o   obesity and diabetes;

o   heart disease;

o   chronic lung disease; and

o   disability.

Part II considers potential explanations for this disadvantage and documents that important antecedents of good health are also frequently problematic in the United States:

•   The U.S. health system is highly fragmented, with weak public health and primary care components and a large uninsured population. Compared with people in other high-income countries, Americans are more likely to find care inaccessible or unaffordable and to report lapses in the quality and safety of ambulatory care.

•   Americans are less likely to smoke and may drink less heavily than their counterparts in other countries; however, they consume the most calories per capita, abuse more prescription and illicit drugs, are less likely to use seatbelts, have more traffic accidents involving alcohol, and own more firearms. U.S. adolescents seem to become sexually active at an earlier age, have more sexual partners, and are more likely to engage in riskier sexual practices than adolescents in other high-income countries.

•   The United States has higher rates of poverty and income inequality than do most rich democracies. U.S. children, especially, are more likely than children in many other affluent countries to grow up in poverty, and they are less likely to surpass their parents socioeconomically. In addition, although the United States was once the world leader in education, it has not kept pace with many other countries for several decades.

•   There are stark differences in land use patterns and transportation systems between the United States and other high-income countries. Americans are less likely than people in other high-income countries to live close to sources of healthy foods. There is also some evidence that residential segregation by socioeconomic position is greater in the United States than in some European countries.

In this chapter we turn to the question of what else the nation should do about the U.S. health disadvantage. We believe that there is sufficient evidence for the country to act now, without waiting for additional research.

The pervasiveness of the U.S. health disadvantage and the fact that it



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