Research Summary: “We can do better – improving the health of the American people”
In the New England Journal of Medicine article, “We can do better – improving the health of the American people”, by Steven A. Schroder M.D., the author advances a paradox where America spends more per capita on healthcare than any other developed nation, yet has the worst outcomes for almost every measure. Schroder proposes a simple two part reasoning: one, healthcare itself doesn’t mean better health. Two, healthcare is most important to the poorest demographic, and they’re the faction the system fails. One of the few measures where America ranks well is life expectancy from the age of 65, perhaps due to the comprehensive health insurance provided to this demographic. It is America’s complacency towards our dismal rankings in life expectancy from birth and infant mortality which is so remarkable.
Healthcare in the United States does not play a primary role in reducing early deaths. Notably, 40% of all deaths are behavioral, for example: obesity, physical inactivity, and smoking. Behavior can change, as was recently demonstrated by the rapid decrease in smoking, with the new behavior modification incentives and options following the Surgeon General report of 1964 linking smoking to lung cancer. Still, tobacco use accounts for 435,000 premature American deaths, annually. This figure disproportionately impacts the poor, the mentally ill, and those facing substance abuse problems, decreasing life expectancy by 15 years. Socioeconomic class is the single most influential factor for health in America- the lower your class, statistically the less healthy. Smoking during pregnancy continues to contribute to premature births and infant mortality. 70% of the current 44.5 million smokers would like to quit, yet they have no access to help. No other public health or medical intervention would have a greater impact on the overall health of the most disadvantaged demographic.
Like tobacco use, obesity is common in lower socioeconomic classes, yet there are still big differences between the behaviors. Smoking is binary where obesity falls on a scale, and is often misclassified. One cannot stop eating and moderation is not dangerous. There is no second hand exposure and hence less pressure from the non-inflicted. There are also less legal and clinical tools available to battle obesity. Proposals to combat obesity range from selective taxes and restrictions in food stamps to support for social-marketing campaigns. Others include more comprehensive labeling for caloric content and ingredients, improved counseling programs and pharmaceutical products. Areas not requiring national legislation are already underway. At the local level schools are beginning to ban soft drinks and offer more nutritious lunches. There are also more opportunities for physical activity while at work or school.
The entrepreneurial nature of America allows more tolerance of large gaps in income, education and housing; all with unintended consequences for health. In 1998 the United Kingdom created 39 policy recommendations to reduce health disparities, only three of which pertain to healthcare directly. Although not fully realized, it shows attention is being paid to social policy’s impact on health.
There are two ways healthcare affects overall health: quality and access. It is access to healthcare in the United States where we trail our peer nations; not quality. Not surprisingly, our 45 million uninsured are disproportionately represented in the lower socioeconomic classes- a group with greater exposure to environmental factors like pollution, crime and less access to physical activity.
In America, all remedies rely on politics, with healthcare receiving the vast proportion of resources. In 2006 we spent 16% of our gross domestic product on healthcare, while most nations never surpass double digits. We lead the world in the use of therapeutic and diagnostic medical technologies, mostly reserved for the middle and upper classes. Yet, the political sphere pays little heed to those public health policies and goals defined by the Department of Health and Human Services with the greatest potential impact, aimed directly at the lower socioeconomic classes.
Most developed nations have active labor movements and sturdy labor parties. In America the disadvantaged see little political representation. Instead, we coalesce around specific diseases impacting the middle class, like autism and breast cancer, although attention to the disadvantaged will have the greatest benefit in public health. Nothing will change until the voices of the disadvantaged can be heard among the political elite. This is exacerbated by our lack of universal health coverage, the weak status of population and public health agencies, their disconnected nature from the delivery of health services and our emphasis on personal responsibility that creates a reluctance to intervene in personal behavioral choices; even by trained clinicians.
Although America is far behind other countries, we have never been more healthy due to improvements in personal behavior, environmental factors and medical care. Tackling the risk factors for smoking and obesity has the largest potential positive impact on public health; most others require political action. Accomplishing these feats will boost the national economy by improving workforce productivity and reducing healthcare expenditures. In the absence of political change, it is left to clinicians to be the champions of public health.
Works Cited
Schroeder, S. A. (2007). We Can Do Better — Improving the Health of the American People. New England Journal of Medicine, 357(12), 1221-1228. doi:10.1056/nejmsa073350
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