U.S. HEALTH

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INTERNATIONAL PERSPECTIVE

Shorter Lives, Poorer Health

Panel on Understanding Cross-National Health Differences
Among High-Income Countries

Steven H. Woolf and Laudan Aron, Editors

Committee on Population
Division of Behavioral and Social Sciences and Education

Board on Population Health and Public Health Practice
Institute of Medicine

NATIONAL RESEARCH COUNCIL AND
INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

Washington, D.C.

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Panel on Understanding Cross-National Health Differences Among High-Income Countries Steven H. Woolf and Laudan Aron, Editors Committee on Population Division of Behavioral and Social Sciences and Education Board on Population Health and Public Health Practice Institute of Medicine

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THE NATIONAL ACADEMIES PRESS  500 Fifth Street, NW  Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineer- ing, and the Institute of Medicine. The members of the panel responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by the John E. Fogarty International Center, the National Center for Complementary and Alternative Medicine, the National Institute on Aging, and the Office of Behavioral and Social Sciences Research, all within the National Institutes of Health, and the Office of Women’s Health within the U.S. Department of Health and Human Services through Contract No. N01-OD-4-2139 Task Orders # 237 and 271 and Contract No. HHSN26300011 between the National Academy of Sciences and the U.S. Department of Health and Human Ser- vices.  Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the views of the organizations or agencies that provided support for the project. International Standard Book Number-13:  978-0-309-26414-3 International Standard Book Number-10:  0-309-26414-6 Library of Congress Cataloging-in-Publication data are available from the Library of Congress. Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu. Copyright 2013 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: National Research Council and Institute of Medicine. (2013). U.S. Health in International Perspective: Shorter Lives, Poorer Health. Panel on Understanding Cross-National Health Differences Among High-Income Countries, Steven H. Woolf and Laudan Aron, Eds. Committee on Population, Division of Behavioral and Social Sciences and Education, and Board on Population Health and Public Health Practice, Institute of Medicine. Washington, DC: The National Academies Press.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi- dent of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Insti- tute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sci- ences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Coun- cil is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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PANEL ON UNDERSTANDING CROSS-NATIONAL HEALTH DIFFERENCES AMONG HIGH-INCOME COUNTRIES STEVEN H. WOOLF (Chair of Panel), Department of Family Medicine, Virginia Commonwealth University PAULA A. BRAVEMAN, School of Medicine, University of California, San Francisco KAARE CHRISTENSEN, Institute of Public Health, University of Southern Denmark EILEEN M. CRIMMINS, Davis School of Gerontology, University of Southern California ANA V. DIEZ ROUX, School of Public Health, University of Michigan DEAN T. JAMISON, Department of Global Health, University of Washington JOHAN P. MACKENBACH, Department of Public Health, Erasmus University, Rotterdam, The Netherlands DAVID V. McQUEEN, Global Consultant, Atlanta, GA ALBERTO PALLONI, Department of Sociology, University of Wisconsin–Madison SAMUEL H. PRESTON, Department of Sociology, University of Pennsylvania LAUDAN ARON, Study Director DANIELLE JOHNSON, Senior Program Assistant v

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COMMITTEE ON POPULATION 2012 LINDA J. WAITE (Chair), Department of Sociology, University of Chicago CHRISTINE BACHRACH, School of Behavioral and Social Sciences, University of Maryland JERE BEHRMAN, Department of Economics, University of Pennsylvania PETER J. DONALDSON, Population Council, New York, NY KATHLEEN HARRIS, Carolina Population Center, University of North Carolina at Chapel Hill MARK HAYWARD, Population Research Center, University of Texas, Austin CHARLES HIRSCHMAN, Department of Sociology, University of Washington WOLFGANG LUTZ, World Population Program, International Institute for Applied Systems Analysis, Laxenburg, Austria ROBERT MARE, Department of Sociology, University of California, Los Angeles SARA McLANAHAN, Center for Research on Child Wellbeing, Princeton University BARBARA B. TORREY, Independent Consultant, Washington, DC MAXINE WEINSTEIN, Center for Population and Health, Georgetown University DAVID WEIR, Survey Research Center, Institute for Social Research, University of Michigan JOHN R. WILMOTH, Department of Demography, University of California, Berkeley BARNEY COHEN, Director (until August 2012) THOMAS PLEWES, Director (after August 2012) vi

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BOARD ON POPULATION HEALTH AND PUBLIC HEALTH PRACTICE 2012 ELLEN WRIGHT CLAYTON (Chair), Center for Biomedical Ethics and Society, Vanderbilt University MARGARITA ALEGRÍA, Cambridge Health Alliance, Somerville, MA SUSAN M. ALLAN, Northwest Center for Public Health Practice, University of Washington GEORGES C. BENJAMIN, American Public Health Association, Washington, DC BOBBIE A. BERKOWITZ, School of Nursing, Columbia University DAVID R. CHALLONER, Vice President for Health Affairs, Emeritus, University of Florida R. ALTA CHARO, University of Wisconsin Law School JOSE JULIO ESCARCE, Department of General Internal Medicine and Health Services Research, Department of Medicine, University of California, Los Angeles ALVIN D. JACKSON, Ohio Department of Health, Fremont, OH MATTHEW W. KREUTER, George Warren Brown School of Social Work, Washington University in Saint Louis HOWARD MARKEL, University of Michigan Medical School MARGARET E. O’KANE, National Committee for Quality Assurance, Washington, DC SUSAN L. SANTOS, School of Public Health, University of Medicine and Dentistry of New Jersey MARTIN JOSE SEPÚLVEDA, Integrated Health Services, International Business Machines Corporation, Somers, NY SAMUEL SO, School of Medicine, Stanford University ANTONIA M. VILLARRUEL, School of Nursing, University of Michigan PAUL J. WALLACE, The Lewin Group, Falls Church, VA ROSE MARIE MARTINEZ, Director vii

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Foreword T he United States spends much more money on health care than any other country. Yet Americans die sooner and experience more illness than residents in many other countries. While the length of life has improved in the United States, other countries have gained life years even faster, and our relative standing in the world has fallen over the past half century. What accounts for the paradoxical combination in the United States of relatively great wealth and high spending on health care with relatively poor health status and lower life expectancy? That is the question posed to the panel that produced this report, U.S. Health in International Perspec- tive: Shorter Lives, Poorer Health. The group included experts in medicine, epidemiology, and demography and other fields in the social sciences. They scrutinized the relevant data and studies to discern the nature and scope of the U.S. disadvantage, to explore potential explanations, and to point the way toward improving the nation’s health performance. The report identifies a number of misconceptions about the causes of the nation’s relatively poor performance. The problem is not simply a mat- ter of a large uninsured population or even of social and economic disad- vantage. It cannot be explained away by the racial and ethnic diversity of the U.S. population. The report shows that even relatively well-off Ameri- cans who do not smoke and are not overweight may experience inferior health in comparison with their counterparts in other wealthy countries. The U.S. health disadvantage is expressed in higher rates of chronic disease and mortality among adults and in higher rates of untimely death and inju- ries among adolescents and small children. The American health-wealth ix

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x FOREWORD paradox is a pervasive disadvantage that affects everyone, and it has not been improving. The report describes multiple, plausible explanations for the U.S. health disadvantage, from deficiencies in the health system to high rates of unhealthy behaviors and from adverse social conditions to unhealthy environments. The panel painstakingly reviews the quality and limitations of evidence about all of the factors that may contribute to poor U.S. health outcomes. In this, and in earlier work the panel cites, many remediable shortcomings have been identified. Thus, the report advances an agenda for both research and action. The report was made possible by the dedicated work of the panel and staff who conducted this study and by the generous support of the Office of Behavioral and Social Sciences Research and other units of the National Institutes of Health. The National Research Council and the Institute of Medicine are very much indebted to all who contributed. The nation’s current health trajectory is lower in success and higher in cost than it should be. The cost of inaction is high. We hope this report deepens understanding and resolve to put America on an economically sustainable path to better health. Harvey V. Fineberg Robert M. Hauser President, Institute of Medicine Executive Director, Division of B ­ ehavioral and Social Sciences and Education, National Research Council

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Preface I n 2011 the Office of Behavioral and Social Sciences Research (OBSSR) of the National Institutes of Health (NIH) asked the National Research Council (NRC) and the Institute of Medicine (IOM) to undertake a study on understanding cross-national health differences among high- income countries. The NRC’s Committee on Population and the IOM’s Board on Population Health and Public Health Practice established our panel for this task. The impetus for this project came from a recently released NRC report that documented that life expectancy at age 50 had been increasing at a slower pace in the United States than in other high-income countries. The charge to our panel was to probe further and to determine whether the same worrying pattern existed among younger Americans, to explore potential causes, and to recommend future research priorities. As readers who know this issue can appreciate, this is a daunting and complex charge. The questions put to the panel involve many fields, including medicine and public health, demography, social science, political science, economics, behavioral science, and epidemiology. They require the examination of data from many countries, drawn from disparate sources. The panel was given 18 months for the task, enough time to pull back the curtain on this issue but not to conduct a systematic review of every con- tributory factor and every relevant study or database. This report serves only to open the inquiry, with the invitation to others to probe deeper and with the disclaimer that the evidence cited here can only skim the surface of highly complex issues. xi

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Contents Summary 1 Introduction 11 PART I: DOCUMENTING THE U.S. HEALTH DISADVANTAGE 21 1 Shorter Lives 25 Mortality Rates, 26 Cross-National Differences in Life Expectancy, 35 Survival to Age 50, 41 Years of Life Lost Before Age 50, 46 Causes of Premature Death, 48 Influence of Early Deaths on Life Expectancy at Birth, 54 Conclusions, 56 2 Poorer Health Throughout Life 57 Health Across the Life Course, 59 Children and Adolescents, 60 Adults, 78 Conclusions, 87 xvii

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xviii CONTENTS PART II: EXPLAINING THE U.S. HEALTH DISADVANTAGE 91 3 Framing the Question 95 The Determinants of Health, 96 The Social-Ecological Framework, 97 A Life-Course Perspective, 99 Conclusions, 104 4 Public Health and Medical Care Systems 106 Defining Systems of Care, 107  Question 1: Do Public Health and Medical Care Systems Affect Health Outcomes?, 109  Question 2: Are U.S. Health Systems Worse Than Those in Other High-Income Countries?, 110  Question 3: Do U.S. Health Systems Explain the U.S. Health Disadvantage?, 132 What U.S. Health Systems Cannot Explain, 133 Conclusions, 135 5 Individual Behaviors 138 Tobacco Use, 140 Diet, 144 Physical Inactivity, 147 Alcohol and Other Drug Use, 149 Sexual Practices, 152 Injurious Behaviors, 154 Conclusions, 159 6 Social Factors 161 Question 1: Do Social Factors Matter to Health?, 163  Question 2: Are Adverse Social Factors More Prevalent in the United States Than in Other High-Income Countries?, 170  Question 3: Do Differences in Social Factors Explain the U.S. Health Disadvantage?, 185 Conclusions, 190 7 Physical and Social Environmental Factors 192 Question 1: Do Environmental Factors Matter to Health?, 193  Question 2: Are Environmental Factors Worse in the United States Than in Other High-Income Countries?, 199

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CONTENTS xix Question 3: Do Environmental Factors Explain the U.S. Health Disadvantage?, 203 Conclusions, 205 8 Policies and Social Values 207 The Role of Public- and Private-Sector Policies, 209  The Role of Institutional Arrangements on Policies and Programs, 211 Societal Values, 219 Policies for Children and Families, 225 Spending Priorities, 233 Conclusions, 236 PART III: FUTURE DIRECTIONS FOR UNDERSTANDING THE U.S. HEALTH DISADVANTAGE 239 9 Research Agenda 241 Background, 242 Data Needs, 249 Analytic Methods Development, 262 New Lines of Inquiry, 267 Conclusions, 270 10 Next Steps 273 Pursue National Health Objectives, 275 Alert the Public, 283 Explore Innovative Policy Options, 286 Looking Ahead, 289 References and Bibliography 292 Appendixes A Recommendations of the National Prevention Council and Evidence Cited in Its Report 347 B Biographical Sketches of Panel Members and Staff 375 Index 379

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Figures, Tables, and Boxes FIGURES 1-1  Mortality from noncommunicable diseases in 17 peer countries, 2008, 27 1-2  Mortality from communicable diseases in 17 peer countries, 2008, 27 1-3 Mortality from injuries in 17 peer countries, 2008, 32 1-3a  Box 1-3) Number of years behind the leading peer country for (in the probability of dying between ages 15 and 50 among females, 1958-2007, 44 1-3b  Box 1-3) Number of years behind the leading peer country for (in female mortality by 5-year age group, 2007, 45 1-4  Motor vehicle fatalities in the United States and 15 other high-income countries, 1975-2008, 33 1-5  U.S. male life expectancy at birth relative to 21 other high-income countries, 1980-2006, 42 1-6  U.S. female life expectancy at birth relative to 21 other high-income countries, 1980-2006, 43 1-7  Probability of survival to age 50 for males in 21 high-income countries, 1980-2006, 46 1-8  Probability of survival to age 50 for females in 21 high-income countries, 1980-2006, 47 1-9  Ranking of U.S. mortality rates, by age group, among 17 peer countries, 2006-2008, 48 xxi

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xxii FIGURES, TABLES, AND BOXES 1-10 Ranking of U.S mortality rates for non-Hispanic whites only, by age group, among 17 peer countries, 2006-2008, 49 1-11 Years of life lost before age 50 by males in 17 peer countries, 2006-2008, 50 1-12 Years of life lost before age 50 by females in 17 peer countries, 2006-2008, 51 1-13 Years of life lost before age 50 due to specific causes of death among males in 17 peer countries, 2006-2008, 52 1-14 Years of life lost before age 50 due to specific causes of death among females in 17 peer countries, 2006-2008, 53 1-15 Contribution of cause-of-death categories to difference in years of life lost before age 50 between the United States and the mean of 16 peer countries, males, 2006-2008, 54 1-16 Contribution of cause-of-death categories to difference in years of life lost before age 50 between the United States and the mean of 16 peer countries, females, 2006-2008, 55 2-1 Infant mortality rates in 17 peer countries, 2005-2009, 65 2-2 Low birth weight in 17 peer countries, 2005-2009, 66 2-3 Global prevalence of preterm births, 2010, 67 2-4  Infant mortality rates in the United States and average of 16 peer countries, 1960-2009, 68 2-5  Prevalence of overweight (including obesity) among children in 17 peer countries, latest available estimates, 72 2-6  Adolescent birth rate in 17 peer countries, 2010, 73 2-7  Transportation-related mortality among adolescent and young adult males in the United States and average of 16 peer countries, 1955-2004, 76 (a) Males Aged 15-19 (b) Males Aged 20-24 2-8  Violent mortality among adolescent and young adult males in the United States and average of 16 peer countries, 1955-2004, 77 (a) Males Aged 15-19 (b) Males Aged 20-24 2-9  Average body mass index (BMI), by age and sex, in 17 peer c ­ ountries, 2008, 79 (a) Ages 15-24 (b) Ages 25-34 (c) Ages 35-44 2-10 Self-reported prevalence of diabetes, by age and sex, in 17 peer countries, 2008, 81 (a) Ages 15-24 (b) Ages 25-34 (c) Ages 35-44

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FIGURES, TABLES, AND BOXES xxiii 3-1 Model to achieve Healthy People 2020 overarching goals, 98 3-2 Panel’s analytic framework for Part II, 104 4-1a  Box 4-1) Access to health care independent of personal (in resources, 113 4-1  General practitioners as a proportion of total doctors in 15 peer countries, 2009, 116 4-2  In-hospital case-fatality rates for acute myocardial infarction in 16 peer countries, 123 4-3 Hospital admissions for asthma in 16 peer countries, 125 4-4  Hospital admissions for uncontrolled diabetes in 14 peer countries, 126 4-5  Frequency of complaints among insured and uninsured U.S. patients with chronic conditions, 131 5-1 Percentage of U.S. adults age 18 and older who were current smokers, by sex and race/ethnicity, 1965-2008, 141 5-2 Prevalence of daily smoking in 17 peer countries, 142 5-3 Four stages of the U.S. tobacco epidemic, 143 5-4 Global map of per capita caloric intake, 146 5-5 Civilian firearm ownership in 16 peer countries, 158 6-1 Poverty rates in 17 peer countries, 173 6-2 Child poverty in 17 peer countries, 174 6-3 Enrollment of children aged 0-2 in formal child care in 16 peer countries, 2008, 177 6-4 Enrollment of children aged 3-5 in preschool in 17 peer countries, 2008, 178 6-5 Upper secondary education rates in 13 peer countries, 2009, 179 6-6 Percentage of adults aged 25-34 with a tertiary education in 17 peer countries, 2009, 181 8-1  model of structural and political influences on population A health, 212 8-2 Infant mortality rate for the United States and 30 other countries, classified by welfare regime type, 214 8-3 Infant mortality rates by welfare regime type, 1960-1992, 216 8-4 A life-course perspective on childhood obesity, 232 8-5 Social benefits and transfers, 17 peer countries, 2000, 235 9-1 Social-ecologic influences on children’s health over time, 254

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xxiv FIGURES, TABLES, AND BOXES TABLES 1-1 Mortality Rates in 17 Peer Countries, 2008, 28 1-2 U.S. Death Rates Relative to 16 Peer Countries, 2008, 38 1-3 Life Expectancy at Birth in 17 Peer Countries, 2007, 39 2-1 Health Indicators by Age Group, Range, and Rank of the United States Among 17 Peer Countries, 61 2-2 Distribution of Cardiovascular Risk for Adults Aged 50-54 Among 11 High-Income Countries, 83 4-1 Cost-Related Access Problems in the Past Year Among U.S. Patients with Complex Chronic Conditions, 2011, 114 5-1 Driving Practices in 16 Peer Countries, 155 6-1 Comparative Ranking of 15-Year-Old Students in High-Income Countries, 2006, 182 8-1 The Association Between Political Themes and Health Outcomes: Findings of 73 Empirical Studies, 211 8-2 Macro-Level Conditions That Affect Work-Family Policy, by Country, Mid-1990s, 218 9-1 Publicly Available Databases for Aging-Related Secondary A ­ nalyses in the Behavioral and Social Sciences, 243 10-1  National Health Objectives That Address Specific U.S. Health Disadvantages, 276 BOXES S-1 Recommendations Relating to Research, 7 S-2 Recommendations Relating to Policy, 8 1-1 The U.S. Morbidity Disadvantage, 36 1-2 Disparities in Life Expectancy in the United States, 40 1-3 How Many Years Behind Is the United States?, 44 4-1 Health Care Decommodification, 113 4-2 Case Study: Trauma Care in the United States, 120 4-3 Quality of Care: Survey Findings from Commonwealth Fund Surveys, 128

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FIGURES, TABLES, AND BOXES xxv 6-1 Social Factors That Affect Health Outcomes, 164 8-1 Explanations for the Scandinavian Welfare Paradox, 220 8-2 The Role of Public Policies on U.S. Traffic Fatalities, 226 9-1 International Health Studies of the Population Age 50 and Older, 248 9-2 International Efforts to Harmonize Data, 256 10-1 Recommendations of U.S. Surgeon General’s National Prevention Council, 280 10-2 Roles for Governments and Nongovernment Actors at All Levels, 284

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