post by Bill Gardner
In the 1950s, the United States, having among the lowest mortality and other indicators of good health, ranked well among nations. Since then, the United States has not seen the scale of improvements in health outcomes enjoyed by most other developed countries, despite spending increasing amounts of its economy on health care services. Trends in personal health-related behaviors are only part of the explanation. Structural factors related to inequality and conditions of early life are important reasons for the relative stagnation in health.
Even though our life expectancy is improving, it is improving less quickly than comparable developed countries. He summarizes the possible reasons for this, about which there is great uncertainty. The health care system is probably not the principal cause of the problem. The high rates of homicides and completed suicides may be important. Americans are more obese but smoke less than many countries, so it is not clear whether health-related behaviors can explain our comparative lack of progress in health. Note also that the US accepts fewer immigrants than many substantially healthier countries, such as Canada.
Bezruchka speculates that
An explanation of the relative health decline 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. Early life may be when these factors matter most. The United States demonstrates among the worst inequalities in outcomes for children of all rich nations.
Ummm... I sort of/kind of agree. In my view, however, the problem is less inequality per se than childhood poverty and adversity. If I understand the Pikety-Saesz data, the recent rise in inequality has been driven by in the increase in the share of wealth and income held at the top of the social ladder. It is not clear to me how growth of wealth and income at the top of distribution would lead to stagnation in life-expectancy improvement for everyone else.
Rather, it seems more plausible that it is the stagnation of improvement in economic well-being for the 99% that slows their improvement in life expectancy. To understand this we should look at the circumstances of those at the bottom of the social ladder. Because I think that much of our health trajectory is set in early childhood, the life circumstances of children are particularly important.
It seems plausible to me that the stagnation of economic well-being for the least-advantaged Americans is in large part a result in the decline of the value of their labor in an economy of services and highly-automated manufacturing. If so, the long run improvement of their well-being and life-expectancy will depend on whether today's poor and middle class children can do a better job of acquiring cognitive skills, social skills, and related human capital than their parents did. Just off the top of my head, we should
- Reduce unplanned and teen-aged pregnancies through both the promotion of abstinence and the subsidization of the use of reliable, long-acting birth control.
- Implement universal maternity leave, and subsidize high-quality child care for low-income working mothers.
- Implement universal, high quality preschool.
- Improve elementary schooling, which could be advanced right away by shedding the bottom 5% of the current cohort of teachers.