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 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 environmental 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 mortality, 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 models. 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., dynamism, 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) 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 historical 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.

POLICIES FOR CHILDREN AND FAMILIES

Just as the high rate of traffic fatalities could arise from multiple causes, other areas of health disadvantage in the United States are equally complex, both in origin and policy solutions. Many of the problems, such as obesity and diabetes, can be addressed by policies directed at middle-aged or older adults, but a life-course perspective becomes important to fully analyze underlying causes.

Consider the example of childhood obesity. shows that energy imbalances that cause weight gain and obesity-related health outcomes originate as early as the prenatal period. While scientists study the responsible physiological mechanisms, such as effects on mood, metabolism, appetite, genes, and the hypothalamic-pituitary-adrenal (HPA) axis (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.

FIGURE 8-4

A life-course perspective on childhood obesity. NOTES: BPA: bisphenol A; HPA: hypothalamic-pituitary-adrenal axis. The life span is depicted horizontally; factors are depicted hierarchically, from the individual level at the bottom of the figure to the (more…)

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 tomorrow’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 virtually every aspect of their lives: the risk of infant mortality and low birth 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 during 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 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 (

  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 (

  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 systematically underfunded in the United States (

  According to many analyses, public health is systematically 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 ). 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 (

  Compared with other countries, the United States spends less on social programs, subsidies, and income transfers than do other countries (see ). 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 emerging economies, including Russia and Brazil ( International Labour Office, 2011 ).

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, (more…)

In contrast, however, the United States ranks high on public spending on education. In 2008, U.S. spending per student on public education (primary through tertiary levels) was equaled only by Switzerland. Among all OECD countries, the United States had the fifth highest public expenditure per student on primary education, the fourth highest for secondary education, 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 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 environmental conditions identified in this report as potential contributors to the U.S. health disadvantage. A variety of policies can contribute to high poverty 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 systematic 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 countries—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] conceptual 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 targeted 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 policies, 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 partnerships 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 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 determinants 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 important 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 [ramifications] and on discrete interventions rather than coordinated, collaborative initiatives. . . .” Lastly, the report notes that globalization has been changing the role of national governments in shaping policy making:

• Governments’ 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 warranted? This report documents that the United States is not keeping pace with other high-income countries in many areas of health and socioeconomic 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.

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.

4

However, there is qualitative evidence regarding these characteristics from research in political science, anthropology, and other social science disciplines.

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 disadvantage 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.

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

A number of other typologies have been proposed: see, for example, Bonoli (1997); Castles 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 mortality 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.

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 variation within individual welfare states and among the countries of each welfare state regime (Bambra, 2007).

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.

11

Social spending was also associated with low birth weight, a finding the authors speculated 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.

13

Even now, the ministers of the G20 (the group of 19 countries with major economies and the European Union) have been discussing plans to extend “social protection floors” to ensure their populations expanded social protection systems amid current fiscal constraints (International Labour Office, 2011).

14

It is also true that cultural values are not uniform, either within the United States or within other countries, and that such values are dynamic and shift over time (Byrne, 2004; McKee, 2002; Staley, 2001).

15

However, sexual content is increasingly prominent in U.S. entertainment media, such as film, television, music, and advertising.

16

Tax burden is defined as the percentage of gross wage earnings of the average production worker that is spent on income tax plus employee social security contributions less cash benefits.