President Trump and his administration have promised to “Make America Wealthy Again” and “Make America Healthy Again.” However, despite spending two to four times more per person on health care as other developed countries, the U.S. has higher mortality and worse health outcomes.
In short, our expensive health system may simultaneously make us less wealthy and leave us less healthy.
This paradox highlights the need for approaches that improve both wealth and health. While Trump addresses our perceived trade gap with other countries, he and his administration might also consider examining America’s international “health gap,” even for the best-off Americans.
A new paper in the New England Journal of Medicine found the wealthiest Americans die at a higher rate than poorer Europeans. The average American was wealthier than the average southern and eastern European (think Italy, Spain and Poland), but not as wealthy as the average northern and western European (think Germany, France and the Netherlands). It was no surprise that, overall and within countries, the rich lived longer. For example, over 10 years, among the wealthiest Americans, about 20 percent died; among the least wealthy Americans, about 35 percent died.
What was surprising is that the mortality in the wealthiest group of Americans was similar to the mortality among the lowest-wealth northern and western Europeans — again, roughly 20 percent died after 10 years — despite the Americans having well over 20 times the wealth.
As the research shows, more wealth is related to better health. The converse is probably true: one needs health to generate wealth. Perhaps we should be thinking about efforts to make America healthy and wealthy as related efforts.
So, what can we do? As a primary care physician-researcher, I recommend we help Americans focus on behaviors that will keep them healthy, make comprehensive primary care available to all Americans, and support research that will enable Americans to lead longer, healthier lives.
Many would be surprised to learn that medical care may be responsible for as little as 10 percent of health outcomes. Most outcomes are the result of one’s behaviors, socioeconomic factors and environment. While some medical discoveries such as “statin” cholesterol medications and the Ozempic-like GLP-1 agonists are indeed game-changing, the most important health-related behaviors — eating right, not smoking, exercising and getting enough sleep — are too often considered “boring” and avoided.
Americans tend to get distracted by the hype around high-tech discoveries, questionable longevity “protocols” and dietary-supplement peddlers. Over half of American adults take a dietary supplement, collectively spending billions, even though, as my colleagues and I have pointed out, most supplements do not improve health. In truth, exercise is as close to a “magic pill” as we have. Aerobic and muscle-strengthening exercise are each associated with decreases in cardiovascular disease, cancer and death.
Second, because primary care is associated with better health both internationally and in the United States, making at least basic primary care available to all Americans could markedly improve Americans’ overall health. My colleagues and I found that Americans with primary care get more preventive services and counseling than Americans without primary care. Unfortunately, the proportion of Americans who have a go-to primary care doctor has been decreasing, especially for younger Americans or those in the South.
We have also found that having a regular checkup is associated with increased detection of chronic conditions, risk factor control — like controlling high blood pressure — getting preventive services, and having an improved sense of wellbeing. The people most likely to benefit from a checkup are people who have not had one or are overdue for recommended preventive services.
Americans’ inability to get primary care is related to our chronically underfunding primary care. In a new survey, a representative group of Americans estimated the proportion of U.S. health care spending that goes to primary care as 52 percent. The actual figure is 5 percent.
Third, while touting good behaviors, exercise and primary care is easy, helping Americans actually do these things is hard. This is where health services research comes in. Health services research is the study of how health care is structured and delivered and how to make health care and population health more affordable, equitable, safe and effective. Unfortunately, beyond threatening billions of dollars in research, the Trump administration has made moves to weaken or eliminate the Agency for Healthcare Research and Quality, the main federal agency that funds health services research.
It’s clear that being wealthy in America is not enough to keep us healthy. To really Make America Healthy Again, we need policies that help Americans focus on healthy behaviors, provide good primary care to all Americans, and invest in ongoing research on how to deliver the best health for the most Americans, regardless of their wealth.
Jeffrey A. Linder, MD, MPH, FACP, is the Michael A. Gertz Professor of Medicine and Chief of the Division of General Internal Medicine and at the Northwestern University Feinberg School of Medicine.
