Our Sick Society
by PAUL KRUGMAN
Is being an American bad for your health? That's the apparent implication of a study just published in The Journal of the American Medical Association.
It's not news that something is very wrong with the state of America's health. International comparisons show that the United States has achieved a sort of inverse miracle: we spend much more per person on health care than any other nation, yet we have lower life expectancy and higher infant mortality than Canada, Japan and most of Europe.
But it isn't clear exactly what causes this stunningly poor performance. How much of America's poor health is the result of our failure, unique among wealthy nations, to guarantee health insurance to all? How much is the result of racial and class divisions? How much is the result of other aspects of the American way of life?
The new study, "Disease and Disadvantage in the United States and in England," doesn't resolve all of these questions. Yet it offers strong evidence that there's something about American society that makes us sicker than we should be.
The authors of the study compared the prevalence of such diseases as diabetes and hypertension in Americans 55 to 64 years old with the prevalence of the same diseases in a comparable group in England. Comparing us with the English isn't a choice designed to highlight American problems: Britain spends only about 40 percent as much per person on health care as the United States, and its health care system is generally considered inferior to those of neighboring countries, especially France. Moreover, England isn't noted either for healthy eating or for a healthy lifestyle.
Nonetheless, the study concludes that "Americans are much sicker than the English." For example, middle-age Americans are twice as likely to suffer from diabetes as their English counterparts. That's a striking finding in itself.
What's even more striking is that being American seems to damage your health regardless of your race and social class.
That's not to say that class is irrelevant. (The researchers excluded racial effects by restricting the study to non-Hispanic whites.) In fact, there's a strong correlation within each country between wealth and health. But Americans are so much sicker that the richest third of Americans is in worse health than the poorest third of the English.
So what's going on? Lack of health insurance is surely a factor in the poor health of lower-income Americans, who are often uninsured, while everyone in England receives health care from the government. But almost all upper-income Americans have insurance.
What about bad habits, which the study calls "behavioral risk factors"? The stereotypes are true: the English are much more likely to be heavy drinkers, and Americans much more likely to be obese. But a statistical analysis suggests that bad habits are only a fraction of the story.
In the end, the study's authors seem baffled by the poor health of even relatively well-off Americans. But let me suggest a couple of possible explanations.
One is that having health insurance doesn't ensure good health care. For example, a New York Times report on diabetes pointed out that insurance companies are generally unwilling to pay for care that might head off the disease, even though they are willing to pay for the extreme measures, like amputations, that become necessary when prevention fails. It's possible that Britain's National Health Service, in spite of its limited budget, actually provides better all-around medical care than our system because it takes a broader, longer-term view than private insurance companies.
The other possibility is that Americans work too hard and experience too much stress. Full-time American workers work, on average, about 46 weeks per year; full-time British, French and German workers work only 41 weeks a year. I've pointed out in the past that our workaholic economy is actually more destructive of the "family values" we claim to honor than the European economies in which regulations and union power have led to shorter working hours.
Maybe overwork, together with the stress of living in an economy with a minimal social safety net, damages our health as well as our families. These are just suggestions. What we know for sure is that although the American way of life may be, as Ari Fleischer famously proclaimed back in 2001, "a blessed one," there's something about that way of life that is seriously bad for our health.
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