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Report Card: Round 2, Health Care

June 27, 2013

As promised in an earlier blog, here is another report card on health care in the United States. The primary source document is the recent report from the Institute of Medicine, U.S. Health in International Perspective: Shorter Lives, Poorer Health (NRC-IOM, 2013). The title is a plot spoiler, so for those of you who are OK with the status quo, you should tune out now.

U.S. Health in International Perspective: Shorter Lives, Poorer HealthThe hefty document (420 pages) follows a 2011 National Research Council study on mortality trends that found the U.S. near the bottom of a group of high-income countries with respect to life expectancy. Consequently, a panel of experts was convened and charged, in an advisory capacity to the federal government, with examining whether a U.S. health disadvantage exists, exploring potential explanations, and assessing the larger implications of the findings.  Steven H. Woolf and  Laudan Aron edited the report, and Woolf chaired the Panel on Understanding Cross-National Health Differences Among High-Income Countries.

The Panel’s analysis compared health outcomes in the U.S. with those of 16 high-income or “peer” countries, and examined historical trends dating back several decades, with a focus on the more extensive data available from the late 1990s to 2008.

NRC-IOM (2013) lives up to its ominous title. The researchers present a “strikingly consistent and pervasive pattern of higher mortality and inferior health in the U.S., beginning at birth.”

The U.S. fares worse in nine health domains, including infant mortality, injuries and homicides, obesity and diabetes, heart disease, and drug-related mortality. For many years, Americans have had a shorter life expectancy than people in almost all the peer countries, a disparity that has been growing, especially among women. What the report calls the “health disadvantage” is widespread—it affects all age groups up to age 75, and comprises multiple diseases, biological and behavioral risk factors, and injuries.

It is a conundrum, especially given the wealth and assets of the U.S. and its enormous level of per capita spending on health care, which far exceeds that of any other country. But perhaps more worrying is the fact that much of the evidence is, as the police say, “in plain view.”

The U.S. collects extensive data on health indicators and a variety of factors that contribute to health and illness. As the report explains, large nationally representative population health surveys are conducted by the Department of Health and Human Services and include the National Health Information Survey, the Behavioral Risk Factor and Surveillance System (BRFSS) survey, and the National Health and Nutrition Examination Survey.

The BRFSS is the world’s largest ongoing telephone survey, and one of the few examples of a sustained systematic collection of data that tracks risk factors over time at the population level. It is a key source of health information in the U.S. on chronic disease conditions, health-risk behaviors, emerging health problems, and the use of preventive health services.

The data are used to set health goals and monitor public health progress at national, state, and local levels. For example, Healthy People 2010 and Healthy People 2020 objectives—representing national goals to prevent diseases, decrease morbidity and mortality, and promote health—are based on several national data sources, BRFSS prominent among them. Indeed, the NRC-IOM (2013) acknowledges the alignment between the 12 priority areas of Healthy People 2020 and the areas of health disadvantage relative to other high-income countries that the report examines.

The Surveillance Summaries published by the CDC have consistently indicated that many of the Healthy People 2010 objectives were not achieved, and that there are “. . . substantial variations in the health-risk behaviors, chronic diseases and conditions, access to healthcare services, and the use of the preventive health services among U.S. adults at the state and territory, MMSA, and county levels.” The report hammers this unpleasant news home, setting it in the disturbing context of international comparison.

In some ways, the NRC-IOM (2013) is puzzling. For example, despite the abundant evidence of data, anecdote, and personal experience to even the most casual observer of the U.S. healthcare system, the authors express (repeatedly) surprise at their findings. They recommend enormous amounts of further study (in its defense, the study was constrained by its funding source and research-focused mandate), and fancifully urge a public dialogue and consensus-building exercise. They suggest that for political reasons government might not want to take a leadership role in trying to spread unpalatable truths. And for this reader, the document lacks any sense of moral outrage at its heartbreaking message. The long-running social experiment of the U.S. for-profit healthcare system seems pretty much a failure, and hoary calls for further study, or private sector efforts to inform the public, could be seen by some as pragmatic and realistic, or fatalistic and defeatist. Undoubtedly there are many explanations for the tragedy, but there are really no excuses.

— Michael Lytton, AJPM Blog Editor

For Further Reading in AJPM:

Froehlich-Grobe K, Lee J, Washburn RA. Disparities in Obesity and Related Conditions Among Americans with Disabilities. Am J Prev Med 2013;45(1):83–90.

Braveman PA, Egerter SA, Woolf SH, Marks JS. When Do We Know Enough to Recommend Action on the Social Determinants of Health? Am J Prev Med 2011;40(1S1):S58–66.

Braveman PA, Egerter SA, Mockenhaupt RE. Broadening the Focus: The Need to Address the Social Determinants of Health. Am J Prev Med 2011;40(1S1):S4–18.

Boyce CA, Olster DH. Strengthening the Public Research Agenda for Social Determinants of Health. Am J Prev Med 2011;40(1S1):S86–8.

Schoeni RF, Dow Wh, Miller WD, Pamuk ER. The Economic Value of Improving the Health of Disadvantaged Americans. 2011;40(1S1):S67–72.

Woolf SH. The Spirit Level: Why Greater Equality Makes Societies Stronger. Am J Prev Med 2010;39(4):392–3.

Holmes JH, Lehman A, Hade E, et al. Challenges for Multilevel Health Disparities Research in a Transdisciplinary Environment. Am J Prev Med 2008;35(2S):S182–92.

Viswanath K, Kreuter MW. Health Disparities, Communication Inequalities, and eHealth. Am J Prev Med 2007;32(5S):S131–3.

Woolf SH, Johnson RE, Geiger HJ. The Rising Prevalence of Severe Poverty in America: A Growing Threat to Public Health. Am J Prev Med 2006;31(4): 332–41, e2.

Woolf SH, Stange KC. A Sense of Priorities for the Healthcare Commons. Am J Prev Med 2006;31(1):99–102.

Murray CJL, Kulkarni S, Ezzati M. Eight Americas: New Perspectives on U.S. Health Disparities. Am J Prev Med 2005;29(5S1):4–10.

Woolf SH. Society’s Choice: The Tradeoff Between Efficacy and Equity and the Lives at Stake. Am J Prev Med 2004;27(1):49–56.

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