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The status of the
United States as an outlier in health could not be presented more
dramatically than it is on the graph of health spending and life
expectancy prepared by the Organization for Economic Co-operation
and Development (OECD)(see below). Compared to the other OECD
countries, the United States at $7960 spends more than two times
the average of OECD countries and 3-7 more than some of the
rapidly advancing countries such as Poland and Czech Republic.
According to the Institute of Medicine Committee on Public Health
Strategies, “Debate over America’s place at the top of economic
superpowers aside, it is clear that it is not a superpower in
health.”
Report
In its new
report entitled “For the Public’s Health: Investing in a Healthier
Future”, the IOM chronicles the relatively poor state of health
indicators in the United States, lays the blame on failure to
invest in more upstream causes of ill-health, and recommends clear
strategies for moving forward to achieve health gains that place
the US at least closer to the average performance of other
comparable high income countries. Interestingly, there is no
mention of the US seeking to place itself among the top ranking
nations in health.
State of the
Nation’s Health
According to
United Nations figures highlighted by the IOM, the US ranks 28th
on life expectancy and 34th on infant mortality out of
146 countries. In describing medical costs, the IOM points out
that non-communicable, chronic conditions now account for more
than 75 percent of the money spent on medical care, and chronic
conditions associated with modifiable risk factors such as
smoking, nutrition, weight, and physical activity represented 6 of
the 10 costliest conditions. The US now spends some 17.3% of gross
domestic product on health and this is projected to rise to 19.3%
by 2019. This can be expected to translate into an increase in
family premiums for a typical insurance plan from approximately
$13,000 to $24,000 by 2020, says the IOM.
Causes
The IOM report
highlights the failure of the US health system to truly tackle the
preventable causes of poorer health. According to the IOM,
“Despite the knowledge that most cases of those costly chronic
conditions are preventable, the national strategy to address the
health crisis is directed predominantly downstream at the medical
care delivery system.” It calls the Affordable Health Care Act “a
legislative precedent worth building on” and says that improving
population health will require a “major strategic focus and
aggressive action on root causes.”
Need For
Population Health Focus
Epidemiologists
and public health professionals are well aware by now of the
importance of the upstream social determinants of health, yet
there continues to be a failure to identify and operationalize
effective strategies. The IOM spreads the blame for this failure
among all the key actors, stating “…poor US health status and
costly medical care consumption reflect a failure of the nation’s
health system as a whole---medical care, governmental public
health, and other actors---to support strategies that advance
population health.”
Social Spending
One indicator
of the failure to put in place more effective strategies is the
failure to make adequate investments in non-health care social
spending compared to health care social spending since there is
evidence of a relationship between the non-health care social
spending and national health status. According to the IOM,
spending allocation in the United States is the reverse of
that in other OECD countries since the ratio of non-health care
social spending to health care social spending was 2.0 in the OECD
countries compared to 0.83 in the United States.
Needed Strategies
The solutions
to achieving better value for health investments are clear
according to the IOM. They involve:
1. Controlling
administrative waste
2. Eliminating
sources of excess cost and other inefficiencies
3. Achieving
universal coverage
4.
Implementing population-based health improvement strategies.
This IOM
Committee report focused on the fourth of strategies and the first
recommendation to help bring about the needed strategic changes
is:
“The Secretary
of HHS should adopt an interim explicit life expectancy target,
establish data systems for a permanent health-adjusted life
expectancy target, and establish a specific per capita health
expenditure target to be achieved by 2030.”
Governmental
Public Health
The IOM
recognizes in its report that governmental public health must play
the key role in bringing about the needed improvements. It cites
progress made nationally through governmental public health in
reducing lead toxicity in children and households, achieving
drinking water fluoridation, reducing motor vehicle fatalities,
and causing a decline in smoking prevalence.
IOM calls
chronic physical and behavioral health conditions the major health
impediments to active living and personal fulfillment and to
national economic competitiveness and productivity. It calls these
non-communicable conditions “downstream effects” of social and
physical environments. The IOM appears to blame the problem on
inadequate funding—“governmental public health departments have
not been adequately funded to take on the complex tasks of
designing and implementing strategies that can limit the burden of
non-communicable diseases in the United States.
Urgent Problem
Says IOM, “the
urgency of a comprehensive national approach to the remediation of
the ‘upstream’ causes of non-communcable diseases, injuries and
other contemporary health challenges, and the urgency of improving
the functioning of the clinical care system could not be more
pronounced.”
The report
speaks positively of the Affordable Health Care Act for its
approaches to improving population health but stresses that “the
investment is small (and has already been substantially
reduced…the national strategy to address the health crisis is
directed predominantly downstream at the locus of health care
delivery and only weakly upstream at the causes of poor health
that continue to generate large volumes of new cases in the
medical care delivery system.”
In effect, the
IOM report is calling for the nation to change how it invests its
health funding and to direct a larger share of this money to
governmental public health which in turns needs retooling of how
it allocates and spends funds. Unmentioned in the IOM report is
the apparent lack of political will to undertake the type and
scope of changes proposed, many of which call for greater
non-health care social spending. The current political opposition
to the Affordable Health Care Act highlights the challenge that
exists in implementing the IOM recommendations, even though they
call for improvements in life expectancy that only bring the US
closer to, but not beyond, the life expectancy of peer nations.
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