U.S. Health in International Perspective Shorter Lives, Poorer Health (2013) / Chapter Skim
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8 Policies and Social Values
8 Policies and Social Values
Pages 207-238
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. • The United States lags in educational achievement, and it has high income inequality and poverty rates and lower social mobility than most other high-income countries (Chapter 6)
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It is highly likely that the U.S. health disadvantage has multiple causes and involves some combination of unhealthy behaviors, harmful environmental factors, adverse economic and social conditions, and limited access to health care.1 Although there are a number of explanations for the U.S.
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health disadvantage go beyond health care practice and policy. People are responsible for their individual behaviors, but individual life-styles are also influenced by the policies adopted by communities, states, and national leaders (Brownell et al., 2010)
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. Tax policy and decisions by employers, business leaders, government, and voters affect job growth, household income, social mobility, savings, and income inequality.
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The U.S. approach to policies that relate to health and social programs is what sociologists classify as an Anglo-Saxon or liberal model TABLE 8-1 The Association Between Political Themes and Health Outcomes: Findings of 73 Empirical Studies Positive Inverse Association Association Mixed Political Theme of with Healtha with Healthb Resultsc Countries N (%)
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212 FIGURE 8-1 A model of structural and political influences on population health. SOURCE: Hurrelmann et al.
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As a group, these social democratic countries report longer life expectancies, lower infant mortality rates, and better self-rated health than do liberal countries, including both the United States and the United Kingdom ( ambra, 2005, 2006; B Chung and Muntaner, 2007; Coburn, 2004; Eikemo et al., 2008b; Lundberg et al., 2008; Navarro et al., 2003) .8 Figure 8-2 shows the high infant mortality rates that exist in liberal countries, especially the United States.
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7 6.83 6.75 Infant Mortality Rate 6 5.53 5.65 5.29 5 4.4 3.98 4 3 2 1 0 es * rn e n n al n Ɵv ia ia r er he ste av As at va Lib ut St Ea in er st So nd d Ea ns ite a Co Sc Un Welfare Regime Type FIGURE 8-2 Infant mortality rate for the United States and 30 other countries, classified by welfare regime type.
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, a likely product of the welfare state. The Luxembourg Income Study provides evidence that social democratic policies have, over time, substantially reduced income inequality (Alderson and Nielsen, 2002)
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30 20 10 0 60 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 Year FIGURE 8-3 Infant mortality rates by welfare regime type, 1960-1992. FIG8-3.eps NOTE: In this study, corporatist countries included Austria, Belgium, France, Germany, and old type masked in Photoshop and replaced with new bitmap, Italy.
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health disadvantage, Avendano and Kawachi (2011) noted a number of potentially important differences between the United States and Europe that may affect health: European tax systems are more progressive, child benefits are traditionally available for parents in many countries regardless of income, social programs are generally not restricted to the poor, employment protection is substantially higher, unemployment benefits are more generous, and labor standards for working parents are more extensive.
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Even the reduction in income inequality achieved by this form of capitalism probably results from the interaction and combination of multiple policies (e.g., universal access to welfare services) (Bambra and Beckfield, 2012; Chung and Muntaner, 2007; Navarro et al., 2006)
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health disadvantage, but other factors unique to the United States may also be important in understanding the relatively poor health of Americans, as discussed in the next section. SOCIETAL VALUES Social, economic, and public health policies are often an expression of societal values, set against the backdrop of other exigencies (e.g., economic turmoil)
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In economic terms, this is tan Conversely, the limited state welfare assistance that exists in East Asian countries (Hong Kong, Singapore, South Korea, Taiwan, and sometimes Japan) -- which rely instead on the family and voluntary sector for the social safety net -- reflect Confucian social ethics, such as obligation for immediate family members, thrift, diligence, and a strong education and work ethic (Aspalter, 2006; Bambra and Beckfield, 2012; Croissant, 2004; Walker and Wong, 2005)
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The United States ranks poorly on a number of factors that could explain its health disadvantages. As detailed in Chapters 4-7:
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health disadvantage. For example, as discussed in Chapter 4, the lack of universal health insurance coverage sets the United States apart from most high-income nations, but there are reasons this situation has existed for generations.
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Self-Reliance In a nation founded by pioneers, many Americans believe in the responsibility of individuals, not the state, to solve personal problems: dependency on government welfare programs or "handouts" is discouraged. Thus, raising taxes for state-financed social or health programs is often unpopular with a large proportion of American voters.
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with low tax revenue and small budgets for Medicaid, public schools, and social services. The potential relevance of these societal values cannot be ignored in attempting to explain the findings documented in this report.
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POLICIES FOR CHILDREN AND FAMILIES Just as the high rate of traffic fatalities could arise from multiple causes, other areas of health disadvantage in the United States are equally complex, both in origin and policy solutions. Many of the problems, such as obesity and diabetes, can be addressed by policies directed at middle-aged or older adults, but a life-course perspective becomes important to fully analyze underlying causes.
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Traffic Fatalities In 2011, the National Academies' Transportation Research Board (TRB) issued a special report, Achieving Traffic Safety Goals in the United States: Lessons from Other Nations.
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The TRB report's findings relating to alcohol, seatbelts, and speeding are presented below, followed by the report's findings on cross-national differences in road design, and finally, the report's observations about dif ferences in policy making and enforcement. Alcohol-Related Fatalities According to the TRB report (p.
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. In the United States in 2008, 12,000 persons were killed in crashes involving a driver who was alcohol-impaired (National Highway Traffic Safety Administration, 2009)
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Driving Speed Management in Selected Countries Speed Management France, United Kingdom, Strategy and Australia United Statesa Management and Focused program with Routine, low-level activity; Planning goals, strategy, and reactive management; budget no long-term plan Timely monitoring and No speed data; no mean publication of relevant ingful crash data speed and crash data Episodic attention; occa Long-term, multiyear, or sional enforcement permanent perspective crackdowns Technical Imple- Major portions of national Haphazard or spot mentation of or state road network enforcement Countermeasures targeted Automated enforcement Automated plus traditional not authorized or rarely enforcement used Penalties designed as Little attention to effective part of the integrated ness of penalties program Political and Public Active support and Politically invisible except Support leadership of elected when speed limits officials; management altered or automated held accountable for enforcement proposed results aDoes not necessarily include all states. SOURCE: Transportation Research Board (2011, Table 4-3)
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Safe Road Design and Highway Network Screening The TRB report found that definitive studies and data linking highway screening to safety improvements are still missing, but it also found that all countries have design standards for new construction and reconstruc tion that are intended to improve safety.* The TRB report noted a shift in some benchmark countries' road programs, which emphasize research on the relationship of design to crash and casualty risk, give higher prior ity and earlier attention to risk reduction in the design of projects and in project programming, and are more willing to trade a degree of traveler convenience for the sake of safety.
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14) : • ecentralization: in most benchmark countries, regulation and D enforcement are highly centralized, often the responsibility of a single national authority, whereas in the United States, 50 states and thousands of local jurisdictions are responsible for traffic safety and the operation of the highway system; • ublic attitudes that oppose measures common elsewhere: for P example, in the United States, motorcycle helmet laws and speed enforcement using automated cameras often encounter active pub lic opposition; • eak support for or opposition to rigorous enforcement in legisla W tures and among the judiciary; • he constitutional prohibition of unreasonable searches, which T prevents police from conducting driver sobriety testing without probable cause, a common practice in some other countries; and • esource limitations that prevent enforcement of the intensity com R mon in other countries.
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, policy solutions occupy the diverse domains at the top: macro issues, such as the built environment that enables children to engage in outdoor physical activity and farm subsidies for corn-based food products, as well as other obesogenic influences, such as cultural norms about body image, commercial messaging, local food environments, and the effects of material deprivation and psychological stresses. A key finding of this report is the alarming scale of health disadvantage among children and adolescents in the United States compared with their peers in other high-income countries.
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health disadvantage, but the problems that affect the nation's youth deserve greater investment. Maternal and child well-being are clearly important to any nation's health, and a comprehensive review of this component of population health in the United States is beyond the scope of this panel.
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• Social services: Compared with other countries, the United States spends less on social programs, subsidies, and income transfers than do other countries (see Figure 8-5)
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.16 Since the 1980s, no country in this peer group except Switzerland has spent less than the United States (as a percentage of employee-employer payroll 16 Tax burden is defined as the percentage of gross wage earnings of the average production worker that is spent on income tax plus employee social security contributions less cash benefits.
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A variety of policies can contribute to high poverty rates, unemployment, inadequate educational achievement, low social mobility, and the absence of safety net programs to protect children and families from the consequences of these problems. However, identifying and implementing policy solutions is a formidable challenge.
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would be valuable for each of the leading causes of the U.S. health disadvantage.
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health disadvantage may have to address the distribution of resources that are now directed to other categorical priorities -- a change that is likely to engender political resistance. Is a shift in priorities warranted?
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