Recently, Democratic Presidential candidate Bernie Sanders released his healthcare reform plan. Suffice it to say, it’s a single-payer system. Others say this is unrealistic, impossible, etc. Many Americans are frustrated by the reality of the Affordable Care Act, when compared to what was promised. (This is ignoring, for the sake of argument, those who hated it all along.) If we could magically have a single-payer system tomorrow, would it work? Would it be cheaper? I wanted to find out.
I soon came across this paper from 2014, which evaluated American health outcomes (specifically, mortality and morbidity) which delves into these issues, trying to determine what factors might contribute to Americans’ overall poor health and high mortality when compared to countries in Western Europe, as well as Japan and Canada. When putting the numbers together, it was found that Americans have worse health outcomes practically from birth, all the way up until old age. Once you make it to an advanced age, you’ve essentially moved past all the things that were likely to kill you, and American statistics fall in line with other OECD countries.
So, who gets hit the hardest by our poor health outcomes? Women in particular, as well as people in the South and the Midwest. And as of 2008, the US had the shortest life expectancy for both women and men in the countries surveyed.
Various causes of death were evaluated for the countries being examined:
* Infectious disease * Complications of pregnancy * Perinatal deaths (infant mortality) * Homicide * Transport-related deaths * Poisonings
The US leads in all of these categories. All of them have seen recent increases except for infant mortality, homicides, and transport-related deaths.
And we don’t just die younger: we are sicker, as well. Poor prenatal care, preterm births, pregnancy complications, and low birth weights all point to a lack of sound healthcare practices at even the earliest stages of life, and the situation doesn’t improve much from there. Adolescent pregnancies and sexually transmitted diseases, though in decline, still outpace our Western peers. Childhood obesity and diabetes are also more prevalent.
Turning to the other end of the age distribution, Americans over 50 have the highest rates of heart disease, diabetes, obesity, lung disease, cancer, stroke, hypertension, and mobility limitations. Our cancer outcomes, however, are better, perhaps a result of more aggressive early screening practices. Even so, the numbers are very troubling.
Many factors presented as possible causes of these high mortality and morbidity rates:
* Access to and quality of healthcare and public health systems * Tobacco use * Obesity * Diet * Inactivity * Substance abuse * Sexual practices * Violence * Car use * Socioeconomic inequality and racial disparities * Environmental factors
Perhaps surprisingly, both insured and uninsured Americans experience worse health outcomes than citizens in the sampled countries. Insured Americans have better outcomes relative to the uninsured, but still worse than in countries with single-payer or highly subsidized public health systems.
Smoking is suggested as a major cause of the discrepancies in life expectancy. A lagging indicator, smoking may be responsible for 2⁄5 of the difference for males, and 3⁄4 of the difference for females. People smoke less now but used to smoke more in the past, and it takes decades for those effects to result in mortality. Americans had much higher rates of smoking in the past, and we started earlier, so it would make sense that higher mortality over the past 10-20 years would result.
A lack of data makes it hard to know for sure, but available information indicates Americans have the highest caloric and sugar intakes of the countries surveyed, and also ranks high in protein and fat intake, while fruit and vegetable intake are similar to other countries. That said, obesity itself is not an explanation–studies are conflicted and there is no clear correlation between weight and health outcomes, despite a tremendous focus on weight as the primary arbiter of health.
Black Americans face significant health risks due to social and environmental circumstances created by the history of slavery, Jim Crow, segregation, and other consequences of racism. Essentially, limited work opportunities and restricted social and geographic mobility have compounded into generations of poor health outcomes.
But outcomes among middle-class white Americans are subpar, too. From the paper:
For example, in a widely cited cross-national comparison of the health of American and English people, Banks et al. (10) found that Americans in the top one-third of the income distribution (97% of whom already have access to health insurance) had rates of hypertension and diabetes comparable to those in the bottom one-third of income earners in England. The comparison was all the more striking because it was restricted to whites in both countries.
The poor and less educated nevertheless face the worst health consequences. Of the factors evaluated, socioeconomic status may be the biggest driver of increased mortality below age 50.
For example, US mortality from homicide is nine times higher among young men in the bottom decile of socioeconomic deprivation compared with young men in the affluent top decile (88, 90). Strikingly, US girls in the bottom decile are 14 times more likely to die from HIV/AIDS than are US girls in the top affluent decile (88, 90). Similar differences by socioeconomic deprivation exist in childhood mortality (89, 90).
The impact of one’s physical environment in relation to health outcomes was also examined. This includes factors like access to recreational facilities, proximity to fast food restaurants and stores selling fresh produce, elements of urban planning, and Americans’ heavy reliance on personal automobiles for transportation. As an example, Americans die more from car accidents because we drive more, but mile-for-mile our mortality rate is similar to other OECD countries. However, driving is a sedentary activity and Americans’ highly sedentary lifestyles likely contribute to our poor health results.
Childhood education and childcare are examined as possible major factors in poor health outcomes, with some striking results. Early education in the US is not as well-developed as in other countries–it begins later, is subsidized less and is less of a public priority, has less stringent requirements for educators, and is less regulated overall. Early education programs are shown to improve health outcomes during childhood and thus later in life, suggesting more effort (and money) should be spent in this area.
On the other hand, the US spends more than other OECD countries on primary and secondary education while producing educational outcomes around or below the OECD average. But the variations within the US are immense. Segregation and financing disparities result in dramatically different educational outcomes from one community to the next. Education quality is, to put it simply, all over the map.
Due to poor worker protections, Americans face high levels of worker displacement–that is, unexpected joblessness. Unemployment programs are comparatively weaker, as are childcare subsidy programs. Famously, the US has no paid maternity or paternity leave by statute, compared with legally-guaranteed paid leave in other OECD countries. Americans work more hours, spend less time at home and have less time to cook, and spend more time driving, leaving less time to pursue activities that may improve health. Maternity leave has been shown to reduce infant mortality and improve postpartum physical and mental outcomes. In short, we work too much and don’t spend enough time with our families (especially our children).
Adjusting for public benefit programs, child poverty rates are still high in the US–21%, compared with 11% in France and 8% in Sweden. Poverty mitigation is woefully inadequate in this country.
Multiple studies are cited that indicate specific programs produce better health outcomes: the Earned Income Tax Credit is correlated with increased birth weight and reduced maternal smoking rates; food stamps appear to lower infant mortality and morbidity; increases in disability income may also reduce physical disability rates among older Americans. In short: giving people money gives them options, which lets them make better choices for their health. American programs in this area are significantly less robust and are frequently cut or otherwise curtailed during government budgeting processes.
Americans with more money have more resources, but this is not surprising–many problems become trivial to resolve when you have considerable sums of money at your disposal. All told, it appears that measures to mitigate poverty and improve access to healthcare, particularly during pregnancy and childhood, would go a long way. More robust worker protections and guaranteed paid leave would also permit workers to take time off when they are sick, and spend time caring for their children during crucial development periods (such as right after birth). Likewise, subsidizing childcare and early educational opportunities offer a lot of bang for the buck in terms of improving overall health. Most of these approaches have nothing to do with a single-payer healthcare system, and that’s what makes them all the more fascinating.
I fully support the United States transitioning to a single-payer system as swiftly as possible. Knowing that this is unlikely (to say the least), we must still look at reforms and other programs that aren’t directly related to healthcare that can still improve health outcomes and reduce mortality. Some of what ails us is cultural: we eat too much, we’re not active enough, and we’re too reactive in terms of seeking out medical treatment. We know all this and repeating it doesn’t change it, nor will any amount of government advocacy for people to eat better and move more attack the roots of the problem–it’s essentially wasted money. Nobody is unhealthy because they want to be; given the choice, we would all be healthy! But in a culture that shows varying degrees of hostility toward workers, toward the poor, toward racial minorities, and toward women, often times choices are made to optimize short-term survival over long-term health. When people are working too many hours for too little money, it shouldn’t come as a surprise that cooking and exercise and even seeing a doctor regularly become unaffordable luxuries. That tells some of the story at low income levels, but our work-life balance is out of whack virtually across the board, which likely contributes to the relatively poor outcomes shown at higher incomes, too.
Not to put too fine a point on it, but I suspect we will remain a sick country so long as we think working hard is more important than looking after ourselves–and each other. Single-payer healthcare can’t and won’t fix that.