CHAPTER 4
It is one of the great and sobering truths of our profession that modern health care probably has less impact on the population than economic status, education, housing, nutrition and sanitation.
—THEODORE COOPER, ASSISTANT SECRETARY FOR HEALTH UNDER PRESIDENT GERALD FORD1
Stephen Bezruchka calls it “America’s best-kept secret.” “We die younger than people in other rich countries,” says Bezruchka, a craggy and fit mountain climber who also serves as an emergency room physician and a professor at the University of Washington’s School of Public Health. “Thomas Jefferson may have said we have a right to life, but we don’t have a right to a very long one. After World War II, we were the healthiest people in the world. Now we’re not even close.”2
Following the psychologist Abraham Maslow’s hierarchy of needs theory, once we’ve obtained oxygen, water, and enough food, clothing, and shelter to keep from starving, freezing, or roasting, health and safety needs express themselves rather urgently; when you’re sick as a dog, you can’t think about much else except getting well, and if you’re lucky and can stay in bed, that’s where you go. Poor health can be life-threatening; you’re way more likely to drop over from a heart attack or a stroke, or expire from cancer, than you are to die from accidents, crime, suicide, bee stings, lightning strikes, or terrorism (in descending order of probability).
So it’s no wonder that health care—which, after all, is supposed to make us healthy—was, in 2009 and early 2010, consistently front-page-above-the-fold in our papers and at the top of our political agenda. From the reports of angry seniors demanding that government keep its hands off their Medicare, and fears of fictional “death panels,” to the people carrying weapons to town-hall meetings, health care was headline news. Stories of underinsured families bankrupted by an operation or a hospital aspirin fed the sense that our medical system was dysfunctional. Though our former president, many Republican members of Congress, and the CEOs of American insurance companies still claim the United States has “the greatest health care system in the world,” most Americans are a bit suspicious.
They have a right to be. But it isn’t for lack of effort.
First of the Big Spenders
You might be surprised to know that by 2012, we Americans will be spending nearly $9,000 per person per year on our medical system, almost 18 percent of our whopping GDP. We’re already spending $2.5 trillion a year on health care.3 Soon, if present trends continue, we’ll be spending one dollar out of every five on health, or rather, sickness, care alone.
We do get something for all that money. Recently, Dave had to go to the emergency room twice in the same day. His wife suffered acute pain and, it turned out, needed surgery to remove her gallbladder. Later that afternoon, his four-year-old son had difficulty breathing. It was pneumonia. The care they received was first-rate and the emergency room staff totally professional. But even though Dave had excellent health insurance, the day in the hospital ended up costing his family $7,000 out of pocket. Dave met many kinds of people in the emergency room. Some were there for frivolous reasons; one man showed up because he had a splinter in his finger! But others had real emergencies—a heart attack victim, a person in shock, people with broken bones or severe allergic reactions.
A nurse explained that many of those with real emergencies were there because they were among the millions of Americans who don’t have health insurance or because other doctors wouldn’t accept their publicly provided insurance. Some were sicker than they otherwise might have been because, lacking insurance, they hadn’t seen the doctor when they suffered their first symptoms. The early care would have been relatively inexpensive, but they waited until their situation was desperate before seeking free emergency help. Each of them costs our medical system a lot of money. The United States wins the Health Care Spending Olympics hands down: We’re not even 5 percent of the world’s population, but we account for nearly half its total annual health care budget.4
So what about other rich countries; how much do they spend? T. R Reid, in his enlightening book, The Healing of America, tracks down the numbers. The Scrooges, such as Japan and the United Kingdom, spend only 7 or 8 percent of their budgets on health care, while profligates like Switzerland and France spend about 11 percent.5 On average, the other developed countries spend about half what America does per person, and they all cover everybody, with universal health insurance. “Ah,” you say, “there must be a catch.” You get what you pay for, right? That’s what our moms taught us, and that’s what traditional economics teaches too. Using that logic, we find it hard to believe that Americans aren’t the healthiest people on Earth. And, as Dr. Bezruchka points out, once upon a time they were; right after World War II, in fact. Back then, Americans’ health and our health care were the envy of the world. But times have changed.
America Is Number Thirty-seven
First, there was that World Health Organization study done in 2000 that ranked the United States thirty-seventh in the quality of its health care.6 Many experts think it has slipped a little farther down in the last decade, but lots of Americans don’t trust the World Health Organization. Some argue that the WHO is part of the United Nations, which favors socialism, so it probably cooked the numbers. Never mind that the WHO commissioned American doctors to do the study; you really can’t trust anyone these days.
But let’s leave the possibly pinko WHO alone for a moment. What do other experts say?
The quality of health care models is a subjective thing, but what about objective health data?
Well, for starters, the Central Intelligence Agency’s World Fact Book ranks the United States forty-ninth in life expectancy.7 Simply put, that means that people in forty-eight other countries live longer on average than Americans do. We’re talking about the CIA here, not the WHO. Forty-ninth: just above Albania. Now some experts take out the puny places—such as Andorra and Malta and San Marino and Singapore—that beat us on that list, getting us up to number thirty.
Even so, the only rich countries that give us a run for our money in the Life Expectancy Race to the Bottom are Portugal, Ireland, and Denmark. They rank just above the United States.
Whoops … did we say “run for our money?” Well, that’s not exactly accurate, since America spends more than twice as much per person on health care as they do. And things are not looking up; to the contrary, the United States was eleventh in life expectancy as recently as 1980.8 (More on the significance of that year in chapter 11 of this book.) Even more ominous: a new study finds that in 30 percent of the counties in America, women’s life expectancy is now actually falling.9
Sadly, it’s not just life expectancy that America is lagging in. It ranks forty-fourth in child mortality and forty-first in maternal mortality, again from the CIA’s World Fact Book. (Its rate of deaths for moms giving birth has actually increased since 1990.) A new University of Washington study put U.S. men in forty-fifth place and U.S. women in forty-ninth place when it comes to the adult mortality rate—the percentage of people who die between the ages of fifteen and sixty. Every rich country does better. (The rate in Canada is nearly 50 percent lower than in the United States.) Even some poor countries also outperform America: Costa Rica ranks twenty-seventh overall, and Cuba, thirty-eighth, for example.10
According to the Los Angeles Times (October 2, 2007), an extensive study by the Emory University School of Public Health found that elderly Americans were much less healthy than Europeans of the same age.
For example, heart disease was diagnosed in nearly twice as many Americans as Europeans 50 and older. More than 16% of American seniors had diagnosed diabetes, compared with about 11% of their European peers. And arthritis and cancer were more than twice as common among Americans as Europeans. “We expected to see differences between disease prevalence in the United States and Europe, but the extent of the differences is surprising,” said lead author Kenneth Thorpe, a public health professor at Emory and former deputy assistant secretary of the U.S. Department of Health and Human Services.
Americans were also nearly twice as likely as Europeans to be obese. “We spend more on healthcare because we are, indeed, less healthy,” Thorpe concluded.11
And if such evidence of failure isn’t enough to cast doubt on our health care system, a recent Harvard study concluded that nearly forty-five thousand Americans die each year out of the 47 million Americans without health insurance.12 Even in the hospital, U.S. patients face unusual dangers. More than one hundred thousand of them die each year from “health care” itself—errors or infections during treatment.13
We pay the most and get the worst results. Why are we putting up with that?
House of Health
So our health care system is sick. We took some steps to fix it in 2009, when the Patient Protection and Affordable Care Act passed Congress and was signed into law by President Obama. The new law will insure 32 million more Americans, prevent the denial of health care for “preexisting conditions,” provide free medical checkups, and, according to the Congressional Budget Office, even reduce the deficit. It’s progress. But fully fixing the system will require a far more holistic approach than has been discussed in the health care debate.
It’s not obvious in the current debate, but no one would argue that good health care is our final goal. Who wants to spend time in the hospital, even the best hospital, even if the food wasn’t so bad? The goal, of course, is good health. Health care is only part of that. Let’s get metaphorical and consider American health as a house. Health care is merely the roof, the final protection against illness.
In our case, it’s an expensive roof, gold plated, yet with millions of holes in it and a lot of other leaks—millions more who are underinsured, insurance companies that spend nearly as much finding ways to deny coverage as they do paying the bills, for example. Elizabeth Warren, chair of the Congressional Oversight Panel for the banking bailout, points out that half of American bankruptcies are due to unpaid medical bills—and 75 percent of those people have insurance.14
In other industrial countries, the roof is a simpler affair, asphalt shingles on a fiberglass mat maybe, but with hardly any leaks. Their health care systems rely more on prevention, less on high-tech treatment. Yet the people in the house below live longer, healthier lives. That’s because in those other countries, the foundation and the walls of the house are stronger, with fewer cracks to let in the cold. If we patch up the leaks in our roof, but do nothing for the floor and the walls, the costs of health care will likely go through that roof.
As Stephen Bezruchka puts it: “It is not health care that makes us healthy. I say this as a medical doctor who has practiced for thirty-five years. During this period working in the emergency department, I have treated heart attacks, motor vehicle crashes, shoulder dislocations and stabbings. I could help many of these people. But when you add up all that medical care does, it still doesn’t make that much of a difference.”15
The Foundation
Let’s start with the foundation. That’s the head start toward health that children in most other rich countries receive. There’s a stronger focus on prenatal care, for example. In part because of this, infant mortality in all other industrial countries is lower than in the United States. You’ve got a better chance of survival if you’re born in Cuba.
Moreover, in every country in the world except, believe it or not, the United States, Liberia, Swaziland, and Papua New Guinea, mothers are guaranteed paid time off from work to take care of newborns.16 Do you even know where Liberia, Swaziland, and Papua New Guinea are? In most rich countries, fathers also receive paid time off to bond with young children. In many cases, such family leave extends for up to a year or more.
That’s even true right next door to the United States, in Canada, where parents can split a year of leave at 55 percent of their salaries. In the United States, by contrast, parents are only guaranteed unpaid time off—by the Family and Medical Leave Act of 1993—and then only if they work for companies with more than fifty employees. So American moms often return to work when children are only a few weeks old. Sharon Lerner, author of The War on Moms: On Life in a Family-Unfriendly Nation, writes that
the effect of all this on babies can be serious and lasting: In an article published in The Economic Journal in 2005, researchers found that infants whose mothers had 12 weeks of maternity leave or fewer had lower cognitive test scores and higher rates of behavior problems at age four than children whose mothers had longer leaves. In Europe, longer paid maternity leaves are linked to lower infant and child mortality … According to research by economists Sara Markowitz and Pinka Chatterji and published in 2008 by the National Bureau of Economic Research, women who return to work soon after the birth of a child are more likely to get depressed than other mothers. They’re also less healthy: According to the study, longer maternity leaves are associated with improvements in mothers’ overall health.17
Paid family leave, and the parental bonding it ensures, pays off in terms of children’s health—fewer childhood illnesses, fewer problems with attention-deficit disorder, less obesity, easier socialization, better readiness to learn. Most countries find that such a social investment in early childhood results in lower health and other costs as children grow up. In Canada, where paid parental leave was recently increased from six months to a year, health care costs for children have dropped, leading to some interest in further extending the leave.18
A 2007 UNICEF study ranked the United States twentieth out of twenty-one rich nations in terms of children’s welfare.19 One factor in its low standing is obesity. American children are the world’s leaders in that unhappy statistic. By the time they reach seventeen, only a quarter of young Americans can pass the physical and mental health tests necessary to enter the military.20 Meanwhile, we still fill our TV screens with ads for junk foods targeting our children.
You might say that the foundation of our “health house” is weak or at least uneven. Metaphorically, the rich enjoy a house with a marble floor, and our middle class, a wooden one (with the floorboards sounding increasingly squeaky). Poor Americans, far less likely to be insured or to have maternity leave and other family benefits, have a dirt floor, with rain leaking through the holes in the roof. (More on that in chapter 7.)
And if the floor of the house is in trouble, what about the walls?
Wall Number One: Lifestyle
Liberal Democrats seem to talk almost exclusively about universal health care as the solution to our health problems. By contrast, Republicans tend to focus on wall number one: lifestyle choices. It’s all a matter of personal responsibility, they say. Americans should simply stop smoking, eat properly, avoid overeating and excessive alcohol consumption, exercise regularly, and sleep enough. “Let Michael Moore slim down before he produces movies like Sicko,” they declare, righteously wagging a finger. And, they argue, he doesn’t need government to do this, nor do the rest of us.
That people should make good lifestyle choices is solid advice. Reducing smoking is good for health. Citizens of other rich countries generally exercise and sleep more than we Americans do, though there is some evidence that we dream more ( just kidding). And non-Americans don’t eat as much, so they are less likely to be obese.
But health isn’t all a matter of personal responsibility. Our tax system subsidizes producers of sugars (have you ever read a label that didn’t include high-fructose corn syrup?) and fats, and our culture relentlessly advertises fast, unhealthy foods. At the same time, Americans tend to work longer hours than people in other rich countries, leaving less time for healthy lifestyle choices. Policy changes are essential. Individual and social actions are both needed to improve lifestyles.
Europeans, for example, work 200–400 fewer hours each year on average than Americans do. Laws guarantee them sufficient time off, mandating a minimum of four weeks of paid vacation a year, curbs on overtime, and shorter weekly working hours. (More on this topic in chapter 6.) This leaves them more time to select foods carefully, eat more slowly—and, as a result, eat less—while exercising and sleeping more. Laws reducing work time enable people to make healthier choices and be healthier.
Wall Number Two: Stress Relief
It’s no secret in the field of public health that stress is a killer. Dr. Sarah Speck, director of the Cardiovascular Wellness Program at Seattle’s Swedish Hospital, calls stress “the new tobacco.”21 Sudden bursts of adrenaline worked to protect our early human ancestors against attack by savage beasts. But continued adrenaline response to the chronic stress of modern life leads to heart problems, obesity, hypertension, and weakened immune systems.
Several factors make American life particularly stressful. The United States is among the most competitive of wealthy capitalist countries and has the widest gap between rich and poor (see chapter 7). Fewer people on top; more on the bottom. Multiple studies (see especially Robert Sapolsky’s classic, Why Zebras Don’t Get Ulcers) clearly show that whether it’s humans or baboons, the lower your status, the higher your stress levels. CEOs don’t have the greatest prevalence of heart attacks; it’s the lower-level managers and grunts. More economically egalitarian societies, like Sweden and Japan, for example, are clearly less stressful and healthier. “About 880,000 deaths a year occur in this nation that wouldn’t be there if we had a smaller income gap like the Western European countries,” argues Stephen Bezruchka.22 This is twenty-six times the total annual road fatalities in the United States.23 Think of what federal, state, and local governments spend in road safety every year, while income inequality and stress kill us off at even greater rates.
Stress is also the result of insecurity. As our social safety net has been gutted in recent years (with more of us losing health and pension benefits, for example; more about this in the next chapter) and job protections have been reduced, life in America is riskier than it used to be. We are far more insecure than people in other rich countries, where strong social safety nets remain in place. Danes, for example, can be fired as easily as Americans, but then they receive generous unemployment benefits, job training, and government jobs if they are unable to find a position in the private sector. Insecurity often leads to anxiety. American rates of anxiety are double or triple those in western European countries.24 Anxiety and other mental illnesses further impact physical health, creating a vicious cycle. Europeans say their social safety net gives them a feeling of peace of mind. It’s certainly good for their health.
One of the most significant contributing factors to stress is debt. Debt and household finances are among the most commonly listed causes for divorce in the United States, another contributor to stress.
Finally, stress is also the result of time pressures and overwork. The extent of this impact was confirmed by a May 11, 2010, report from Kristen Hallam of Bloomberg News.
Working 10 hours or more a day may harm the heart, according to a study of more than 10,000 British civil servants. People who added three or more hours to a seven-hour day had a 60 percent greater risk of heart attack, angina and death from cardiovascular disease than those with no overtime work, researchers from the U.K., Finland and France reported today in the European Heart Journal.
The results bolster evidence that suggests working overtime is linked to poor health and may play a greater role in heart disease than previously thought, wrote Gordon McInnes, a professor of clinical pharmacology at the University of Glasgow, in an editorial accompanying the study.25
More and longer breaks from stressful work are seen by Europeans as yet another way to improve health. Changing inequality in the United States is a long-term goal—there is no quick fix. But policies offering shorter work time and longer vacations, clear stress reducers, could be enacted more easily and quickly, and they should be. (More about this in chapter 6.)
Wall Number Three: Social Connection
It’s another clear understanding in the field of public health that social connection strengthens immune systems and improves physical well-being. Studies even show that the more social connections you have, the less likely you are to get a cold when a virus is released into the room. In fact, connecting with others may be the most important single thing you can do to be healthier. On the other hand, being lonely is one of the worst things you can do for your health. Yet, despite Facebook and “social networking,” America is an increasingly lonely country.
More and more Americans, especially older people, live alone, far more than in other rich countries. A recent study found that the average American has only two close friends he or she can turn to. A quarter of us have none at all.26 Loneliness too often turns into depression. As with anxiety, Americans are two to three times as likely to suffer from depression as western Europeans. Depression further weakens immune systems and lowers physical health outcomes.
A National Institutes of Health study comparing frequency of chronic illness in the United States and the United Kingdom found that Americans are far more likely to suffer from heart disease, diabetes, and hypertension in old age. The study controlled for age, race, income, and gender differences and found, surprisingly, that poor Brits are as healthy as rich Americans.27
The study didn’t find that eating fish and chips makes you healthier. And it wasn’t drinking or smoking either. The Brits smoke a bit more than we do and drink a lot more. The major reasons for the difference were related to the fact that the Brits have more security and more free time, which they use to exercise more and, especially, to socialize more. Here again, public policies giving workers more time off the job would improve health, in this case, by allowing Americans more time to spend with family and friends. Clearly, this would also strengthen families and communities.
Wall Number Four: A Safe Environment
Americans, according to the UNICEF study of children’s welfare, rank at the bottom in child safety, with the highest rates of accidents among children. This is partly due to time pressure on American parents, which leaves them less able to supervise their children. Other studies also show extremely high rates of accidents in American workplaces compared with those of other nations. Preventable death rates in the United States, including deaths from automobile accidents, are the highest among industrial countries. Republican senator John Ensign of Nevada acknowledges this, but says deaths from gunshots and traffic accidents shouldn’t count in the mortality stats. “We Americans like our guns,” he observes. “It’s a cultural thing.”28 (We also like our fast food, so perhaps obesity shouldn’t count either.) One can imagine Ensign in an earlier era saying that Americans shouldn’t be considered bigoted because they like their segregation, but we digress.
On average, Americans breathe more polluted air than western Europeans, contributing to higher rates of child asthma. The European Union also has stricter controls on the release of toxic chemicals into the environment. Even children’s toys are different in Europe. The Chinese, who make most of them, have been allowed to include various toxic plastics in those that are shipped to the United States, but are barred from selling the same unsafe toys to Europe.
Finally, and this is no small matter, every other industrial country guarantees its workers paid time off from work when they are sick; only the United States does not. Forty percent of American workers—and 86 percent of restaurant workers—get no paid sick days.29 This is quite strange really, in light of the sermons from public officials telling Americans to stay home and keep their children home to prevent a swine flu epidemic, for example. You might not be able to afford food and your house might be foreclosed, but don’t spread that flu around! In thousands of cases, parents, especially single mothers, are fired because they stay home from work to care for sick children.
In many other countries, as much as a month of paid sick leave is required by law and workers are allowed to use some of this time to care for sick children. These countries know that without paid time off, workers will come to work sick, as many American workers do. Their children will come to schools and day care centers sick. They will get others sick and stay sick longer, often requiring more expensive treatment for their illnesses. This line of thought is not rocket science. Most Americans get it immediately. That is why more than 80 percent of them favor a law that would guarantee paid sick days for workers.30
Health Improves During Recessions
There may be an upside to the recession that hangs over the United States. Health has actually improved during this period. As Stephen Bezruchka says, “Contrary to popular thinking, American health always gets better during recessions.”
Christopher Ruhm, an economist at the University of North Carolina, Greensboro, estimates that for every 1 percent increase in unemployment during recessions, we’re seeing a 0.5 percent drop in the adult mortality rate. “When I first got the results, I didn’t particularly believe them,” Ruhm said in an interview. “I made a picture that overlaid the national mortality rates and unemployment rates. I found that they were a mirror image. It was at that point that I really believed my results.”31
This is counterintuitive; how can something so contrary be? Well, Americans are working less, and these findings are clear proof of how important that is for health. Among those who lose their jobs, the health impact is indeed mixed. Suicides have risen, and some turn to alcohol or abuse their spouses in reaction to their sudden sense of uselessness—“redundant,” in the British expression. But others among the unemployed have used the time to exercise more, spend more time with family and friends, read, learn new hobbies, and generally pay more attention to their health.
For those who have not lost their jobs, the results are also complicated. A minority has seen hours and workloads increased, as they are expected to do the work of laid-off former colleagues. But overall, through furloughs, reduced schedules, and reductions in overtime, working hours for Americans are at their lowest in decades. People have more time and less money. They are using that time to sleep more, exercise more, and visit more with friends and family.
Since we are earning less, we are buying fewer drinks and cigarettes, eating fewer high-calorie, high-fat, high-salt restaurant meals, and driving less. While auto sales have fallen, sales of bicycles are up. As a result of reduced driving, traffic fatalities fell by nearly a quarter from 2007 to 2009. Less driving and reduced industrial output have also meant a drop in air pollution, reducing children’s asthma deaths and improving overall respiratory health.32 It’s too early to tell whether these trends will continue if economic insecurity worsens further, but the preliminary findings are surprisingly positive for many Americans.
Interestingly, epidemiological studies show that health has improved in all recessions since the Great Depression. The positive impact of recessions on health is not nearly so dramatic in countries that already have shorter working hours and a stronger social safety net. But neither does their citizens’ health suffer as much during economic expansions.33
This is not an argument for unemployment, but these findings raise a question: How can we return to full employment while not losing the health benefits that the recession has brought us? Here, the answer is clear: We should find ways to reduce working hours, share existing work, and trade productivity gains for free time instead of more production, even if it means that incomes will rise more slowly or not at all. There are many ways to do this; some will be explored later in this book.
What Else Can We Do to Improve Our Health?
Right now, our house of health has a foundation that is marble for the rich, rotting wood for the middle, and dirt for the poor. It has four walls that are a mixture of teak, balsa wood, and bamboo, all of them in sorry shape. And finally, it has a golden roof with millions of holes.
It is not enough to talk of making the roof all gold and eliminating the holes, though the health care bill helped in that regard. We need to eliminate the gold as well, taking the profit motive and costly complexity from the system and expanding a program like Medicare to cover everyone, potentially at less cost.
In 2002, John was hit by a motorcycle in Rome and quickly whisked away in a tiny (and we do mean tiny) ambulance to the polyclinic, where he received quick and efficient care. “The bad news from the X-rays is that your ribs are broken,” the nurse informed him, “and we can’t do much about that except tape you up and give you some pain killers.” Before leaving the clinic, John asked what he needed to do about the bill. “No charge,” the nurse said, smiling, “Italian hospitality.” And, we might add (whispering the words, of course), “socialized medicine.” When John returned home and went to his HMO to check things out, he was told that the Italians had done an excellent job and that he would be billed $300 from his HMO for that information.
So the roof does need to be fixed. But fixing the roof is only a first step. It’s time for an extreme makeover. If we also pay attention to the foundation and the walls, we can ensure better outcomes at lower cost. We can:
• Strengthen the foundation by improving prenatal care and providing at least three months or more of paid leave to all parents of babies or very young children. We should make the Family and Medical Leave Act a paid provision and extend it to all workers. Early life lasts a lifetime.
• Strengthen the wall of lifestyle by encouraging healthy diets, teaching children the value of eating nutritious foods, eliminating subsidies to the purveyors of sugars and fats, and, especially, reducing working hours to give Americans more time for exercise, sleep, and healthy eating.
• Strengthen the wall of stress relief by reinstituting tax policies that narrow the gap between rich and poor, rebuilding our social safety net, and adopting policies like paid vacation time to give Americans periodic relief from the stress of hypercompetitive and long-hour workplaces. We must also provide more resources for the early identification and treatment of mental illnesses such as anxiety and depression.
• Strengthen the wall of connection, again by reducing working time, and by stimulating, through programs like national service, greater volunteer involvement with our neighbors and communities. Design of communities matters here too; our sprawling suburbs encourage disconnection, while urban village designs with smaller home sizes but more public space, from coffeehouses to car-free shopping districts, encourage it.
• Strengthen the wall of safety by improving OSHA and other protections for workers, building more pedestrian- and bicycle-friendly cities, and regaining the environmental zeal of the early 1970s, which led to much cleaner water and air for all Americans. Pass legislation—now in place only in San Francisco, Washington, D.C., and Milwaukee—that would require the provision of paid sick days. The late Senator Edward Kennedy’s proposed Healthy Families Act would do this.
Most of these policies and provisions are taken for granted in other nations. Any or all of them will make the United States healthier, and almost certainly at less cost than our current system. Improving our health outcomes is less a matter of better science and more money than one of political will and an ability to see the connections between things.
How will our extreme health makeover affect the economy? Business leaders variously support and oppose these policies. In any case, most of the costs of such changes should not fall on business but be borne more generally by all of us. Fox News pundits will no doubt suggest that these reforms will cost too much and make us less competitive. But the cost of poor health is, and will continue to be, far greater than the price tag for such reforms. In their book, Raising the Global Floor, Jody Heymann and Alison Earle show clearly that the policies we recommend here do not make countries less competitive, nor do they increase unemployment rates. One thing more than any other makes it hard for American businesses to compete: the escalating cost of health care. Health care payments make producing an automobile far more expensive in the United States than in Canada, for example. Our failing health care system is actually making us less competitive.
Rules Matter
When it comes to health, rules matter more than sermons. Our most significant health gains have come when we required clean air, pure water, and safe food. Vaccination requirements and quarantines made an important difference in preventing epidemics. Cigarette and alcohol consumption declined when high taxes made the choice of such products less tempting. Seat belts, car seats, required safety improvements in auto structural design and road engineering all helped lower the number of traffic fatalities.
Whatever the health problems we Americans face, our health and our life expectancy today are now better than they were in our parents’ or grandparents’ time. But there are troubling signs. For example, childhood obesity has become a serious problem. Many doctors predict that the life expectancy of today’s children will be shorter than that of their parents, reversing decades of progress. In light of this, the elimination of physical education (or in some cases, even recess!) in many American schools can be seen as misguided, if not criminally insane.
But what should truly concern us is that right after World War II, Americans were among the very healthiest people on Earth. Though our health has improved since then, more than forty other nations caught up to us and passed us. In fact, America is now far behind most of those countries. For nearly every measurable health outcome, the United States ranks near the bottom among the world’s rich countries and below even some of the poor ones. This is only partly the result of our health care system. It is more the result of economic policies that have encouraged overwork, underconnection, poor diets, hazardous working conditions, and hell on the highway.
When it comes to health, it can hardly be argued that the American economy is promoting the greatest good for the greatest number or the longest run for any of us.
Doesn’t it make you want to pop a pill? Instead, let’s work for policy reforms that not only will improve our health but can actually make our businesses more competitive, not less.