8

Policies and Social Values

Chapters 4-7 identified intriguing differences between the United States and other high-income countries that might plausibly contribute to the health gap:

•   The U.S. health system suffers from a large uninsured population, financial barriers to care, a shortage of primary care providers, and potentially important gaps in the quality of care (Chapter 4).

•   Americans have a higher prevalence of certain unhealthy behaviors involving caloric intake, sedentary behavior, drug use, unprotected sex, driving without seatbelts, and the use of firearms (Chapter 5).

•   The United States lags in educational achievement, and it has high income inequality and poverty rates and lower social mobility than most other high-income countries (Chapter 6).

•   Americans live in an obesogenic built environment that discourages physical activity, and they live in more racially segregated communities (see Chapter 7).

Although each of these unfavorable patterns could be examined in isolation, the panel was struck by a recurring theme: data compiled from unrelated sources show that the United States is losing ground to other high-income countries on multiple measures of health and socioeconomic well-being. This finding is true for the young and old and perhaps even for affluent and well-educated Americans. Other rich nations outperform the



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8 Policies and Social Values C hapters 4-7 identified intriguing differences between the United States and other high-income countries that might plausibly con- tribute to the health gap: • The U.S. health system suffers from a large uninsured population, financial barriers to care, a shortage of primary care providers, and potentially important gaps in the quality of care (Chapter 4). • Americans have a higher prevalence of certain unhealthy behav- iors involving caloric intake, sedentary behavior, drug use, unpro- tected sex, driving without seatbelts, and the use of firearms (Chapter 5). • The United States lags in educational achievement, and it has high income inequality and poverty rates and lower social mobility than most other high-income countries (Chapter 6). • Americans live in an obesogenic built environment that discourages physical activity, and they live in more racially segregated commu- nities (see Chapter 7). Although each of these unfavorable patterns could be examined in isolation, the panel was struck by a recurring theme: data compiled from unrelated sources show that the United States is losing ground to other high-income countries on multiple measures of health and socioeconomic well-being. This finding is true for the young and old and perhaps even for affluent and well-educated Americans. Other rich nations outperform the 207

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208 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE United States not only on health status but also on protecting children from poverty, educating youth, and promoting social mobility. It is highly likely that the U.S. health disadvantage has multiple causes and involves some combination of unhealthy behaviors, harmful environ- mental factors, adverse economic and social conditions, and limited access to health care.1 Although there are a number of explanations for the U.S. health disadvantage, the panel began to consider the possibility that this confluence of problems reflects more upstream, root causes. Is there a “common denominator” that helps explain why the United States is losing ground in multiple domains at once? This pattern began decades ago. As long ago as the 1970s and 1980s, the United States began losing pace with other high-income countries in preventing premature death, infant mortal- ity, and transportation-related fatalities; in alleviating income inequality and poverty; and in promoting education. More research is needed to determine if there is a common underlying cause, but the panel did discuss possibilities, such as characteristics of life in America that create material interests in certain behaviors or business mod- els. For example, those characteristics include the typically pressured work and child care schedules of the modern American family, the strong reliance on automobile transportation, and delays created by traffic congestion often leave little time for physical activity or shopping for nutritious meals. Busy schedules create a market demand for convenient fast food restaurants.2 It is plausible, but as yet unproven, that societal changes in the United States in the post–World War II period set the stage for many of the deteriorating conditions that appeared in the 1970s and continue to this day.3 Certain character attributes of the quintessential American (e.g., dyna- mism, rugged individualism) are often invoked to explain the nation’s great achievements and perseverance. Might these same characteristics also be associated with risk-taking and potentially unhealthy behaviors? Are there health implications to Americans’ dislike of outside (e.g., government) 1 Similarly, there are also probably multiple explanations for the health advantages the United States experiences relative to other countries, such as the potential dietary, medical, and policy explanations for the country’s below-average rate of stroke mortality. 2 The panel notes the “chicken and egg” question of whether U.S. preferences—for fast foods, traveling in large automobiles, etc.—originated historically from consumer demand or from efforts by companies to create a market for these products and build an infrastructure for them (e.g., highways, drive-in restaurants) that is less prevalent in other rich nations. The currently strong market demand for these products in a society that has grown accustomed to a life-style that depends on these conveniences provides less incentive for businesses to change and strengthens the argument that they are providing products and services that consumers want. 3 Some of these trends are increasingly observed in other countries as well.

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POLICIES AND SOCIAL VALUES 209 interference in personal lives and in business and marketing practices? Few quantitative data exist to answer these questions or to assert that these characteristics actually occur more commonly among Americans than among people in other countries.4 Nor is it reasonable to apply a stereotype to an entire society, especially one with the demographic, geographic, and cultural diversity of the United States. Still, for a variety of social or histori- cal reasons, these values have salience for a large segment of U.S. society and may be important in understanding the pervasiveness of the U.S. health disadvantage. The nature of the interaction between the free market economy and consumer preferences may also be somewhat distinctive in the United States. Manufacturers and other businesses cater to consumer demand for products and services that may not optimize health (e.g., soft drinks and large portion sizes) or, as in the case of cigarettes, are dangerous (Brownell and Warner, 2009). The tobacco industry’s long success in manufacturing and marketing products that have been known for five decades to cause cancer and other major diseases (Kessler, 2001; Lovato et al., 2003) reflects, in part, a symbiotic interdependence between producers and consumers who want (or are addicted to) the products. Another systemic explanation considered by the panel is whether there is something unique in how decisions are made in the United States, in contrast with other countries, which might produce different policy choices that affect health. Not all of the problems identified in this report are affected by policy decisions—many relate to individual choices or perhaps the inherent nature of life in America—but decisions by government and the private sector may play a role in shaping many of the health determinants discussed throughout this report. THE ROLE OF PUBLIC- AND PRIVATE-SECTOR POLICIES The relevance of public policy to health is perhaps most conspicuous in relation to recognized problems in the U.S. health care system—­imited l access, especially for people who are poor or uninsured; fragmentation, gaps, and duplication of care; inaccessibility of medical records; and misalignment of physician and patient incentives (Institute of Medicine, 2001, 2010)—and the policies that are designed to address them. But the potential causes of the U.S. health disadvantage go beyond health care practice and policy. People are responsible for their individual behaviors, but individual life-styles are also influenced by the policies adopted by communities, states, and national leaders (Brownell et al., 2010). Ciga- 4  However, there is qualitative evidence regarding these characteristics from research in political science, anthropology, and other social science disciplines.

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210 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE rette smoking, second-hand smoke inhalation, and societal norms about smoking are influenced by the price of cigarettes, bans on indoor smoking, and advertising regulations (Brownson et al., 2006; Garrett et al., 2011). The obesogenic environment reflects decisions by the food industry and restaurants about the content and sizes of their offerings; business strate- gies about where to locate supermarket chains and fast food outlets; ballot decisions on parks, playgrounds, and pedestrian walkways; school board policies on high-calorie cafeteria menus and vending machine contracts; and the marketing of electronic devices to children (Brownell and Warner, 2009; Institute of Medicine, 2006, 2009b, 2009c, 2011c; Nestle, 2002). Public- and private-sector policies affect drinking and driving, binge drinking, prescription and illicit drug abuse, and the use of contaminated needles by injection drug users. Policies can also influence access to con- traceptives and firearms. Both the incidence and lethality of injuries are affected not only by personal choices, but also by decisions made by manu- facturers, builders, lawmakers, and regulatory agencies that control product safety, road design, building codes, traffic congestion, law enforcement of safety regulations (e.g., use of seatbelts, blood alcohol testing), fire hazards, and the availability of firearms. Policies also affect the social and economic conditions in which people live, and the quality of education—from preschool through college and pro- fessional schools (Bambra et al., 2010). Political and economic institutions, which help drive the economic success of nations, are subject to a range of public policies (Acemoglu and Robinson, 2012). Tax policy and decisions by employers, business leaders, government, and voters affect job growth, household income, social mobility, savings, and income inequality. They determine the strength of safety net and assistance programs and the quality of the environment, from its physical characteristics (e.g., pollution, hous- ing quality) to social surroundings (e.g., crime, stress, social cohesion). The relevance of macroeconomic government policies on health was exhibited in a natural experiment when East and West Germany unified in 1989-1990: after unification, the mortality rates for the elderly in the eastern part of the country declined to those of the western part (Scholz and Maier, 2003; Vaupel et al., 2003).5 5  The German experience also provides a useful reminder that interventions to improve health outcomes (and address the U.S. health disadvantage) can be effective among older adults. Notwithstanding the importance of addressing the causes of the U.S. health disadvan- tage among young people (e.g., violence, transportation-related accidents) and the influence of early life conditions on future health trajectories (see Chapter 3), policies to improve the health of middle-aged and older adults are also vitally important.

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POLICIES AND SOCIAL VALUES 211 THE ROLE OF INSTITUTIONAL ARRANGEMENTS ON POLICIES AND PROGRAMS Policies that affect public health, education, and the economy are them- selves shaped by the institutional arrangements in a society—the govern- mental and nongovernmental arrangements that organize social relations, rank people into social hierarchies, assign worth, structure employment and the labor market, and address working conditions (Bambra and Beck- field, 2012). As illustrated in Table 8-1, some studies of what has been described as the political economy of health (Muntaner et al., 2011) have demonstrated a positive association between styles of governance and health outcomes. Institutional arrangements in a society determine the population’s entitlement and access to housing, health care, education, pensions, unemployment insurance, collective bargaining, political incor- poration, incarceration, and culture (Hall and Lamont, 2009; Krieger et al., 2008; Pinto and Beckfield, 2011). These influences are multilayered and complex. Figure 8-1 presents a model by Hurrelmann and colleagues (2011), which illustrates the multitude of social and political factors that contribute to population health and, by extension, to cross-national dif- ferences in health. The U.S. approach to policies that relate to health and social pro- grams is what sociologists classify as an Anglo-Saxon or liberal model TABLE 8-1  The Association Between Political Themes and Health Outcomes: Findings of 73 Empirical Studies Positive Inverse Association Association Mixed Political Theme of with Healtha with Healthb Resultsc Countries N (%) N (%) N (%) Total N Democracy 21 (81) 3 (12)   2 (8) 26 Globalization   1 (17) 4 (67)   1 (17)  6 Egalitarian political tradition   9 (90) 1 (10)  0 10 Welfare state generosity 19 (61) 1 (3) 11 (36) 31 Total N (%) 50 (69) 9 (14) 14 (19) 73 (100) aPoliticalvariable demonstrates a positive, direct or indirect, association with a population- related health outcome. bPolitical variable demonstrates a negative, direct or indirect, association with a population- related health outcome. cPolitical variable is either unrelated or inconsistently related to a population-related health outcome. SOURCE: Adapted from Muntaner et al. (2011, Table 2).

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212 FIGURE 8-1  A model of structural and political influences on population health. SOURCE: Hurrelmann et al. (2011, Figure 3). FIG8-1.eps bitmap, marked changes not made, landscape

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POLICIES AND SOCIAL VALUES 213 (Esping-Andersen, 1990).6 In this terminology, “liberal” refers to the many English-speaking countries with economies that are more oriented to the free market (with relatively low levels of regulation, taxes, and government services) than other capitalist economies. Sociologists distinguish the Anglo- Saxon/liberal model of the United States and the United Kingdom from countries like Sweden, which operate under a social democratic model in which the state makes generous commitments to full employment, income protection, housing, education, health, and social insurance. Most Euro- pean welfare programs came into existence after World War II with the goal of providing more universal access to assistance (Bambra and Beckfield, 2012). The social democratic model promotes social equality through wage compression, organized through strong collective bargaining by unions, and tax policies that direct resources to the social security system (Bambra and Beckfield, 2012).7 As detailed in Part I of the report, the Scandinavian (social democratic) countries generally have higher health rankings than the United States, along with more favorable measures of social and economic well-being. As a group, these social democratic countries report longer life expectancies, lower infant mortality rates, and better self-rated health than do liberal countries, includ- ing both the United States and the United Kingdom (­ ambra, 2005, 2006; B Chung and Muntaner, 2007; Coburn, 2004; Eikemo et al., 2008b; Lundberg et al., 2008; Navarro et al., 2003).8 Figure 8-2 shows the high infant mortal- ity rates that exist in liberal countries, especially the United States. Figure 8-3 shows that this pattern has existed for decades (Conley and Springer, 2001). Sociological research is beginning to suggest that the style of gov- ernance in a country may exert its own influence on health outcomes, independent of individual-level variables. One study found that whether a country had a social democratic, Anglo-Saxon/liberal, or other sociopoliti- cal model explained 47 percent of the variation in life expectancy between countries (Karim et al., 2010). Another study concluded that the model type predicted approximately 20 percent of the difference in infant mortality 6  As distinct from the meaning of “liberal” as commonly used in the United States to describe left-leaning or progressive social or political ideology. 7  number of other typologies have been proposed: see, for example, Bonoli (1997); Castles A and Mitchell (1993); Eikemo and Bambra (2008); Ferrera (1996); Korpi and Palme (1998); Leibfreid (1992); and Navarro and Shi (2001). 8  There is substantial between-country variation within Scandinavia (Christensen et al., 2010), and health outcomes in Scandinavian countries are not always the best. For example, mortality rates in Denmark approach those of the United States, and Finland has high mor- tality rates for some conditions. Similarly, there is substantial between-country variations in Anglo-Saxon/liberal countries, such as the marked differences between the United States and England discussed in previous chapters.

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214 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE 8 (deaths per 100,000 live births) 7 6.83 6.75 Infant Mortality Rate 6 5.53 5.65 5.29 5 4.4 3.98 4 3 2 1 0 es * rn e n n al n Ɵv ia ia r er he ste av As at va Lib ut St Ea in er st So nd d Ea ns ite a Co Sc Un Welfare Regime Type FIGURE 8-2 Infant mortality rate for the United States and 30 other countries, classified by welfare regime type. Fig8-2.eps *The United States is included in the group of countries classified as having “­ iberal” L regimes, but it is also presented here in isolation for comparison. NOTE: Scandinavian countries: Denmark, Finland, Norway, Sweden; Conserva- tive countries: Austria, Belgium, France, Germany, Luxembourg, the Netherlands, Switzerland; East Asian countries: Hong Kong, Japan, Korea, Singapore, Taiwan; Liberal countries: Australia, Canada, Ireland, New Zealand, United Kingdom, United States; Southern countries: Greece, Italy, Portugal, Spain; Eastern countries: the Czech Republic, Hungary, Poland, Slovenia. SOURCE: Adapted from Karim et al. (2010, Table 5). rates among countries and 10 percent of the difference in low birth weight (Chung and Muntaner, 2007). However, the panel notes the limitations of current evidence on this topic, which relies heavily on cross-sectional associations. Such associa- tions often provide only circumstantial evidence; they do not prove a causal effect, and population trends may not apply to individuals (the “ecological fallacy”). Controlled trials to produce more definitive evidence would be untenable, and all studies on this subject must cope with a variety of meth- odological challenges, such as the potential endogeneity of the political and social environments, as well as issues relating to aggregate efficiency, inter- temporal dynamics, and macroeconomic effects. Typologies for regimes, such as welfare states, can be blunt measures that require further refinement to properly differentiate policy nuances across and within countries and to

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POLICIES AND SOCIAL VALUES 215 track changes that affect countries over time.9 For these reasons, among others, research on the effect of welfare states on population health has often produced mixed results and has not fully explained cross-national health patterns. For example, social democratic countries like Sweden had low infant mortality rates early in the 20th century (Regidor et al., 2011), even before the introduction of their social welfare benefits, prob- ably because of improved sanitation and other public health interventions (­ urström et al., 2005). B There is little question that the European welfare model is effective in redistributing income and reducing poverty. More universal and generous welfare systems achieve greater income equality than other systems through more generous income transfers through taxes and services (Esping-Andersen and Myles, 2009). These entitlement benefits may buffer the health effects of material deprivation and thereby improve health outcomes but they may have other consequences that are not economically or politically viable in the United States. Related characteristics of Scandinavian society, such as greater gender equality (Stanistreet et al., 2005) and social cohesion (Putnam, 2000), are also cited as potential explanations for the region’s relatively good health outcomes. Political empowerment of minority groups and women appears especially important to health (Beckfield and Krieger, 2009). As noted in Chapter 7, citizen engagement in the United States, such as voting in elec- tions, is lower than in most other OECD countries (2011e), and the United States has one of the lowest rates of female participation in the national legislature (Congress) (Armingeon et al., 2012). Scandinavian society is also known for having less income inequality than in the United States (see Chapter 6), a likely product of the welfare state. The Luxembourg Income Study provides evidence that social democratic policies have, over time, substantially reduced income inequality (Alderson and Nielsen, 2002). The Scandinavian welfare programs (universalism, gen- erous wage replacement rates, extensive welfare services) may also narrow income inequalities and provide low-income individuals with greater access to services (Coburn, 2004). However, as discussed in Chapter 6, it remains unclear whether income inequality itself, or the policies that affect income inequality, bear more on the U.S. health disadvantage (Beckfield, 2004). There is some evidence to suggest that aggregate spending on social programs is associated with better health. One study examined spending 9  The categories assume that all the policies in a particular regime reflect a similar approach and that each category reflects a coherent set of principles, neither of which may be true (Kasza, 2002). No single country adheres to all aspects, and there is internal policy varia- tion within individual welfare states and among the countries of each welfare state regime (Bambra, 2007).

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216 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE 40 Social DemocraƟc Liberal CorporaƟst Infant Mortality Rate (deaths per 1,000 live births) 30 20 10 0 60 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 Year FIGURE 8-3  Infant mortality rates by welfare regime type, 1960-1992. FIG8-3.eps NOTE: In this study, corporatist countries included Austria, Belgium, France, Ger- many, and old type masked in Photoshop and replaced with new bitmap, Italy. SOURCE: Conley and Springer (2001, Figure 3). on health care and social services in 30 OECD countries and found that U.S. spending on social services (13.3 percent of gross domestic product [GDP]) was less than the OECD average (16.9 percent) and less than that of all countries except Ireland, Korea, Mexico, New Zealand, and the Slovak Republic (Bradley et al., 2011).10 The ratio between spending on 10  Social services expenditures included public and private spending on old-age pensions and support services for older adults, survivors benefits, disability and sickness cash benefits, family support, employment programs (e.g., public employment services and employment training), unemployment benefits, housing support (e.g., rent subsidies), and other social policy areas excluding health expenditures.

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POLICIES AND SOCIAL VALUES 217 social services and health care was 0.91 in the United States and 2.00 in the OECD. More importantly, the study found a significant association between social spending and life expectancy, infant mortality, and poten- tial years of life lost (Bradley et al., 2011).11 Another study also found an association between social spending12 and mortality in an analysis of 15 European countries (Stuckler et al., 2010). According to that study, each additional $100 per capita in social spending was associated with a 1.19 percent decrease in all-cause mortality (Stuckler et al., 2010). In a commentary about the U.S. health disadvantage, Avendano and Kawachi (2011) noted a number of potentially important differences between the United States and Europe that may affect health: European tax systems are more progressive, child benefits are traditionally avail- able for parents in many countries regardless of income, social programs are generally not restricted to the poor, employment protection is sub- stantially higher, unemployment benefits are more generous, and labor standards for working parents are more extensive. Authors of another study also noted that the United States ranks poorly on measures of full- time employment, public child care, union representation, and parental leave (Pettit and Hook, 2009) (see Table 8-2). Many of these may be less acceptable in the United States because of related tax burdens and other implications. In seeking a systemic cause for the U.S. health disadvantage, Avendano and Kawachi (2011, p. 4) noted the following: We have suggested a potentially promising line of inquiry based upon dif- ferences in social policy contexts. However, the challenge is obviously to identify the particular social and labor policies that have a causal impact on health and that may contribute to cross-national health differences. For example, do the more generous parental leave policies in Europe contrib- ute to their comparative health advantage? Have employment protection policies contributed to the better health of European workers compared with their U.S. counterparts? The great variation in policy reform during the last 50 years across Europe and the United States provides us with a potentially fruitful set of natural experiments to consider. Broadening the scope of our inquiry to include the social and policy context of nations might help to solve the puzzle of the U.S. health disadvantage. 11  Social spending was also associated with low birth weight, a finding the authors specu- lated might reflect genetic factors or sociocultural features of the population that were not controlled for in the analysis. 12  This study defined social spending as spending related to family support programs (such as preschool education, child care, and maternity or paternity leave), old-age pensions and survivors benefits, health care, housing (such as rent subsidies), unemployment benefits, active labor market programs (to maintain employment or help the unemployed obtain jobs), and support for people with disabilities.

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228 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE BOX 8-2  Continued of intensive campaigns of selective testing at sobriety checkpoints in U.S. jurisdictions (following procedures now legal in most states) have reported reductions of 20 to 26 percent in alcohol fatal injury crashes (Shults et al., 2001, 76; Fell et al., 2004, 226). In the United States in 2008, 12,000 persons were killed in crashes involving a driver who was alcohol-impaired (National Highway Traffic Safety Administration, 2009). Therefore, widespread implementation of sustained, high-frequency sobriety testing programs in the United States could be expected to save 1,500 to 3,000 lives annually. Seatbelts The TRB report noted that almost every high-income country requires the use of seatbelts, but the share of front seat occupants who use seat- belts is lower in the United States than in many of these countries (see Table 5-1, in Chapter 5). The report noted the effects of decentralized safety regulation (a major theme of the report) and political opposition (p. 181): The cases of seat belts and of motorcycle helmets . . . provide clear illustrations of how public and political attitudes can restrain risk-reducing measures despite the availability of effective and well-managed coun- termeasure programs in many states. The effectiveness of seat belts in reducing casualties and of specific interventions (primary laws and high-visibility enforcement) in increasing usage are well established by research and by the experience of many states. The interventions are not complex or expensive compared with the efforts required for speed control or impaired-driving control. Nonetheless, some jurisdictions have chosen not to apply these measures. Speed Control Speeding may contribute to as many as one-third of fatal accidents (Aarts and van Schagen 2006, pp. 220, 223), and speed is an aggra- vating factor in the severity of all accidents. In light of these findings, the results of a survey by the Governors Highway Safety Association (2005, p. 5) are especially troubling: “[S]tates are becoming increasingly concerned that gains made in the areas of safety restraint usage and impaired driving have been offset by increased fatalities and injuries due to higher speeds.” In addition, the TRB report noted (p. 151): [I]n contrast, in several of the countries that are making the greatest progress in highway safety, speed control is one of the interventions receiving the greatest attention and resources. If speed control is weak- ening in the United States, this trend may explain part of the safety performance gap between the United States and other countries.

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POLICIES AND SOCIAL VALUES 229 The TRB report documented how U.S. failures in addressing this problem span research, planning, practice, and policy: see table below. In compar- ing U.S. policy with efforts in benchmark countries, the report concluded (p. 233): Successful speed management initiatives in other countries are of high visibility (through publicity and endorsement of elected officials), are long term (sustained for periods of years), target major portions of the road system, use intensive enforcement (e.g., automated enforcement and high penalties), sometimes use traffic-calming road features (such as narrow lanes and traffic circles that cause drivers to reduce speed), and monitor progress toward publicly declared speed and crash reduc- tion objectives. No U.S. speed management program today is compa- rable in scale, visibility, and political commitment to the most ambitious programs in other countries. Driving Speed Management in Selected Countries Speed Management France, United Kingdom, Strategy and Australia United Statesa Management and Focused program with Routine, low-level activity; Planning goals, strategy, and reactive management; budget no long-term plan Timely monitoring and No speed data; no mean- publication of relevant ingful crash data speed and crash data Episodic attention; occa- Long-term, multiyear, or sional enforcement permanent perspective crackdowns Technical Imple- Major portions of national Haphazard or spot mentation of or state road network enforcement Countermeasures targeted Automated enforcement Automated plus traditional not authorized or rarely enforcement used Penalties designed as Little attention to effective- part of the integrated ness of penalties program Political and Public Active support and Politically invisible except Support leadership of elected when speed limits officials; management altered or automated held accountable for enforcement proposed results aDoes not necessarily include all states. SOURCE: Transportation Research Board (2011, Table 4-3). continued

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230 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE BOX 8-2  Continued    The role of societal values is central in a striking observation by the AAA Foundation for Traffic Safety: “[C]urrent methods for controlling speed are virtually powerless in the face of this [U.S.] speeding culture” (Harsha and Hedlund, 2007, p. 1). This report notes that a successful nationwide program to reduce speeding will require political leadership at the federal, state, and local levels, starting with congressional action, as well as a staged approach to speed control campaigns that includes efforts to increase public awareness and support for these efforts. Safe Road Design and Highway Network Screening The TRB report found that definitive studies and data linking highway screening to safety improvements are still missing, but it also found that all countries have design standards for new construction and reconstruc- tion that are intended to improve safety.* The TRB report noted a shift in some benchmark countries’ road programs, which emphasize research on the relationship of design to crash and casualty risk, give higher prior- ity and earlier attention to risk reduction in the design of projects and in project programming, and are more willing to trade a degree of traveler convenience for the sake of safety. Road designers in these countries are expected to quantify the predicted crash frequency and to justify the level of risk in the design. Political Factors and Public Attitudes Interestingly, just as the TRB report’s opening paragraph parallels the cross-national mortality patterns observed by this panel, the committee that wrote that report also looked upstream in search of explanations *Unlike laws that proscribe risky individual behaviors (such as speeding), highway screen- ing and safe road design aim to make roads inherently safer. Highway screening programs use data to identify places with frequent crashes and then modify these locations to reduce accident risk. The changes can include adjusting alignment, widening shoulders, remov- ing roadside obstacles, improving signage and pavement markings, changing intersections, installing barriers, and increasing traffic law enforcement. When new roads are built or old ones rehabilitated, various design standards can be used to introduce safer road character- istics, including alignment; lane, shoulder, and median widths; sight distance; superelevation (i.e., banking on curves); pavement surface; number of lanes; intersection design; and the roadside environment.

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POLICIES AND SOCIAL VALUES 231 for the U.S. poor performance on traffic safety. The committee noted the following obstacles (p. 14): •  ecentralization: in most benchmark countries, regulation and D enforcement are highly centralized, often the responsibility of a single national authority, whereas in the United States, 50 states and thousands of local jurisdictions are responsible for traffic safety and the operation of the highway system; •  ublic attitudes that oppose measures common elsewhere: for P example, in the United States, motorcycle helmet laws and speed enforcement using automated cameras often encounter active pub- lic opposition; •  eak support for or opposition to rigorous enforcement in legisla- W tures and among the judiciary; •  he constitutional prohibition of unreasonable searches, which T prevents police from conducting driver sobriety testing without probable cause, a common practice in some other countries; and •  esource limitations that prevent enforcement of the intensity com- R mon in other countries. The obstacles are, to an extent, the product of differences in political systems and in the physical characteristics of transportation systems, and possibly of other social and cultural factors. Many of these underlying explanations are not only applicable to traffic fatalities but also may contribute to other health and injury risks that are more prevalent in the United States than elsewhere (as detailed in this and other chapters). For example, decentralization contributes to lapses in traffic safety, to fragmented public health, and medical care systems in the United States (Institute of Medicine, 2011d). Opposition to rigorous enforcement applies to speed control, life-style choices, and restrictions on industry. Constitutional prohibitions restrict not only unreasonable searches but also proscribe interventions on gun possession. Resource limitations apply not only to law enforcement but also explain deficiencies in public health programs (Institute of Medicine, 2012), the foods chosen for school lunch menus (Institute of Medicine, 2010b), and weakness in social and safety net services.

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232 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE (portrayed in the bottom of the diagram), policy solutions occupy the diverse domains at the top: macro issues, such as the built environment that enables children to engage in outdoor physical activity and farm subsidies for corn-based food products, as well as other obesogenic influences, such as cultural norms about body image, commercial messaging, local food environments, and the effects of material deprivation and psychological stresses. A key finding of this report is the alarming scale of health disadvantage among children and adolescents in the United States compared with their peers in other high-income countries. This finding has major implications not only for public health (especially when today’s children become tomor- row’s older adults), but also for the economy and national security (World Economic Forum, 2011). The spectrum of problems that disproportionately affect youth in the United States relative to other countries covers virtu- ally every aspect of their lives: the risk of infant mortality and low birth FIGURE 8-4  A life-course perspective on childhood obesity. NOTES: BPA: bisphenol A; HPA: hypothalamic-pituitary-adrenal axis. The life span FIG8-4.eps is depicted horizontally; factors are depicted hierarchically, from the individual level at the bottom of the figure to the community level made of the figure. bitmap, no changes at the top SOURCE: Trasande et al. (2009, Figure 1).

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POLICIES AND SOCIAL VALUES 233 weight; injuries and homicide; behavioral health problems involving drug use, high-risk sex, and depression; high rates of childhood disease (e.g., obesity, diabetes, asthma); high rates of child poverty; lower educational achievement; and lower social mobility. This list is a powerful signal for greater attention and investment in policies and programs for children and families (National Research Council and Institute of Medicine, 2008) but, historically and even now, the United States has made greater investments in assisting the elderly than the nation’s youth. Some analysts have concluded that the underinvestment in children and adolescents may be the product of their limited political power compared with older voters (Isaacs et al., 2012; Preston, 1984). Those investments in older adults have produced important social and public health benefits for older Americans and offer an important avenue for addressing the U.S. health disadvantage, but the problems that affect the nation’s youth deserve greater investment. Maternal and child well-being are clearly important to any nation’s health, and a comprehensive review of this component of population health in the United States is beyond the scope of this panel. However, the areas of disadvantage among U.S. children and adolescents relative to other rich nations that we document point to a number of important areas that should be considered. These include environmental factors—at home, school, and elsewhere—that promote obesity and limit physical activity; the need for child care and early childhood education; reducing barriers that children and mothers face in obtaining essential preventive services and health care; providing a range of supports for youth, especially around sexual health and preventing tobacco, alcohol, and other drug use; and interventions to prevent car crashes and fatalities that involve children or young drivers. Child protection policies would also be important to reduce children’s exposure to family violence, crime, and the risk of violent deaths (especially from firearms), to unhealthy air and housing, to the material deprivations of poverty, and to schools and home environments that compromise learning, educational opportunities, and social mobility. The life-course perspective is a reminder that adverse exposures dur- ing childhood—from fetal life through other critical periods of children’s physical, sexual, and emotional development—have profound implications in shaping health outcomes later in life and, increasingly, the chances of even surviving to old age. Investing in today’s youth is thus an investment in all age groups. SPENDING PRIORITIES The familiar adage to “follow the money” is a reminder that a society’s policy priorities are often reflected in budget decisions. The panel’s review of data on the U.S. health disadvantage and its potential causes shows that

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234 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE the United States often spends less per capita in many of the areas in which its performance is lagging, with the obvious exception of health care. Levels of spending should be interpreted with caution because they say little about the efficiency or effectiveness of programs, but the spending patterns of the United States stand in contrast to those of other high-income countries with better health outcomes. Examples include early childhood education, family and children’s services, education, and public health. • Early childhood education: In 2007, the United States spent only 0.3 percent of its GDP on formal preschool programs (for children aged 3-5 years), less than that of seven peer countries and even some emerging economies in Eastern Europe (OECD, 2012i). • Family and children’s services: Total public spending by the United States on services for families and young children places the United States last among the 13 peer countries studied. In 2004, the most recent year reported by the OECD, the United States devoted only 0.78 percent of GDP to public services for families and young children, whereas Nordic countries spent approximately 4 percent (OECD, 2006). Only Korea ranked lower than the United States on the proportion of its economy devoted to public services for families and young children. • Public health: According to many analyses, public health is system- atically underfunded in the United States (Institute of Medicine, 2012; Mays and Smith, 2011), for a variety of reasons (Hemenway, 2010), but valid data for international comparisons are lacking. The OECD does measure the proportion of public expenditures devoted to health and to public health, but classification schemes are too variable by country to draw meaningful inferences. • Social services: Compared with other countries, the United States spends less on social programs, subsidies, and income transfers than do other countries (see Figure 8-5). As noted above, U.S. spending on social services (13.3 percent of GDP) was less than the OECD average (16.9 percent) and that of all 30 countries except Ireland, Korea, Mexico, New Zealand, and the Slovak Republic (Bradley et al., 2011). A recent report found that the United States spent less on public social protection (as a percentage of GDP) than any peer country but Australia and less than some emerg- ing economies, including Russia and Brazil (International Labour Office, 2011). In contrast, however, the United States ranks high on public spending on education. In 2008, U.S. spending per student on public education (pri- mary through tertiary levels) was equaled only by Switzerland. Among all

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POLICIES AND SOCIAL VALUES 235 Switzerland United States Australia Japan Canada Spain Portugal Netherlands United Kingdom Norway Italy Finland Germany Austria France Denmark Sweden 0 5 10 15 20 25 30 35 40 Percentage of Gross Domestic Product FIGURE 8-5  Social benefits and transfers, 17 peer countries, 2000. NOTES: Social benefits reflect current transfers to households in cash or in kind to provide for the needs that arise from certain events or circumstances (e.g., sickness, unemployment, retirement, housing, education, family circumstances) that may ad- Figure 8.5 versely affect the well-being of households either by imposing additional demands on resources or by reducing incomes. Transfers are typically made by governments. SOURCE: Data from National Accounts at a Glance: 5. General Government, OECD (2012l). OECD countries, the United States had the fifth highest public expenditure per student on primary education, the fourth highest for secondary educa- tion, and the highest for tertiary education (OECD, 2011a). Measured as a percentage of GDP, U.S. public expenditures on education ranked eighth (tied with France, Ireland, Israel, the Netherlands, Switzerland, and the United Kingdom) (OECD, 2012h). Many of the programs discussed above are financed in other countries by taxes, an approach with limited political support in the United States. Of the 17 peer countries that are the focus of Part I of this report, 11 report a higher tax burden than the United States (U.S. Census Bureau, 2008).16 Since the 1980s, no country in this peer group except Switzerland has spent less than the United States (as a percentage of employee-employer payroll 16  Tax burden is defined as the percentage of gross wage earnings of the average produc- tion worker that is spent on income tax plus employee social security contributions less cash benefits.

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236 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE taxes) on social security programs such as old-age, disability, and survivors insurance; public health or sickness insurance; workers’ compensation; unemployment insurance; and family allowance programs (U.S. Census Bureau, 1995). CONCLUSIONS Nine areas of health disadvantage are documented in Part I of this report: • adverse birth outcomes; • injuries, accidents, and homicides; • adolescent pregnancy and sexually transmitted infections; • HIV and AIDS; • drug-related mortality; • obesity and diabetes; • heart disease; • chronic lung disease; and • disability. There are policy implications for each of these. Although much is still to be learned, for many of these public health issues there are evidence- based policies that could address them at the national, state, and local levels. Policy is also relevant to the unfavorable social, economic, and environ- mental conditions identified in this report as potential contributors to the U.S. health disadvantage. A variety of policies can contribute to high pov- erty rates, unemployment, inadequate educational achievement, low social mobility, and the absence of safety net programs to protect children and families from the consequences of these problems. However, identifying and implementing policy solutions is a formidable challenge. For example, national health objectives to address many of the conditions listed above were adopted decades ago by the federal government but only some have been achieved, a problem that global initiatives to improve public health have also encountered. Although there have been important public health successes in the United States and elsewhere, such as the remarkable progress in reducing the rate of tobacco use (Brownson et al., 2006), a variety of barriers have impeded progress on other fronts, such as stemming the obesity epidemic or reducing smoking among adolescents. Other high-income countries with better health status, lower rates of poverty, and more impressive advances in education may owe their success to creative policies or strategies that could find application in the United States. These suppositions, however, amount only to informed speculation and are without empirical evidence. This panel did not undertake a system-

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POLICIES AND SOCIAL VALUES 237 atic review of the policies and outcomes in other countries, but we believe that such an exercise would be worthwhile to identify useful lessons (see Chapter 9). Reports like the Transportation Research Board study (see Box 8-1) would be valuable for each of the leading causes of the U.S. health disadvantage. However, there are valid questions about the generalizability of “imported” models from overseas, and comparisons with other coun- tries—even other high-income countries—may be seen as less applicable if the comparison countries are much smaller, have a more homogenous population, or have very different social or political systems. The Measurement and Evidence Knowledge Network (Kelly et al., 2007, pp. 31-32) examined these issues in its final report to the World Health Organization Commission on the Social Determinants of Health. Its conclusions included the following challenges to implementation of such policies: • [Social factors and other nonmedical determinants of health (SDH)] are multifaceted phenomena with multiple causes. [Although] con- ceptual models of SDH are useful, they do not necessarily provide policy makers with a clear pathway towards policy development and implementation. As specific policy initiatives tend to be tar- geted to a specific (population) group in certain circumstances and for prescribed time-periods, they can neglect the wider context within which the social and other determinants are generated and re-generated. • . . . [R]ecent studies of SDH have emphasized the significance of the life-course perspective (Blane, 1999). Such a perspective poses serious challenges to policy-making processes whose time-scales are rarely measured over such long periods. The tenure of elected or appointed officials is measured in months and years rather than decades. Moreover, coalitions of interests in support of [these policies] may be unsustainable over the time periods necessary to [achieve] significant change. There have been some exceptions to this [general finding], especially in the field of public pension poli- cies, but the general problem of time-scales remains important. • . . . SDH necessarily imply policy action across a range of different sectors. It is increasingly recognized that action beyond health-care is essential and, as such, intersectoral partnerships are critical to formulating and implementing effective . . . [policies]. However, there is a significant body of evidence which shows that partner- ships are hampered by cultural, organizational, and financial issues (Sullivan and Skelcher, 2002). • Traditionally, government agencies have been organized vertically according to service delivery (Bogdanor, 2005; Ling, 2002) and

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238 U.S. HEALTH IN INTERNATIONAL PERSPECTIVE such “silo” or “chimney” approaches are not well equipped to tackle issues that cut across traditional structures and processes. The report notes that silos within and across agencies make it difficult for leaders who address one social factor (e.g., education) to interact with health agencies. With the exception of some success stories (e.g., school health), meetings across agencies occur only occasionally except the Cabinet level. Looking at policies on social factors and other nonmedical determi- nants of health, the report notes: • [They] must be viewed as only one of several competing priorities for policy makers’ attention and resources. Economic policy or foreign affairs [often] take precedence over health concerns. More specifically, SDH may be over-shadowed . . . by [concerns over] health-care itself. However, this health care focus is often to the neglect of health and [its broader determinants]. The report further notes that a focus on health care also ignores the impor- tant connection between health and the economy: nonhealth policies that reduce disease burden and thus the costs of health care have enormous implications for medical spending and the economy itself (Milstein et al., 2011; Woolf, 2011). Unfortunately, the report notes, political realities often limit attention to “short-term [returns] rather than the long-term [ramifica- tions] and on discrete interventions rather than coordinated, collaborative initiatives. . . .” Lastly, the report notes that globalization has been chang- ing the role of national governments in shaping policy making: • G overnments’ ability to shape and mould SDH with the goal of improving their population’s health is becoming limited as many of the [upstream causes] no longer fall within their responsibility. There is a parallel argument that decentralization [of authority] to regions and cities has had a similar effect on the policy-making capacity of national governments. Ultimately, meaningful initiatives to address the underlying causes of the U.S. health disadvantage may have to address the distribution of resources that are now directed to other categorical priorities—a change that is likely to engender political resistance. Is a shift in priorities war- ranted? This report documents that the United States is not keeping pace with other high-income countries in many areas of health and socioeco- nomic well-being, and the consequences to the nation can be measured not only in lives, but also in dollars. Understanding why this is occurring and identifying policies that could reverse these unfavorable trends are clearly important for the nation’s future.