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Chapter 1 The Health Effects of Social and Economic Policy: The Promise and Challenge for Research and Policy James S. House, Robert F. Schoeni, George A. Kaplan, and Harold Pollack T he United States faces a growing paradox between its declining levels of population health relative to other wealthy nations—and even to some developing ones—and its burgeoning spending on health insurance and medical care. By an increasing margin each year, the United States spends a larger percentage of its gross domestic product (GDP) on health care than any other nation, with health care expenditures now totaling $1.9 trillion per year and large increases projected over coming decades (Chernew, Hirth, and Cutler 2003). Scholars, policy makers, and citizens debate the marginal value and cost-effectiveness of these expenditures. Specific advances—for example, neonatal intensive care, highly active antiretroviral therapy (HAART), improved cardiac care, and new outpatient pharmaceuticals—bring gains in longevity and well-being which meet standard benchmarks for cost-effectiveness (Cutler 2004). Yet other care is of uncertain effectiveness or low quality (Institute of Medicine 2001a, 2001b). Moreover , increasing medical expenditures create serious challenges for individuals, employers, and all levels of government. Expenditure growth threatens the continued availability and affordability of health insurance and medical services, and creates fiscal strains at the federal, state, and local levels which reduce nonmedical assistance to needy people and spending in other non-health areas such as education and infrastructure (Baicker 2001). Paradoxically, despite marked growth in medical-care spending, the United States’s standing on major indicators of population health such as life expectancy at birth and infant mortality has declined relative to other wealthy nations, as well as relative to some much less affluent ones (Organization for Economic Co-Operation and Development [OECD] 2005; United Nations Development Programme 2005). As shown in table 1.1, while rising in rank over the past half century in per- / 3 cent of GDP spent on health, the United States has fallen during this time period from being among the top nations in life expectancy and infant mortality to a ranking near the bottom among the thirty nations of the Organization for Economic Co-operation and Development or OECD. Only Mexico, Turkey, and three relatively new OECD members from the former Soviet bloc (Hungary, the Czech Republic , and the Slovak Republic) consistently rank below the United States on such indicators. Most current political and policy analysis related to health in the United States focuses on medical-care and insurance expenditures, incentives, and prices. Much less attention is paid to levels of population health beyond the worry that controls and reductions necessary to constrain spending growth may adversely affect overall health or health within specific vulnerable groups. Much can be done to enhance the quality and cost-effectiveness of American health care, and many contributors to this volume have actively addressed these challenges in other venues. However, this chapter and the research presented throughout this book pursue a different agenda: to address neglected opportunities for improving population health via social and economic policy outside of the traditional domains of preventive and curative health care. The concentration in so many health policy discussions on medical services as the sine qua non for improving population health neglects historical knowledge about the causes of major changes in the health of populations. It also neglects real opportunities outside the domain of medical care to improve population health. It may seem paradoxical and impossible that a society could achieve better population health without explicitly increasing health care expenditures, but this is only if we assume that health care is the major determinant of health. As dramatic and consequential as medical care is for individual cases and for specific conditions , much evidence suggests that such care is not, and probably never has been, the major determinant of levels or changes in population health. This evidence is Making Americans Healthier 4 / TABLE 1.1 / U.S. Rank Among Thirty OECD Developed Nations on Indicators of Population Health and Percent GDP Spent on Health Percentage of GDP Spent on Health U.S. Rank Average on Life U.S. Rank United Spending Among Expectancy on Infant United States All Other Year at Birth Mortality States Rank Spending OECD Countries 1960 15.5 12 2 5.1% 3.7% 1970 19 14 3, tied 7.0 5.0 1980 14 18 1 8.8 6.7 1990 18 21 1 11.9 6.8 2000 22 25 1 13.3 7.6 2003 23...

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