Unfinished Business
UnHealthy, Wealthy, and UnWise?
It's not surprising if you overlooked, or perhaps ignored, the weighty news contained in a CDC report at the end of 2022. After all, we were at the peak of holiday preparations, and this report hardly was cause for celebration: For the second year in a row, life expectancy in the United States declined. The new benchmark for Americans was pegged at 76.4 years, down from 77 in 2020.
Does this rock your world? After all, most of us grew up listening to family stories of the deadly diseases and unsanitary conditions that caused so many premature deaths two generations ago. We all have visited cemetery plots punctuated by small white stones marked "Infant." But our parents vaccinated us against polio and other awful childhood diseases, and they sent us to Red Cross swimming lessons every summer!
The unhealthy news cycle continued into 2023 with the headline that 2021 maternal mortality in the U.S. reached a new high. A Journal of the American Medical Association article also reported that mortality rates among U.S. children and adolescents were increasing.
How could this be? The U.S. is the wealthiest country in the world, and it leads in per capita spending on health care. Our life-saving medical technology and pharmaceuticals are the envy of the world. Aren't they?
Early Warnings Ignored
Yes, but . . .
If we had been paying attention back in 2013, we would have known that Americans, across every demographic group, were dying at younger ages, compared to other wealthy nations of the world.
It was thoroughly detailed in a 400-page canary-in-the-coal-mine report by the National Academy of Sciences, titled Shorter Lives, Poorer Health. Funded by the National Institutes of Health, the report compared the U.S. with other developed countries, and found that our country was falling behind.
"American children are less likely to live to age 5 than children in other high-income countries," the report concluded.
Compared to other countries, a key distinction was that 2/3 of the difference in life expectancy was attributed to Americans dying or being killed before age 50. This was true even for relatively well-off Americans who did not smoke and weren't overweight.
How could it be that U.S. life expectancy in 2013 was lower than in countries like Cuba, Lebanon, and Czechia?
Why the U.S. was losing the race
The answer is much more complex than Americans skipping on servings of fruits and vegetables or spending too much time in the Barca Lounger. It also stretches beyond the obvious shortfalls of the U.S. health care system.
Shorter Lives, Poorer Health divided the problem into five broad categories:
·     Public health and medical care system
·     Individual behaviors (diet and tobacco use)
·     Social-economic factors (poverty and inequality)
·     Physical environment
·     Public policies and values
Not surprisingly, these five broad categories are inextricably intertwined.
Public health and medical care: Unlike most of the other developed countries in the 2013 report, the U.S. has no universal health care. Its reliance on federal, state, and private funds often leads to fragmented and inefficient results.
·     Health insurance, prior to retirement, typically is tied to employment.
·     The U.S. has less access to primary health care and has shortages of OB-GYNs and hospital maternity care in rural areas as well as poor urban neighborhoods.
·     Many Americans end up in emergency rooms, requiring expensive surgeries or treatments.
·     Pharmaceuticals cost Americans about twice as much as in other developed countries in 2019.  (healthsystemtrackerorg)
·     Higher costs cause many Americans to forgo medical care or drugs, and contribute to shorter, less healthy lives.
Individual behaviors: Americans often hear the argument that other people are responsible for their own unhealthy behaviors and choices. This includes their poor diets, tobacco use, substance abuse, reckless driving, violence, and low immunization rates, etc., etc. However, there's more to it. Choices and behaviors are influenced by physical and social environments. Read on.
Social-economic factors: These revolve around poverty and inequality, but also include education, and many other issues. The U.S. excels among developed countries in high rates of child poverty, and income inequality. Income inequality is inversely related to good health. Socio-economic factors also interact with individual behaviors and public policy.
Physical environment: Our physical surroundings and neighborhoods limit certain choices, including healthy diet (food deserts), safe neighborhoods (kids playing outside), housing (asthma and lead), pollution, proximity to toxins, as well as workplace safety, and homicides. Place matters.
Public policies and values: The preceding four categories all are impacted by policies, governance, and societal values. Our values are reflected in our state and federal budget decisions. How are we distributing our resources? What are we spending on early childhood, family and children's services, public health, or social services?
Unfortunately, very few of the recommendations in the 2013 Shorter Lives, Poorer Health were followed up. Why didn't leaders learn from other countries how the U.S. could improve its health and safety outcomes? Is it a case of American exceptionalism? If the United States is truly destined to play a prominent role on the world stage, these statistics revealed an inconvenient truth. The U.S. was backsliding.
Where the rubber hits the road
Over the past decade, the U.S. standing hasn't appreciably improved. What specific factors are contributing to shorter, unhealthier lives in the United States of America? Are our public policies and values exerting an increasingly harmful impact? What policies are Iowa legislators pursuing to improve the longevity of Iowans?
What follows isn't an exhaustive list, but it's a close-up on a few specific factors:
Health insurance: More Americans were enrolled in Medicaid under a special provision during the Covid-19 Pandemic. Now, in April, an estimated 15 million Americans will be removed, unless they re-enroll to verify their personal information and confirm their eligibility. If not, some won't qualify for Obamacare subsidies because they don't earn enough income. Others will fail to fill out forms. An estimated 100,000 Iowans will be disenrolled.
Families, children, and education: The American Rescue Plan provided the largest child tax credit in history. Under it, child poverty was cut in half. Food insecurity in households with children also dropped to a record low. But it expired in 2022, and the credit reverted to a $2,000 annual benefit that includes high-income families but due to a design flaw doesn't fully reach families in the bottom one-third. With the exception of government employees, there's no requirement to offer paid parental leave in Iowa. Hunger is a policy choice. Republicans want to limit SNAP and tighten requirements (Senate File 494) so that the benefits can go to "those who truly are in need." Why isn't the same measuring stick applied to qualifying students for private school vouchers?
Infant deaths and maternal mortality. Beginning in the 1970s and 1980s, the US began losing ground to other countries in preventing infant mortality and low birth rates. The U.S. maternity mortality rate is an anomaly among other comparable countries. In 2021, it was 32.9 deaths per 100,000 live births (Black and Hispanic rates are higher). Yet, according to the CDC, 84% of U.S, maternal deaths are preventable. Extending postpartum Medicaid coverage to 12 months could reduce maternal mortality, but Iowa is one of 11 states that hasn't expanded Medicaid coverage from 60 days to one year; eight states have legislation pending. Now the midwives’ program at MercyOne is being discontinued. It was a band aid for Iowa's short supply of OB-GYNs.
Teen pregnancy, birth control, and abortion. A total of 13 states ban abortions with few exceptions. Last year, the Iowa Supreme Court overturned its 2018 ruling, and decreed that our state constitution doesn't allow a fundamental right to abortion. Now we're waiting for the Iowa Supreme Court to rule on lifting the court injunction blocking the fetal heartbeat bill. Planned Parenthood clinics in Iowa that provided STS testing, cancer screenings, and birth control education have closed, but Iowa legislators have voted to spend $2 million on maternal support programs (MOMS) that offer no medical care to pregnant women.
After two years of stalling, it appears that the Iowa legislature finally may pass an over-the-counter provision for birth control pills for women 18 years and older. A total of 20 U.S. states currently allow this. But this week, the newly elected Iowa Attorney General stopped payment of emergency contraception for rape victims, saying more review was needed to determine if it was an appropriate use of taxpayer funds.
Drug overdoses. Synthetic opioids like fentanyl are the primary drivers. U.S. drug companies have been front and center in the opioid epidemic. In 2021, fatalities from drug overdoses topped 106,000. According to the 2013 Shorter Lives report, drug overdoses were responsible for the difference in 76% of deaths and 24% of alcohol before age 50. Iowa legislation is pending to increase criminal penalties for selling fentanyl or fentanyl-laced substances, and make opioid overdose reversal drugs more available.
Homicide, suicide, and guns. The U.S. also is an outlier in gun ownership and violence. Guns account for 49,000 of the annual deaths in the U.S. (10,000 Americans have died so far in 2023.) Firearms are responsible for 6.9% of the deaths of Americans 19 years or younger; suicide causes 6.8%, (JAMA 2023.) Gun violence now is the leading cause of death among U.S. youth. In Iowa last November voters agreed to approve a gun rights' ballot initiative adding a strict scrutiny wording to Iowa's state constitution. Pending legislation in Iowa would allow employees to keep guns in locked car on their company's parking lot. Iowans with valid gun permits would be able to drop off or pick up children from school carrying a gun in the vehicle.
Covid 19: U.S. lost 417,000 lives to Covid in 2021. It was a huge factor in the life span decline, and the third leading cause of death for two consecutive years. Vaccinations, mask-wearing and school closures were caught up in policies/politics in Iowa. Iowa ended its Covid public health emergency proclamations earlier than required and Iowans lost extra federally funded SNAP benefits. Federal Covid funds were mis-spent on state government computers and software, and have been refunded to the Coronavirus Relief Fund. So far, in Iowa, 10,770+ have died from Covid-19. Our governor's advice focused on Iowans taking personal responsibility.
Fatal car crashes: Americans drive more miles and have more cars. Distraction, speeding, and alcohol are contributing to a 16-year peak in traffic deaths, according to the National Highway Traffic Safety Administration. Nearly 43,000 people died in the U.S. in traffic crashes in 2021-- a 10.5% increase in deaths from 2020. Unbelted fatalities rose 8.1%; alcohol-impaired driving fatalities were up 17%.
Data shows a 12% rise in fatalities involving at least one distracted driver, killing 3,522 people. Kristi Castenson, Harcourt, Iowa, testified in favor of banning hand-held cell phones while driving. Her husband Dave was driving his mom to a doctor's appointment in 2015 when a pickup hit their car and killed both. The truck's driver was texting. This hits close to home: the two families knew one another, and most of us in the surrounding communities know them as well. The Iowa Senate has passed this bill, but it's still pending in the House. Twenty-five states have laws against use of hand-held cells. In those states, traffic deaths, crashes and insurance rates have dropped. Â Iowa legislators also are proposing more funds for traffic enforcement cameras.
Traffic enforcement is a public policy and choice. When is the last time you've seen a Highway Patrol car on the open road?
Workplace protections and labor standards. Is Iowa planning to put children in danger with legislation allowing them to work longer hours, hold jobs previously considered unsafe (if they've had training), and serve drinks at age 15?
Industrial food complex: The U.S. has the highest diabetes prevalence rate in adults, ages 20 to 79, compared to peer countries. It also has the highest adult obesity. Compared to other states Iowa has the second highest cancer rate, based on the University of Iowa 2023 Cancer Registry. It’s some comfort, however, that fewer Iowan are dying from it. One common risk factor: our food culture. It’s ubiquitous. I was appalled two decades ago when I visited college campuses with our daughters: vending machines and snack bars everywhere. Beyond college campuses, why do we need to buy food (snacks, soda, etc.) at gas stations? Good old American free enterprise, of course.
Some bright spots for older Americans
The good news in the 2013 "Shorter Lives" report was that the U.S. has a higher survival after age 75 than other developed countries. The U.S. also came out ahead in:
·     Higher rates of cancer screening and survival
·     Better control of blood pressure and cholesterol levels
·     Lower stroke mortality
·     Lower rates of current smoking
·     Higher average household income.
But these advantages aren't enough to offset the premature fatalities of younger Americans. The lives of our children and teenagers are at stake.
It's hard to escape the through line from the declining life expectancy in the U.S. to our American adherence to individualism, free enterprise, de-regulation, Federalism, and religion mixed with politics. Our macho American self-reliance ethic also piles more pressure on families struggling to balance work and childcare.
Many Americans insist on the right to be free to make bad and risky choices, and argue that they'll bear the consequences. But they aren't the only ones who will suffer, right? There are huge costs to this country. An estimated $50 billion in U.S. health care costs are attributed to the heart disease, diabetes, stroke associated with poor food choices. Think of the lives that were cut short by Covid-19, and the emotional and economic pain of their children and families.
Today's children are tomorrow's older adults. They deserve greater attention from us, ranging from the rising risks of low-birth weights, gun violence and suicide, drug abuse, obesity, and diabetes--and much more. They're our future. Isn't it time for this country to harness its resources, expertise, technology, and energy to create a new clean bill of health?
I’m delighted to be part of this group!
Iowa Writers’ Collaborative ColumnistsÂ
Laura Belin:Â Iowa Politics with Laura Belin, Windsor Heights
Doug Burns:Â The Iowa Mercury, Carroll
Dave Busiek:Â Dave Busiek on Media, Des Moines
Art Cullen: Art Cullen’s Notebook, Storm Lake
Suzanna de Baca Dispatches from the Heartland, Huxley
Debra Engle:Â A Whole New World, Madison County
Julie Gammack: Julie Gammack’s Iowa Potluck, Des Moines and Okoboji
Joe Geha:Â Fern and Joe, Ames
Jody Gifford:Â Benign Inspiration, West Des Moines
Beth Hoffman:Â In the Dirt, Lovilla
Dana James: New Black Iowa, Des Moines
Pat Kinney:Â View from Cedar Valley, Waterloo
Fern Kupfer:Â Fern and Joe, Ames
Robert Leonard:Â Deep Midwest: Politics and Culture, Bussey
Tar Macias:Â Hola Iowa, Iowa
Kurt Meyer, Showing Up, St. Ansgar
Kyle Munson, Kyle Munson’s Main Street, Des Moines
Jane Nguyen, The Asian Iowan, West Des Moines
John Naughton:Â My Life, in Color, Des Moines
Chuck Offenburger:Â Iowa Boy Chuck Offenburger, Jefferson and Des Moines
Barry Piatt: Piatt on Politic Behind the Curtain, Washington, D.C.
Mary Swander: Mary Swander’s Buggy Land, Kalona
Mary Swander: Mary Swander’s Emerging Voices, Kalona
Cheryl Tevis:Â Unfinished Business, Boone County
Ed Tibbetts:Â Along the Mississippi, Davenport
Teresa Zilk:Â Talking Good, Des Moines
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Thank you for all of this important and surprising information.
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