In Brief

America’s health care system is more expensive by 40–60 percent than health care systems in any other industrialized country (it makes up nearly half the health care budget of the entire world), but the results it produces are arguably the worst of the group. To fix this broken system, we need to consider the diverse factors that affect our health. By going beyond health care and focusing on good health, we can find ways to reduce stress, give children a better start on life, strengthen social connections, improve safety, and live healthier lives.

Key Concepts

  • America has the most expensive health care system in the world, yet Americans rank 50th in life expectancy, just below Bosnia and above Albania.
  • We can fix this system by taking a more holistic approach to good health.
  • We should start by improving children’s health by focusing on prenatal care and providing at least three months or more of paid leave to all parents of babies or very young children.
  • We can improve our lifestyle by reducing working hours to give Americans more time for exercise, sleep, and healthy eating.
  • And we can reduce stress by reinstituting tax policies that narrow the gap between rich and poor and guaranteeing vacation time and paid sick days.

It’s no secret that the United States is still locked in an ideological battle over how to reform our health care system. The health care reform bill passed by Congress in early 2010 is a watered-down version of what progressive Democrats advocated that lacks the “public option.” Yet Republicans seek to repeal it as too radical. The health care debate generated far more heat than light, with conservative opponents even carrying guns to town meetings. But the biggest problem with the debate is its focus on health care.

It is true that, by any objective, data-based evidence, the American health care system is on life support: it is priced at more than $8,000 a year per American and will soon be 20 percent of our gross domestic product. In a few years, we’ll be spending one dollar out of every five in our economy on health care alone. Our system is more expensive by 40–60 percent than health care systems in any other industrialized country and makes up nearly half the health care budget of the entire world.

Health insurance premiums for those who have them have been rising in cost by double digits each year. Some companies in California have proposed increases of 39 percent next year. Yet this enormously expensive system leaves millions of Americans completely without health insurance and millions more underinsured: 47 million lacked insurance before the health care bill passed. If the bill is not repealed, about 32 million of them should now be insured, but that still leaves 15 million without coverage. Uncovered medical bills account for about half of all our personal bankruptcies each year.

To top it all off, our health care system produces results that are arguably the worst in any of the wealthy nations of the world. The Central Intelligence Agency’s World Factbook reports that Americans now rank 50th in life expectancy. We’re just below Bosnia and above Albania and we’ve fallen from a ranking of 11th in 1980. The CIA list includes some tiny nations like Malta, Gibraltar, and Andorra, but even among the 31 larger nations included in the Organisation for Economic Co-operation and Development (OECD), we rank 27th.

A National Institutes of Health study comparing frequency of chronic illness in the United States and the United Kingdom also found that Americans are far more likely to suffer from heart disease, diabetes, and hypertension in old age. In California, such diseases account for some 80 percent of hospital health care costs. The NIH study comparing British and American health controlled for age, race, income, and gender differences and found, surprisingly, that poor Britons are as healthy as rich Americans.

And if such evidence of failure isn’t enough to cast doubt on our health care system, a recent Harvard study concluded that some 44,000 Americans die each year for lack of health insurance. Even in the hospital, U.S. patients face unusual dangers. More than 100,000 of them are victims of health care itself: they die of errors or infections during treatment. So the system is broken. But fixing it will require a far more holistic approach than has been discussed in the health care debate thus far.

Forty-four thousand deaths from lack of health care is a national scandal. Justice demands insurance coverage for all Americans as in every other wealthy country. Yet few would argue that good health care is our ultimate goal. If you doubt that, ask yourself: would you rather spend the next year convalescing in the world’s best hospital free of charge or living at home feeling good? The goal, of course, is good health. Health care is only part of that.

Health Has Improved during the Recession

Consider, for a moment, the counterintuitive outcome that in the United States and many industrialized countries, especially those with weak social safety nets, health tends to improve during recessions, while remaining relatively stable or declining during economic booms. Indeed, research suggests that, during the current recession, Americans are working less and earning less. But in response, they actually exercise more, socialize more, eat less high-calorie restaurant food, sleep more, smoke and drink less, volunteer more, drive less, and face less exposure to air pollutants, all helpful to their health. Home gardening, for example, rose 40 percent last year, improving both exercise and food choices, while traffic deaths have dropped about 25 percent since the current recession began.

On the other hand, high levels of unemployment are hard on workers and families. For those who actually lose their jobs, results are more mixed—higher numbers commit suicide, for example—but the aggregate numbers are positive. According to Dr. Christopher Ruhm of the University of North Carolina–Greensboro, on average in the United States, a one percent increase in unemployment leads to a one-half percent drop in the death rate.

Is there a way to return to a healthier economy and much lower unemployment rate without jeopardizing the improvements in health that recessions regularly bring?

The Foundation

Let’s start with the foundation of good health. That’s the head start toward health that children in most other rich countries receive. There’s a stronger focus on prenatal care, for example, which leads to lower infant mortality rates. The United States has a higher infant death rate than any other industrialized country and ranks 45th in the world, again according to the CIA. Moreover, fewer mothers die in childbirth in other industrialized countries, whereas the United States ranks a comparatively poor 41st in the world. Maternal mortality rates for poor and African American mothers are particularly high here. Every other rich country does better.

But equally important to children’s health is a policy taken for granted in nearly every country in the world except, believe it or not, the United States, Liberia, Swaziland, and Papua New Guinea. In all other countries, mothers are guaranteed paid time off from work to take care of newborns. In most rich countries, fathers also receive paid time off to bond with young children. In many cases, such family leave extends for up to a year or more. In the United States, by contrast, parents often return to work when children are only a few weeks old.

Paid family leave—and the parental bonding it ensures—pays off in terms of children’s health: fewer childhood illnesses, fewer problems with attention deficit disorder, lower rates of obesity, easier socialization, and better readiness to learn. Most countries find that such a taxpayer investment in early childhood results in lower health and other costs as children grow up. In Canada, for example, the government pays 55 percent of the stay-at-home parent’s salary during parental leave. Health care costs for children have dropped there since 2004 when leave was increased from six months to a year, leading to some interest in further extending the leave.

Meanwhile, American children are increasingly less healthy. According to the Journal of the American Medical Association, the prevalence of chronic health problems, including obesity and asthma, among children more than doubled between 1994 and 2006. While many of these children improve as they get older, the results are troubling to researchers.

A 2007 United Nations Children’s Fund (UNICEF) study ranked the United States 20th out of 21 rich nations regarding children’s welfare, with particularly poor health and accident outcomes. Only the United Kingdom fared worse. Americans ranked at the bottom in child safety, with the highest rate of accidents among children. Furthermore, in spite of evidence that American children are less fit than those in other developed countries, many American schools have reduced or eliminated physical education classes and even recess time in recent years.

At the same time, prompted in part by television advertising and subsidies that keep prices low for such unhealthy food additives as high fructose corn syrup, American children have doubled their intake of “snack” foods since the 1970s. Some researchers suggest that the present generation of American children may be the first to live shorter lives than their parents. Epidemiologist Stephen Bezruchka of the University of Washington points out that “the things that happen to children in their earliest years create health impacts that last a lifetime.”1


If Democrats talk almost exclusively about universal health care as the solution to our health problems, Republicans tend to focus on wall number one: lifestyle choices. It’s a matter of personal responsibility, they say. Americans should simply stop smoking, eat properly, avoid overeating and excessive alcohol drinking, exercise regularly, and sleep enough. And, the conservatives argue, we don’t need the government to make us do this. Of course, this is sensible advice. Citizens of other rich countries generally exercise and sleep more than we do. And they don’t eat as much, so they are less likely to be obese.

Michelle Obama has taken a page from the Republican playbook, launching a campaign called “Let’s Move” to fight childhood obesity. Much of the campaign includes exhortations to get out and exercise. But Mrs. Obama realizes it isn’t all a matter of personal responsibility. She advocates programs to make sure that children get healthy foods in the schools and that poor Americans have access to fresh fruits and vegetables. She might also advocate some important policy changes. As mentioned earlier, our tax system subsidizes producers of sugars and fats and our marketing system relentlessly advertises fast, unhealthy foods. Consumers are far less likely to face these pressures outside the United States.

At the same time, Americans tend to work longer hours than people in other rich countries. Europeans, for example, work 200–400 fewer hours each year on average, depending on the country. Laws guarantee them sufficient time off, including a minimum of four weeks of paid vacation a year, curbs on overtime, and shorter weekly working hours. These regulations leave them more time to select foods carefully, eat more slowly and, as a result, eat less, while exercising and sleeping more. Laws reducing work time have the effect of making them healthier.

One of the most innovative of European shorter work-time laws is the Netherlands’ Hours Adjustment Act, adopted in 2000. Under this law, employees can ask for shorter work hours and the requests must be granted unless their bosses can show that a reduction of hours would materially damage the firm, an occurrence in fewer than five percent of cases. Employees keep the same hourly wage and retain their health care while seeing other benefits, such as pension contributions and vacation days, prorated. The popular idea has spread to Germany and is one reason why the Netherlands has the highest percentage of part-time workers in the world and the shortest annual hours. It is a practical sort of freedom of choice. Workers can choose time over money without risking their entire livelihoods, benefits, and health care.

An equally interesting law now spreading to many countries is Germany’s Kurzarbeit or “short-time work” policy. It allows employers to avoid layoffs by reducing hours all around and permits employees to receive unemployment benefits to compensate for salary losses. Policies such as the Hours Adjustment Act and the Kurzarbeit program could be used to grant Americans more time for healthy lifestyles. Reducing work time might also help strengthen other aspects of our health as well.

Stress Relief

It’s no secret in the field of public health that stress is a killer. Sudden bursts of adrenaline and cortisol worked to protect our early human ancestors against attack by savage beasts. But as Stanford’s Robert Sapolsky shows in Why Zebras Don’t Get Ulcers (2004), continued adrenaline response to the chronic stress of modern life leads to heart problems, obesity, hypertension, and weakened immune systems.

Several factors make American life particularly stressful. We are among the most competitive of wealthy capitalist countries and have the widest gap between rich and poor. Fewer people are on top; more are on the bottom. Studies clearly show that, whether you’re a person or a baboon, the lower your status, the higher your stress levels are. As Richard Wilkinson and Kate Pickett point out in their book, The Spirit Level (2009), members of more economically egalitarian societies, such as Sweden and Japan, lead less stressful, healthier lives—an improvement that holds true for every segment of the population, including the wealthy.

Stress is also the result of insecurity. As the American social safety net has been gutted in recent years, as more of us have lost health and pension benefits, and job protections have declined, life in America has become riskier than it used to be. Life here is certainly far more insecure than in other rich countries, where strong social safety nets remain in place. Danes, for example, can be fired as easily as Americans, but then they receive generous unemployment benefits, job training, and government jobs, if they are unable to find a position in the private sector.

Insecurity leads to increased anxiety levels. American rates of anxiety are double or triple those in western European countries. Such mental illness negatively impacts physical health even further. The health department in the United Kingdom suggests that “there is no health without mental health.”2 Europeans say their social safety net gives them a feeling of peace of mind. It’s certainly good for their health.

Finally, stress is also the result of time pressures and overwork, which are far more common in the United States than in other rich countries. Dr. Sarah Speck, a prominent Seattle cardiologist, has gone so far as to call stress from overwork in the United States, “the new tobacco.”3 More breaks from a stressful workplace are seen by Europeans as yet another way to improve health. It’s unlikely that we will be able to quickly change the levels of hierarchy and inequality in the United States or to suddenly strengthen our safety net—although we should. But policies offering shorter work time and longer vacations—clear stress reducers—could be enacted more easily and quickly. At present, there are several waiting in committee in Congress, including the Paid Vacation Act of 2009 and a major work-sharing bill.

Social Connection

Nic Marks, a psychologist with the New Economic Foundation in London, calls social relationships “the bedrock of good health.”2 Other population health experts agree. In fact, connecting with others may be the single most important thing we can do to be healthier. It’s widely understood in the field of public health that social connection strengthens immune systems and improves physical well-being. On the other hand, one of the worst things you can do to your health is to be lonesome. Yet despite all of our “social networking,” America is an increasingly lonely country. More and more people, especially older Americans, live alone, far more than in other rich countries.

A recent study by Harvard political scientist Robert Putnam found that the average American has only two close friends he or she can turn to. A quarter of us have none at all.4 Loneliness quickly turns into depression. As with anxiety, Americans are two to three times as likely to suffer from depression as western Europeans. Depression further weakens immune systems and lowers physical health outcomes. We respond not by changing the conditions that give rise to depression but by prescribing drugs; Americans consume two-thirds of the world’s antidepressants each year, a depressing thought indeed. “I’m always amazed at your huge pharmaceutical supermarkets,” says Nic Marks. “We have nothing like that in the UK.”2

A Safe Environment

Other studies show extremely high rates of accidents in the American workplace compared to other nations. Preventable death rates in the United States, including deaths from automobile accidents, are the highest among industrialized countries. Moreover, on average, Americans breathe in air pollutants such as sulfur and nitrous oxides at double the levels of western Europeans. The European Union also has stricter controls on the release of toxic chemicals into the environment. Recent actions in Congress to ban toxins in children’s toys are a step in the right direction. Before then, many toys, particularly those imported from China, contained toxins that had been outlawed in Europe for years.

Finally—and this is no small matter—every other industrialized country guarantees its workers paid time off from work when they are sick. Only the United States does not: half of American workers—86 percent of restaurant workers—get no paid sick days. In contrast, many other countries allow up to a month of leave. These countries know that without paid time off, workers will come to work sick, as many Americans do. Sick workers pass you your hamburger or garden burger and you get sick. They get their coworkers sick. They stay sick longer and often require more expensive treatment for their illnesses.

This is not rocket science. Most Americans get this immediately. That is why more than 80 percent of them favor a law that would guarantee paid sick days for workers and why cities like San Francisco and Milwaukee have passed paid sick leave bills. Senator Edward Kennedy’s last piece of legislation, still waiting to be passed, would help alleviate this problem. It’s called the Healthy Families Act and would offer seven paid sick days a year for full-time American workers. But sadly, the recent health care reform legislation ignored this reality.

What Can We Do to Improve our Health?

To achieve better health outcomes, Americans must begin to see health as a holistic matter, like the house I will describe. Right now, the house has a foundation and four walls that are in sorry shape. It has a gilded roof with millions of holes. It is not enough to talk of making the roof all gold and eliminating the holes, though we do need to eliminate the holes. We need to eliminate the gold as well. We need to take the profit and costly complexity out of the system and expand a program like Medicare to cover everyone, potentially at less cost. But such a system must rely more on preventive methods than high tech cures. What is clear is that universal health care is only a first step. We can:

Strengthen health care in the early years by improving prenatal care and providing at least three months or more of paid leave to all parents of babies or very young children. Make the Family and Medical Leave Act a paid provision and extend it to all workers. Change the rules that subsidize sweeteners and other foods that are unhealthy for children. Restrict advertising of junk foods aimed at children.

Improve our lifestyle by encouraging consumption of whole grains and vegetables. Teach children the value of eating healthy foods. Reduce working hours to give Americans more time for exercise, sleep, and healthy eating.

Reduce stress by reinstituting tax policies that narrow the gap between rich and poor. Rebuild our social safety net and adopt policies like the Paid Vacation Act of 2009 to assure Americans periodic relief from the stress of our hyper-competitive and long-hour workplaces. Provide more resources for the early identification and treatment of mental illnesses, such as anxiety and depression. Deal with root causes, instead of merely treating symptoms.

Strengthen connections by reducing work time and encouraging greater volunteer involvement with our neighbors and communities. Promote national service programs. Design communities that have smaller homes and more public gathering space from coffeehouses to car-free shopping districts.

Improve safety by improving the Occupational Safety and Health Administration (OSHA) and other worker protections. Build higher density cities that are more pedestrian and bicycle friendly. Regain the environmental zeal of the early 1970s, which led to much cleaner water and air for all Americans. Pass the Healthy Families Act guaranteeing paid sick days to American workers.

Most of these changes are taken for granted in other nations. All of them will make the United States healthier and will almost certainly cost less than our current system. Improving our health outcomes is less a matter of better science and more money than of stronger political will and the ability to see the connections between things.

Many business leaders (though certainly not all!) will object to these ideas on the grounds that they will cost too much and make us less competitive in the world economy. Yet enlightened business leaders and business schools see the value of such changes, even for the bottom line. A 2009 Harvard business school study showed that workers in a large Boston firm who put in shorter hours were more productive than longer-hour workers. Another found that companies that reduced work hours and shared jobs did far better after recessions than those that eliminated parts of their work forces.5 In their book, Raising The Global Floor (2009), Jody Heymann and Alison Earle show conclusively that countries that adopt more generous worker and health care policies are no less competitive and often have lower unemployment rates than those, like the United States, that practice a harsher form of capitalism.

The cost of poor health is and will continue to be far greater than the price tag for such reforms. If there is one thing more than any other that makes it harder for American businesses to compete, it’s the escalating cost of health care. Health care payments make the cost of producing an automobile, for example, far more expensive in the United States than in Canada.

We can do better. We owe it to ourselves and our children to make these changes without delay.


  1. Bezruchka, S. Presentation to Population Health Forum (July 2010).
  2. Marks, N. Personal communication (July 2010).
  3. Speck, S. Presentation to National Vacation Matters Summit (August 2009).
  4. Kornblum, J. Study: 25% of Americans have no one to confide in. USA Today (July 2006).
  5. Perlow, L & Porter, J. Making Time off predictable—and required. Harvard Business Review (October 2009).