect that 'the explanation may simply be that the United States is at the leading edge of global trends that other high-income countries will follow'.

Rather than indulge in self-congratulatory comparisons with America's dismal health record, other industrialized countries would be wise to ask themselves if these global trends may soon erode their own hard-earned health gains of past decades.

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