The U.S. Health Disadvantage: A Crisis That We Must Address Together Today
What's the problem?The problem is as simple as it is perplexing. The U.S. spends far more per capita on healthcare than other high-income countries, yet the nation has fallen in relative standing because it has the worst health outcomes. For example, compared to the average country in the NRC/IOM study, the U.S. ranks the worst for infant mortality and low birth weight, obesity, diabetes, heart disease, chronic lung disease, disability, adolescent pregnancy and sexually transmitted infections, HIV and AIDS, drug-related deaths, injuries and homicides. As the report title aptly states: "U.S. Health in International Perspective: Shorter Lives, Poorer Health."
Moreover, studies confirm that poor health outcomes in the U.S. have disproportionate impact based on factors such as ethnicity, education, race, geography, sexual orientation, socioeconomic circumstance and immigration status. The result is unconscionable health disparities among population sub-groups that reflect shameful underlying healthcare injustices. For example, African-American women are more than twice as likely as white women to die of cervical cancer and have the highest rate of breast cancer death of any racial or ethnic group. People with less than a high school education are more than four times as likely as those with a college degree to report poor or fair health. Rural residents are less likely to have health insurance and have fewer doctor visits and preventive tests.
What's the solution?The NRC/IOM report found that "no single factor can fully explain the U.S. health disadvantage … [It] has multiple causes and involves some combination of inadequate healthcare, unhealthy behaviors, adverse economic and social conditions, and environmental factors, as well as public policies and social values that shape those conditions." This means the challenge is multifaceted and requires a new paradigm that focuses on these three new pieces to help solve the puzzle:
1. Reform what matters. The Patient Protection and Affordable Care Act's expansion of health insurance to millions of uninsured individuals is a step forward, but could overburden a broken healthcare system that is struggling to meet current needs. The system must be fundamentally transformed — from a disease-based system to one that emphasizes wellness and prevention, from hospital-based acute intervention and crisis care to an approach driven by primary care and population health, and from fragmented health services to a coordinated continuum of care across the life span. Today's medical model of healthcare must be replaced with a more inclusive social determinants model.
2. Focus on the real drivers of health. Contrary to what many Americans believe, medical care influences only 10 percent of premature mortality and health status. The truly powerful determinants of health are genetics, behaviors and social circumstances such as income, housing, transportation, safe neighborhoods, job security, education and access to healthy foods. Sustainable improvements in health and the elimination of health disparities will occur only when society removes the silos between medical care and other social services. The nation must embrace an approach that addresses these upstream determinants of health.
3. Spend where it counts. The U.S. needs to follow peer nations that spend less money and get better results because they spend money on the right things at the right time. U.S. healthcare funds must be redirected upstream on social services that help prevent disease and promote wellness, instead of waiting downstream for high-cost disease to develop. For example, a recent report from the National Health Foundation illustrates the significant cost savings that have been achieved through programs that use special centers to provide housing for homeless patients who are not sick enough to stay in hospitals, yet are too sick for shelters. The centers offer homeless patients a clean and safe place to recover and receive medical assistance, help with appointments and information about support services.
What's the next step?A key to addressing the nation's "health disadvantage" is a new perspective that focuses on "health," rather than just "healthcare." The country needs a renewed sense of social responsibility that asks difficult questions about health disparities and finds sustainable answers by addressing the social determinants of health. This new direction requires all sectors of society — academia, community leaders and the public — to come together for the common cause of securing our nation's health.
The NRC/IOM report clearly warns that "of particular concern … is whether the public is fully aware of the U.S. health disadvantage. The depth and breadth of the problem … came as a surprise to many of us." The situation is dire. The time to act is now. The U.S. is a great nation in many ways. It is time to add health to the country's sphere of greatness.
Claire Pomeroy is vice chancellor for human health sciences and dean of the School of Medicine at the University of California, Davis. She chairs the Board of Directors of the Association of Academic Health Centers and the Council of Deans of the Association of American Medical Colleges.
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