2019: The Ten Greatest Threats to Health Worldwide

How should the planet’s ten biggest health threats affect our approach to health reform in the United States?

The world we live in is facing multiple health challenges. The World Health Organization (WHO) recently released a report detailing the top ten major threats to global health.  From outbreaks of vaccine-preventable diseases like measles, growing rates of obesity, to the health impacts of environmental pollution and climate change, these issues are relevant in our approach to health reform and health policy in the United States.

Here are the planet’s ten biggest health threats according to WHO:

1.    Air pollution and climate change

According to WHO, nine out of ten people breathe polluted air every day. In 2019, air pollution is considered by WHO as the greatest environmental risk to health. Microscopic pollutants in the air can penetrate respiratory and circulatory systems, damaging the lungs, heart and brain, killing 7 million people prematurely every year from diseases such as cancer, stroke, heart and lung disease.

2. Noncommunicable diseases

Seventy percent of deaths worldwide are due to noncommunicable diseases, such as diabetes, cancer, and heart disease.

According to WHO, the five risk factors driving increases in noncommunicable diseases are tobacco use, alcohol use, physical inactivity, unhealthy diets, and air pollution. 

3. Influenza

The world will face another influenza pandemic – the only thing not known is when it will hit and how severe it will be. Global defenses are only as effective as the weakest link in any country’s health emergency preparedness and response system WHO says. 

4. Fragile and vulnerable settings

Over 22% of the world’s population lives in fragile settings, which are defined as places where access to basic health care is minimal, often due to being in a state of crisis and having poor health services.

Fragile settings exist in almost all regions of the world, and these are where half of the key targets in the sustainable development goals, including on child and maternal health, remain unmet. 

5. Antimicrobial resistance

The development of antibiotics, antivirals and antimalarials are some of modern medicine’s greatest successes. Now, time with these drugs is running out. Antimicrobial resistance – the ability of bacteria, parasites, viruses and fungi to resist these medicines – threatens to send us back to a time when we were unable to easily treat infections such as pneumonia, tuberculosis, gonorrhea, and salmonellosis. The inability to prevent infections could seriously compromise surgery and procedures such as chemotherapy. 

Drug resistance is driven by the overuse of antimicrobials in people, but also in animals, especially those used for food production, as well as in the environment, according to WHO.

6. Ebola and high-threat pathogens

When it comes to responding to a high-threat pathogen such as Ebola, context is “critical,” according to WHO. The way a high-threat pathogen spreads and impacts a rural area might look very different from the way it would look in urban areas or active conflict zones—making it difficult for health systems and governments to prepare an effective emergency response.

WHO’s current watchlist of high-treat pathogens includes Ebola, Zika, SARS, and disease X—a placeholder for any unknown pathogen that could cause an epidemic.

7. Weak primary care

Primary care is supposed to be the most consistent and accessible form of health care a patient has over their lifetime, WHO explains. But when a country lacks adequate primary care facilities, patients lack affordable and comprehensive care for their needs, which can cause everyday health problems to evolve into health emergencies.

8. Vaccine hesitancy

Vaccine hesitancy – the reluctance or refusal to vaccinate despite the availability of vaccines – threatens to reverse progress made in tackling vaccine-preventable diseases. Vaccination is one of the most cost-effective ways of avoiding disease – it currently prevents 2-3 million deaths a year, and a further 1.5 million could be avoided if global coverage of vaccinations improved. 

Measles, for example, has seen a 30% increase in cases globally. The reasons for this rise are complex, and not all of these cases are due to vaccine hesitancy. However, some countries that were close to eliminating the disease have seen a resurgence (including the United States). 

9. Dengue

About 40% of the world is at risk of becoming infected with dengue, a mosquito-borne illness that infects 390 million people each year and kills up to 20% of people with a severe form of the disease, according to WHO.

10. HIV

The progress made against HIV has been enormous in terms of getting people tested, providing them with antiretrovirals (22 million are on treatment), and providing access to preventive measures such as a pre-exposure prophylaxis (PrEP, which is when people at risk of HIV take antiretrovirals to prevent infection). 

However, the epidemic continues to rage with nearly a million people every year dying of HIV/AIDS. Since the beginning of the epidemic, more than 70 million people have acquired the infection, and about 35 million people have died.

The list provides an overview of the top 10 health threats WHO and the organization’s partners will target under a five-year strategic plan that kicks off this year. According to WHO, the goal is to ensure one billion more people benefit from access to universal health coverage, one billion more people are protected from health emergencies, and one billion more people enjoy better health and well-being.


For Consideration:

  • Does the WHO list of the top Global Health Risks fit with what you consider to be the top health risks facing the United States?
  • Which risks as noted by WHO should be included in the top health risks faced by Americans?  
  • What other issues do you consider to be the Top Health Risks facing the United States?
  • Many of the top risks defined by WHO are “Social and Environmental Determinants of Health.” What is your view on whether these should be considered part of health reform?

Additional Resources:

Visit the World Health Organization’s web page to learn more about the Top Global Health Threats of 2019.

Review this primer on Social Determinants of Health from NEJM Catalyst.

Go deeper on Social Determinants of Health by visiting the Centers for Disease Control and Prevention’s website: Social Determinants of Health: Know What Affects Health

The High Cost of Self-Inflicted Disease

The role of citizens vs. government in managing health goes beyond the current health reform debate in Washington.

An issue as big as healthcare is the environment. And so, what if there was a way to dramatically improve the health of all Americans while decreasing our consumption of fossil fuels by a billion gallons a year?

Transformational new technology? Innovative legislation from Washington?  The answer is simple. We would achieve these goals by reducing the weight of the average American to what it was in 1962. [1]

Sheldon Jacobson is a computer science professor who has studied the effects of obesity and fuel consumption.  His work points to a simple matter of physics. Heavier drivers increase fuel consumption. Car engines use more energy to move more weight. The added weight Americans have packed on since the sixties costs motorists an estimated $4 billion a year.[2]

Supersizing America

Americans are being “supersized” at an alarming rate as part of a global obesity pandemic that is driven by a variety of lifestyle and environmental factors. Around the world today more people now die from obesity than malnutrition. It has overtaken tobacco as the largest cause of preventable disease.

Obesity is a real disease recognized by the American Medical Association, World Health Organization and others. Like smoking, overreliance on alcohol and drugs, it is a non-communicable disease.

Communicable diseases, like flu, malaria and measles are caused by forces in nature. Most non-communicable diseases may be influenced by things like genetics or exposure to hazardous materials in the environment, but in some manner, are self-inflicted by choices we as consumers and as a society make.[3]

Let’s use obesity to illustrate how self-inflicted diseases impact both our health and our wallet.

Today, more than two-thirds (68 percent) of American adults are either overweight or obese.[4]  Since 1980 adult obesity rates have more than doubled.[5] [6] If nothing changes 42 percent of U.S. adults will be obese by 2030 with more than ten percent of Americans being severely obese. [7] 

And while obesity is an “equal opportunity” disease affecting all walks of society, it is more pervasive and impactful among low income Americans and minorities. [8]

Beyond its direct impact, obesity is also a “gateway disease”. It dramatically increases the prevalence of diabetes, cardiovascular disease, cancer, osteoarthritis, infertility, sleep apnea and other health conditions.[9]   For example, as the prevalence of obesity grows, new cases of type 2 diabetes, coronary heart disease and stroke, hypertension and arthritis are on track to increase 10 times between 2010 and 2020 — and then double again by 2030.[10]

Over the next twenty years it is estimated that obesity will be a causal factor in 8 million cases of diabetes, seven million cases of coronary heart disease and stroke and a half million cases of cancer.[11]

A heavy price paid by all

Obesity is not only bad for our health, it’s also very expensive. Worldwide, obesity has the same economic impact as smoking or armed conflict.[12]

Within the United States, obesity-related illness treatments cost Americans an estimated $190.2 billion annually and will add another $550 billion in additional costs between now and 2030. [13] [14]

On average Americans who are obese spend more on medical services and medications than smokers and heavy drinkers. [15]  They incur 40% higher inpatient hospital costs, 27% more physician visits and outpatient costs and consume 80% more prescription drugs.[16]

Beyond direct medical, obesity impacts the productivity and competitiveness of America’s employers and workforce. A study by the Society of Actuaries estimates that U.S. employers are losing $164 billion in productivity each year due to obesity-related issues with employees.[17] The Robert Wood Johnson Foundation predicts that annual economic productivity loss due to obesity is likely to reach $550 billion by 2030.[18]

Without significant change, obesity-related costs will rise dramatically with increases being absorbed by employers and goods and services they provide. Consumers will be increasingly impacted by larger out of pocket expenses as well as higher taxes to support programs such as Medicare and Medicaid which are already teetering on the brink of disaster because of their national price tag. Obesity-related medical expenditures already cost these programs an extra $62 billion annually.[19]

Solving for Obesity is simple and complex

When it comes to understanding what is driving obesity and what can be done to slow or stop this epidemic, the answer is both simple and complex.

At a simple level the obesity epidemic is caused by Americans consuming more calories through food and beverages than they expend.

But the deeper answer to why this is occurring is rooted in a myriad of issues that have unfolded over the past four decades.

Today we live in a world where inactive lifestyles are the norm and inexpensive, high calorie foods and drinks are readily available 24 hours a day.

There are fewer safe places to walk or play. Parts of our communities (especially low-income neighborhoods) lack food outlets offering affordable, healthy foods. We are constantly bombarded by advertisements for unhealthy foods and beverages.

While we are all affected by these trends, our children are at greatest risk. Today, one in three American children is overweight or obese. The prevalence of obesity in children more than tripled since 1971 and is now the Number One health concern among parents in the United States, topping drug abuse and smoking.[20]

If you are a parent and want your child to be healthy, it would seem reasonable that there are simple things to do to ensure that they are not overweight or obese. For example, a study from the American Journal of Preventive Medicine found that eliminating just 41 calories a day could halt rising body weight trends in children and teens.[21]

Unfortunately, a variety of forces make it difficult to achieve such a simple goal.

Today the majority of children in the United States are high in added sugar and fat and too low in fruits and vegetables, whole grains, and low-fat and nonfat dairy products.[22]

Children are less active today than at any point in our history. On average, kids consume 7.5 hours of screen or media time a day.  In 1969, half of all children walked or biked to school. Today about 13 percent walk or bike to school.[23]

Fast food companies are specifically marketing to children and adolescents. In one study by the Robert Wood Johnson Foundation, McDonald’s was found to have the strongest emphasis on the children’s market, with 40 percent of 44,062 ads studied aimed at kids.[24]

Beyond the blitz of airtime focused on children, the fast-food companies use free toys and popular movies to appeal to kids by focusing on promotions, brands, and logos—not on food.[25]  

As a result, on any given day, more than one third of U.S. children eat fast food.[26]  French fries are now the most common “vegetable” that kids eat, making up 25% of American children’s total vegetable intake.[27]

And so, can something like regulating fast food advertising to children (like advertising bans and warning labels for tobacco products) impact the obesity epidemic in children, which in turn, may improve health and lower medical costs?

The province of Quebec banned fast-food advertising to kids in electronic and print ads 34 years ago. And while Canada is seeing as similar explosion in childhood obesity like the United States, Quebec has the lowest childhood obesity rate in Canada.

Researchers from the University of British Columbia who studied the impact of the advertising ban in Quebec concluded two things. First, the ban resulted in a 13 percent reduction in fast food expenditures.  At the same time, they estimate that 4 billion fewer calories were consumed by children in the province.[28]

In the end, childhood obesity has many consequences for our kids and our country. The most dire is that obesity may lead to a shorter life span for our children than that of their parents.[29] Children who are obese are more than twice as likely to die before the age of 55 compared to non-obese children.[30]

Solving for the Obesity epidemic brings us face-to-face with the need to better understand and make decisions as part of the health reform debate. Like other self-inflicted diseases (think smoking/vaping, alcohol/drugs), highlighting the consequences of Obesity illustrates the need to broaden the health reform discussion to include a view towards creating new paradigms and models to prevent or mitigate many of the health issues we now face.   Failure to do this means such medical and health conditions will continue to fill hospitals beds, cost more in dollars and deaths that would otherwise be prevented.


For Consideration:

  • What is your view in how to balance the responsibility of a citizen to manage their own health with the role government plays in legislating or regulating products and services in an attempt to create healthier environments and citizens?
  • Should drinks containing high amounts of sugar be regulated or taxed in an effort to reduce obesity (similar treatment to how alcohol and tobacco are taxed and regulated)?
  • What other actions might be taken by state and local governments to put forward legislation or regulations to create healthier environments which encourage a high level of health status or mitigate the effects of personal choices leading to a growing number of Americans who are destined to have costly health and medical conditions that could be avoided?

Additional Resources:

“Sugar: Consumption at A Crossroads” by the Credit Suisse Research Institute

Get the Facts: Sugar-Sweetened Beverages and Consumption from Centers for Disease Control and Prevention (CDC)

Learn more about Noncommunicable Diseases with news and information from the World Health Organization.


References:

[1] Sheldon Jackson (2006,2008), The Engineering Economist. “The Economic Impact of Obesity on Automobile Fuel Consumption,” published in The Engineering Economist (Volume 51, Number 4, 307-323, October –December 2006)

[2] Ibid

[3] Noncommunicable diseases fact sheet, (2013), World Health Organization, http://www.who.int/mediacentre/factsheets/fs355/en/

[4] Flegal KM, Carroll MD, Ogden CL, et al.  Prevalence and Trends in Obesity among U.S. Adults, 19992008. Journal of the American Medical Association, 303(3): 235-41, 2010.

[5] National Center for Health Statistics.  “Prevalence of Overweight, Obesity and Extreme Obesity among Adults.”

[6] Ogden CL, Carroll MD, Kit BK, Flegal KM.  Prevalence of Obesity in the United States, 2009-2010.  NCHS data brief, no 82.  Hyattsville, MD: National Center for Health Statistics, 2012.

[7] Ibid

[8] Trust for America’s Health and Robert Wood Johnson Foundation.  F as in Fat: How Obesity Threatens America’s Future — 2011.  http://www.tfah.org/report/88/ (accessed July 2012).  Based on data using the previous BRFSS methodology in use from 2008-2010.

[9] Y Claire Wang, Klim McPerhson, Tim Marsh, Steven L. Gortmaker, Martin Brown. Health and economic burden of othe projected obesity trends in the USA and the UK. The Lancet. 2011. 815-827

[10] F as in Fat: How Obesity Threatens America’s Future. Trust for America’s Health (TFAH) and the Robert Wood Johnson Foundation. 2012.

[11] Y Claire Wang, Klim McPerhson, Tim Marsh, Steven L. Gortmaker, Martin Brown. Health and economic burden of other projected obesity trends in the USA and the UK. The Lancet. 2011. 815-827

[12] Overcoming Obesity: An Initial Economic Analysis, McKinsey Global Institute, November 2014 http://www.mckinsey.com/Insights/Economic_Studies/How_the_world_could_better_fight_obesity

[13] John Cawley, Chad Meyerhoefer. The medical care costs of obesity: An instrumental variables approach. Journal of Health Economics, 2012; 31 (1): 219 DOI: 10.1016/j.jhealeco.2011.10.003

[14] [14] Ogden CL, Carroll MD, Kit BK, Flegal KM.  Prevalence of Obesity in the United States, 2009-2010.  NCHS data brief, no 82.  Hyattsville, MD: National Center for Health Statistics, 2012.

[15] Sturm R.The Effects of Obesity, Smoking,and Problem Drinking on Chronic Medical Problems and Health Care Costs.Health Affairs.2002;21(2):245–253.

[16] Ibid

[17]  Overweight and obesity study. Society of Actuaries. 2009. https://www.soa.org/Research/Research-At-A-Glance.aspx

[18] Trust for America’s Health and Robert Wood Johnson Foundation.  F as in Fat: How Obesity Threatens America’s Future — 2011. 

[19] Finkelstein, Trogdon, Cohen, et al.  “Annual Medical Spending Attributable to Obesity”.

[20] Overweight in Children, American Heart Association. http://www.heart.org/HEARTORG/HealthyLiving/HealthyKids/ChildhoodObesity/Overweight-in-Children_UCM_304054_Article.jsp#.WGavuWwzWbg

[21] Wang YC, Orleans CT and Gortmaker SL.  Reaching the Healthy People Goals for Reducing Childhood Obesity: Closing the Energy Gap.  Am J Prev Med, doi: 10.1016/j.amepre.2012.01.018, 2012.

[22] Ibid

[23] The National Center for Safe Routes to School, 2011.   http://guide.saferoutesinfo.org/introduction/the_decline_of_walking_and_bicycling.cfm

[24] Fast-Food Television Ads Use Toys, Movies to Target Kids. Robert Wood Johnson Foundation. April 2013. http://www.rwjf.org/en/library/articles-and-news/2013/08/fast-food-television-ads-use-toys–movies-to-target-kids.html

[25] Ibid

[26] Caloric Intake From Fast Food Among Children and Adolescents in the United States, 2011–2012. Centers for Disease Control. September 2015. https://www.cdc.gov/nchs/data/databriefs/db213.htm

[27] Obesity in Infants to Preschoolers. American Heart Association. http://www.heart.org/HEARTORG/HealthyLiving/HealthyKids/ChildhoodObesity/Obesity-in-Infants-and-Preschoolers-Infographic_UCM_467593_SubHomePage.jsp

[28] Fast Food Consumption and the Ban on Advertising Targeting Children: The Quebec Experience. Tirtha Dhar Assistant Professor, Division of Marketing, Sauder School of Business, University of British Columbia. April 2011. http://www.marketingpower.com/aboutama/documents/jmr_forthcoming/fast_food_consumption.pdf

[29] American Heart Association, 2010; Olshansky et al., 2005

[30] Franks PR, Hanson W, Knowler M, et al.  “Childhood Obesity, Other Cardiovascular Risk Factors, and Premature Death.”  New England Journal of Medicine, 362(6):485-93, 2010.

Health Reform: What a Long Strange Trip it’s Been – Part 1

Implementation of health reform poses formidable challenges for Democrats, Republicans, and the political process itself. What can the past teach us about what to do now?


“What is old is new again”


Today’s health reform debate is deeply rooted in the ideologies and legislative efforts of the past 75 years.

Should Social and Environmental Determinants of Health be part of reform efforts? In 1945, President Harry Truman proposed solutions to these issues as part of comprehensive health reform. Can we legislate “healthcare for all” while maintaining a private system that allows consumers to choose their own physicians? In 1962, President John F. Kennedy championed such an approach.

Sound like familiar issues relevant to today?

Understanding past struggles helps to shape our current efforts for positive change by providing useful perspectives on the similarities of issues as well as the politics of reform that have persisted for decades.

And so, here’s a short history on the “roots” of today’s issues and efforts to improve health systems in America.

This installment (Part 1) begins in the 1940’s and culminates in 1969 with the landmark passage of both Medicare and Medicaid.

In Part 2, we’ll look at reform efforts from the 1970’s leading up to the passage of the Affordable Care Act and what’s happening today.


1933-1945: Franklin D. Roosevelt Administration

While health reform as a movement in the United States goes back to the early 1900’s, a national effort supported by a significant political party emerged in the 1940’s. President Franklin Delano Roosevelt believed in the concept of “healthcare for all” as part of his broader view on the role of government to create and manage “social programs” to benefit all Americans.

His key push to provide Healthcare for All was part of what would become known as “America’s Second Bill of Rights.”

President Roosevelt taking his case for Universal Health Coverage to the people as part of his initiative known as America’s Second Bill of Rights.

As World War II was coming to a close, it had been rumored that Universal Health Care was to be President Roosevelt’s next big political crusade. Unfortunately, he died just before the end of the war and so the world would never really know what might of come from President Roosevelt’s resolve to make healthcare accessible to all.


1945-1953: The Truman Administration

In November of 1945 President Harry Truman called on Congress with a special message recommending passage of a Comprehensive Health Program.

President Harry S. Truman

You can access the full speech here which enumerates the vision, issues and opportunities to deliver universal coverage to all Americans.

While the full speech is worth reading, there are two areas that are especially relevant to the challenges of today.

The first area of importance is where the Truman administration puts forward the tenent of healthcare as a “right”:

“In my message to the Congress of September 6, 1945, there were enumerated in a proposed Economic Bill of Rights certain rights which ought to be assured to every American citizen. One of them was: “The right to adequate medical care and the opportunity to achieve and enjoy good health.” Another was the “right to adequate protection from the economic fears of sickness.”

Millions of our citizens do not now have a full measure of opportunity to achieve and enjoy good health. Millions do not now have protection or security against the economic effects of sickness. The time has arrived for action to help them attain that opportunity and that protection.”

Harry S. Truman in a speech to Congress advocating healthcare as a right.

The second area that is especially noteworthy to today’s challenges and struggle for comprehensive reform is this: Long before contemporary experts began championing the notion of Social and Environmental Determinants of Health, Harry Truman nailed the correlation of these factors to the health of a nation. His proposal tied social and environmental issues to the macro view of what “systems of health” should include:

” If we agree that the national health must be improved, our cities, towns and farming communities must be made healthful places in which to live through provision of safe water systems, sewage disposal plants and sanitary facilities. Our streams and rivers must be safeguarded against pollution. In addition to building a sanitary environment for ourselves and for our children, we must provide those services which prevent disease and promote health.”

Harry S. Truman advocating that Social and Environmental Determinants of health be part of a national health plan.

The issue that ultimately became the lightning rod for Turman’s proposal was a provision that called for universal health insurance coverage to be administered and paid for by a National Health Insurance Board. The American Medical Association, quickly decried this to be “socialized medicine,” with a Congressional subcommittee labeling the approach “communistic.” The bill died, but Truman continued pushing for expanded access to health services right up to the outbreak of the Korean War which then took priority.


1953-1961: The Eisenhower Administration

President Dwight Eisenhower was known from his military career as a brillant strategist who then became an effective and savy politician.

In reviewing the impact of Truman’s push for health reform, Eisenhower came forward with a more modest approach and a very clear message for Congress, voters and special interest groups to hear:

“I am flatly opposed to the socialization of medicine. The great need for hospital and medical services can best be met by the initiative of private plans. But it is unfortunately a fact that medical costs are rising and already impose severe hardships on many families. The Federal Government can do many helpful things and still carefully avoid the socialization of medicine.”

President Dwight Eisenhower
National television broadcast to promote Eisenhower proposal for national health reform.

President Eisenhower proposed a four-part plan to increase access to affordable care for more Americans that included:

  • Federal funding to increase number of hospitals in the United States.
  • Legislation and funding increase services to those with “disabilities.”
  • Greater flexibility in allowing states to utilize federal funds for public health services.
  • Private health insurance reform to encourage new types of plans to cover more Americans.

To pitch this plan to the American public, and make very clear the differences compared to the proposals made by the Truman Administration, President Eisenhower made use of the new political tool of television (social media of the 1950’s) to make his case for health reform.

Sidenote: While the clip above is worth watching for the sake of understanding what was being proposed, it is most noteworthy in that the majority of the broadcast features one of America’s first female cabinet members Oveta Culp Hobby.

Like so many woman leaders whose contributions are lost in history, Hobby was first female secretary, of the new Department of Health, Education, and Welfare. In this role, she made the (then controversial) decision to approve Jonas Salk‘s polio vaccine. She was also the first women to receive the Army’s Distinguished Service Medal for her leadership efforts during WWII, including serving as the head of the Women’s Army Corps which was created to fill the gaps left by a shortage of men. The brilliance and contributions of Oveta Culp Hobby comes through in this short clip.


1961-1963: The Kennedy Administration

Under President John F. Kennedy, a proposal for expanding access to health services included health insurance coverage for those 65 years and older as part of a Social Security benefits package.

While this work began laying a foundation for what would ultimately become Medicare, it was met with strong opposition by special interest groups. Frustrated by the efforts of special interests to kill a bill making its way through Congress, President Kennedy went on the road to make the case for his proposal directly to the public in a series of public rallies. This effort culminated in the spring of 1962 with a rally in New York City.

Madison Square Garden: President Kennedy making the case for expanding access to health care.

Eighteen thousand citizens packed Madison Square Garden with Kennedy’s speech being televised nationally. Despite public opinion being in favor of Kennedy’s proposal the bill was defeated in Committee. President Kennedy vowed to press forward but did not live to see his plan come to fruition.


1963-1969: The Johnson Administration

Following the death of President Kennedy, Lyndon B. Johnson (LBJ) was sworn in as the President of the United States. He then won a landslide victory to be elected to a full term as President in November, 1964.

President Johnson was purposeful in visibly picking up the social programs that President Kennedy had proposed in order to “keep a promise made to the American Public.” With a Democratic majority in both houses of Congress, President Johnson had a receptive body for extensive social reforms that came to be known as the Great Society.

Even with control of Congress, there was strong opposition from the American Medical Association, conservative Republicans and congressional leaders within his own party.

With President Johnson working behind the scenes to build a coalition to support both Medicare and Medicaid programs, the Social Security Amendment was introduced in the House Ways and Means Committee in March of 1965, gained final approval by the Senate on July 28, 1965 and was signed into law by President Johnson on July 30, 1965.  It is noteworthy that such landmark legislation was passed within the first six months of President Johnson taking office.

“No longer will older Americans be denied the healing miracle of modern medicine. No longer will illness crush and destroy the savings that they have so carefully put away over a lifetime.

President Johnson on the signing of Medicare into law

As originally enacted, healthcare coverage would now be provided to those 65 years of age and older, and to the poor, blind and disabled. It covered healthcare services provided by hospitals, physicians, nursing facilities and home care providers. 

A behind-the-scenes look at what it took to make Medicare a reality.

Medicare was milestone legislation that guaranteed healthcare as a right for seniors. It showed that major reform is possible with the support of the public, and the alignment of the powers in Washington.

It should also be noted that such progress was made because elected leaders made healthcare access a legislative and executive priority. Even then, reform was a hard-fought battle.

The clip above from CBS’ Washington Unplugged is an exceptionally candid behind-the-scenes look at what President Johnson went through to make Medicare a reality. It demonstrates the kind of resolve and types of action needed today to enact meaningful reform going forward.

In Part 2, we will look at health reform events in the 1970’s leading up to the passage of the Affordable Care Act in 2010.

All videos used in this story provided via links to original content on YouTube. Full attribution and copyrights property of the original content owner who post to YouTube.

Has Healthcare Value Improved in the Last 25 Years?

Measuring the value we receive from the U.S. Health system is a tricky but important part of the health reform conversation.

Measuring the value we receive from the U.S. Health system is a tricky but important part of the health reform conversation. If we strip down the complexities there are two questions worth considering:

  • Is the U.S. health system generating better value than in the past?
  • How do factors other than the healthcare system affect health outcomes (compared to other countries)?


As noted in other articles on this site, the United States spends more per citizen than any other country but ranks lower than most on almost all comparative value measures including quality, costs and outcomes.

To examine the issue of “value” the Kaiser Family Foundation developed an approach to measure the level of improvement in health outcomes over time, and the incremental costs incurred by the health system.

This work is part of the Peterson-Kaiser Health System Tracker which includes a “Dashboard” of indicators that can be used to describe, evaluate and compare changes in the value of U.S. healthcare over time. With many measures spanning 25 years, or approximately a generation, the Dashboard paints a picture of how the value of the system has changed over time.

The assessment looks at whether the value of the U.S. health system has improved or worsened from 1991 – 2016 by measuring the level of improvement in health outcomes, and the incremental costs the healthcare system incurred at the same time.

Here is a summary of results:

  • Between 1991 and 2016, life expectancy increased by 3.1 years to 78.6, representing a 4% improvement. In the same time, disease burden (as measured by  something known as the total number of disability adjusted life years, or DALYs) improved by 12%.
  • At the same time, there was a worsening of years living in disability which is largely due to  an increase in substance use disorders. Substance use is actually one of the primary contributors to the decline in life expectancy in 2015 and 2016, the first time life expectancy has dropped two years in a row in several decades. This trend clearly points to the importance of social and environmental determinants being included in the broader debate of health reform.
  • In looking at this data there is a very troubling trend in Women’s Health where outcomes have actually gotten worse.  In the United States maternal mortality has gone up significantly from 14 deaths per 100,000 live births in 1991 to nearly 31 in 2016.  

The good news is that the study shows that health outcomes have generally improved in the U.S. over the past 25 years as measured by life expectancy and disease burden. However, since value is a function of outcomes and costs, one must also take into account the increase in health spending

In 1991, the Gross Domestic Product (GDP) attributable to healthcare was 12.8% or $788 billion. By 2016, healthcare consumed 17.9% of GDP or $3.3 Trillion. This brings us to a key question in how we evaluate value:

  • Is the 4% improvement in life expectancy and 12% reduction in disease burden enough to warrant a 40% increase in GDP consumption over the past 25 years?
  • What does this portend for future access and affordability? This is an especially important issue to address as part of health reform in the United States as we consider a shift in demographics such as increase in elderly population, as well as the impact of other key health challenges such as the Opioid epidemic.

As a comparison to America’s performance as noted above, similar nations during the same period generated an average increase in life expectancy of 5.2 years, or 7%, compared to the U.S.’s 3.1 years, or 4% improvement. In these countries, disease burden improved by 22%, compared to the U.S.’s 12%.

By these indicators, comparable countries spent under two thirds (60%) of what the U.S. spent on healthcare relative to GDP.

Relative to the health reform debate, another interesting finding is that the United States spends less on social services and more on healthcare,  but has worse health outcomes than similar countries.

And so, to summarize the question of whether value from the healthcare system has improved:

  • The outcomes generated by U.S. healthcare as measured by life expectancy, mortality amenable to healthcare, and years lost to premature death have improved over the past quarter century.
  • Total years living in disability have increased with mental health and substance use issues being the leading contributors to the increase.
  • If total spending for health had remained constant at 12.8% of GDP, one could easily conclude that the value proposition had improved dramatically. Unfortunately, healthcare spending in 2016 consumed 17.9% of the nation’s wealth, which is a 40% increase from 1991.  

This assessment points to a significant opportunity to be more efficient and effective in improving life expectancy and reducing the burden of disease while shedding light on socioeconomic factors and the potential impact lower investment in social services is having on outcomes.


For Consideration:

  • Did improvements seen over the past quarter century need to cost this much as they did?
  • Had the level of investment in the U.S. health system been at a similar level (percentage of GDP) from 1991, or mirrored other countries, what else might we have invested in to improve the health and wellbeing of citizens?
  • Do you believe that higher levels of investment in public and social services (as happens in other countries) correlates to higher levels of health outcomes?

Additional Resources:


Americans Remain Dissatisfied With Healthcare Costs

This report from Gallup summarizes results of a recent poll showing that most Americans consider healthcare costs and access to be a major issue. Provides a breakdown of the issues along with useful charts to explain details surrounding the issues.

Peterson-Kaiser Health System Dashboard

This site includes a rich set of data from credible sources that allow users to explore a variety of indicators of health spending, quality of care, access, and health outcomes. Provides great visuals and infographics that can be downloaded and used (with attribution). While easy to use, the site also includes a brief tutorial.

The Kaiser Family Foundation (KFF)

The Kaiser Family Foundation (KFF) is a non-profit, private operating foundation focusing on the major health care issues facing the U.S., as well as the U.S. role in global health policy. KFF’s website focuses on policy research, basic health care facts and numbers, and health reform implementation information. The Kaiser Family Foundation is not associated with Kaiser Permanente or Kaiser Industries.

Does Sugar Addiction Impact $1 Trillion in U.S. Healthcare Spending?

This article looks at the explosion of added sugars in our food and drink supply and reports on the health and cost consequences to all.

It is clear that the obesity epidemic is a key issue in the health reform debate as research conclusively shows that it drives significant increases in chronic diseases like coronary heart disease and diabetes.

What is less clear from a science and public policy perspective is the role sugar plays in both obesity and chronic diseases and what, if anything, should be done to regulate or manage its presence in our food and drink supply as part of the health reform debate in the United States.

“Sugar: Consumption at A Crossroads” is a groundbreaking report from the Credit Suisse Research Institute that explores the medical, economic, consumer and public policy implications of global sugar consumption.

Amongst the many data points and in-depth content in the report is this estimate of the economic impact of sugar in the United States:

“30% – 40% of healthcare expenditures in the USA go to help address issues that are closely tied to the excess consumption of sugar.”

The consumption of added sugar (sugar not contained in natural products like fruit or milk) or high-fructose corn syrup (HFCS) has increased dramatically over the last few decades. According to this report:

  • The world daily average consumption of sugar and HFCS per person now averages 17 teaspoons per day, up 46% from 30 years ago. This is the equivalent of 280 calories per day.
  • In comparison, Americans now consume an average of 40 teaspoons per day. As a benchmark, the American Heart Association recommendation for daily sugar intake is six teaspoons for women and nine for men.
  • Added sugars now represent 17% of a normal US diet with 43% of added sugars coming from sweetened beverages.

The report also includes a survey of physicians in the US, Europe and Asia. Key points from the physician view include:

  • 90 percent of the doctors surveyed believe that the sharp growth in type II diabetes and the current obesity epidemic are strongly linked to excess sugar consumption.
  • 82% of the doctors surveyed in the U.S. and Europe believe that sugar calories are handled differently by the body. 
  • On the question “is sugar addictive,” 65% think this is the case.

While medical research has yet to prove conclusively that sugar is the leading cause of obesity, diabetes type II and metabolic syndrome, the balance of recent medical research studies are coalescing around this conclusion. Advances in understanding the negative effects of refined carbohydrates on blood sugar regulation and cholesterol, and the metabolic impacts of fructose, are changing the traditional view that all calories are the same.

From a public policy perspective, governments and regulators have done little to address the impact of sugar consumption. Typical options often discussed, but rarely acted upon, include higher taxation as an attempt to reduce sugar intake while helping to fund healthcare costs related to obesity and diabetes, as well as increased spending on educating and explicit product labeling and warnings.

Worldwide, obesity now kills more people than starvation and malnutrition. The rapid growth of obesity, diabetes and related nutritional issues is arguably America’s top social health concern for which solutions can be devised to slow the growth and improve both health outcomes and costs.

And so, there is an opportunity to bring this social determinant of health into the mainstream of the health reform discussion. It’s a great example of the choices we can make to either continue to spend more money caring for the those medical maladies that come from the over-consumption of added sugars, or investing in a thoughtful response to increasing public awareness to deal with the root causes to slow the trend and improve the health of citizens.


For Consideration:

  • As part of health reform, what role, if any, should government play to address the growing implications in how the rapid rise of sugar impacts health status and eventually health costs?
  • Should sugar be regulated in ways similar to the treatment of other items that impact consumer health such as tobacco products?
  • Do you look at, or monitor, the level of added sugars found in the items you and your family consume? How does personal responsibility come into play when it comes to reducing the impact of sugar becoming a significantly higher portion of the average Americans caloric intake?

Additional Resources:

To go deeper on this topic:

“Sugar: Consumption at A Crossroads” by the Credit Suisse Research Institute

Get the Facts: Sugar-Sweetened Beverages and Consumption from Centers for Disease Control and Prevention (CDC)