This issue of Public Health Reports makes significant contributions to the available evidence used to support decisions addressing disparities in U.S. child health and health care. Per capita spending for health care in the U.S. in 2001 was $4,887, nearly twice that for Japan ($2,627) and more than 2.5 times that for the United Kingdom ($1,835).1 This relatively large and growing investment of public and private U.S. dollars does not necessarily result in commensurate returns in health: the U.S. ranks in the third decile for many measures of population health for children and adults. In 2000, infant mortality in the U.S., roughly 7 infant deaths for every 1,000 live births, was no better than that observed either in the UK or in Japan, which reported an infant mortality rate of 3 per 1,000 births.2 This paradox exists in a disconcerting context. The health of U.S. residents overall and the health of many U.S. subgroups has improved remarkably by nearly all measures over recent decades. Many individuals enjoy better health, yet large disparities persist among racial/ethnic, socioeconomic, and geographic subgroups. It is these disparities that in large part explain the persistently low U.S. ranking in international comparisons. For example, if the U.S. infant mortality rate for African Americans (14.4 deaths for every 1,000 live births in 2002) was similar to that for whites (5.8 deaths for every 1,000 live births), the U.S. ranking among reporting United Nations member countries would rise from 24th to approximately 7th. In economic terms, the primary output of the U.S. health care system is the health of its citizens. In the broadest sense, health care is supported by both public and private sources of funding and encompasses both preventive and treatment services. Health, as a public good, returns to society as improved productivity and reduced downstream expenditures for care. Because health is also subject to influences that are independent of health care, it is difficult sometimes to identify the sources of suboptimal health. Moreover, those responsible for specific health-related inputs may find opportunity to attribute poor health to inputs other than those for which they are responsible. For example, those with poor health sometimes blame the health care delivery system. The delivery system tends to blame harmful behaviors and social inequities related to poverty and discrimination. Some health inputs depend neither on individual behavior nor the functioning of the health care system. These include community structures and policies that influence health, environmental, and workplace hazards and external barriers to care access. Complicating the independent influences of individual decision-making, socio-environmental context, and health care delivery are important but poorly understood interactions among these sets of effects. Distinctly, but also importantly, health status impacts personal decision-making and may even influence the behavior of the delivery system to the extent that systems perceive themselves as relevant only to narrowly defined disease states (Figure 1). Interactions between preventive services that might be available in the largely government-funded U.S. public health arena and health services provided outside the public health system may be particularly important determinants of the apparent discrepancy between spending for health services and health. National investments in public health services, which are largely preventive, vary greatly in international comparisons as a proportion of total health care spending, and perhaps carry a stronger association with overall population health (Table 1). Funding decisions for public health services in the U.S. tend to be made independently from such decisions for other health services. Moreover, public health practitioners tend to be segregated both professionally and geographically from other health care providers. In response to criticism that they pay insufficient attention to prevention, nonpublic health physicians and the organizations with which they are associated sometimes offer suboptimal training and associated inefficiencies in busy practices as explanations. These separations between public health providers and other health care providers in the U.S. offer opportunities to partition care and thus responsibility. Poor use of preventive services, high prevalence of potentially preventable conditions, and suboptimal access to care become public health issues—while poor response to treatment, errors in care, unsafe care delivery, and high costs of cure are outside the responsibility of public health officials. Consumer decisions are sandwiched between, and as perceived by some, layered
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Jan 1, 2023
Vadim Yuriev + 2
Open Access