The United States leads the world in healthcare spending. On a per capita basis the United States spends twice the Organisation for Economic Co-operation and Development average on healthcare, or 13% of national income. Yet some countries that spend substantially less than the United States have healthier populations. US public health indicators are marred by deep inequalities linked to income, health insurance coverage, race, ethnicity, geography and—critically—access to care.
Key US health indicators are far below those that might be anticipated on the basis of national wealth. Infant mortality trends are especially troublesome. Since 2000 a half century of sustained decline in infant death rates first slowed and then reversed. The infant mortality rate is now higher for the United States than for many other industrial countries. Malaysia — a country with an average income one-quarter that of the United States — has achieved the same infant mortality rate as the United States (figure 1). And the Indian state of Kerala has an urban infant death rate lower than that for African Americans in Washington, DC.
Wide differences in health across socio - economic groups partly explain the poorer health outcomes in the United States than in other industrial countries. From the cradle to the grave the health of US citizens shows extreme divergence. For example, racial and ethnic health disparities are persistent—a result of differences in insurance coverage, income, language and education, among other factors (figure 2). African American mothers are twice as likely as white mothers to give birth to a low birthweight baby. Their children are twice as likely to die before their first birthday. Income differences are closely correlated with health differences. A baby boy from a family in the top 5% of the US income distribution will enjoy a life span 25% longer than a boy born in the bottom 5%.
Many factors contribute to health inequalities. One important driver is the coverage of healthcare provision. The United States is the only wealthy country with no universal health insurance system. Its mix of employer-based private insurance and public coverage has never reached all Americans. While more than half the population have health insurance coverage through their employers and almost all the elderly are covered through Medicare, more than one in six non-elderly Americans (45 million) lacked health insurance in 2003. Over a third (36%) of families living below the poverty line are uninsured. Hispanic Americans (34%) are more than twice as likely to be uninsured as white Americans (13%), and 21% of African Americans have no health insurance. Health insurance coverage also varies widely across the 50 states, depending on the share of families with low incomes, the nature of employment and the breadth of each state’s Medicaid programme for low-income
people.
More than in any other major industrial country the cost of treatment is a major barrier to access in the United States. Over 40% of the uninsured do not have a regular place to receive medical treatment when they are sick, and more than a third say that they or someone in their family went without needed medical care, including recommended treatments or prescription drugs, in the last year because of cost.
Unequal access to healthcare has clear links to health outcomes. The uninsured are less likely to have regular outpatient care, so they are more likely to be hospitalized for avoidable health problems. Once in a hospital, they receive fewer services and are more likely to die than are insured patients. They also receive less preventive care. The Institute of Medicine estimates that at least 18,000 Americans die prematurely each year solely because they lack health insurance. Being born into an uninsured household increases the probability of death before age 1 by about 50%.
Unequal access to healthcare has a powerful effect on health inequalities linked to race, which are only partly explained by insurance and income inequalities. One study finds that eliminating the gap in healthcare between African Americans and white Americans would save nearly 85,000 lives a year. To put this figure in context, technological improvements in medicine save about 20,000 lives a year.
The comparison highlights a paradox at the heart of the US health system. High levels of personal healthcare spending reflect the country’s cutting-edge medical technology and treatment. Yet social inequalities, interacting with inequalities in health financing, limit the reach of medical advance
Categories: Development, Discrimination, Economy, Inequity, Poverty, Race, USA
