JULY 15, 2013 I S S U E F O C U S United States Lags in Global Health Gains S horter lives and poorer health: this was the striking infections, HIV and AIDS, drug-related deaths, obesity and conclusion of leading public health experts convened by diabetes, chronic lung disease, and disability. For a number of the National Research Council (NRC) and the Institute key indicators that have been tracked over time, the gap of Medicine (IOM) when examining the research evidence on between the United States and other high-income countries how health and life expectancy in the United States compares has been growing, particularly among women. to that of other high-income democracies around the world.1 The size of the gap between the United States and its peers, They also found that this U.S. “health disadvantage” has been the widening of this gap over time, and the consistency of this growing over the past several decades and that unless we gap across indicators are all causes for concern. Nevertheless, change course, the United States will continue to miss out on there are a few areas in which the United States demonstrates the superior health and life expectancy enjoyed in Western an advantage over its peers, notably in lower cancer death rates Europe, Japan, Australia, and Canada. and better control over blood pressure and cholesterol levels. Interestingly, once Americans reach age 75, they can expect to LEAST HEALTHY AND SHORTEST-LIVED live longer than their counterparts in 16 peer countries. Research to uncover why this is so may help us learn more On a range of diverse measures, Americans rank poorly about the most effective ways of improving the relative health compared to people living in other high-income countries. of people in the under-75 age groups. For example: • The infant mortality rate has stagnated in the United States WHAT EXPLAINS THE U.S. HEALTH over the past decade but continued to improve elsewhere. SHORTFALL? Over the period 2005-2009, the U.S. rate was more than There is no evidence to suggest that U.S. health fares poorly as twice as high as countries like Sweden, Japan, Finland, and a result of inadequate spending. At present, the United States Norway, and exceeded other wealthy countries by a sizeable devotes almost one-fifth of its national income to health- margin (OECD 2012). related goods and services, with expenditures amounting to • A boy born in the United States in 2007 could expect to $7,960 per person in 2009, a level that is more than double live 75.6 years, a full 3.7 years less than a boy born at the the $3,223 median per capita spending among member same time in Switzerland and less than a male child born in countries of the Organization for Economic Cooperation and any of 16 peer countries (Ho and Preston 2011). Development (OECD 2011). Certainly, the large number of Americans without health • U.S. children and adults experience significantly higher rates insurance and the barriers in access to services faced by some of premature death compared to people in other high- segments of the population help explain why the United States income countries. In 1990, Americans lost approximately has a health disadvantage relative to countries with universal 35 percent more years of life before age 50 than did their peers; by 2009 this discrepancy had grown to close to 75 percent (Palloni and Yonker 2012). Factors explaining U.S. health shortfalls, relative to • Americans reach middle age in relatively poor health: U.S. other wealthy countries, include: adults between the ages of 50-54 have a higher prevalence of heart disease, stroke, diabetes, hypertension, and obesity • health care that is inaccessible or unaffordable for the than their counterparts in 10 European countries (NRC uninsured and underinsured, and IOM 2013). U.S. mortality rates for men and women • unhealthy behaviors, between 50-74 are among the very highest of peer nations. • social and economic conditions, and This pattern of relatively poor performance in health and • community and environmental factors. survival extends to the incidence of low birthweight, injuries and homicides, adolescent pregnancy and sexually transmitted 1 The summary research findings and conclusions presented in this Issue Focus are drawn from U.S. Health in International Perspective: Shorter Lives, Poorer Health (NRC and IOM 2013). The implications of these findings and conclusions for health grantmakers were developed by the author of this Issue Focus in consultation with the report’s editors. I S S U E F O C U S GIH BULLETIN health coverage or national health care service delivery systems. how likely it is that government actors will take the lead in The NRC/IOM report, however, makes clear that this is not disseminating information about U.S. health performance, the whole story. In fact, findings from several studies indicate leaving the door open for grantmakers to take on this public that the gap between the United States and peer countries service. cannot be fully explained by the relatively poor health status of Examples of a public information campaign on which others people who are impoverished or uninsured. Even Americans could build include the work of The California Endowment, from advantaged groups—those who are insured, well-edu- which has led efforts to inform Californians that their “zip code cated, upper-income, and not a racial minority—are in worse is more important than their genetic code” as a determinant of health, on average, than people in similar circumstances who their health, emphasizing that health care is determined by the live in other countries. Such findings indicate that expanding conditions in which people live, learn, work and play, and not coverage will not, in and of itself, suffice to address the U.S. just the medical care they receive (Flores 2013). In light of the health disadvantage. low level of public awareness and potential resistance to find- The report points to a number of other factors that are ings that run counter to existing beliefs, it will be important for likely contributors to the U.S. health disadvantage, although such campaigns to be designed carefully, choosing appropriate their specific roles and relative importance require further messages and taking into account what is known about how investigation. Certain health-related behaviors are known to such information is best delivered, absorbed, and spread. affect health outcomes: while Americans are less likely to Grantmakers can also help raise awareness by including smoke cigarettes and may consume less alcohol than people information about relative U.S. health status in outreach and in other countries, Americans also take in more calories per public engagement efforts, in the context of ongoing disease- person, have higher rates of drug abuse, are less likely to use or population-focused work. Similarly, when selecting new seat belts, are involved in more alcohol-related traffic accidents, priorities for programming, foundations may want to prioritize and are more likely to use firearms in acts of violence. Certain efforts to address health problems in which the U.S. health characteristics of American communities and physical environ- disadvantage, relative to what has been achieved elsewhere, ments, such as land-use decisions predicated on automobile appears greatest. transportation, likely contribute to health indirectly, through Additionally, grantmakers can help address the U.S. health influence on behavior, as well as directly. In addition, the disadvantage through actions that go beyond public informa- United States has relatively higher levels of poverty, tion and prioritization of programs to address health including child poverty, greater income inequality, and disadvantages. The results of international comparisons suggest lower rates of social mobility. At the same time, safety net the need to evaluate the potential for rechanneling the flow of programs that serve to cushion the negative health effects health resources to activities that will promote population of poverty and socioeconomic disadvantage are less robust health, as determined by evaluations of domestic programs and in the United States in comparison with other wealthy studies of how other countries are achieving better health nations. outcomes. Such efforts could conceivably include prioritizing policies and practices that improve health through socioeco- IMPLICATIONS FOR HEALTH GRANTMAKERS nomic, environmental, or other indirect channels, as well as The NRC/IOM report documented trends that have long been directly through the provision of preventative or curative health appreciated by population health experts, but that have not yet services. Grantmakers stand to play a role in advocating for and infiltrated the knowledge base of many policymakers or the sponsoring investigations of this kind, and in promoting general public. In fact, findings of deficiencies in relative health change based on the results of such work, as evidenced by status run contrary to pervasive beliefs among Americans gen- examples such as the Robert Wood Johnson Foundation’s erally about the relative performance of the U.S. health care Commission to Build a Healthier America, which recently system and the quality of its services. Therefore, spreading the reconvened to develop guidance on promoting health in early word about the pervasive U.S. health disadvantage is a key childhood and through community-level improvements recommendation of the report. This is an activity for which (RWJF 2013). health grantmakers are well suited and arguably best situated to In light of the compelling evidence of the need for change take the lead. that has now been documented by the nation’s most presti- Conducting an information campaign would be a public gious scientific academies, health grantmakers working in all service, in that such knowledge could help drive demand for areas of the field will want to consider whether and how they remedial actions and stimulate debate regarding priorities and can serve as advocates and agents for change. Successful acceptable trade-offs. Nevertheless, some stakeholders in the outreach, investigation, and advocacy could drive the improve- health care industry have incentives to downplay information ments in population health that are needed for the United that might be viewed as evidence of ineffective or inefficient States to achieve the better health outcomes other countries are use of resources. Such political realities call into question enjoying now. I S S U E F O C U S GIH BULLETIN SOURCES Flores, George R., “Health Happens Here: The Social Determinants of Health, PowerPoint for Capitol Briefing, Sacramento,” <http://www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/ PDF/S/PDF%20Sacto02152013HealthPolicy101HealthEquity.pdf>, February 15, 2013. National Research Council (NRC), and Institute of Medicine (IOM), U.S. Health in International Perspective: Shorter Lives, Poorer Health, Steven H. Woolf and Laudan Aron, Eds. (Washington, DC: The National Academies Press, 2013). Ho, J.Y., and S.H. Preston, Population Studies Center, University of Pennsylvania, “International Comparisons of U.S. Mortality,” unpublished data analyses for the National Academy of Sciences/ Institute of Medicine Panel on Understanding Cross-National Health Differences Among High-Income Countries, 2011. Organization for Economic Cooperation and Development (OECD), Health at a Glance, 2011 (Paris, France: 2011). Organization for Economic Cooperation and Development (OECD), OECD Factbook, 2011-2012: Economic, Environmental and Social Statistics (Paris, France: 2012). Palloni, A., and J. Yonker, Health in the U.S. at Young Ages: Preliminary Findings (CDE Working Paper 2012-04), (Madison, WI: Center for Demography and Ecology, University of Wisconsin, 2012). Robert Wood Johnson Foundation (RWJF), “Commission to Build a Healthier America,” <http://www.rwjf.org/en/about-rwjf/newsroom/features-and-articles/Commission.html>, 2013.