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Wealth but not health in the USA
Editorial
Last week, American people, health-care workers, and policy makers received shocking news. Despite spending more on health care per person than other high-income countries, Americans die sooner, are least likely to reach the age of 50 years, and have higher rates of disease or injury. When judged by health alone, Americans are less healthy from birth to 75 years of age than people in 16 other economically wealthy countries, and this health disadvantage has been getting worse for 30 years, especially among women. In a report released on Jan 9 from the US National Research Council and Institute of Medicine, U.S. Health in International Perspective: Shorter Lives, Poorer Health, comprehensive mortality and morbidity data are presented, comparing the USA with affluent democratic countries including Australia, Canada, France, Italy, most of the Nordic countries, Spain, and the UK. Life expectancy is shorter at birth for American men than for men in any of the other 16 countries, and American women fare little better—Denmark is the only country that has a lower life expectancy for women at birth. In nine key areas of health, Americans fare least well, or are near the bottom of the tables. These areas are: infant mortality and low birthweight; injuries and homicides; teenage pregnancies and sexually transmitted infections; HIV/AIDS prevalence; drug-related deaths; obesity and diabetes; heart disease; chronic lung disease; and disability. This health disadvantage applies to those with health insurance, a college education, higher incomes, and healthy behaviours as well as to those without. Some good news in the report is that those Americans who reach 75 years live longer than their peers in other countries, and that Americans have low death rates from stroke and cancer. Moreover, current smoking rates are low, which should lead to future health benefits, and household income is relatively high. US health spending was US$2·7 trillion in 2011, which is $8700 for every person in the country, and represents 17·9% of the economy—far greater than any other economically advanced country. But spending on health care bears little relation to good health. Why are Americans at a health disadvantage compared with those in other countries? The fragmented US health-care system, and, in particular, poor access to health care and to primary care, are partly to blame. Lack www.thelancet.com Vol 381 January 19, 2013
of insurance, or inadequate insurance, restricts access to health care for many Americans. But the system is not the only problem. Unhealthy behaviours abound in the USA, particularly overeating, drug abuse, and other risk-taking activities such as not wearing motorcycle helmets, drinking and driving, and using firearms. Social and economic conditions in the USA contribute to high incomes for some, but to high poverty and income inequality for others, and to low standards of education. Welfare safety nets are not as robust as they are in other countries. Moreover, cities in the USA are often built around car use, which discourages physical activity and contributes to obesity. Change is needed. The first step is to implement the National Prevention Strategy: America’s Plan for Better Health and Wellness, which was published in June, 2011. Next, two dominant causes of the US health disadvantage deserve special mention. For people over 50 years, preventing cardiovascular disease through, for example, the Million Hearts campaign is key. For those under 50 years, preventing injury and deaths in road traffic accidents or by guns, and HIV prevention and treatment, are important targets. Considering and adapting health-promoting policies from other countries is recommended, as is further research to work out why, for example, Japan, Switzerland, and Italy have relatively good health outcomes in many areas overall. In addition to improving access to health care, it will take social, economic, health, and environmental policies to increase job availability, education, healthy eating, and physical activity, in order to reduce the US health disadvantage. To promote and inform continuing debate, health in the USA will be the theme of a Series in a special issue of The Lancet in 2014. In conjunction with Tom Frieden and Harold Jaffe at the Centers for Disease Control and Prevention, we will publish papers reviewing new opportunities to substantially improve health in the era of the Affordable Care Act. Planned topics include more on premature mortality in the USA, the impact of violence and injury, the challenges of non-communicable diseases and infections, public health and biosecurity, and the role of the USA in global health. The USA is one of the world’s wealthiest countries; it should be one of the world’s healthiest. ■ The Lancet
Copyright 2013 by the National Academy of Sciences
Wealth but not health in the USA
For the report on US health disadvantage see http://www. nap.edu/catalog.php?record_ id=13497 For the US prevention strategy see http://www.healthcare.gov/ prevention/nphpphc/strategy/ report.pdf
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Last week, American people, health-care workers, and policy makers received shocking news. Despite spending more on health care per person than other high-income countries, Americans die sooner, are least likely to reach the age of 50 years, and have higher rates of disease or injury. When judged by health alone, Americans are less healthy from birth to 75 years of age than people in 16 other economically wealthy countries, and this health disadvantage has been getting worse for 30 years, especially among women. In a report released on Jan 9 from the US National Research Council and Institute of Medicine, U.S. Health in International Perspective: Shorter Lives, Poorer Health, comprehensive mortality and morbidity data are presented, comparing the USA with affluent democratic countries including Australia, Canada, France, Italy, most of the Nordic countries, Spain, and the UK. Life expectancy is shorter at birth for American men than for men in any of the other 16 countries, and American women fare little better—Denmark is the only country that has a lower life expectancy for women at birth. In nine key areas of health, Americans fare least well, or are near the bottom of the tables. These areas are: infant mortality and low birthweight; injuries and homicides; teenage pregnancies and sexually transmitted infections; HIV/AIDS prevalence; drug-related deaths; obesity and diabetes; heart disease; chronic lung disease; and disability. This health disadvantage applies to those with health insurance, a college education, higher incomes, and healthy behaviours as well as to those without. Some good news in the report is that those Americans who reach 75 years live longer than their peers in other countries, and that Americans have low death rates from stroke and cancer. Moreover, current smoking rates are low, which should lead to future health benefits, and household income is relatively high. US health spending was US$2·7 trillion in 2011, which is $8700 for every person in the country, and represents 17·9% of the economy—far greater than any other economically advanced country. But spending on health care bears little relation to good health. Why are Americans at a health disadvantage compared with those in other countries? The fragmented US health-care system, and, in particular, poor access to health care and to primary care, are partly to blame. Lack www.thelancet.com Vol 381 January 19, 2013
of insurance, or inadequate insurance, restricts access to health care for many Americans. But the system is not the only problem. Unhealthy behaviours abound in the USA, particularly overeating, drug abuse, and other risk-taking activities such as not wearing motorcycle helmets, drinking and driving, and using firearms. Social and economic conditions in the USA contribute to high incomes for some, but to high poverty and income inequality for others, and to low standards of education. Welfare safety nets are not as robust as they are in other countries. Moreover, cities in the USA are often built around car use, which discourages physical activity and contributes to obesity. Change is needed. The first step is to implement the National Prevention Strategy: America’s Plan for Better Health and Wellness, which was published in June, 2011. Next, two dominant causes of the US health disadvantage deserve special mention. For people over 50 years, preventing cardiovascular disease through, for example, the Million Hearts campaign is key. For those under 50 years, preventing injury and deaths in road traffic accidents or by guns, and HIV prevention and treatment, are important targets. Considering and adapting health-promoting policies from other countries is recommended, as is further research to work out why, for example, Japan, Switzerland, and Italy have relatively good health outcomes in many areas overall. In addition to improving access to health care, it will take social, economic, health, and environmental policies to increase job availability, education, healthy eating, and physical activity, in order to reduce the US health disadvantage. To promote and inform continuing debate, health in the USA will be the theme of a Series in a special issue of The Lancet in 2014. In conjunction with Tom Frieden and Harold Jaffe at the Centers for Disease Control and Prevention, we will publish papers reviewing new opportunities to substantially improve health in the era of the Affordable Care Act. Planned topics include more on premature mortality in the USA, the impact of violence and injury, the challenges of non-communicable diseases and infections, public health and biosecurity, and the role of the USA in global health. The USA is one of the world’s wealthiest countries; it should be one of the world’s healthiest. ■ The Lancet
Copyright 2013 by the National Academy of Sciences
Wealth but not health in the USA
For the report on US health disadvantage see http://www. nap.edu/catalog.php?record_ id=13497 For the US prevention strategy see http://www.healthcare.gov/ prevention/nphpphc/strategy/ report.pdf
177