Shorter Lives and Poorer Health on the Campaign Trail

For those desiring serious and compelling conversation on the presidential campaign trail about the future of our nation’s health, this is a dispiriting time for two reasons. First, candidates have precious little to say about our most compelling challenges relating to the nation’s health as opposed to our medical care. They follow familiar and politically reliable prescriptions on both sides of the partisan divide. Second, the raw material for a rich and potent debate concerning the public’s health has never been more abundant. I have hope that this conversation can occur, though not in the context of the 2016 political circus.

Here is one example of what I would love to hear presidential candidates discuss in at least one debate: the 2013 report from the National Academy of Medicine (NAM) called “Shorter Lives, Poorer Health.”¹ It is a 394-page indictment of our nation’s health and health care systems. Here is the opening:

The United States spends more money on health care than any other country. Yet Americans die sooner and experience more illness than residents in many other countries. While the length of life has improved in the United States, other countries have gained life years even faster, and our relative standing in the world has fallen over the past half century.^1(p.ix)

Extensive research confirms “a large and rising international ‘mortality gap' among adults age 50 and older,”^1(p.1) according to the NAM panel.

The U.S. health disadvantage cannot be attributed solely to the adverse health status of racial or ethnic minorities or poor people, because recent studies suggest that even highly advantaged Americans may be in worse health than their counterparts in other countries.^1(p.1)

The report’s comparison group includes Australia, Austria, Canada, Denmark, Finland, France, Germany, Italy, Japan, Norway, Portugal, Spain, Switzerland, the Netherlands, and the United Kingdom using data between the 1990s and 2008. The health disadvantage was sharpest in nine health domains:

• Adverse birth outcomes—the highest infant mortality rate among high income countries;

• Injuries and homicides—a leading cause of death in children, adolescents, and young adults;

• Adolescent pregnancy and sexually transmitted infections—the highest rate of pregnancies among high income countries;

• HIV and AIDS—the highest incidence of AIDS and the second highest prevalence of HIV infection;

• Drug-related mortality—more lives lost to alcohol and drugs than in any other nation, even when excluding drunk driving deaths;

• Obesity and diabetes—the highest rates of obesity and diabetes among high income nations;

• Heart disease—the second highest rate among 17 peer nations;

• Chronic lung disease—higher mortality than in the United Kingdom and other European countries; and

• Disability—one of the highest prevalence rates of activity limitations among older adults.

The NAM results are not totally bad and include higher survival after age 75 years, as well as better rates regarding cancer, blood pressure and cholesterol levels, smoking, and stroke mortality. Of note, given recent public preoccupations in the political campaign, the health status of recent immigrants is better than that of native-born Americans.

Yet,

Americans under age 75 fare poorly among peer countries on most measures of health. This health disadvantage is particularly striking given the wealth and assets of the United States and the country's enormous level of per capita spending on health care, which far exceeds that of any other country.^1(p.4)

The Report is a staggering indictment of our American society in this new century. Back in 1980s, President Ronald Reagan taught the nation the power of positive thinking in shaping attitudes. This report is downer, which may help to explain why it is so hard to break into the national conversation.

Yet it is also true is that in recent years, we have seen other reports that paint a bleak picture of our nation’s health.

In November, a new study by Case and Deaton documented rising morbidity and mortality rates among US Whites aged 45 to 54 years.² A reexamination of the data by Aron et al. at the Urban Institute revealed a shocking increase in the rate of mortality among middle-aged women three times faster than the rate of increase among similarly aged White males: 26.8 deaths per 100 000 population among White women aged 45 to 54 years versus a 7.7% increase among men between 1999 and 2013.³ Figure 1 supports Aron et al.’s conclusion:

There is simply no mistaking the reality that American women are currently dying much earlier than their counterparts in other advanced nations … [including] women of reproductive and childrearing ages, a finding that has huge implications for children, families and communities.³

FIGURE 1—

Chances of Women Surviving to Age 50 Years

Source. Adapted from Aron et al.³

And not to let US health care off the hook, the performance of our medical care system continues to underwhelm. A recently released study by the World Health Organization and The Economist Intelligence Unit, “Healthcare Outcomes Index 2014,” examining the health care systems of 166 nations, ranked the United States number one in spending and number 33 in quality outcomes, placing it among the least efficient systems on the planet, and ranking behind nations such as Lebanon and Costa Rica.⁴ Figure 2 shows the broad ranges of nations that achieve better results for their societal investments in health care.

FIGURE 2—

Outcomes vs Health Spending

Note. PPP = purchasing power parity.

I recall in the 1980s reading health economists speculate about “flat of the curve medicine,” the hypothetical point at which further expenditures on medical care could actually produce worse health. Figure 2 illustrates that US spending now is beyond the flat of the curve and that the hypothesized adverse outcomes from outsized medical care spending are now real.

Research over the past five years by Bradley at Yale offers a compelling hypothesis to explain at least part of our nation’s dismal performance—among all advanced nations, the United States spends by far the most on a per person basis on medical care while spending nearly the least on a per person basis on nonmedical social service spending such as education, day care, job training, housing support, nutritional assistance, and more.⁵ Focusing less on medical care and more on needs relating to the social determinants of health seems to help produce more beneficial population health outcomes than our nation’s prioritization on the reverse. Figure 3 illustrates Bradley’s key findings.

FIGURE 3—

Two Approaches to Staying Healthy

Source. Data from Bradley and Taylor.⁶ Figure adapted from Neff.⁷

So here we are with an accumulating knowledge base of a deep and profound societal problem. Our approach—or perhaps nonapproach—to health is killing us and weakening our nation. Is there a presidential candidate talking about any of this? Yes, Senator Bernie Sanders proposes a Medicare-for-all single payer system that might provide the best opportunity for systemic reorientation. Yet the real-world chances for such a radical redesign do not offer great confidence.

One of the most surprising developments in American politics in recent years has been the emerging common ground from the nation’s political right and left regarding US criminal justice and prison policies that leave us with the world’s highest incarceration rates. From widely diverging ideological perspectives, deeply divided political adversaries are engaging in serious and substantive collaboration to change these policies.

I see the basis for a new conversation between the political left and right regarding our nation’s over-reliance on medical care to address human needs that could far more effectively and efficiently be addressed in preventive and nonmedical ways by tackling the social determinants of health. Surely, citizens who identify as conservatives have no reason to cheer our outsized and debilitating level of spending on medical care. Might we see in the new incarceration dialogues inspiration for a new and path-breaking conversation on how to get our nation’s health care needs and spending in better order?

Although it is already late to get these issues planted in the 2016 national political agenda and campaign, it is not too late to spur conversation and education. While the process for major political change takes time, the work has to begin somewhere. The nation’s public health community has a lot to say and much to contribute to this process.

Let’s begin.