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

The United States is among the wealthiest nations in the world, but it is far from the healthiest. Although Americans’ life expectancy and health have improved over the past century, these gains have lagged behind those in other high-income countries. This health disadvantage prevails even though the United States spends far more per person on health care than any other nation. To gain a better understanding of this problem, the National Institutes of Health (NIH) asked the National Research Council and the Institute of Medicine to convene a panel of experts to investigate potential reasons for the U.S. health disadvantage and to assess its larger implications. The panel’s findings are detailed in its report, U.S. Health in International Perspective: Shorter Lives, Poorer Health.

A Pervasive Pattern of Shorter Lives and Poorer Health

The report examines the nature and strength of the research evidence on life expectancy and health in the United States, comparing U.S. data with statistics from 16 “peer” countries—other high-income democracies in western Europe, as well as Canada, Australia, and Japan. (See Table.) The panel relied on the most current data, and it also examined historical trend data beginning in the 1970s; most statistics in the report are from the late 1990s through 2008. The panel was struck by the gravity of its findings. For many years, Americans have been dying at younger ages than people in almost all other highincome countries. This disadvantage has been getting worse for three decades, especially among women. Not only are their lives shorter, but Americans also have a longstanding pattern of poorer health that 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 U.S. health disadvantage spans many types of illness and injury. When compared with the average of peer countries, Americans as a group fare worse in at least nine health areas:

1. infant mortality and low birth weight
2. injuries and homicides
3. adolescent pregnancy and sexually transmitted infections
4. HIV and AIDS
5. drug-related deaths
6. obesity and diabetes
7. heart disease
8. chronic lung disease
9. disability

Many of these conditions have a particularly profound effect on young people, reducing the odds that Americans will live to age 50. And for those who reach age 50, these conditions contribute to poorer health and greater illness later in life.

The United States does enjoy a few health advantages when compared with peer countries, including lower cancer death rates and greater control of blood pressure and cholesterol levels. Americans who reach age 75 can expect to live longer than people in the peer countries. With these exceptions, however, other high-income countries outrank the United States on most measures of health.

The U.S. health disadvantage cannot be fully explained by the health disparities that exist among people who are uninsured or poor, as important as these issues are. Several studies are now suggesting that even advantaged Americans— those who are white, insured, college-educated, or upper income—are in worse health than similar individuals in other countries.

Why Are Americans So Unhealthy?

The panel’s inquiry found multiple likely explanations for the U.S. health disadvantage:

• Health systems. Unlike its peer countries, the United States has a relatively large uninsured population and more limited access to primary care. Americans are more likely to find their health care inaccessible or unaffordable and to report lapses in the quality and safety of care outside of hospitals.
• Health behaviors. Although Americans are currently less likely to smoke and may drink alcohol less heavily than people in peer countries, they consume the most calories per person, have higher rates of drug abuse, are less likely to use seat belts, are involved in more traffic accidents that involve alcohol, and are more likely to use firearms in acts of violence.
• Social and economic conditions. Although the income of Americans is higher on average than in other countries, the United States also has higher levels of poverty (especially child poverty) and income inequality and lower rates of social mobility. Other countries are outpacing the United States in the education of young people, which also affects health. And Americans benefit less from safety net programs that can buffer the negative health effects of poverty and other social disadvantages.
• Physical environments. U.S. communities and the built environment are more likely than those in peer countries to be designed around automobiles, and this may discourage physical activity and contribute to obesity.