The Road to Real Health
It’s no secret that the United States is still locked in an ideological battle over how to reform our health care system. The health care reform bill passed by Congress in early 2010 is a watered-down version of what progressive Democrats advocated, lacking the “public option.” Yet Republicans seek to repeal it as too radical. The health care debate generated far more heat than light, with conservative opponents even carrying guns to town meetings. But the biggest problem with the debate is its focus on health care.
It is true that, by any objective, data-based evidence, the American health care system is on life support: it is priced at more than $8,000 a year per American and will soon be 20 percent of our gross domestic product. In a few years, we’ll be spending one dollar out of every five in our economy on health care alone. Our system is more expensive by 40–60 percent than health care systems in any other industrialized country and makes up nearly half the health care budget of the entire world.
Health insurance premiums for those who have them have been rising in cost by double digits each year. Some companies in California have proposed increases of 39 percent next year. Yet this enormously expensive system leaves millions of Americans completely without health insurance and millions more underinsured: 47 million lacked insurance before the health care bill passed. If the bill is not repealed, about 32 million of them should now be insured, but that still leaves 15 million without coverage. Uncovered medical bills account for about half of all our personal bankruptcies each year.
To top it all off, our health care system produces results that are arguably the worst in any of the wealthy nations of the world. The Central Intelligence Agency’s World Factbook reports that Americans now rank 50th in life expectancy. We’re just below Bosnia and above Albania and we’ve fallen from a ranking of 11th in 1980. The CIA list includes some tiny nations like Malta, Gibraltar, and Andorra, but even among the 31 larger nations included in the Organisation for Economic Co-operation and Development (OECD), we rank 27th.
A National Institutes of Health study comparing frequency of chronic illness in the United States and the United Kingdom also found that Americans are far more likely to suffer from heart disease, diabetes, and hypertension in old age. In California, such diseases account for some 80 percent of hospital health care costs. The NIH study comparing British and American health controlled for age, race, income, and gender differences and found, surprisingly, that poor Britons are as healthy as rich Americans.
And if such evidence of failure isn’t enough to cast doubt on our health care system, a recent Harvard study concluded that some 44,000 Americans die each year for lack of health insurance. Even in the hospital, U.S. patients face unusual dangers. More than 100,000 of them are victims of health care itself: they die of errors or infections during treatment. So the system is broken. But fixing it will require a far more holistic approach than has been discussed in the health care debate thus far.
Forty-four thousand deaths from lack of health care is a national scandal. Justice demands insurance coverage for all Americans as in every other wealthy country. Yet few would argue that good health care is our ultimate goal. If you doubt that, ask yourself: Would you rather spend the next year convalescing in the world’s best hospital free of charge or living at home feeling good? The goal, of course, is good health. Health care is only part of that.
Health Has Improved During the Recession
Consider, for a moment, the counterintuitive outcome that in the United States and many industrialized countries, especially those with weak social safety nets, health tends to improve during recessions, while remaining relatively stable or declining during economic booms. Indeed, research suggests that, during the current recession, Americans are working less and earning less. But in response, they actually exercise more, socialize more, eat less high-calorie restaurant food, sleep more, smoke and drink less, volunteer more, drive less, and face less exposure to air pollutants, all helpful to their health. Home gardening, for example, rose 40 percent last year, improving both exercise and food choices, while traffic deaths have dropped about 25 percent since the current recession began.
On the other hand, high levels of unemployment are hard on workers and families. For those who actually lose their jobs, results are more mixed—higher numbers commit suicide, for example—but the aggregate numbers are positive. According to Dr. Christopher Ruhm of the University of North Carolina–Greensboro, on average in the United States, a 1 percent increase in unemployment leads to a one-half percent drop in the death rate.
Is there a way to return to a healthier economy and much lower unemployment rate without jeopardizing the improvements in health that recessions regularly bring?
Childhood: The Foundation of Good Health
Let’s start with the foundation of good health: the head start toward health that children in most other rich countries receive. There’s a stronger focus on prenatal care, for example, which leads to lower infant mortality rates. The United States has a higher infant death rate than any other industrialized country and ranks 45th in the world, again according to the CIA. Moreover, fewer mothers die in childbirth in other industrialized countries, whereas the United States ranks a comparatively poor 41st in the world. Maternal mortality rates for poor and African American mothers are particularly high here. Every other rich country does better.
But equally important to children’s health is a policy taken for granted in nearly every country in the world except, believe it or not, the United States, Liberia, Swaziland, and Papua New Guinea. In all other countries, mothers are guaranteed paid time off from work to take care of newborns. 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. In the United States, by contrast, parents often return to work when children are only a few weeks old.
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, lower rates of obesity, easier socialization, and better readiness to learn. Most countries find that such a taxpayer investment in early childhood results in lower health and other costs as children grow up. In Canada, for example, the government pays 55 percent of the stay-at-home parent’s salary during parental leave. Health care costs for children have dropped there since 2004 when leave was increased from six months to a year, leading to some interest in further extending the leave.
Meanwhile, American children are increasingly less healthy. According to the Journal of the American Medical Association, the prevalence of chronic health problems, including obesity and asthma, among children more than doubled between 1994 and 2006. While many of these children improve as they get older, the results are troubling to researchers.
A 2007 United Nations Children’s Fund (UNICEF) study ranked the United States 20th out of 21 rich nations regarding children’s welfare, with particularly poor health and accident outcomes. Only the United Kingdom fared worse. Americans ranked at the bottom in child safety, with the highest rate of accidents among children. Furthermore, in spite of evidence that American children are less fit than those in other developed countries, many American schools have reduced or eliminated physical education classes and even recess time in recent years.
A World Fit for Children
by Raffi Cavoukian
A movement to put children’s rights at the center of our collective decisions is taking hold—and it’s good news for adults, too.
At the same time, prompted in part by television advertising and subsidies that keep prices low for such unhealthy food additives as high fructose corn syrup, American children have doubled their intake of “snack” foods since the 1970s. Some researchers suggest that the present generation of American children may be the first to live shorter lives than their parents. Epidemiologist Stephen Bezruchka of the University of Washington points out that “the things that happen to children in their earliest years create health impacts that last a lifetime.”1
Enabling a Healthy Lifestyle
If Democrats talk almost exclusively about universal health care as the solution to our health problems, Republicans tend to focus on wall number one: lifestyle choices. It’s a matter of personal responsibility, they say. Americans should simply stop smoking, eat properly, avoid overeating and excessive alcohol drinking, exercise regularly, and sleep enough. And, the conservatives argue, we don’t need the government to make us do this. Of course, this is sensible advice. Citizens of other rich countries generally exercise and sleep more than we do. And they don’t eat as much, so they are less likely to be obese.
Michelle Obama has taken a page from the Republican playbook, launching a campaign called “Let’s Move” to fight childhood obesity. Much of the campaign includes exhortations to get out and exercise. But Mrs. Obama realizes it isn’t all a matter of personal responsibility. She advocates programs to make sure that children get healthy foods in the schools and that poor Americans have access to fresh fruits and vegetables. She might also advocate some important policy changes. As mentioned earlier, our tax system subsidizes producers of sugars and fats and our marketing system relentlessly advertises fast, unhealthy foods. Consumers are far less likely to face these pressures outside the United States.
At the same time, Americans tend to work longer hours than people in other rich countries. Europeans, for example, work 200–400 fewer hours each year on average, depending on the country. Laws guarantee them sufficient time off, including a minimum of four weeks of paid vacation a year, curbs on overtime, and shorter weekly working hours. These regulations leave 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 have the effect of making them healthier.
One of the most innovative of European shorter work-time laws is the Netherlands’ Hours Adjustment Act, adopted in 2000. Under this law, employees can ask for shorter work hours and the requests must be granted unless their bosses can show that a reduction of hours would materially damage the firm, an occurrence in fewer than 5 percent of cases. Employees keep the same hourly wage and retain their health care while seeing other benefits, such as pension contributions and vacation days, prorated. The popular idea has spread to Germany and is one reason why the Netherlands has the highest percentage of part-time workers in the world and the shortest annual hours. It is a practical sort of freedom of choice. Workers can choose time over money without risking their entire livelihoods, benefits, and health care.
The Work-Sharing Boom: Exit Ramp to a New Economy?
To cope with the recession, some companies are cutting hours instead of employees. Will the trend have long-term effects?
An equally interesting law now spreading to many countries is Germany’s Kurzarbeit or “short-time work” policy. It allows employers to avoid layoffs by reducing hours all around and permits employees to receive unemployment benefits to compensate for salary losses. Policies such as the Hours Adjustment Act and the Kurzarbeit program could be used to grant Americans more time for healthy lifestyles. Reducing work time might also help strengthen other aspects of our health as well.
It’s no secret in the field of public health that stress is a killer. Sudden bursts of adrenaline and cortisol worked to protect our early human ancestors against attack by savage beasts. But as Stanford’s Robert Sapolsky shows in Why Zebras Don’t Get Ulcers (2004), continued adrenaline response to the chronic stress of modern life leads to heart problems, obesity, hypertension, and weakened immune systems.