The US Health Disadvantage Relative to Other High-Income Countries
Findings From a National Research Council/Institute of Medicine Report
Steven H. Woolf, MD, MPH; Laudan Y. Aron, MA
The United States spends more on health care than does any other country, but its health outcomes are generally worse than those of other wealthy nations. People in the United States experience higher rates of disease and injury and die earlier than people in other high-income countries. Although this health disadvantage has been increasing for decades, its scale is only now becoming more apparent.
A new report1 from the National Research Council and Institute of Medicine (NRC/IOM) documents that US males and females in almost all age groups—up to age 75 years—have shorter life expectancies than their counterparts in 16 other wealthy, developed nations: Australia, Austria, Canada, Denmark, Finland, France, Germany, Italy, Japan, Norway, Portugal, Spain, Sweden, Switzerland, the Netherlands, and the United Kingdom. The scope of the US health disadvantage is pervasive and involves more than life expectancy: the United States ranks at or near the bottom in both prevalence and mortality for multiple diseases, risk factors, and injuries.
US newborns begin life with a health disadvantage: they have a shorter life expectancy than newborns in other wealthy countries, and not just because of the diseases of aging. For decades, US infants have been less likely to reach their first birthday than infants born in peer countries.2 Outcomes such as low birth weight are more prevalent in the United States, and mortality rates up to age 5 years are also higher. US adolescents die at higher rates from motor vehicle crashes and homicides, a pattern that has distinguished the United States from other wealthy nations since the 1950s.1 Adolescents in the United States have the highest pregnancy rates and the highest prevalence of sexually transmitted infections. The United States has the second highest prevalence of HIV infection among 17 peer countries and the highest incidence of AIDS.1
For decades, the United States has also had the highest obesity rates. The nation has the highest prevalence of diabetes among adults aged 20 years and older and the second highest death rate from ischemic heart disease. Lung disease and drug-related deaths are more prevalent in the United States, and older US adults report higher rates of arthritis and activity limitations than do seniors in England, other European countries, and Japan.1 A 2011 NRC report documented that life expectancy at age 50 years is lower in the United States than in 16 high-income countries.3 The United States has some advantages—better control of hypertension and serum lipids, lower cancer and stroke mortality rates, and higher life expectancy after age 75 years—but otherwise people in the United States face a broad health disadvantage relative to those in other wealthy countries.
What accounts for this? What could explain a health disadvantage that involves conditions as varied as motor vehicle crashes, heart disease, preterm birth, and diabetes? The NRC/IOM panel explored this paradox and found clues in almost every class of health determinants it considered. The United States lacks universal health insurance coverage, and its health system has a weaker foundation in primary care and greater barriers to access and affordable care.4 Care coordination also is a problem. In multiple surveys of patients with chronic illnesses in up to 11 countries, The Commonwealth Fund has shown that US patients are more likely than patients elsewhere to report lapses in care quality and safety outside of hospitals.1 US patients appear more likely than those in other countries to require emergency department visits or readmissions after hospital discharge, perhaps because of premature discharge or problems with ambulatory care. Confusion, poor coordination, and miscommunication between clinicians and patients are reported more often in the United States than in comparable countries.
Health is determined by more than health care, and the NRC/IOM panel explored differences beyond health care to explain the US health disadvantage. It considered individual behaviors and found that although US adults are less likely to smoke (due to successful tobacco control efforts) and may drink less alcohol than adults in peer countries, they have a greater propensity for other unhealthy behaviors. People in the United States consume more calories per capita, are more likely to abuse drugs, are less likely to fasten seat belts, have more motor vehicle crashes involving alcohol, and own more firearms than do people in other high-income countries. US adolescents seem less likely to practice safe sex than adolescents in European countries. These problems are not products of the health care system.
Socioeconomic conditions matter greatly to health. Although the United States is an affluent nation with high aggregate wealth, it also has pronounced income inequality and high rates of relative poverty. Since the 1980s the United States has had the highest child poverty rate of all wealthy nations.5 The United States ranks below other countries in social mobility, the ability of individuals to climb higher on the economic ladder than their parents.6 The United States was once the world leader in education, but its education of young people is not keeping pace with educational outcomes in some peer countries.
Given the racial and ethnic diversity of the country, might the US health disadvantage reflect the profound health disparities and socioeconomic disadvantages that affect low-income and minority racial/ethnic populations? The data reviewed by the NRC/IOM panel indicate that the US health disadvantage is more pronounced among vulnerable populations, but it also can be found among more privileged groups. Even non-Hispanic white adults or those with health insurance, a college education, high incomes, or healthy behaviors appear to be in worse health (eg, higher infant mortality, higher rates of chronic diseases, lower life expectancy) in the United States than in other high-income countries.1,7- 8
The committee considered whether the physical and social environment might explain this phenomenon. It reviewed the role of US policies in shaping environmental conditions and influencing behaviors, injury risks, public health and health care delivery, and socioeconomic conditions. Could certain aspects of US lifestyle and models of governance explain why the nation is falling behind other wealthy countries across so many domains, such as health, education, social mobility, and child well-being? Might certain strongly held social values, such as attitudes about the role of government and personal autonomy, have a link to weaker injury prevention policies, the higher firearm homicide rate, the lower prevalence of safe sex among adolescents, and the weaker public investment in early childhood education and safety net programs?
The NRC/IOM committee found inadequate empirical data to reach definitive conclusions and recommended more research, including an international collaboration to collect prospective data and devise innovative study designs to pursue new lines of scientific inquiry to explore the roots of the US health disadvantage. However, the committee cautioned against waiting for research before taking action, because effective solutions have already been identified. Warning that the US health disadvantage may only worsen with time, the committee urged prompt action to implement proven strategies, such as those outlined in Healthy People 2020 and the recommendations of the National Prevention Council, which target the conditions responsible for the US health disadvantage—from infant mortality to injuries, obesity, and chronic diseases.
Public support is necessary to propel these efforts, but awareness of the low US ranking is limited. Many people are aware that health care spending is higher in the United States than in other countries, but fewer understand that Americans are sicker and die younger than people in other wealthy nations.9 The NRC/IOM recommends a robust outreach effort to alert the public about the scope of the US health disadvantage and to stimulate a national discussion about the investments and trade-offs the public is prepared to consider to attain the health status that other countries now enjoy. It recommended studies of whether policies that other countries are using to achieve their health gains might be adaptable in the United States.
Cross-national comparisons such as those provided by the NRC/IOM report vividly demonstrate that people in the United States—notably children—are dying earlier and experiencing illnesses and injuries at rates that other countries have demonstrated are unnecessary. Apart from the human and economic consequences affecting today's adults and workforce, the health disadvantages faced by today's children carry profound implications for tomorrow's adults, the nation's economy, and national security. Now the question is what US society is prepared to do about it.
