U.S. Health in International Perspective: Shorter Lives, Poorer Health (2013)

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Chapter: 8 Policies and Social Values

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Suggested Citation:"8 Policies and Social Values." Institute of Medicine and National Research Council. 2013. U.S. Health in International Perspective: Shorter Lives, Poorer Health. Washington, DC: The National Academies Press. doi: 10.17226/13497.

C hapters 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)

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.

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.

The relevance of public policy to health is perhaps most conspicuous in relation to recognized problems in the U.S. health care system—-limited 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). Cigarette

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

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 strategies 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 contraceptives and firearms. Both the incidence and lethality of injuries are affected not only by personal choices, but also by decisions made by manufacturers, 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 professional 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, housing 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 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.

Policies that affect public health, education, and the economy are themselves shaped by the institutional arrangements in a society—the governmental 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 Beckfield, 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 incorporation, 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 differences in health.

The U.S. approach to policies that relate to health and social programs is what sociologists classify as an Anglo-Saxon or liberal model

Political Theme of Countries	Positive Association with Health a N (%)	Inverse Association with Health b N (%)	Mixed Results c 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)

aPolitical variable demonstrates a positive, direct or indirect, association with a populationrelated health outcome.

bPolitical variable demonstrates a negative, direct or indirect, association with a populationrelated 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).