A look at Americans' health reveals the astonishing inequalities in our society. American girls are born with a life expectancy that ranks 19th in the world (in another survey they fall to 28th). Male babies rank 31st -- in a dead tie with Brunei. Among the 13 wealthiest countries, the United States ranks last or nearly so in almost every way we measure health: infant mortality, low birth weight, life expectancy at birth, life expectancy for infants. The average American boy lives three and a half fewer years than the average Japanese baby, despite higher rates of cigarette smoking in Japan. The American adolescent death rate is twice as high as, say, England's.
These dismal American averages mask vast differences across our population. A male born in some sections of Washington, D.C., for example, has a life expectancy 40 years lower than a woman born in many wealthy neighborhoods. In short, great differences in wealth match up to -- indeed, they create -- terrible differences in health.
Why do Americans come out so badly in the cross-national health statistics? Why are our infants more likely to die than those in, say, Croatia? Our health troubles have three interrelated causes: inequality, poverty, and the way we organize our health-care system.
Let's start with inequality. A famous study of the British civil service found that with each rung up the ladder of success, people suffered fewer fatal heart attacks -- the clerks and messengers at the bottom were four times more likely to die than the executives at the top. Researchers following up this study reached a surprising conclusion that seems to hold up in one nation after another: The wider the inequality, the worse the nation's overall health.
Why should this be so? For one thing, falling behind in the race to make ends meet generates stress and physiological harm -- the results are depression, hypertension, other illnesses, and high mortality rates. In addition, the middle-class scramble to get ahead erodes neighborly feelings, frays our communities, and lowers trust in institutions like churches and governments. All of these are factors in other countries. But most industrial nations buffer their citizens against economic uncertainty and lost jobs. In the United States, only the market winners get security.
Of course, American health problems go beyond inequality and are closely correlated with the poverty in which more than one in 10 Americans now live. Of our 34.6 million "poor" citizens, according to the U.S. Census Bureau, more than 14 million are "severely poor," meaning they don't even make it halfway to the federal poverty line. The numbers are worse for minorities, with nearly a quarter of blacks and more than a fifth of Hispanics living in poverty.
And poverty brings troubles like hunger (33 million Americans live with "food insecurity," as defined by the Department of Agriculture) and homelessness (perhaps as many as 3.5 million a year), which disproportionately fall on kids. Poor neighborhoods face high crime, inferior schools, few good jobs, and inadequate health-care facilities. Instead, poverty attracts danger -- too much alcohol and tobacco, illegal drugs, and fast foods. One observer after another has gone off to study poor communities and come back with the same report: The lives of the poor are full of stress and the struggle to get by.
People die younger in Harlem than in Bangladesh. Why? It is not what most people think -- homicide, drug abuse, and AIDS are far down the list. Rather, as The New England Journal of Medicine reports, the leading causes of death in poor black neighborhoods are "unrelenting stress," "cardiovascular disease," "cancer," and "untreated medical conditions."
Finally, beyond the fundamentals -- inequality and poverty -- there is that stubborn American policy dilemma: No other industrial nation tolerates such yawning gaps in health insurance. According to the Congressional Budget Office, 43.6 million people were uninsured in 2002, with 19.9 million coming from the ranks of full-time workers; 74.7 million Americans under 65 were without health insurance for all or part of 2001 and 2002. Part of the problem is that workplace coverage is unraveling as more employers shift costs like premiums, co-payments, and coverage limitations onto their workers. Meanwhile, medical costs are rising faster than personal-income growth.
Simple medical care -- annual check-ups, screenings, vaccinations, eyeglasses, dentistry -- saves lives, improves well-being, and is shockingly uneven. Well-insured people get assigned hospital beds; the uninsured get patched up and sent back to the streets. From diagnostic procedures -- prostate screenings, mammograms, and Pap smears -- to treatment for asthma, the uninsured get less care, they get it later in their illnesses, and they are roughly three times more likely to have an adverse health outcome. The Institute of Medicine recently blamed gaps in insurance coverage for 17,000 preventable deaths a year.
Even middle-class parents worry about the next medical emergency or, in many cases, the routine trip to the doctor's office. Life without health insurance means constantly measuring aches and fevers against the next payday. Changing jobs brings a new set of anxieties about shifts in medical coverage. Health bills are the largest cause of personal bankruptcy in the United States.
Of course, no health-care system treats everyone the same way. But in America, our disparities are unusually wide and deep.
How can we reverse these trends and begin to build the good society? Recent experience counsels incremental reform that builds on past successes while pushing bold new proposals for the future.
As recent history shows, even half steps -- like adding amendments to bipartisan legislation -- can add up to something important. Back when the Reagan administration was attacking poverty programs while cutting taxes and running up enormous deficits, California Congressman Henry Waxman oversaw bipartisan support for a series of minor expansions in Medicaid eligibility. The result: In the late 1980s, the program grew to cover an additional 5 million children and 500,000 pregnant women.
While Bill Clinton's failure to pass national health insurance got most of the press, his administration quietly enacted the Children's Health Insurance Program for states in 1997. Using federal matching funds as a prod, the program pushed states to widen coverage to uninsured children, helping Medicaid reach 20 million kids by 2000 and funding non-Medicaid programs to cover an additional 2 million.
Even further below the national radar screen, the Robert Wood Johnson Foundation induced state governments to place health-care clinics directly in schools. Families in underserved neighborhoods suddenly -- and usually for the first time -- found it easy for their kids to get into a physician's office. Despite strong initial opposition from the cultural right over birth control, teachers, public-health advocates, parents, and community organizers have managed to open 1,498 school centers from Maine to California.
Reforms beyond medical care can also improve general living conditions and boost American health. The Earned Income Tax Credit, for example, has lifted millions of low-income workers and their children out of poverty. To be sure, making Americans healthy means addressing the economic insecurity that threatens these struggling families, forcing middle-class Americans to work double shifts and the poor to confront hunger and homelessness.
Making Americans healthy also means casting off the political torpor of this new Gilded Age and reclaiming a long-standing commitment to our neighbors and communities. Only great aspirations will galvanize a new populist politics and leverage our reluctant state.
There is not much mystery about what works. Other industrial countries (stout capitalists who gave us thinkers like Adam Smith) rely on three familiar paths to good health. First, government plays an important role through such policies as family and housing allowances, universal health care, pensions, and tax credits. The generous welfare states of northern Europe and nations with more modest programs like France, Germany, and Canada all have poor, middle-class, and wealthy populations. However, all these nations achieve much narrower income gaps among groups than now exist in the United States.
A second type of policy fosters opportunity. Governments invest in education to expand the supply of skilled labor and help workers help themselves. Lowering the barriers to college education and worker retraining reduces the high premium for skilled labor. In addition, European governments collaborate with businesses by regularly adjusting the minimum wage and overseeing the negotiations between business and labor.
Finally, most wealthy nations maintain taxes. The new global economy was expected to spark dramatic tax cuts as governments competed with one another to create an attractive business climate and lure investment and skilled labor. In Europe and Canada, international pressures did not eviscerate the government's capacity to raise revenues. Instead, domestic support to maintain programs (and international pressure to limit deficits) barred governments from plunging into tax-cut wars.
In short, America's allies have tried to defend all their citizens from the worst effects of a global economy. The results across the industrial world are powerful: Policies that moderate income disparities turn out to be good for your health.
American public policy has, on balance, gone the other way: Tax cuts, deregulation, and unmediated markets sabotage our incremental stabs at fostering real opportunity. Some individuals have grown fantastically wealthy; most struggle to make ends meet. The dirty policy secret lies in the health consequences: Our population suffers more illness and dies younger.
Our call to reform is simple: A civilized society should not accept gaping disparities in life and death, health and disability. Americans are too generous and fair-minded to tolerate so much preventable suffering. This moral vision undergirds a hardheaded analysis of the rapidly changing global economy that has reshuffled the distribution of money in American society and unsettled the life circumstances that nurture and protect the health of the country. The solutions are no mystery. Other nations successfully protect their people. So can we.