Healthier People: Setting Targets for Life Expectancy and Health Care Expenditures

The United States has a lower life expectancy than peer countries in the Organisation for Economic Co-operation and Development (OECD), despite its vastly higher health care expenditure per capita. Notably, the United States remains unique among wealthy nations in lacking universal health care coverage, which compounds inequities in health outcomes between affluent and disadvantaged populations. Medical care itself, however, contributes relatively little to population health when compared with a nation’s social, economic, and environmental factors, and excessive US expenditures compete with needed investments in broader health determinants.¹

Achieving parity of life expectancy with comparable OECD countries by 2030 requires increasing life expectancy by 0.32% per year from 2016 to 2030, per Kindig et al.² In this issue of AJPH, McCullough et al. (p. 1735) note that achieving parity in per capita costs with peer OECD countries by 2030 or 2040 requires annual cost declines of 7.0% or 3.2%, respectively. Also, in this AJPH issue, Speer et al. (p. 1743) offer a framework on health care waste as a way to think about how to reduce spending.

WHY SET TARGETS?

In an effort to generate wider attention to the mismatch of US health outcomes relative to medical care expenditures, the 2012 Institute of Medicine (IOM) report For the Public’s Health: Investing in a Healthier Future recommended setting targets both for life expectancy from birth and for per capita health (care) expenditures. Many developed countries and the World Health Organization have used targets to improve health and health system performance.^3,4 Likewise, the United States has decades of history—dating to the 1979 Healthy People objectives—using targets to generate attention, provide focus on priorities, and garner collaboration. Across diverse health care, public health, and nonhealth sectors, targets helped to influence America’s health and well-being. In themselves, national targets do not ensure the accomplishment of health objectives. Rather, they assist in developing policies that have greater transparency and rationality and that create greater accountability, even with the disjointed authority that is a feature of the US health care system’s mixture of private and public sectors.

Setting targets serves an educational function for US public and health professionals by highlighting the aspirations and the deficiencies of the current system. A broader understanding of the determinants of population health beyond medical care provides perspectives that motivate directions of action, improve commitment, and, ultimately, guide resources to the social and environmental investments that have the greatest influence on health. To be credible, however, targets must be guided by reliable and valid data inputs and analyses that can be tracked, allowing evaluation and course corrections as needed.

As an example of target setting, the national and state transportation goals of Toward Zero Deaths have educated and focused local, state, and national work on decreasing traffic fatalities. The complementary Data Driven Safety Analysis and Every Day Counts initiatives from the Federal Highway Administration identify high-risk roadway components, best interventions in the face of limited resources, and innovations in changing the culture of the transportation community related to highway safety (http://bit.ly/0Deaths). Although states are at different stages of implementation, evidence suggests that such programs accelerate a decrease in traffic fatalities.⁵ Another example is Healthy People 2020’s target of increasing to 61.2% the percentage of adults with hypertension whose blood pressure is under control (http://bit.ly/HP2020BPcontrol). Starting with a measure of 24.8% (1988–1994), the current Healthy People 2020 baseline is 43.7% (2005–2008), and the interim measures are 48.9% (2009–2012) and 47.8% (2013–2016). Antihypertensives, policy interventions, education, and culture change have contributed to this improvement. These two examples indicate that targets can support mobilizing or synergizing education, action, data, and culture change. The examples also reinforce that long-term monitoring and intervention are necessary with any target.

SETTING NATIONAL TARGETS

The US Health and Human Services’ (HHS’) Healthy People 2020 called for monitoring life expectancy, without naming a specific target or goal (https://bit.ly/36dFnKp). Its leading health indicators, however, included targets for many broader health determinants that were disaggregated by race, ethnicity, and other demographics (http://bit.ly/HP2020targets; http://bit.ly/HP2020disparities). For the development of Healthy People 2030, a recent National Academies report (http://bit.ly/HP2030LHI) recommended that the 2030 leading health indicators place a still greater emphasis on targets for upstream determinants of equitable health outcomes and recommended setting a target for life expectancy.

Notably, the National Academies leading health indicators report did not include a recommendation for a per capita cost target for Healthy People 2030. That committee concluded that such a target alone was insufficient without understanding regional variations in overtreatment, undertreatment, or excess prices. However, lacking a plan for measuring and decreasing total health care costs,⁶ the United States will continue to miss opportunities for improved value.⁷

Failing to set cost targets is a route this nation can ill afford. Before COVID-19, medical care cost was growing at 4.6% a year and was responsible for 17.7% of the nation’s gross domestic product. With better understanding and incentives (e.g., aligned payment mechanisms and investments to maximize health and coverage), the country can progress toward meeting cost targets. The For the Public’s Health report recommends that the HHS secretary set targets, but target setting (albeit starting with health care cost growth) is already occurring in Massachusetts, Delaware, Connecticut, Rhode Island, and Oregon. All of those states have made promising inroads toward universal coverage. State target-setting efforts may lead to insights with respect to adjusting for regional differences in cost of living, the percentage of uninsured, the balance of necessary versus unnecessary care, and so on.

But national leadership is key. The next steps that the HHS and others can take include the following:

1. synthesize learning from natural experiments on cost targets occurring in states;

2. create collaboratives for state public and private health care leaders to learn from each other about identifying and removing waste;

3. support and standardize data for measuring waste and for access and quality measures to monitor for unintended consequences (e.g., a decrease in coverage or undertreatment);

4. support research on achieving targets and balancing investments for health and equity; and

5. encourage states to set targets on disaggregated life expectancy, understanding where removing waste can be coupled with actions and investments to improve access and address upstream health factors.

With these experiences, HHS officials will become better equipped to set national targets on life expectancy and per capita costs.

Engaging stakeholders and setting targets for life expectancy and per capita expenditures are only first steps for improving US health and well-being. To be successful, targets must stimulate all actors—policymakers, providers of medical and social care, government officials, legislators, purchasers, and the public—to decrease waste and invest more wisely in the production of health. Some sectors that currently benefit from exorbitant prices will certainly resist. But comparisons with other OECD nations on life expectancy and per capita health care spending demonstrate powerfully the opportunity cost of what is lost when resources are poorly deployed. If US investments over the years had been directed away from excessive medical care and instead to a robust public health infrastructure and the well-known upstream factors that support health, our COVID-19 experience might have been very different.

Addressing this untenable state of affairs is overdue. Future generations deserve no less.