At 17.9 percent of the nation’s total economic activity, also known as the gross domestic product, healthcare spending in the United States leads all countries in overall and per capita measures (KFF 2012). Yet its health system does not perform well compared to those of other industrialized countries. A 2010 World Health Organization (WHO) report ranks the US health system thirty-seventh among 191 countries, and a Commonwealth Fund study completed the same year ranks it last among six other countries—Australia, Canada, Germany, the Netherlands, New Zealand and the United Kingdom—on the basis of quality, efficiency, access, equity, and healthy lives measures (Davis, Schoen, and Stremikis 2010).
Why have health policies tended to fail in the United States while they appear to be succeeding in other countries? The answer might be found in the context—the United States—and the determinants of health and health policy in the United States.
The main purpose of this chapter is to present a framework of health policy determinants and discuss their impact in the United States. Understanding this framework helps the reader appreciate factors that contribute to health policy development in general and in the United States in particular. The chapter first defines key concepts related to health policy and later discusses the importance of studying health policy, including an awareness of the international perspective. The stakeholders of health policy are also presented and analyzed as key parts of the policy context.
WHO (1946) defines health as “not merely the absence of disease or infirmity but a state of complete physical, mental and social well-being.” This broad definition recognizes that health encompasses biological and social elements in addition to individual and community well-being. Health may be seen as an indicator of personal and collective advancement. It can signal the level of an individual’s well-being as well as the degree of success achieved by a society and its government in promoting that well-being (Shi and Stevens 2010). This definition of health strikes a common chord among governments that allows policymakers at WHO, and others in the global health community, to build the case that issues such as poverty; lack of education; discrimination; and other social, cultural, and political conditions found around the world are essentially public health issues.
However, health is also the result of personal characteristics and choices. This concept is the source of the fundamental tension in public health and has been a major topic in the United States in the past few years. Major debates continue over whether people can be forced to take actions to ensure their own health, such as buying health insurance (the individual mandate in the Affordable Care Act), or be prohibited from performing actions that are unhealthy, such as limiting soft drinks in schools. Health policy in the United States must attempt to balance the good of the public health with personal liberty, often a difficult compromise to make. Indeed, the conflict between WHO’s definition of health
The most common measure of physical health is life expectancy—the anticipated number of remaining years of life at any stage. Exhibit 1.1 shows the ten countries ranking highest in their population’s life expectancy as of 2006 and includes the US ranking for comparison.
Although good or positive health status is commonly associated with the definition of health, the most frequently used indicators measure the lack of health or the incidence of poor health—for example, mortality, morbidity, disability, and various indexes that combine these factors. One such measure is quality-adjusted life years, which combines mortality and morbidity in a single index. The Learning Point box titled “Measures of Mortality, Morbidity, and Disability” lists categories by which each indicator is measured.
In contrast to physical health, measures of mental health are limited. The major categories of mental health measures are mental conditions (e.g., depression, disorder, distress), behaviors (e.g., suicide, drug or alcohol abuse), perceptions (e.g., perceived mental health status), satisfaction (with life, work, relationships, etc.), and services received (e.g., counseling, drug treatment).
The most commonly used measure of relative social well-being is one’s socioeconomic status (SES). An SES index typically considers such factors as education level, income, and occupation. Quality of life is another common measure and may include one’s ability