We Can Do Better — Improving the Health of the American People

T he united states spends more on health care than any other nation in the world, yet it ranks poorly on nearly every measure of health status.How can this be?What explains this apparent paradox?The two-part answer is deceptively simple -first, the pathways to better health do not generally depend on better health care, and second, even in those instances in which health care is important, too many Americans do not receive it, receive it too late, or receive poor-quality care.In this lecture, I first summarize where the United States stands in international rankings of health status.Next, using the concept of determinants of premature death as a key measure of health status, I discuss pathways to improvement, emphasizing lessons learned from tobacco control and acknowledging the reality that better health (lower mortality and a higher level of functioning) cannot be achieved without paying greater attention to poor Americans.I conclude with speculations on why we have not focused on improving health in the United States and what it would take to make that happen. He a lth S tat us of the A mer ic a n Publ icAmong the 30 developed nations that make up the Organization for Economic Cooperation and Development (OECD), the United States ranks near the bottom on most standard measures of health status (Table 1).1-4 (One measure on which the United States does better is life expectancy from the age of 65 years, possibly reflecting the comprehensive health insurance provided for this segment of the population.)Among the 192 nations for which 2004 data are available, the United States ranks 46th in average life expectancy from birth and 42nd in infant mortality.5,6 It is remarkable how complacent the public and the medical profession are in their acceptance of these unfavorable comparisons, especially in light of how carefully we track health-systems measures, such as the size of the budget for the National Institutes of Health, trends in national spending on health, and the number of Americans who lack health insurance.One reason for the complacency may be the rationalization that the United States is more ethnically heterogeneous than the nations at the top of the rankings, such as Japan, Switzerland, and Iceland.It is true that within the United States there are large disparities in health status -by geographic area, race and ethnic group, and class.[7][8][9] But even when comparisons are limited to white Americans, our performance is dismal (Table 1).And even if the health status of white Americans matched that in the leading nations, it would still be incumbent on us to improve the health of the entire nation. Path wa ys t o Improv ing P opul at ion He a lthHealth is influenced by factors in five domains -genetics, social circumstances, environmental exposures, behavioral patterns, and health care (Fig. 1).10,11 When it