Editorial
It began with an ambitious idea. The Lancet reached out to Tom Frieden, Director of the US Centers for Disease Control and Prevention (CDC), about a potential collaboration to put together a set of papers representing a report card on health in the USA. This week, a year and a half after its inception, we publish the results of this partnership, The Health of Americans Series—a one-of-a-kind compendium of the challenges faced and opportunities presented by the state of health in the USA. The timing of its release is no coincidence. In reference to July 4, Independence Day, a day on which Americans collectively observe and celebrate, The Lancet also pays tribute with an issue of US-focused content alongside the Series. With Harold Jaffe, Associate Director of Science at CDC, serving as the chief facilitator amongst the group, the collection of papers were written by health experts and leaders from the CDC, the Department of Health and Human Services, and the Organisation for Economic Cooperation and Development. The final product is a state of the union for health in the USA: five reviews spanning chronic and infectious diseases, violence and injury, the Patient Protection and Affordable Care Act (ACA), and health-care expenditure, and two Viewpoints on health security and the role of the USA in global health. Notable progress has been made in many areas, such as access to contraception, deaths from heart disease, and infectious disease surveillance, but threats and disparities persist. As the introductory Comment written by Jaffe and Frieden points out, improving Americans’ health will rely on the public health measures implemented by all levels of government—federal, state, and local—and that responsibility also rests with individuals. It is here that addressing the social determinants of health becomes a crucial consideration. In designing effective public health interventions, it is clear that one size does not fit all. The effect of public interventions will always be subject to the influences of identity, culture, physical environments, and socioeconomic status. Modifying the behaviour of Americans is dependent on knowing who they are, how they live, and what they need to improve their health and wellbeing. The USA is one nation, indivisible, but comprising 50 distinct states, each with its own healthcare system, and 314 million people deserving equal opportunities to pursue healthy lives. www.thelancet.com Vol 384 July 5, 2014
The ACA, often referred to as “Obamacare”, is perhaps the most transformative development in American health in the past 50 years. Although the full extent of the positive changes that the ACA has prompted are not yet known, at least 8 million people have enrolled and 90% of people who purchased plans through the federal marketplace were eligible for a subsidy—an early indicator of its utility in facilitating increased health-care coverage among lower-income Americans. But difficulties remain. Increased coverage in most states relies on the expansion of Medicaid, the federal programme that provides health insurance to low-income individuals and families. Nearly half of the uninsured adults who fall below the poverty level reside in the states that have opted out of Medicaid expansion. It is not surprising that many of these states have lower median household incomes and higher chronic disease burdens, such as stroke and diabetes. Infectious diseases also continue to be a formidable threat, especially in underserved groups. Racial and ethnic minorities, for example, are disproportionately affected by the transmission of hepatitis C, HIV, and tuberculosis—a shifting burden that provides yet another example of how prevention and outreach strategies must be tailored to reach the various segments of the population. Furthermore, although no Americans are completely impervious to their threats, injury and violence remain some of the most urgent issues in communities where disadvantage is most entrenched. Improving the health of Americans has to be both art and science. The CDC has embraced this dual approach by expanding how it addresses health disparities, accommodating to the vicissitudes of American politics, and by adapting to a changing world. But no single agency can shoulder the great responsibility of being both a watchdog and motivating one of the largest countries in the world to take better care of itself, to promote protection and prevention. The next 3 years—encompassing the remainder of President Obama’s term, an election, and the formation of a new administration—will be a decisive time in the history of health for the USA. There is an unprecedented opportunity to deliver health improvements for the least advantaged Americans. But there are dangers too—not the least of which is securing the sustainability of American health care. The Lancet
Carlos Javier Ortiz/Aurora Photos/Corbis
Life, liberty, and the pursuit of healthiness
Published Online July 3, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60981-8
1
It began with an ambitious idea. The Lancet reached out to Tom Frieden, Director of the US Centers for Disease Control and Prevention (CDC), about a potential collaboration to put together a set of papers representing a report card on health in the USA. This week, a year and a half after its inception, we publish the results of this partnership, The Health of Americans Series—a one-of-a-kind compendium of the challenges faced and opportunities presented by the state of health in the USA. The timing of its release is no coincidence. In reference to July 4, Independence Day, a day on which Americans collectively observe and celebrate, The Lancet also pays tribute with an issue of US-focused content alongside the Series. With Harold Jaffe, Associate Director of Science at CDC, serving as the chief facilitator amongst the group, the collection of papers were written by health experts and leaders from the CDC, the Department of Health and Human Services, and the Organisation for Economic Cooperation and Development. The final product is a state of the union for health in the USA: five reviews spanning chronic and infectious diseases, violence and injury, the Patient Protection and Affordable Care Act (ACA), and health-care expenditure, and two Viewpoints on health security and the role of the USA in global health. Notable progress has been made in many areas, such as access to contraception, deaths from heart disease, and infectious disease surveillance, but threats and disparities persist. As the introductory Comment written by Jaffe and Frieden points out, improving Americans’ health will rely on the public health measures implemented by all levels of government—federal, state, and local—and that responsibility also rests with individuals. It is here that addressing the social determinants of health becomes a crucial consideration. In designing effective public health interventions, it is clear that one size does not fit all. The effect of public interventions will always be subject to the influences of identity, culture, physical environments, and socioeconomic status. Modifying the behaviour of Americans is dependent on knowing who they are, how they live, and what they need to improve their health and wellbeing. The USA is one nation, indivisible, but comprising 50 distinct states, each with its own healthcare system, and 314 million people deserving equal opportunities to pursue healthy lives. www.thelancet.com Vol 384 July 5, 2014
The ACA, often referred to as “Obamacare”, is perhaps the most transformative development in American health in the past 50 years. Although the full extent of the positive changes that the ACA has prompted are not yet known, at least 8 million people have enrolled and 90% of people who purchased plans through the federal marketplace were eligible for a subsidy—an early indicator of its utility in facilitating increased health-care coverage among lower-income Americans. But difficulties remain. Increased coverage in most states relies on the expansion of Medicaid, the federal programme that provides health insurance to low-income individuals and families. Nearly half of the uninsured adults who fall below the poverty level reside in the states that have opted out of Medicaid expansion. It is not surprising that many of these states have lower median household incomes and higher chronic disease burdens, such as stroke and diabetes. Infectious diseases also continue to be a formidable threat, especially in underserved groups. Racial and ethnic minorities, for example, are disproportionately affected by the transmission of hepatitis C, HIV, and tuberculosis—a shifting burden that provides yet another example of how prevention and outreach strategies must be tailored to reach the various segments of the population. Furthermore, although no Americans are completely impervious to their threats, injury and violence remain some of the most urgent issues in communities where disadvantage is most entrenched. Improving the health of Americans has to be both art and science. The CDC has embraced this dual approach by expanding how it addresses health disparities, accommodating to the vicissitudes of American politics, and by adapting to a changing world. But no single agency can shoulder the great responsibility of being both a watchdog and motivating one of the largest countries in the world to take better care of itself, to promote protection and prevention. The next 3 years—encompassing the remainder of President Obama’s term, an election, and the formation of a new administration—will be a decisive time in the history of health for the USA. There is an unprecedented opportunity to deliver health improvements for the least advantaged Americans. But there are dangers too—not the least of which is securing the sustainability of American health care. The Lancet
Carlos Javier Ortiz/Aurora Photos/Corbis
Life, liberty, and the pursuit of healthiness
Published Online July 3, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60981-8
1
