In My View: Exploring America’s health disadvantage

America, we have a problem.

Despite spending more on healthcare than other wealthy nations, the United States ranks near the bottom of health indicators. One factor driving U.S. health care costs is high demand for expensive medical services that could have been mitigated with basic preventive efforts. Remarkably, these well-documented phenomena have primarily yielded astounding silence, and inaction at the policy level, from political leaders and government agencies responsible for improving the health of Americans. Authoritative reports by leading experts have provided ample evidence on the factors known to contribute to the American health disadvantage and high health care costs – enough to design and implement a national action plan to improve Americans’ health.

While many factors are at play, improving and strengthening the public health system through prevention and population-level policies and programs is key to improving the health of Americans. Simultaneously, investments in research and strategic solutions are needed to advance knowledge about the dynamics of the American health disadvantage. We can’t afford to wait to implement decisive policy action and research initiatives.

Numerous studies consistently show Americans live shorter lives and experience more injuries and illnesses than people in other high-income countries. This finding holds across age and income groups. The U.S. health disadvantage is not new; it has been growing for decades. It extends to a broad range of conditions including adverse birth outcomes, maternal mortality, injuries homicides, adolescent pregnancy, sexually transmitted infections, HIV and AIDS, drug-related mortality, obesity, diabetes, heart disease, chronic lung disease, disability and deaths due to medical errors. The COVID-19 pandemic further widened the gap between America and comparable nations.

In 2022, the U.S. spent an average of $12,555 per capita on health care compared to an average of $6,651 in other wealthy countries. Additionally, in 2022, U.S. health care spending grew 4.1%, reaching $4.5 trillion or $13,493 per person. As a share of the nation’s Gross Domestic Product, spending on health care accounted for 17.3%, yet the U.S. public health system continues to be grossly underfunded, accounting for about 3% of the total government expenditures on health.

A growing body of literature is available to inform design and implementation of a robust national action plan to improve America’s health and health system. The 2013 landmark report by the National Academies, The U.S. Health in International Perspective: Shorter Lives, Poorer Health, concluded that the U.S. health disadvantage is likely related to multiple factors (e.g., problems with the health care system; a fragmented, under-funded and under-appreciated public health sector; economic conditions; individual behaviors; physical and social environment). The report called for research on the effects of policies, their variations over time across high-income countries, and the extent to which policy differences explain the U.S. health disadvantage.

Regarding the cost of medical care, several studies have suggested that major contributors include administrative burdens and waste, drug costs, and wages for physicians and nurses. The cost of prescription drugs, which are significantly higher in the U.S. than other high-income countries, is a major factor and the focus of the Inflation Reduction Act of 2022, which enables Medicare to negotiate some drug prices with pharmaceutical companies. A 2023 report by the Council on Health Care Spending and Value provided a road map for action with recommendations in four areas: administrative streamlining, price regulation and supports for competition, spending growth targets, and value-based programs. These recommendations should be implemented with corresponding adjustments for differing contributory factors found across U. S. regions and states.

Perhaps more fundamental to addressing the American health disadvantage is aligning policies with the consensus that the health of populations is largely influenced by factors other than health care.

The World Health Organization proposed the Health in All Policies (HiAP) approach for cross-sector collaboration to consider the health impact of all policies. Steven Woolf, an internationally renowned expert on population health, asserts that new policies that target the social determinants of health are needed. He and other experts agree that lack of action to correct the trajectory of American health disadvantage will threaten our workforce, economy, businesses, and defense capabilities.

estimates that productivity losses linked to health-related absenteeism cost employers $225.8 billion annually, and (2) a 2022 Department of Defense report to Congress noted that 71% of Americans between the ages of 17-24 are ineligible for military service due to obesity, mental and other health conditions, or substance abuse. I am astounded and perplexed by our country’s inadequate national response to these problems despite numerous authoritative reports, spanning more than two decades, calling for action and specifying paths for such action.

Where to Start?

Start Early. One well-agreed upon international goal is to improve child health, which has implications for children’s outcomes on numerous life domains, but also for adult health, well-being and productivity. A key factor affecting health throughout the lifespan is education, and early education is particularly critical. Compared to other wealthy nations, the U.S. spends much less of its gross domestic product on early childhood education and day care. However, there is some good news: Access, affordability and quality of early childhood education and day care have recently risen in visibility in the U.S. policy agenda. However, policy initiatives have yet to be realized sufficiently to meet the needs of American families. Lack of access to day care and early education also has negative implications for the workforce and for business. Improving access to day care and early education is an effective approach for addressing two recognized drivers of health: education and income.

Start Upstream. A second agreed-upon international goal is to reduce poverty, especially among children and their families. Improving the safety net (e.g., via social welfare and income-support benefits) is known to improve health and student performance in childhood and earnings and some health indicators throughout the lifespan. The 2021 expanded U.S. child tax credit is an example of a policy that helped reduce child poverty from 9.7% to 5.2%, the lowest rate ever. However, once the child tax credit expired, improvement in the child poverty rate was lost. Experts agree that a combination of strategies are needed. The 2019 National Academies report, A Roadmap to Reducing Child Poverty, set forth 10 recommendations for modifications in existing programs in the U.S. In 2021, the Center for American Progress reiterated and supplemented many of the Academies’ recommendations.

As I was writing this editorial, The Commonwealth Fund released a report, Mirror, Mirror 2024: A Portrait of the Failing U.S. Health System. In it, this independent research group compared the health system performance of 10 countries, including the United States, to “glean insights for U.S. improvement.” Its conclusion? “The U.S. continues to be in a class by itself in the underperformance of its health care sector.”

The path forward for America is clear; a roadmap exists. But until political leaders and government agencies responsible for improving the health of Americans acknowledge that health is most importantly created by life/living conditions rather than health care services, our country’s performance in key health indicators will continue to lag behind that of other high-income countries.