Thirty-five years ago, the United States ranked 13th among the 34
industrialized nations that are today in the Organization for Economic
Cooperation and Development in terms of life expectancy for newborn girls. These
days, it ranks 29th.
In 1980, the infant mortality rate in the United States was about the same as in
Germany. Today, American babies die at almost twice the rate of German babies.
“On nearly all indicators of mortality, survival and life expectancy, the United
States ranks at or near the bottom among high-income countries,” says a report
on the nation’s health by the National Research Council and the Institute of
What’s most shocking about these statistics is not how unhealthy they show
Americans to be, compared with citizens of countries that spend much less on
health care and have much less sophisticated medical technology. What is most
perplexing is how stunningly fast the United States has lost ground.
The blame for the precipitous fall does not rest primarily on the nation’s
doctors and hospitals.
The United States has the highest teenage birthrate in the developed world —
about seven times the rate in France, according to the O.E.C.D. More than one
out of every four children lives with one parent, the largest percentage by far
among industrialized nations. And more than a fifth live in poverty, sixth from
the bottom among O.E.C.D. nations.
Among adults, seven out of every 1,000 are in prison, more than five times the
rate of incarceration in most other rich democracies and more than three times
the rate for the United States four decades ago.
The point is: The United States doesn’t have a narrow health care problem. We’ve
simply handed our troubles to the medical industry to fix. In many ways, the
American health care system is the most advanced in the world. But whiz-bang
medical technology just cannot fix what ails us.
As economists from the University of Chicago, M.I.T. and the University of
Southern California put it in a recent research paper, much of America’s infant
mortality deficit is driven by “excess inequality.”
American babies born to white, college-educated, married women survive as often
as those born to advantaged women in Europe. It’s the babies born to nonwhite,
nonmarried, nonprosperous women who die so young.
Three or four decades ago, the United States was the most prosperous country on
earth. It had the mightiest military and the most advanced technologies known to
humanity. Today, it’s still the richest, strongest and most inventive. But when
it comes to the health, well-being and shared prosperity of its people, the
United States has fallen far behind.
Pick almost any measure of social health and cohesion over the last four decades
or so, and you will find that the United States took a wrong turn along the way.
How did we get here? How do we exit?
As the presidential campaign draws the political debate to our national
priorities, these questions must take center stage. As candidates argue over the
budget deficit and the national debt, debate what to do about income inequality,
address the problem of mass incarceration or refight the battles over the
Affordable Care Act and the minimum wage, they should be forced to address how
their policy wish list adds up to an answer.
Looking at how the United States compares with other nations is illuminating. As
I noted in last week’s column, over the last four decades or so, the labor
market lost much of its power to deliver income gains to working families in
many developed nations.
But blaming globalization and technological progress for the stagnation of the
middle class and the precipitous decline in our collective health is too easy.
Jobs were lost and wages got stuck in many developed countries.
What set the United States apart — what made the damage inflicted upon American
society so intense — was the nature of its response. Government support for
Americans in the bottom half turned out to be too meager to hold society
The conservative narrative of America’s social downfall, articulated by the
likes of Charles Murray from the American Enterprise Institute, posits that a
large welfare state, built from the time of the New Deal in the 1930s through
the era of the Great Society in the 1960s, sapped Americans’ industriousness and
undermined their moral fiber.
A more compelling explanation is that when globalization struck at the jobs on
which 20th-century America had built its middle class, the United States
discovered that it did not, in fact, have much of a welfare state to speak of.
The threadbare safety net tore under the strain.
Call it a failure of solidarity. American institutions, built from hostility
toward collective solutions, couldn’t hold society together when the economic
underpinning of full employment at a decent wage gave in.
The question is, Is there a solution to fit these ideological preferences? The
standard prescriptions, typically shared by liberals and conservatives, start
with education, building the skills needed to harness the opportunities of a
high-tech, fast-changing labor market that has little use for those who end
their education after high school.
Ensuring everybody has a college degree might not stanch the flow of riches to
the very pinnacle of society. But it could deliver a powerful boost to the
incomes and the well-being of struggling families in the bottom half.
And yet the prescription — embedded in the social reality that is contemporary
America — falls short. In contemporary America, education is widening inequity,
not closing it. College enrollment rates have stagnated for lower-income
Americans. Sean Reardon from Stanford University notes that the achievement gap
between rich and poor children seems to have been steadily expanding for the
last 50 years.
On the left, there are calls to build the kind of generous social insurance
programs, which despite growing budget constraints remain largely intact among
many European social democracies. Senator Elizabeth Warren, Democrat of
Massachusetts, for example, is calling for an expansion of Social Security, paid
for by lifting the cap on payroll taxes so the rich pay the same share of their
income to support the system as everybody else.
That may be desirable, though at the moment, our greatest problems are not about
the elderly. And at least for the foreseeable future, it remains a political
nonstarter in a nation congenitally mistrustful of government. Just in time to
kick off the presidential campaign, Republicans in the House and Senate were
working on a budget that would gut Obamacare — most likely increasing the pool
of the nation’s uninsured — and slash funding for programs for Americans of low
and moderate income.
Yet despite the grim prognosis, there is hope. The challenge America faces is
not simply a matter of equity. The bloated incarceration rates and rock-bottom
life expectancy, the unraveling families and the stagnant college graduation
rates amount to an existential threat to the nation’s future.
That is, perhaps, the best reason for hope. The silver lining in these dismal,
if abstract, statistics, is that they portend such a dysfunctional future that
our broken political system might finally be forced to come together to prevent