What the Supreme Court Did Not Hear

As the nine Supreme Court justices listened to arguments about the constitutionality of the Patient Protection and Affordable Care Act (aka "Obamacare"), which was passed by Congress and signed into law in 2010, they probably missed the article in the Annual Review of Public Health that described the deteriorating status of the US in international health lists.

The article, by Steven Bezruchka of the Departments of Health Services and Global Health at the University of Washington School of Public Health, contains some disturbing facts that the justices and every other American should ponder.

Based on validated indicators of population health (life expectancy, infant mortality, maternal mortality ratio, nqx*, and health-adjusted life expectancy), the US has dropped approximately 20 places in world health rankings since the early 1950s.

Life expectancy in the US was 79.6 years in 2010. The longest-lived country, Japan, had a life expectancy of 83.2 years. "A gap of 3.6 years of life expectancy at birth between the United States and Japan reflects major differences in health," says Bezruchka. Even eradicating coronary heart disease, the leading cause of death in the US, would likely not be enough to transcend the mortality gap. Eliminating cancer deaths would add only about three years.

To put it another way, Berzuchka says, "The United States currently has a life expectancy that Japan achieved around 1993, suggesting it lags some 15 calendar years behind in achieving the best health outcomes."

Life expectancy has been diminishing or stagnating in absolute terms for women in almost 20 percent of US counties. Moreover, from 2000 to 2007, most US counties fell behind the progress seen in the leading countries. "When life expectancy in U.S. counties is ranked with comparable local areas of other nations," says Berzuchka, "only a very few are at the level of the international frontier [the average of the 10 highest county life expectancies for a given year], suggesting that even the healthiest U.S. subpopulations suffer from suboptimal health."

The US ranked in 48th adult female mortality in 2010 -- tied with Macedonia and Armenia, behind the Maldives, and ahead of Poland.

Infant mortality data was similarly discouraging. In 1960, the US ranked 12th among selected countries listed by the Centers for Disease Control and Prevention. By 2006, it had fallen to 28th. A National Center for Health Statistics report observed that in 2004, the US "ranked 29th in the world in infant mortality, tied with Poland and Slovakia." Berzuchka says health inequalities within this country have not been improving over time, either. Life expectancy distributions "appear to be more skewed than in other nations, with a long tail of poorer health reflecting continued health inequities."

An explanation of the relative health decline in the US "may come from a population health approach that highlights the importance of structural, economic, and political factors that govern the level of inequality tolerated in society," he says. These factors probably matter most in early life. "The United States demonstrates among the worst inequalities in outcomes for children of all rich nations."

Berzuchka cites findings of a meta-analysis suggesting that one-third of all deaths in the US can be linked to inequality. And he notes that neither paid maternity leave nor paid prenatal leave are generally provided here, "which may be important factors in affecting health outcomes." The US has one of the highest reported stress levels of all nations, and stress "may be the 21st century tobacco."

"Addressing these issues is a major challenge and requires a level of understanding that does not exist in today’s corporatized medical environment," he concludes. "European policies addressing social and economic safety nets may help present some direction for improving health in the United States."

Such a goal "would require major policy changes that the country may not be willing to make." Nevertheless, "residents and leaders of the nation should be aware of the state of their health so that their decision is an informed one," Berzuchka says. "Communicating to the American public their dismal health status ranking is a first step toward improving population health."

*The statistic nqx represents the probability of dying between age x and x + n. This represents a useful midlife health measure for the most economically and socially active segment of society, when x is early adulthood and n is such that x + n is close to the end of working age.