MS Speaks

America, all things not being equal

In a special message to Congress, the case was made for a comprehensive national health programme, “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.” The time was Nov 19, 1945, and the author was President Harry S Truman. With that letter, the idea of a federally run, optional, universal health-care plan for the USA was born—a proposal considered as radical and groundbreaking to some now as it was to the Republican-controlled Congress of Truman's presidency. But is it really such a radical idea? 72 years on, millions of Americans still do not have the full measure of opportunity to enjoy good health and still lack basic economic protection against sickness.

In 2014, The Lancet, as the classic Simon and Garfunkel song goes, went to “look for America”, to capture the state of health in the USA. Partnering with authors from the Centers for Disease Control and Prevention, the resulting Series USA: The Health of Americans was in many ways a point of entry for understanding the often staggeringly complex patchwork of American health. It examined several themes centred on improving health outcomes, including chronic and infectious diseases, injury and violence, health security during global pandemics such as the Ebola virus crisis, as well as the serious challenges to implementing effective prevention and public health interventions, even in the face of unparalleled health expenditure per person. The first Lancet US Series made salient two powerful messages. First, despite appreciable improvements in addressing socially determined disparities, deep and notable gaps remain in the progress that has been made with respect to health; and second the America we found deserved better.

In the nearly 3 years since the first Series was published, health in the USA has changed and not for the better. The outcome of a vitriolic presidential election resulted in Republicans controlling all three branches of government. After years of bitter political dispute around the Patient Protection and Affordable Care Act (ACA), the signature Obama-era health legislation, and a recent failed attempt by Republicans to dismantle it, there is, nevertheless, building momentum towards health-care reform, although the division between parties is vast and the vision of what that reform should embody could not be more discordant. Despite the entrenched ideological disagreements about how to proceed, there is consensus that the financing of the US health-care system has become increasingly precarious and that many Americans are being left behind.

In an effort to better understand the conditions and mechanisms driving health disparities in the USA, this week, The Lancet breaks ground once again by publishing, America: Equity and Equality in Health—a stark and dire update to the first Series—focused on appraising where the greatest discrepancies lie. Comprising five papers, the Series looks in depth at the current inequalities in the health-care system and chronicles the beneficial influence of the ACA on health-care equity as well as the continued barriers and shortcomings in providing coverage. The Series also considers the ways in which structural racism—the systematic and interconnected web of institutions and factors that lead to adverse health outcomes—works to further exacerbate extant disparities, and makes a strong condemnation against the insidious force of mass incarceration in perpetuating health inequities for Americans of colour. Strikingly, the Series warns of the rapid, profound, and deepening effects of income inequality that have produced notable decrements in mortality and life expectancy in the USA in just a matter of decades.

As a Comment by former presidential candidate Senator Bernie Sanders published alongside the Series notes, “Making sure that every citizen has the right to child care, health care, a college education, and a secure retirement is not a radical idea. It is as American as apple pie.” Although a Series about health published in a medical journal may seem far removed from the political arena where much of the decision making about how to address these factors lies, the message of this collection of papers transcends that distance. It echoes the call of President Truman or Senator Sanders—to improve health equality will require a more equitable system. Whether that change takes the form of a single-payer option, it is no radical statement to say that Americans deserve better and, most importantly, the time for action has arrived.