Getting to Average Life Expectancy: It Takes Commitment

In 2012, the Institute of Medicine (now the National Academies of Science, Engineering, and Medicine) report For the Public’s Health: Investing in a Healthier Future recommended that

the Secretary of the Department of Health and Human Services . . . adopt an interim explicit life expectancy target and establish a specific per capita health expenditure target to be achieved by 2020 [to] engage all health system stakeholders in actions intended to achieve parity with averages among comparable nations.^1(p33)

In this issue of AJPH, Kindig et al. (p. 87) provide a historical perspective on how achievable the life expectancy target might be.

LOST MOMENTUM

The sad truth is that the United States, once the nation with the longest life expectancy, has slipped further and further behind competitor nations. It is not for lack of per capita health care spending. In that, the United States leads the world. The United States remains mired in health inequity as well. The Affordable Care Act enabled millions of people to get health insurance—surely a step forward. But the reality is that more fundamental change will be needed if we are to resume the extraordinary life expectancy trajectory that we had in the 20th century. Over that time, life expectancy rose from 47.3 years in 1900 to 76.8 years in 2000—a gain of almost 0.3 years for each year over the entire century. That momentum has been lost. By 2012, life expectancy had increased to 78.8 years, a gain of less than 0.2 years for each year so far this century.²

MEDICAL CARE

Although medical care has become more sophisticated and more costly, it can solve only a small part of the problem. As formulated by County Health Rankings, clinical care accounts for only approximately 20% of health, whereas 40% can be attributed to social factors, 30% to individual behaviors, and 10% to the physical environment.³ Yet, as Bradley has shown,⁴ the United States devotes an inordinate proportion of its dollars to clinical care and badly underspends in social services. Medical spending is virtually uncapped, whereas social services are squeezed and policies to enhance equity languish. Childhood poverty, inadequate educational opportunities, unsafe communities with poor access to parks, high rates of incarceration, racism, lack of active transportation, unhealthy diets, and unaffordable housing exemplify structural problems that underlie our poor health indices.

FOSTER EQUITY

The enormous achievements (and ultimately the size) of clinical care over the second half of the 20th century fostered public acceptance of and overconfidence in the medical model of health. Yet most of the greatest progress has historically been in population health initiatives—clean water, safe homes and workplaces, decreases in smoking, safe roadways, vaccinations, and many more. Recognition is growing that we must more vigorously address the social and environmental determinants of health if we want to regain the levels of progress in life expectancy that we had in the past century. This will require major changes in the public perception of what produces health as well as a commitment to addressing and supporting the policies and activities that will improve them. Investments in, for example, education, employment, living wages, criminal justice, active transportation, and parks, can foster equity and substantially improve health. Many of those resources should come from squeezing the wasted money from the medical care system and investing it where it can do more good for the public’s mental, physical, and social well-being.⁵

BECOME “AVERAGE”

Which brings us back to the Institute of Medicine’s goal to become “average” by 2030. Kindig et al. show how challenging it will be to accomplish even that seemingly modest feat. Ambitious goals are set for many reasons and in many ways. The goal to become average was very much a wake-up call. Becoming average was indeed an audacious goal despite the 18 years the nation had to achieve it. The goal was intended to capture the country’s attention and galvanize action to address the underlying reasons we lag behind our competitor nations and, despite our enormous investments in clinical care and clinical research, suffer from poorer life expectancy and unacceptable health inequity. Kindig et al. show that many nations and US jurisdictions do achieve the levels of improvement in life expectancy needed to meet the goal. The question is not one of feasibility, but will.

Importantly, the goal shines a light on what we as a nation must do. Life expectancy is, of course, a long-term measure, and arguably not the most important. But it is indicative of many of the underlying problems that contribute to the well-being and prosperity of the country. Substantial change is needed, and the changes that are needed are to reorient our priorities and resources to the social and environmental determinants of health. If we fail to do that, the United States will fall further and further behind other developed nations and our future will be bleak indeed.