•   Do public health and medical care systems affect health outcomes?

•   Are U.S. health systems worse than those in other high-income countries?

•   Do U.S. health systems explain the U.S. health disadvantage?


As other chapters in this report emphasize, population health is shaped by factors other than health care, but it is clear that health systems—both those responsible for public health services and medical care—are instrumental in both the prevention of disease and in optimizing outcomes when illness occurs. The importance of population-based services is marked by the signature accomplishments of public health, such as the control of -vaccine-preventable diseases, lead abatement, tobacco control, motor vehicle occupant restraints, and water fluoridation to prevent dental caries (Centers for Disease Control and Prevention, 1999, 2011b). Public health efforts are credited with much of the gains in life expectancy that high-income countries experienced in the 20th century (Cutler and Miller, 2005; Foege, 2004). The effectiveness of a core set of clinical preventive services (e.g., cancer screening tests) is well documented in randomized controlled trials (U.S. Preventive Services Task Force, 2012), as are a host of effective medical treatments for acute and chronic illness care (Cochrane Library, 2012). For example, gains in cardiovascular health have occurred with the adoption of evidence-based interventions including antiplatelet therapy, beta-blockers, and reperfusion therapy (Khush et al., 2005; Kociol et al., 2012).

Although some authors have questioned the impact of medical care on health (McKeown, 1976; McKinlay and McKinlay, 1977), others estimate that between 10-15 percent (McGinnis et al., 2002) to 50 percent (Bunker, 2001; Cutler et al., 2006b) of U.S. deaths that would otherwise have occurred are averted by medical care. Across various countries, medical care is credited with 23-47 percent3 of the decline in coronary artery disease mortality that occurred between 1970 and 2000 (Bots and Grobbee, 1996; Capewell et al., 1999, 2000; Ford and Capewell, 2011; Ford et al., 2007; Goldman and Cook, 1984; Hunink et al., 1997; Laatikainen et al., 2005; Unal et al., 2005; Young et al., 2010).

Barriers to health care also influence health outcomes. Inadequate


3The same studies estimate that between 44 and 72 percent of the fall in mortality resulted from a reduction in cardiovascular risk factors (smoking, lipids, and blood pressure); see Chapter 5.

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