Each week it seems, more evidence emerges regarding the poor health of Americans. We first documented a "U.S. health disadvantage" as chair and study director of the panel on understanding cross-national health differences among high-income countries at the National Academies in 2013.
Our panel's report Shorter Lives, Poorer Health showed that, as long ago as 1980, the United States began to take a different path in terms of the health and survival of its population. We found evidence that the U.S health disadvantage compared to other countries existed among Americans at every age below 75, among all races/ethnicities, and among both men and women—but especially among women. We even found evidence of a health disadvantage among white, college-educated, non-obese, non-smoking, and health-insured Americans.
Why is This Happening?
Our panel considered the obvious explanations — deficiencies in the U.S. health care system, such as the lack of universal health insurance, and higher rates of unhealthy behaviors, such as those responsible for obesity. We also considered the physical and social environments in which Americans live, conditions that too often are not conducive to good health or longer lives. We documented the adverse socioeconomic conditions in the United States, such as inadequate education, higher poverty, especially child poverty, and greater income inequality than in other countries. We understood that all of these factors are powerful contributors to poor health and wellbeing, but we also recognized that these conditions exist because of the policies and spending priorities of our nation, our states, and our communities. The decisions we make as a society shape socioeconomic conditions, the design of our communities, our health behaviors, our access to health care, and how all of these are distributed across people and places.
An intriguing study featured in our report was a 2011 study by Elizabeth Bradley and her colleagues at Yale University, who compared the ratio of social spending to health care spending in various countries and found that countries that spent proportionately more on social services had longer life expectancy. The Bradley study, along with other work by Kimberly Morgan of George Washington University, showed that the U.S. is an outlier when it comes to spending on health and social welfare.
Bradley's study showed that the U.S. spends $2 on health care for every $1 spent on social services, while Morgan's showed that U.S. spending per capita on health and social welfare, including tax-based subsidies and private social spending, ranks fifth highest in the world (just behind Sweden). What distinguishes the U.S. is how that that money is spent: more goes to health care, while still leaving many without health insurance or access to care. Fewer dollars are spent on children, families, and the disadvantaged. Both studies conveyed a powerful message: Meaningful change in our nation's health may come less from investing in medical care than in addressing the social determinants of health. It's a timely message for the United States, given weekly confirmation of our poor state of health, as well as current debates about growing inequality and what to do about it.
A Chicken-and-Egg Question
Bradley and colleagues have just released a new study in the May issue of Health Affairs, exploring the same relationship between spending and health but this time comparing spending across the 50 U.S. states. For seven health outcomes ranging from obesity to mentally unhealthy days, the authors found a correlation between state health and the state's ratio of social spending to health care spending. The implication is clear: the tendency of state governments to curtail spending on budget items that support education, employment, housing, and safety-net programs—often to offset heavy expenditures on health care (e.g., Medicaid)—may ultimately undermine our health and thereby drive up the costs of health care. The problem in America may not be that we spend too much on our health but that we spend it the wrong way.
Unfortunately, the new study by Bradley does little to answer a number of unresolved issues that linger from her earlier work. Key among them is the "chicken and egg" question: is the social-to-health spending ratio correlated with health because social spending improves health or because healthier places (be they countries or states) have less need to spend on health care? The new study lags spending variables by one to two years to address this issue but health-promoting investments take much longer to document and observe in the context of lifecourse health development or from one generation to another. The authors' findings would have been more compelling if they had reported per capita spending rather than only the ratio, and if they had examined longer time horizons.
Although the authors rightly caution readers that association does not prove causation, their article concludes with a claim that a 20 percent change in the social/health spending ratio would be "associated with" the prevention of obesity among 85,000 adults. The nuance between association and causation was lost on the media: USA Today reported that "a 20 percent change in the median ratio of social to health spending would result in there being 85,000 fewer obese adults in a state the following year."
A Deeper Dive
The authors also should have shared a list of health outcomes found to be uncorrelated with their spending ratio: sometimes we can learn just as much from hypotheses unsupported by the empirical evidence. A valuable body of research that might serve as a model for this emerging area is the work of James Heckman on the long-term effects of investments in early childhood development, a social determinant of health in itself. We are witnessing the consequences of our country's inadequate investment in the health and human development of our children — our nation's future.
An important and practical question, especially for policymakers, is what social services matter most? Bradley's study collapses all manner of social services into a single measure, but a composite "kitchen sink" measure does little to delineate exactly where the benefit lies. There is every reason to believe that some of our social welfare spending is as ineffective and inefficient as some aspects of our health care spending.
Cross national studies of K-12 education by the Organisation for Economic Co-operation and Development indicate that, as with health care, the U.S. spends more than other high-income countries but we get much less bang for our buck. Clarifying which social services are responsible for the correlation with better health—and which are not—would go a long way toward advancing the evidence base in a way that decision-makers from across the political spectrum can use. This would include identifying programs and initiatives that should no longer be funded.
Diving into the data—both quantitative and qualitative—to unpack these details and generate actionable evidence is not an arcane academic exercise. Recent studies have underscored the gravity of poor U.S. health and the urgency to find solutions. David Kindig and Erika Cheng showed that mortality among women increased in 43 percent of U.S. counties between 1992–96 and 2002–06 (the corresponding figure for men was only 3 percent). Other work by researchers at the Urban Institute have shown that these increases are concentrated among white women in midlife, and that the primary causes of death appear to be accidental poisoning (linked to the prescription opioid epidemic), suicide, and obesity- and smoking-related diseases.
Yet more evidence about the poor health and survival of Americans has recently come from Anne Case and Angus Deaton (as reported in PNAS) and Raj Chetty and colleagues (as reported in The Journal of the American Medical Association). And finally, in April the CDC reported a dip in life expectancy among white women and rising suicide rates among many groups of Americans.
Each new study places a new piece of evidence into a larger jigsaw puzzle, and a worrying bigger picture is emerging as these puzzle pieces come together. The study by Bradley and colleagues reminds us that the answer to our health disadvantage cannot be solved by reforming health care alone or by admonishing Americans to adopt healthier habits. Rather, the social and fiscal issues that dominate today's news may matter as much or even more to our health than any cure medicine can render.
from Health Affairs BlogHealth Affairs Blog http://ift.tt/1Ufllyt
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