Eight Americas

Since Americans pay more for health insurance and health care than do people in most other highly developed countries, it is reasonable to ask: Are we getting our money’s worth, if value is measured by a long and presumably healthy life? Are our national health expenditures a good investment, if long life equals high return? The answer, it turns out, is yes for some Americans and no for others. It is yes for a small minority of the healthiest, who enjoy one of the world’s highest rates of life expectancy. Take the Asian women of Bergen County, N.J., for instance, who will likely live to age 91. For them the national investment pays off handsomely. For most Americans, however, such longevity is less likely, and for some it is unthinkable. Native American males in several counties of South Dakota can expect to die by age 58. For them, returns are poor.

Those two examplesand many morecan be found in Eight Americas, a comprehensive new report that details the disparities in life expectancy throughout our nation. Issued jointly by the Harvard University School of Public Health and the Initiative for Global Health, the report analyzes data collected from 1982 to 2001. As the title of the report makes clear, the researchers present their findings using the image of eight Americasfrom Asians (1) and northland low-income rural whites (2) to low-income southern rural blacks (7) and high-risk urban blacks (8)grouped by race and county, not by population size. America 3, Middle America, for example, is by far the whitest and largest group; it represents some 214 million Americans and falls literally in the middle on most measures.

The report states that 10 million Americans with the best health have achieved one of the highest levels of life expectancy on record, three years better than Japan for women, and four years better than Iceland for men. At the same time, tens of millions of Americans are experiencing levels of health that are more typical of people in developing countries.

It is shocking that between the highest life-expectancy level and the lowest yawns a gap of more than 35 years. So much for the good investment notion of health carethat is, if all Americans are to be included.

While the relation between longevity and demographic factors (race, gender, age, income, education) has long been understood, this report goes further. It adds in the cumulative homicide rate and the risk of disease and injury, and it establishes mortality patterns in counties across the nation, mapping who lives how long and where.

The contrasts it pinpoints are startling. Among U.S. males, for instance, Asians can expect to outlive urban blacks in high-risk areas by more than 15 years. When chronic diseases and injuries are factored in (including H.I.V./AIDS and homicides), the mortality rate among young black men in high-crime urban areas resembles that of Russians and sub-Saharan Africans more than millions of other Americans.

Despite health education programs and policies over the nearly two decades studied, the disparities have persisted. Among low-income white women in Appalachia and the Mississippi Valley, the gap actually widened.

Comprehensive studies like this are important, because the information they provide enables policymakers to tailor their initiatives to fit specific subgroups of Americans. One health care policy does not fit all.

Also, voters and policymakers would do well to heed what Christopher Murray, the director of the Harvard Initiative for Global Health, wrote about health insurance: The variation in health plan coverage across the eight Americas is small relative to the very large difference in health outcome, and while expanded coverage would help, it would still leave huge disparities in young and middle-aged adults. Why? Because insurance does not address many of the causes of mortality. Violent neighborhoods, obesity and behaviors like smoking and alcohol use, while contributing to disease across all eight Americas, play an outsize role in the life expectancy of America 8.

What else is needed? Since no single cause accounts for the disparities, the researchers recommend public policies that reduce socioeconomic inequalities. Lessening the socioeconomic risk factors for chronic disease and injuries would benefit those with the highest death rates. Governments can increase tobacco taxes, enforce drinking-and-driving laws and reduce barriers to medicines and lifestyle changes effective in controlling obesity, high blood pressure, high cholesterol, high blood sugar and H.I.V./AIDS.

Is our nation’s investment in health paying off? The short answer is that as long as eight Americas exist when it comes to life expectancy, the good investment notion should be dismissed out of hand. The high returns enjoyed by some Americans reach far too few of the rest of us.

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