Shorter Lives, Poorer Health
Panel on Understanding Cross-National Health Differences
Among High-Income Countries
Steven H. Woolf and Laudan Aron, Editors
Committee on Population
Division of Behavioral and Social Sciences and Education
Board on Population Health and Public Health Practice
Institute of Medicine
NATIONAL RESEARCH COUNCIL AND
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the panel responsible for the report were chosen for their special competences and with regard for appropriate balance.
This study was supported by the John E. Fogarty International Center, the National Center for Complementary and Alternative Medicine, the National Institute on Aging, and the Office of Behavioral and Social Sciences Research, all within the National Institutes of Health, and the Office of Women’s Health within the U.S. Department of Health and Human Services through Contract No. N01-OD-4-2139 Task Orders # 237 and 271 and Contract No. HHSN26300011 between the National Academy of Sciences and the U.S. Department of Health and Human Services. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project.
International Standard Book Number-13: 978-0-309-26414-3
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Suggested citation: National Research Council and Institute of Medicine. (2013). U.S. Health in International Perspective: Shorter Lives, Poorer Health. Panel on Understanding Cross-National Health Differences Among High-Income Countries, Steven H. Woolf and Laudan Aron, Eds. Committee on Population, Division of Behavioral and Social Sciences and Education, and Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: The National Academies Press.
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering and Medicine
The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering.
The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.
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PANEL ON UNDERSTANDING CROSS-NATIONAL HEALTH
DIFFERENCES AMONG HIGH-INCOME COUNTRIES
STEVEN H. WOOLF (Chair of Panel), Department of Family Medicine, Virginia Commonwealth University
PAULA A. BRAVEMAN, School of Medicine, University of California, San Francisco
KAARE CHRISTENSEN, Institute of Public Health, University of Southern Denmark
EILEEN M. CRIMMINS, Davis School of Gerontology, University of Southern California
ANA V. DIEZ ROUX, School of Public Health, University of Michigan
DEAN T. JAMISON, Department of Global Health, University of Washington
JOHAN P. MACKENBACH, Department of Public Health, Erasmus University, Rotterdam, The Netherlands
DAVID V. McQUEEN, Global Consultant, Atlanta, GA
ALBERTO PALLONI, Department of Sociology, University of Wisconsin–Madison
SAMUEL H. PRESTON, Department of Sociology, University of Pennsylvania
LAUDAN ARON, Study Director
DANIELLE JOHNSON, Senior Program Assistant
COMMITTEE ON POPULATION
LINDA J. WAITE (Chair), Department of Sociology, University of Chicago
CHRISTINE BACHRACH, School of Behavioral and Social Sciences, University of Maryland
JERE BEHRMAN, Department of Economics, University of Pennsylvania
PETER J. DONALDSON, Population Council, New York, NY
KATHLEEN HARRIS, Carolina Population Center, University of North Carolina at Chapel Hill
MARK HAYWARD, Population Research Center, University of Texas, Austin
CHARLES HIRSCHMAN, Department of Sociology, University of Washington
WOLFGANG LUTZ, World Population Program, International Institute for Applied Systems Analysis, Laxenburg, Austria
ROBERT MARE, Department of Sociology, University of California, Los Angeles
SARA McLANAHAN, Center for Research on Child Wellbeing, Princeton University
BARBARA B. TORREY, Independent Consultant, Washington, DC
MAXINE WEINSTEIN, Center for Population and Health, Georgetown University
DAVID WEIR, Survey Research Center, Institute for Social Research, University of Michigan
JOHN R. WILMOTH, Department of Demography, University of California, Berkeley
BARNEY COHEN, Director (until August 2012)
THOMAS PLEWES, Director (after August 2012)
BOARD ON POPULATION HEALTH
AND PUBLIC HEALTH PRACTICE
ELLEN WRIGHT CLAYTON (Chair), Center for Biomedical Ethics and Society, Vanderbilt University
MARGARITA ALEGRÍA, Cambridge Health Alliance, Somerville, MA
SUSAN M. ALLAN, Northwest Center for Public Health Practice, University of Washington
GEORGES C. BENJAMIN, American Public Health Association, Washington, DC
BOBBIE A. BERKOWITZ, School of Nursing, Columbia University
DAVID R. CHALLONER, Vice President for Health Affairs, Emeritus, University of Florida
R. ALTA CHARO, University of Wisconsin Law School
JOSE JULIO ESCARCE, Department of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles
ALVIN D. JACKSON, Ohio Department of Health, Fremont, OH
MATTHEW W. KREUTER, George Warren Brown School of Social Work, Washington University in Saint Louis
HOWARD MARKEL, University of Michigan Medical School
MARGARET E. O’KANE, National Committee for Quality Assurance, Washington, DC
SUSAN L. SANTOS, School of Public Health, University of Medicine and Dentistry of New Jersey
MARTIN JOSE SEPÚLVEDA, Integrated Health Services, International Business Machines Corporation, Somers, NY
SAMUEL SO, School of Medicine, Stanford University
ANTONIA M. VILLARRUEL, School of Nursing, University of Michigan
PAUL J. WALLACE, The Lewin Group, Falls Church, VA
ROSE MARIE MARTINEZ, Director
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The United States spends much 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.
What accounts for the paradoxical combination in the United States of relatively great wealth and high spending on health care with relatively poor health status and lower life expectancy? That is the question posed to the panel that produced this report, U.S. Health in International Perspective: Shorter Lives, Poorer Health. The group included experts in medicine, epidemiology, and demography and other fields in the social sciences. They scrutinized the relevant data and studies to discern the nature and scope of the U.S. disadvantage, to explore potential explanations, and to point the way toward improving the nation’s health performance.
The report identifies a number of misconceptions about the causes of the nation’s relatively poor performance. The problem is not simply a matter of a large uninsured population or even of social and economic disadvantage. It cannot be explained away by the racial and ethnic diversity of the U.S. population. The report shows that even relatively well-off Americans who do not smoke and are not overweight may experience inferior health in comparison with their counterparts in other wealthy countries. The U.S. health disadvantage is expressed in higher rates of chronic disease and mortality among adults and in higher rates of untimely death and injuries among adolescents and small children. The American health-wealth
paradox is a pervasive disadvantage that affects everyone, and it has not been improving.
The report describes multiple, plausible explanations for the U.S. health disadvantage, from deficiencies in the health system to high rates of unhealthy behaviors and from adverse social conditions to unhealthy environments. The panel painstakingly reviews the quality and limitations of evidence about all of the factors that may contribute to poor U.S. health outcomes. In this, and in earlier work the panel cites, many remediable shortcomings have been identified. Thus, the report advances an agenda for both research and action.
The report was made possible by the dedicated work of the panel and staff who conducted this study and by the generous support of the Office of Behavioral and Social Sciences Research and other units of the National Institutes of Health. The National Research Council and the Institute of Medicine are very much indebted to all who contributed.
The nation’s current health trajectory is lower in success and higher in cost than it should be. The cost of inaction is high. We hope this report deepens understanding and resolve to put America on an economically sustainable path to better health.
Harvey V. Fineberg
Robert M. Hauser
In 2011 the Office of Behavioral and Social Sciences Research (OBSSR) of the National Institutes of Health (NIH) asked the National Research Council (NRC) and the Institute of Medicine (IOM) to undertake a study on understanding cross-national health differences among high-income countries. The NRC’s Committee on Population and the IOM’s Board on Population Health and Public Health Practice established our panel for this task.
The impetus for this project came from a recently released NRC report that documented that life expectancy at age 50 had been increasing at a slower pace in the United States than in other high-income countries. The charge to our panel was to probe further and to determine whether the same worrying pattern existed among younger Americans, to explore potential causes, and to recommend future research priorities.
As readers who know this issue can appreciate, this is a daunting and complex charge. The questions put to the panel involve many fields, including medicine and public health, demography, social science, political science, economics, behavioral science, and epidemiology. They require the examination of data from many countries, drawn from disparate sources. The panel was given 18 months for the task, enough time to pull back the curtain on this issue but not to conduct a systematic review of every contributory factor and every relevant study or database. This report serves only to open the inquiry, with the invitation to others to probe deeper and with the disclaimer that the evidence cited here can only skim the surface of highly complex issues.
The report that follows could not have been produced without the help of many dedicated individuals. We begin by thanking the report’s sponsor, OBSSR, and also the National Institute on Aging (NIA), which contributed financing for our work and was the primary sponsor of the prior NRC report that led to this study. We are especially grateful for guidance and contributions from Robert M. Kaplan, director, and Deborah H. Olster, deputy director of OBSSR, and Richard M. Suzman, director of the Division of Behavioral and Social Research at NIA. Ronald Abeles and Ravi Sawhney, both formerly with NIH, were also instrumental in conceiving of this project and seeing it get off the ground.
In fulfilling its charge, the panel also relied heavily on presentations and background papers and analyses from many of the world’s leading experts on the social and health sciences that relate to cross-national health disparities. Specifically, the panel benefited greatly from presentations by Michele Cecchini, OECD; Neal Halfon, University of California, Los Angeles; Ronald Kessler, Harvard University; Sir Michael Marmot, University College London; Ellen Nolte, RAND Europe; Robert Phillips, Robert Graham Center; Cathy Schoen, Commonwealth Fund; and David Stuckler, Cambridge University. Also critical to the panel’s deliberations and thinking were presentations and commissioned background papers from Clare Bambra, University of Durham; Jason Beckfield, Harvard University; and Russell Viner, University College London.
Several postdoctoral and graduate students worked intensively with a number of panel members to produce unique and compelling data analyses that appear throughout this report. We thank these contributors: Jessica Ho, University of Pennsylvania, who collaborated with Samuel Preston on developing much of the evidence presented in Chapter 1; Stéphane Verguet, University of Washington, who collaborated with Dean Jamison on a “years-behind” analysis presented in Chapter 1; James Yonker, University of Wisconsin, who collaborated with Alberto Palloni on an extensive analysis of health indicators across the life course presented in Chapter 2; and Aïda Solé Auró, University of Southern California, who collaborated with Eileen Crimmins on evaluating the health of adults at age 50.
Several other individuals at the home institutions of panel members contributed to their analyses for this report. In particular, the panel thanks Jung Ki Kim at the University of Southern California for assisting Eileen Crimmins; Malavika Subramanyam at the University of Michigan for assisting Ana Diez Roux with her review of environment factors for Chapter 7; and Karen Simpkins at the University of California, San Francisco, for assisting Paula Braveman with tables and figures for Chapter 6.
We also thank the authors of two background papers the panel commissioned: Russell Viner, University College London, for an assessment of cross-national differences in adolescent health and the importance of adolescence
in shaping life-long health outcomes; and Clare Bambra, Durham University, and Jason Beckfield, Harvard University, for an analysis of how cross-national differences in political systems, governance structures, and public policy making might influence health at the national level.1
During the course of this project, the panel also benefited from targeted consultations with national experts to help make sense of data uncovered in this review. In particular, the panel thanks Sheldon H. Danziger, University of Michigan; Thomas Getzen, International Health Economics Association; and Timothy M. Smeeding, Institute for Research on Poverty, University of Wisconsin–Madison, for their advice on interpreting poverty statistics and Clemencia Cosentino de Cohen for her advice on interpreting data on educational attainment. We also thank J. Michael McGinnis, senior scholar at the IOM, for the valuable advice he offered this panel and for serving as a discussant at a crucial panel meeting.
This report would not have been possible without the support of NRC staff. I first thank Laudan Aron, our study director, who toiled over every page of this document. The panel is also indebted to Barney Cohen, former director of the NRC’s Committee on Population; Thomas Plewes, who succeeded him and shepherded the report to its release; and Rose Marie Martinez, senior director of IOM’s Board on Population Health and Public Health Practice, who provided oversight and support of this project at every level. The panel also thanks Wendy Jacobson and Robert Pool for assistance with background research and writing; Danielle Johnson for administrative and logistical support and formatting of references, figures, and tables; Alina Baciu, Amy Geller, and Keiko Ono, for assembling the bibliography; Amy Geller, Hope Hare, and Rose Marie Martinez for assistance with graphics; Kirsten Sampson Snyder for guiding the report through review; Eugenia Grohman for editing; Yvonne Wise for managing the production process; and Sara Frueh, Patricia Morison, Lauren Rugani, Christine Stencel, and Steve Turnham for help with communications.
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Academies’ Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.
We thank the following individuals for their review of this report: James Banks, Department of Economics, Institute for Fiscal Studies, University
1All background papers and analyses are available directly from the authors.
College London; Daniel G. Blazer, Duke University Medical Center; James S. House, Survey Research Center, University of Michigan Institute for Social Research; David A. Kindig, School of Medicine, University of Wisconsin–Madison; Cato T. Laurencin, University of Connecticut Health Center; David Melzer, Department of Epidemiology and Public Health, Exeter University; Carlos Mendes de Leon, University of Michigan; Angelo O’Rand, School of Social Sciences, Duke University; Mauricio Avendano Pabon, Center for Population and Development Studies, Harvard University; David Vlahov, School of Nursing, University of California, San Francisco; and John R. Wilmoth, Department of Demography, University of California, Berkeley. Dana Glei of Georgetown University also provided a focused mid-project technical review of the commissioned data analysis conducted by Jessica Ho and Samuel Preston for Chapter 1.
Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. Robert Wallace, College of Public Health, University of Iowa, and Patricia Danzon, Health Care Management Department, The Wharton School, University of Pennsylvania, oversaw the review of this report. Appointed by the NRC and the IOM, they were responsible for ensuring that this report underwent an independent examination in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring panel and the institution.
Finally, I would like to thank my fellow panel members for their wisdom, collegiality, and energy in producing this important report. Every member was immensely helpful, but I wish to specifically acknowledge Samuel Preston, Alberto Palloni, Paula Braveman, and Ana Diez Roux for their first drafts of Chapters 1, 2, 6, and 7, respectively. This report is truly an ensemble effort. I hope that readers will notice the interdisciplinary collaboration reflected in the pages of this document. The panel members, all highly regarded experts in their fields, contributed wonderful insights and the literatures of their disciplines to give our discussions and data analysis the holistic perspective this topic deserves. I am indebted to these colleagues, who despite many demanding responsibilities, gave generously of themselves and operated under a very demanding timeline. I am sure I speak for the panel and staff in collectively thanking our spouses and families for the disruption in lives this undertaking required.
Our panel was unprepared for the gravity of the findings we uncovered. We hope that others will take notice. Our charge was to give advice to the scientific community, and this report fulfills that charge by outlining ways that the NIH, other research agencies, and investigators can collect new data and advance understanding of the causes of cross-national health disparities.
But the gravity of our findings also deserves attention outside the scientific community. A broader audience—most importantly the American public—should know what this report says. Concerted action is required on many levels of society if the nation is to change the conditions described here and to give the people of the United States—particularly the nation’s children—the superior health and life expectancy that exist elsewhere in the world.
Steven H. Woolf, Chair
Panel on Understanding Cross-National
Health Differences Among High-Income Countries
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PART I: DOCUMENTING THE U.S. HEALTH DISADVANTAGE
Cross-National Differences in Life Expectancy
Years of Life Lost Before Age 50
Influence of Early Deaths on Life Expectancy at Birth
2 Poorer Health Throughout Life
PART II: EXPLAINING THE U.S. HEALTH DISADVANTAGE
The Social-Ecological Framework
4 Public Health and Medical Care Systems
Question 1: Do Public Health and Medical Care Systems Affect Health Outcomes?
Question 2: Are U.S. Health Systems Worse Than Those in Other High-Income Countries?
Question 3: Do U.S. Health Systems Explain the U.S. Health Disadvantage?
What U.S. Health Systems Cannot Explain
Question 1: Do Social Factors Matter to Health?
Question 2: Are Adverse Social Factors More Prevalent in the United States Than in Other High-Income Countries?
Question 3: Do Differences in Social Factors Explain the U.S. Health Disadvantage?
7 Physical and Social Environmental Factors
Question 1: Do Environmental Factors Matter to Health?
Question 2: Are Environmental Factors Worse in the United States Than in Other High-Income Countries?
Question 3: Do Environmental Factors Explain the U.S. Health Disadvantage?
The Role of Public- and Private-Sector Policies
The Role of Institutional Arrangements on Policies and Programs
Policies for Children and Families
PART III: FUTURE DIRECTIONS FOR UNDERSTANDING THE U.S. HEALTH DISADVANTAGE
Pursue National Health Objectives
Explore Innovative Policy Options
A Recommendations of the National Prevention Council and Evidence Cited in Its Report
B Biographical Sketches of Panel Members and Staff
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Figures, Tables, and Boxes
Quality of Care: Survey Findings from Commonwealth Fund Surveys
International Health Studies of the Population Age 50 and Older
Recommendations of U.S. Surgeon General’s National Prevention Council
Roles for Governments and Nongovernment Actors at All Levels