As we careen from the fiscal cliff toward a dispute over the debt ceiling, even moderates have been adopting the spirit of austerity. “Entitlement reform” is the slogan of the season, and health care programs are high on the list of likely targets. The case for action is compelling: if federal health spending continues to expand at its recent pace, it will eventually swallow the economy. But there’s more than one way to approach the challenge. Should we focus on cost (cut payments and eligibility to balance the books)? Or should we set our sights on value (finding ways to buy more health for our money)? That’s a big question, so we’ll chip away at it between now and the next congressional mêlée. Let’s start with a more basic question. Is the U.S. over-committed to social welfare? Is the government doing more than it can afford to support public health?
A new report from the Institute of Medicine (IOM) puts the question into context by comparing U.S. rates of death and disability to those of 16 “peer nations” including Canada, Australia, Japan and the countries of Western Europe. Despite our top-tier medical expenditures, we trail the rest of the developed world on virtually every measure of health and well-being. “For many years, Americans have been dying at younger ages than people in almost all other high-income countries,” the authors observe. “This disadvantage has been getting worse for three decades, especially among women.”
By international standards, our lives are not only short but also brutish–marred by higher rates of injury, homicide, teen pregnancy and drug overdose, not to mention obesity, heart disease and chronic lung disease. The report notes that our “longstanding pattern of poorer health…is strikingly consistent and pervasive over the life course–at birth, during childhood and adolescence, for young and middle-aged adults, and for older adults.”
The problems extend far beyond our health care system. True, 49 million Americans lack basic health coverage, and suffer demonstrably for it. “Compared with people in other countries, Americans are more likely to find care inaccessible or unaffordable and to report lapses in the quality and safety of care outside of hospitals,” according to the report. But the research implicates a host of other factors as well. Our fast-food cuisine makes over-eating the national default. Our car-centered communities discourage physical activity. Our gun laws foster lethal violence. And our high rates of poverty, especially among children, leave millions feeling hopeless and excluded.
Exclusion may not sound like a health condition, but studies suggest that economic inequality contributes to problems ranging from infant mortality to addiction and obesity. In their 2009 book The Spirit Level, the British epidemiologists Richard Wilkinson and Kate Pickett used data from 21 high-income countries to tease out this connection. People in the wealthiest counties were no healthier for their higher average incomes. But the picture changed dramatically when Wilkinson and Pickett ranked the same countries by levels of equality they’d achieved. By 10 different measures of health and well-being, the most equal societies were the hardiest, and those with the deepest income disparities were the sickest and most dysfunctional. As you can see from the graph below, the United States landed in a class by itself–rich, unequal and plagued by social failure.
The cost of inequality doesn’t fall just on the poor. Wilkinson and Pickett’s work suggests that inequality hurts everyone–a finding echoed loudly in the new IOM report: “Even advantaged Americans–those who are white, insured, college-educated, or upper income–are in worse health than similar individuals in other countries.”
It’s not hard to see how this all relates to social spending. The entitlements that deficit hawks see choking our economy are also an essential antidote to the poison of social inequality. Medicare and Medicaid deliver basic health care for millions who lack other options. They provide it more efficiently than private insurers, their costs are rising less rapidly, and the need for their services is growing. Our healthier peer countries offer health coverage to everyone–for half of what the United States spends per capita.
It will take more than health care to heal the ills the IOM details. But the report should give pause to anyone who would balance the budget by pruning the social safety net. “The health disadvantages faced by today’s children carry profound implications for tomorrow’s adults, the nation’s economy, and national security,” Dr. Steven Woolf of Virginia Commonwealth University warns in a commentary on the new report. In other words, inequality is expensive, and the price is rising fast. As the report itself concludes, “The fact that other high-income countries have better health outcomes is evidence that better health is achievable for Americans.” It’s time for our policymakers to seize that challenge.
Geoffrey Cowley