A greatest-country-in-the-world syndrome sometimes makes it hard for us Americans to recognize ways in which other societies are outpacing the United States. Health care presents a striking discrepancy between common domestic perceptions of relative U.S. performance and actual comparisons with other high-income countries. A common argument in the debate over U.S. health care reform has been that "the American health care system... is already the finest health care system in the world" (as Senator Mitch McConnell put it on Fox News Sunday on July 1, 2012). But evidence continues to mount that health outcomes in the United States are among the worst in high-income countries, while expenditures on health are far and away the highest! Wealthy foreigners come to the United States for the most sophisticated operations, and medical research and pharmaceutical development is outstanding, but from the perspective of society as a whole, something is badly wrong.
The latest wide-ranging evidence regarding comparative health outcomes comes from an impeccable American source. At the request of the U.S. National Institutes of Health, the National Research Council and Institute of Medicine established a Panel on Understanding Cross-National Health Differences Among High-Income Countries. The Panel's report appeared in pre-publication form last month (January 2013) under the title U.S. Health in International Perspective: Shorter Lives, Poorer Health.* Health outcomes in the United States were compared to 16 "peer" countries: Canada, Australia, Japan and 13 European countries (Portugal, Spain, Italy, Austria, Switzerland, Germany, France, the Netherlands, the United Kingdom, Denmark, Norway, Sweden and Finland).
Panel members were themselves surprised by the strength of their findings. "We uncovered a strikingly consistent and pervasive pattern of higher mortality and inferior health in the United States, beginning at birth:
• "For many years, Americans have had a shorter life expectancy than people in almost all of the peer countries....
• "For the past three decades, this difference in life expectancy has been growing, especially among women.
• "The health disadvantage is pervasive - it affects all age groups up to age 75 and is observed for multiple diseases, biological and behavioral risk factors, and injuries."
Comparing U.S. outcomes to peer countries in specific "health domains," the Panel found, for instance, that
• "For decades, the United States has experienced the highest infant mortality rate of high-income countries....
• "Since the 1990s, among high-income countries, U.S. adolescents have had the highest rate of pregnancies and are more likely to acquire sexually transmitted infections....
• "For decades, the United States has had the highest obesity rate among high-income countries."
How is this "growing U.S. health disadvantage" to be explained? The Panel finds no single factor that fully explains what is happening.
• The U.S. "health system" is one prominent factor. It "is highly fragmented, with limited public health and primary care resources and a large uninsured population. Compared with people in other countries, Americans are more likely to find care inaccessible or unaffordable and to report lapses in the quality and safety of care outside of hospitals."
• Adverse social and economic conditions matter to an important extent, though further research is needed to establish specific causal links, not just "co-occurrence." The United States "has higher rates of poverty and income inequality than most high-income countries. U.S. children are more likely than children in peer countries to grow up in poverty....(A)lthough the United States was once the world leader in education, students in many countries now outperform U.S. students."
• More surprisingly, and pointing to different societal phenomena, the Panel found worse health outcomes even among Americans not afflicted by adverse social and economic conditions. "Americans with healthy behaviors or those who are white, insured, college-educated, or in upper-income groups appear to be in worse health than similar groups in comparison countries." Just as surprising, "the nation's large population of recent immigrants is generally in better health than native-born Americans."
From a societal perspective, it is baffling and unsettling that comparatively poor U.S. health outcomes go along with U.S. health expenditures far higher than any other peer country. The OECD Factbook 2013 gathers the numbers for the United States and peer countries in 2010 or the latest available year. U.S. public and private expenditures on health came to almost 18 percent of U.S. GDP, roughly half again higher -- an astonishing difference -- than the Netherlands, next highest at 12 percent.
The mounting evidence of a "U.S. health disadvantage," against a backdrop of extraordinarily high health expenditures, should erode whatever complacency remains about the performance of U.S. society in this regard. In the television interview noted at the outset, Senator McConnell went on to say that "we're not going to turn the American health care system into a Western European system." There is more than one health care system in Western Europe, and no need to adopt any other system wholesale. But given the better health outcomes in Western Europe (and in Canada, Australia and Japan), it would be the worst of American blind self-satisfaction not to look for innovative ideas beyond our borders as well as within them.