Why Aren’t Americans Healthier?

Examining why American health lags behind other affluent nations.
Rachel Pomerance Berl

Last week, a new catch phrase punctuated media reports: the so-called “U.S. health disadvantage.” The term summarizes a report released Thursday by the Institute of Medicine and National Research Council, which, as suggested by its title, “U.S. Health in International Perspective: Shorter Lives, Poorer Health,” found America lagging far behind the global health curve.

This is not, of course, a zero-sum game. Health for all is the ideal, if not a moral imperative. But the dismal U.S. ranking raises some soul-searching questions about flagging health in America.

Why, for example, do American men rank dead last in life expectancy among 17 nations? While their Swedish counterparts lead the longevity pack with an average life span of 79.3 years, American men can look forward to nearly four fewer years. Much of the disparity is due to deaths before the age of 50, according to the report, which underscores another issue—that American youth are especially subject to hardships in health due to high rates of teen pregnancy, sexually transmitted diseases, and death from traffic accidents and violence, as well as obesity and its consequent diseases.

“We expected that we would find some possible disadvantages in certain age groups,” said Steven Woolf, a professor of family medicine at Virginia Commonwealth University and chair of the panel that authored the report. “We were not prepared for what we found, which was there was a profound health disadvantage across all age groups beginning with infancy, all the way up to age 75,” and across so many measures, even when controlling for income, education, and healthy behaviors. “It’s a problem that all classes of our society need to be concerned about … we’re all in this and potentially affected by it.”

It’s not news that Americans suffer poorer health than their peers in high-income countries—such patterns emerged in the 1980s. What is? The broad extent to which the gap has widened in the last 30 years. This, in spite of the fact that Americans spend $2.8 trillion per capita on health care each year—far more than any other country spends on health care.

“If we live sicker and die younger in almost every way, shape, or form, and we pay more, it’s a damning indictment of how we’ve done,” says James Marks, senior vice president and director of the New Jersey-based Robert Wood Johnson Foundation Health Group and retired assistant surgeon general. The scope of the problem requires multiple solutions to realize what Marks is calling for: “a culture of health.” Indeed, the report ascribes the sobering data to numerous issues, including social and economic disparities, high rates of obesity, risky behaviors, and the substantial uninsured population. To a large extent, those concerns fall outside the realm of traditional medicine, he says, suggesting, for example, that how and what we eat involves everything from agricultural policies to the built environment.

That’s a point Woolf makes as well, noting where U.S. dollars are and aren’t spent. America is an “outlier from the other high-income countries,” spending more on health care and less on social programs that provide various safety nets.

In a 2011 study of 30 industrialized countries, researchers at Yale University’s Global Health Leadership Institute found that for every dollar America spends on health care, it puts 90 cents toward social services. But among peer countries, twice as much is invested in social services as health care. The study further found that countries putting more money into health care than social services have lower life expectancies and higher infant mortality rates than those with the reverse strategy, according to a December 2011New York Times op-ed piece by Elizabeth Bradley and Lauren Taylor, professor of public health and program manager, respectively, at Yale’s Global Health Leadership Institute.


“Homelessness isn’t typically thought of as a medical problem, but it often precludes good nutrition, personal hygiene, and basic first aid, and it increases the risks of frostbite, leg ulcers, upper respiratory infections, and trauma from muggings, beatings and rape,” they write. They note a report by the Boston Health Care for the Homeless Program, which tracked the medical expenses of 119 chronically homeless people for five years and found that the group accounted for 18,834 emergency room visits, amounting to roughly $12.7 million.”

The Institute of Medicine’s report wasn’t all bad news. In the global health accounting, America has lower death rates from cancer and stroke and is doing a better job of controlling cholesterol and blood pressure. Plus, if you make it past age 75, you’re likely to outlive your contemporaries elsewhere.

That said, the results overall are “devastating,” Marks says.

So, U.S. News asked him: What would it take to boost the health of Americans, to get to his proposed “culture of health?” What would the halcyon vision of healthy living look like? Marks rattles off a number of components that constitute the dream: “increasing availability of fresh fruits and vegetables, farmers markets nearby, parks that are safe, sidewalks and crosswalks, room for bike lanes in streets,” and so on. That’s an ideal, he notes, something to strive for, but a destination that’s still a long way from here.


But there are fledgling movements under way. In December 2012, Mayor Michael Bloomberg announced that life expectancy for New York City reached a record of 80.9 years. The achievement has been attributed to many of his administration’s initiatives, among them, addressing socioeconomic disparities in infant and maternal health, early identification and treatment of HIV, banning trans fats and mandating calorie counts in restaurants, anti-smoking campaigns, and the creation of bike lanes and green space.

In Philadelphia, which has the highest obesity rate of America’s 10 biggest cities, the public health department has teamed up with a nonprofit called the Food Trust to establish a “Healthy Corner Store Initiative” to stock corner stores with staples of a healthy diet, such as fruits, vegetables, low-fat diary, and whole grains.

The National League of Cities is working with municipalities to promote better health through parks and gardens, and public education campaigns, for example. And, of course, Michelle Obama has helped lead and support numerous advancements with her Let’s Move! program, which aims to address childhood obesity with active living and healthy eating, including paving the way for healthier school lunches.

In the long-term, such efforts can bolster the social systems that promote health—like good education and incomes, communities that support active living, public transportation, and access to quality health care.

Meanwhile, people can get to work on an individual level.

As David Katz, director of the Yale-Griffin Prevention Research Center, likes to say, health hinges on “feet, forks, and fingers” (the last of these referring to smoking). “The power over health resides with each of us as individuals—not with health professionals. We keep waiting for the next Nobel Prize to grant us vitality or longer life, while squandering the power we have to give ourselves those same gifts every day.”

But just because we know what’s right or wrong for us doesn’t mean we make the right choice. Indeed, NIH dollars are increasingly being put toward understanding behavior change.

Because, as Katz and others point out, the culture we live in can make healthy choices that much harder.

U.S. News