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OCR for page 207
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.
