US Health Disadvantage Flashcards
US health disadvantage relative to other high-income countries
Avendano and Kawachi, 2014. ‘Why do Americans have shorter life expectancy and worse health than people in other high-income countries?’
o “In 2012, life expectancy in the US ranked 32 worldwide, below most other industrialized nations. Recent reports (Avendano et al., 2009) suggest that Americans also experience higher rates of disease, injury and health-damaging behaviors than men and women in other high-income countries”
o “Life expectancy among European countries has also diverged and converged at several points, partly coinciding with major wars and economic hardship episodes in European history (Mackenbach, 2013)”
o “In contrast, the US health disadvantage emerged during the second half of the 20th century and has steadily grown, which is remarkable given that this coincided with a period of unprecedented economic growth and stability in the US. This raises questions about specific aspects of post-war America which may be responsible for the US health disadvantage”
(1) Higher mortality and morbidity
“US gains in life expectancy [over the last 50 years] (7.5 years for women and 9 years for men) have been substantial but only about half of those in the best performing country. Next to the US, Denmark, the Netherlands and Norway have had comparatively modest gains in life expectancy, while women in Japan and Southern Europe (Portugal, Spain and Italy) have enjoyed the largest gains (Ho and Preston, 2010)”
o “As a result, in 2008, the US had the shortest life expectancy for both women (80.6) and men (75.6), while life expectancy was longest for Japan (86.1) among women and for Switzerland (79.8) among men”
“Cross-national variations in life expectancy at ages 40, 60 and 80 years are smaller than differences in life expectancy at birth, suggesting that excess deaths before age 40 substantially contribute to life expectancy variations between the US and other countries”
“The fact that mortality at relatively young ages accounts for much of the US life expectancy disadvantage was highlighted in a recent analysis examining mortality under age 50 across countries (Ho, 2013; National Research Council and Institute of Medicine, 2013)”
“Results from this study indicate that mortality differences below age 50 account for two thirds of the gap in life expectancy at birth between men in the US and an average of 17 other OECD countries, and 40% of this difference among women. These findings underscore the point that the US life expectancy disadvantage originates at early age and extends across the life-course”
(2) The US health disadvantage begins at birth and extends across the life-course
“The fact that mortality at relatively young ages accounts for much of the US life expectancy disadvantage was highlighted in a recent analysis examining mortality under age 50 across countries (Ho, 2013)”
“Results from [Ho, 2013] indicate that mortality differences below age 50 account for two thirds of the gap in life expectancy at birth between men in the US and an average of 17 other OECD countries, and 40% of this difference among women. These findings underscore the point that the US life expectancy disadvantage originates at early age and extends across the life-course”
o “Mortality rates from infectious diseases; complications of pregnancy, childbirth and the puerperium; and conditions originating in the perinatal period are higher in the US than in nearly all other OECD countries”
o “Differences in some causes emerged around 1980; for example, the gap in transport accidents and accidental poisoning became stark in recent decades due to larger declines in other countries paired with increasing or stagnant trends in the US”
o “In contrast, homicide mortality has consistently been higher in the US for several decades, which is consistent with prior evidence of substantially higher US rates of fire-arm related deaths (Krug et al., 1998)”
o “Recent evidence indicates that the major causes of death contributing to years of life lost below age 50 between the US and an average of 17 other OECD countries among women were non-communicable diseases, perinatal conditions, transport injuries and non-transport injuries (Ho, 2013)”
o “Among men, homicide mortality was the largest contributor, followed by transport injuries, non-transport injuries and perinatal conditions (Ho, 2013)”
“Compared to most other countries, Americans have higher prevalence of low birth weight, traffic injuries and HIV incidence”
“A recent review shows that Americans have also higher prevalence of preterm births and poor maternal health; adolescent pregnancy and sexually transmitted infections; and overweight, obesity and diabetes during childhood and mid-age (National Research Council and Institute of Medicine, 2013)”
“Older Americans report a higher prevalence of heart disease, stroke, hypertension, diabetes, obesity, lung disease and limitations with basic instrumental activities of daily living (IADL) than their European counterparts at ages 50 and above. Similar patterns have been reported for ages 50–74 (Avendano et al., 2009)”
“Differences between the US and Europe are also evident for biologically assessed outcomes such as blood pressure, blood cholesterol, fasting glucose levels and C-reactive protein (Banks, Marmot et al., 2006)”
(3) The lag in US life expectancy is particularly large for American women
“Results from [Ho, 2013] indicate that mortality differences below age 50 account for two thirds of the gap in life expectancy at birth between men in the US and an average of 17 other OECD countries, and 40% of this difference among women”
“Mortality rates from infectious diseases; complications of pregnancy, childbirth and the puerperium; and conditions originating in the perinatal period are higher in the US than in nearly all other OECD countries (Ho, 2013)”
“Recent evidence indicates that the major causes of death contributing to years of life lost below age 50 between the US and an average of 17 other OECD countries among women were non-communicable diseases, perinatal conditions, transport injuries and non-transport injuries (Ho, 2013)”
“A recent review shows that Americans have also higher prevalence of preterm births and poor maternal health; adolescent pregnancy and sexually transmitted infections (National Research Council and Institute of Medicine, 2013)”
“American women in the five census divisions located in the south and Midwest regions have higher mortality than women in most other OECD countries, but even the best US divisions, the US Pacific and New England, have higher mortality than 11 other OECD countries”
“Earlier reports indicate that even in the healthiest US regions, female life expectancy lags behind that in the least healthy regions of countries such as Japan and France (Wilmoth et al., 2010)”
(4) The US health disadvantage is most pronounced for the Midwest and Southeast regions
“Among men, most divisions in the south and Midwest perform poorly compared to most other OECD countries, while the Pacific and New England divisions have relatively low mortality. Both men and women in the East South Central US divisions have the highest rates (Wilmoth et al., 2010)”
Proposed explanations for the US health disadvantage
BROAD MECHANISM
o SPECIFIC FACTORS
Medical care and public health
o Access to health care insurance
Individual behaviors o Tobacco use o Obesity o Diet o Physical inactivity o Alcohol and other substance use o Sexual practices o Violence (especially firearm suicide and homicide) o Automobile reliance
Social/demographic factors
o Socioeconomic inequality and poverty
Physical environmental factors
o Racial disparities and residential segregation
o Social integration and social interactions
o Built environment (urban design, transport infrastructure, land use mix, urban planning and design)
o Food environment
Medical care and public health systems
“The US spends more on healthcare than any other OECD country (OECD Health Data, 2013), yet medical care is often proposed as an explanation for the US health disadvantage (Bezruchka, 2012; National Research Council and Institute of Medicine, 2013)”
“Although whether insurance coverage is causally linked to health status has been debated (Ross and Mirowsky, 2000), the lack of universal coverage may be an exacerbating factor (National Research Council and Institute of Medicine, 2013)”
“Nonetheless, both insured and uninsured Americans experience poorer health than their European counterparts, suggesting that health insurance might not be the only explanation (Banks, Marmot et al., 2006; National Research Council and Institute of Medicine, 2013)”
“Overall, health care provides at best a partial explanation. For example, excess deaths from violent causes (homicides, suicides, accidents) are hardly due to lack of health care; indeed, if it were not for advances in emergency medical care, it is estimated that thousands of more homicides would be recorded in the United States each year (Harris et al., 2002)”
“In addition, US survival rates for several chronic conditions contributing to the US health disadvantage, such as heart disease, ischemic stroke and cancer, might be better in the US than in other high-income countries, suggesting that care for these conditions might not be worse in the US than in other OECD countries (Coleman et al., 2008)”
“Macinko, Starfield and Shi [2003] have linked the weaker primary health care system in the US to higher premature mortality”
“NEVERTHELESS, regardless of cross-national differences in access to quality medical care, the fact remains that the overwhelming contributors to the incidence of disease (e.g. poor health behaviors) operate largely outside the influence of medical care”
Individual behaviors
“Differences in tobacco use, diet, physical inactivity, obesity, alcohol and other drug use, sexual practices and harmful behavior have been proposed as potential explanations of the US health disadvantage”
“A recent report released by the National Academy of Sciences (NAS) concluded that smoking was likely the most important factor explaining the lag in US life expectancy at older age, particularly among women (National Academy of Science Panel, 2010, 2011)”
o “While the US enjoys currently lower smoking prevalence than most other high-income countries, the smoking epidemic started earlier and reached a higher pick in the US than in other countries, particularly among women (Cutler and Glaeser, 2006; National Academy of Science Panel, 2010, 2011)”
o “Due to the long lag between smoking and lung cancer, current mortality reflects smoking trends two to three decades earlier. A recent study concluded that smoking explained two fifths of the difference in male life expectancy between the US and other high-income countries, and over three quarters of the difference in female life expectancy (National Academy of Science Panel, 2011; Preston et al., 2010)”
“Assessing the role of other individual behaviors has proved challenging given limited comparable data on risk factors across decades and countries. Yet, data suggest that the US has one of the highest total caloric intake and the highest sugar intake among all OECD countries (National Research Council and Institute of Medicine, 2013; OECD Health Data, 2013)”
“The US also ranks high in total fat intake and total protein intake, while vegetable and fruit consumption in the US is similar to that in several other OECD countries (OECD Health Data, 2013)”
“A poor diet, in combination with relatively low levels of physical activity (Hallal, 2012; Steptoe and Wikman, 2010), may explain the high US obesity rates”
o “Recent estimates based on macro-level data suggest that obesity might explain as much as two thirds of the US shortfall in male life expectancy and two fifths of the US female life expectancy disadvantage (Preston and Stokes, 2011)”
o “HOWEVER, this contrasts with another report showing that increasing trends in obesity are not specific to the US and might not explain current differences in life expectancy (Alley et al., 2010)”
o “In support of this [latter] view, cohort studies suggest that even after adjusting for obesity and other risk factors, differences in morbidity across countries remain (Avendano and Glymour, 2008)”
“While it is likely that smoking and other unhealthy behaviors contribute to the poorer health of Americans, smoking does not explain why Americans have poorer health and worse trends in mortality below age 50”
o “It is unlikely that parental smoking alone could account for the higher rate of infant mortality, poorer childbirth outcomes, injuries and homicide in the US compared to other high-income countries”
o “Since mortality below age 50 from these and other causes explains two thirds of the difference in life expectancy at birth between the US and other countries among men, and two fifths among women (Ho, 2013; National Research Council and Institute of Medicine, 2013), smoking is at best only one among several factors explaining the US health disadvantage”
“While understanding the contribution of individual behaviors is crucial, an approach that focuses solely on behavioral differences is impoverished by its focus on “proximal” individual choices”
o “The earlier adoption of smoking among US females, for example, may reflect features of the US environment that encouraged American women to smoke more than women in other countries”
o “The fact that Americans behave poorly only raises the follow-up question of why Americans more often than adults in other countries make behavioral choices that are detrimental to their health”
Social and demographic explanations
“The US is characterized by pronounced racial, ethnic and socioeconomic disparities in health, which may contribute to the overall US health disadvantage”
o “For example, although life expectancy for the United States as a whole improved during the past three decades, Ezzati et al. [2008] documented declining or stagnant life expectancy between 1983–1999 for women in 963 out of 2,068 counties, and 59 counties for men”
“The history of the United States also diverges from that of other OECD countries in terms of its legacy of three centuries of slavery followed by post-abolition Jim Crow laws (1876–1965) which shaped racial segregation, whose cumulative influences are still felt to this day”
o “For example, Williams and Collins [2001] argue that the persistent residential segregation of African Americans shapes their educational opportunities and labor market success, and contributes to their unequal exposures to environmental pollutants, violence, and other health threats”
“While it is true that poor and black Americans are at increased health disadvantage, studies suggest that also white, middle class Americans have poorer health than their European counterparts (Avendano et al., 2009; Avendano et al., 2010; Banks, Marmot et al., 2006)”
o “For example, in a widely cited cross-national comparison of the health of American and English people, Banks et al. [2006] found that Americans in the top third of the income distribution (97% of whom already have access to health insurance) had rates of hypertension and diabetes comparable to those in the bottom third of income earners in England. The comparison was all the more striking because it was restricted to whites in both countries”
“Nevertheless, the largest share of the American health disadvantage is likely to be borne by the poor and least educated, who have much higher rates of disease and death than their counterparts in Europe (Avendano et al., 2009; Avendano et al., 2010; Banks, Marmot et al., 2006; Martinson, 2012)”
“The role of socioeconomic status may be particularly salient for mortality under age 50”
o “For example, US mortality from homicide is nine times higher among young men in the bottom decile of socioeconomic deprivation compared to young men in the affluent top decile (Singh et al., 2013; Singh and Kogan, 2007b)”
o “Strikingly, US girls in the bottom decile are fourteen times more likely to die from HIV/AIDS than their counterparts in the top affluent decile (Singh et al., 2013; Singh and Kogan, 2007b)”
o “Similar differences by socioeconomic deprivation exist in childhood mortality (Singh and Kogan, 2007a, 2007b)”
“…a recent paper concluded that social participation and integration did not explain the US health disadvantage relative to other European countries (Banks et al., 2010)”
The built physical environment
“A separate line of explanations argues that aspects of the built physical environment, such as access to recreational facilities, land use mix, transportation infrastructure, urban planning and design, as well as access to fast food outlets and fresh fruit and vegetable stores, might underlie cross-national variations in healthy behavior and associated health outcomes”
o “For example, the built physical environment in most of the US provides limited opportunities for physical activity with few alternatives other than driving. The reliance of Americans on automobiles as their primary mode of transport is well documented (National Research Council and Institute of Medicine, 2013)”
o “Interestingly, the fatality rate per 100 million vehicle kilometers travelled is similar in the US and a set of other 15 high-income countries, but the annual number of kilometers driven in the US far exceeds that in other countries (Ho, 2013; Transportation Research Board, 2010)”
o “IN OTHER WORDS, Americans die more from car crashes because they drive more”
“There is an extensive literature on the relationship between the built environment and health-related behavior (French et al., 2001), but there are no systematic investigations of the contribution of the built environment to the US health disadvantage”
o “Although it is difficult to draw firm conclusions, explanations based on the physical environment beg the follow-up question of why the US has less health-promoting built environments compared to other countries”
Public policies that may contribute to differences in health and life expectancy between the US and other high-income countries
PUBLIC POLICY DOMAIN
o SPECIFIC PROGRAMMES
Childcare and early childhood education policies
o Policies determining the availability, cost, and quality of childcare and early childhood education programs
Education policies
o The share of public vs. private education systems
o Compulsory schooling laws
o Spending and distribution of resources for education
o Access to higher education
Labor and employment protection policies o Labor laws that affect job security, work conditions, working hours, worker's benefits and work flexibility o Parental leave o Minimum wage laws o Trade union membership laws o Work incentives and worker's compensation o Retirement policies o Unemployment insurance policy o Active labor market programmes
Income support and family and children support policies
o Child poverty alleviation and income tax credits
o Family allowance programmes
o Child support maintenance systems
o Child-related leave
Housing policies
o Incentives for homeownership
o Access to public housing
o Policies to improve housing conditions
Income inequality
o Tax and redistribution policies
Childcare and early childhood education policies
“Early childhood education in the US is less well established than in Europe, where formal and subsidized pre-primary education is often the norm”
o “The typical starting age for early childhood education in the US is four years, compared to three years or younger in 21 other OECD countries (Education at a Glance 2012, OECD)”
o “While regulations in most of Europe require that a qualified teacher delivers a formal curriculum, this is less well regulated in the US (OECD Family Database, 2013)”
o “The overall enrolment rate in early education programmes is 69% in the US, compared to rates above the OECD average of 80% in most European countries”
o “While 84% of children in the OECD attend public or Government-funded private institutions, only 55% of early childhood pupils in the US attend public schools (Education at a Glance 2012, OECD)”
o “In addition, as a percentage of GDP, the US spends far less on childcare support for families than almost any other OECD country (OECD Family Database, 2013)”
“Early childhood interventions appear to bring important health benefits, especially among disadvantaged children (Heymann et al., 2013; Keating and Simonton, 2008)”
o “Studies indicate that early education programmes do not only improve educational outcomes but also lead to higher immunizations and height-for-age, and reduce child mortality at ages five to nine (Heymann et al., 2013; Keating and Simonton, 2008)”
o “More comprehensive childcare and early education programmes for children in Europe may thus partly contribute to their better health compared to that of American children”
Education policies
“There are important differences between the US and other high-income countries in education policy”
o “While the US spends more on public school education than most other OECD countries, American students perform around or below the OECD average (OECD, 2011)”
o “There are moreover substantial disparities in the quality of public schooling (e.g. reflected by student-teacher ratios) across communities in the United States, which are partly driven by residential segregation and the financing of the public school system by local property taxes (OECD, 2011)”
o “While educational attainment is relatively high in the US (OECD Stat., 2013), inequalities in spending may lead to substantial disinvestment among socially disadvantaged groups most at risk of poor health”
“Evidence from across the US (Glymour et al., 2008; Lleras-Muney et al., 2008; Lleras-Muney, 2005) and Europe (Banks and Mazzonna, 2012; van Kippersluis et al., 2009) suggests that education policies such as compulsory schooling laws have had long-run effects on health and mortality”
o “Other policies, such as education grant aid programmes, have increased schooling completion and college attendance (Dynarski, 2003)”
o “[NEVERTHELESS] The health benefits of these and other policies expanding access to and improving quality of education remain poorly understood”
Labor and employment protection policies
“The US stands out for its weaker employment protection laws (euphemistically referred to as ‘labor flexibility’) compared to other OECD countries. US workers face comparatively high risks of job displacement, as employers bear relatively low costs associated with collective dismissals or contract termination (OECD Benefits and Wages: Statistics, 2012; OECD Indicators of Employment Protection 2013)”
“In addition, social policies to protect workers who become ill or displaced, as well as maternity leave policies, are modest in the US in comparison to most European countries (OECD Benefits and Wages: Statistics, 2012)”
o “For example, net wage replacement rates for long-term unemployment insurance for a single-earner married couple with two children in 2010 were 45% in the US, compared to 66% in France, 86% in Sweden and 90% in Japan (OECD Stat., 2013)”
o “Programmes to support working parents are also substantially less comprehensive in the US. In 2011–2012, the duration of fully-paid maternity and parental leave was 45 weeks in France, 46 weeks in Sweden, and 21 weeks in the Netherlands, compared to none in the United States (OECD Family Database, 2013)”
“A potential hypothesis is that as a result of these policies, Americans work longer hours (Rogerson, 2006), spend less time cooking and eating meals at home (Brunello et al., 2008), drive more as opposed to investing time in healthy transportation alternatives (Ho, 2013; Transportation Research Board, 2010), and in general spend less time in non-market activities that might be conductive of health”
“Some employment protection policies have been shown to improve health”
o “For example, extending weeks of job-protected paid maternity leave significantly decreases infant mortality rates and improves child health (Rossin, 2011), with the large effects on post-neonatal mortality (Ruhm, 2000; Tanaka, 2005)”
o “Longer maternity leave may also improve maternal mental health around the post-partum weeks (Chatterji and Markowitz, 2012) and increase mothers’ labor market attachment (Brugiavini et al., 2013; Ruhm, 2011), leading to lung-run benefits for mothers and children (Ruhm, 2011)”
o “Statutory retirement age laws may also influence health and mortality (Coe and Zamarro, 2011)”
“Less is known about the health impact of unemployment insurance and other employment protection laws”
o “However, the negative effects of unemployment on workers’ subsequent earnings are mitigated through generous unemployment benefit systems or strict labor market regulation (Gangl, 2004; Gangl, 2006)”
o “More evidence is needed to assess whether differences in these policies contribute to the US health disadvantage”
Income support policies
“After taxes and transfers, poverty rates are considerably higher in the US than in other OECD countries, particularly among children”
o “In 2010, 21% of children in the United States lived in poverty, compared with 11% in France, 10% in the United Kingdom, and 8% in Sweden (OECD Income distribution: Poverty, 2013)”
o “In 2006, educational deprivation –a measure of whether children have the necessary items for school - was 5% in the United States, as opposed to 1% in France and 2% in Sweden and the United Kingdom”
o “These differences partly reflect the fact that cash minimum-income benefits are considerably lower in the US than in most other OECD countries (OECD Tax and Benefits, 2013)”
“There is some evidence that income transfer programmes have important health effects on low-income mothers and their children”
o “Expansions of the Earned Income Tax Credit may have led to increased birth weight and reduced maternal smoking (Strully et al., 2010)”
o “Similarly, pregnancies exposed to the Food Stamps program had better birth outcomes than pregnancies unexposed, particularly among African American mothers (Almond et al., 2011)”
“Income transfer programmes may also improve the health of older Americans”
o “For example, an increase in state maximum Supplemental Security Income benefits was shown to reduce disability among older Americans (Herd et al., 2008)”
“Comparable programmes in Europe are far more comprehensive than those in the US (Alesina et al., 2001; OECD Benefits and Wages: Statistics, 2012), which may contribute to the poorer health of Americans (Avendano et al., 2009; Avendano et al., 2010)”
