What do we know about social determinants of health in the U.S. and comparable countries?

This collection of charts explores international comparisons of social, environmental, and economic factors that influence health but are in some respects outside the control of the health system. Relative to similarly wealthy countries, the U.S. has worse life expectancy, mortality, and disease burden rates, which may be due in part to the quality of care provided (a comparative chart collection is available here). However, these external factors – broadly referred to as social determinants – may contribute to some of the cross-national differences in costs and outcomes between the U.S. and comparable countries. A related brief discusses data available as of February 2016.

The U.S. is an outlier for health spending, but when combined with other social services, spending is similar to other countries

Researchers have pointed out that while the U.S. spends much more on healthcare than other countries, it also spends significantly less on other social services, which could also support health in the long run. When combining health spending with other social spending, both public and private (which includes cash assistance, such as social security and pensions), the U.S. actually has similar costs as other countries.

Though the U.S. population is aging, it has a younger average age and smaller elderly population than comparable countries

The aging population in the U.S. may help explain why the U.S. medical costs are rising, but it likely does not explain the difference in outcomes and spending between the U.S and other countries. The populations of comparably sizable and wealthy countries are aging more rapidly, with larger percentages of their populations over the age of 65.

The U.S. has the shortest life expectancy among comparable countries

Life expectancy can be influenced by a number of factors, including those within the domain of the health system (e.g., quality of care, access to preventive health services) as well economic, behavioral, and environmental factors that may be outside the control of the health system (e.g. poverty, lifestyle, violence, and accidents). Life expectancy at birth in the U.S is lower than comparable OECD countries. In 2015, U.S. life expectancy was just under 79 years, compared to an average of 82 years for comparable OECD countries.

In the U.S., both blacks and whites have shorter average life expectancies than the average of comparable countries

Although the racial gap in life expectancy has improved in recent years, recent data from the Centers for Disease Control indicate that black Americans continue to have shorter life expectancies than whites and Hispanics. Both black and white Americans have shorter average life expectancies than the average of comparably wealthy and sizable countries. However, people of Hispanic origin in the U.S. have average life expectancies that are similar to other large and wealthy nations.

The U.S. has a higher degree of income inequality than comparably wealthy countries

The U.S. has a higher degree of income inequality than any comparably wealthy and sizable country. The Gini index is a measure of income inequality on a scale of 0 to 100, where higher values indicate a less equal distribution of income. The most recent available data from the World Bank indicate that the U.S. has the highest level of income inequality among comparably wealthy and sizable nations. This trend has held steady for at least 2 decades in the countries with available data.

Americans with lower incomes are less likely to report being in good health than those with high incomes

The complex nature of social determinants makes it difficult for researchers to estimate their relative contribution to health. Racial inequality, for example, can coincide  with other factors that affect health, such as income and education.  A large body of research has examined the ways in which income can significantly influence health outcomes. People who are lower income are less likely than people with higher incomes to report being in good health, and there is a growing disparity in the life expectancies of low and high income Americans. While income is also correlated with behavioral factors that can influence health, recent research has found that these factors only explain some of the difference in outcomes between low and high income people

The U.S. has the lowest insured rate of comparable countries

Health insurance shelters people from high medical costs that can result from illness and injury and therefore improves access to care. Although coverage in the U.S. has increased recently with implementation of the Affordable Care Act, the U.S. still has a lower rate of health coverage (91.2% in 2016) than any comparable country, all of which cover 100% of their citizens.


Uninsured adults are much more likely to go without needed medical care due to costs

Uninsured adults in the U.S. have consistently experienced more difficulty accessing health care due to cost than insured Americans. The U.S. is unusual in that insurance coverage has been generally tied to employment status.

Per capita cigarette consumption is lower in the United States than in comparably wealthy countries

Tobacco use is a well-documented risk factor for adverse health outcomes and puts individuals at a higher risk of premature mortality than any other behavioral factor. According to OECD data, overall tobacco consumption (total grams per capita) has decreased dramatically in both the U.S. and comparable countries since the 1980s, with U.S. total consumption similar on average to that of other sizable and wealthy countries. Data from the World Lung Foundation and The American Cancer Society show that fewer cigarettes are smoked per capita per year in the U.S. than in most comparable countries.

The U.S. has higher than average disease burden from lung cancer

Cigarette smoking is the primary risk factor for lung cancer. Linked to almost 9 out of 10 instances of lung cancer, it is also known to cause cancer in the trachea, bronchus, and elsewhere in the body. The U.S. has higher than average disease burden from lung and related cancers (797 DALYs per 100,000 capita) compared to similarly wealthy countries (608 DALYs per 100,000 capita).

Despite a dramatic decrease in overall tobacco consumption in the past fifty years, long-term health outcomes associated with smoking continue to present for former and long-term smokers. In addition, the risk of developing lung cancer is much higher for smokers today, due in part to changes made to cigarettes over time. Use of tobacco products other than cigarettes also increases the risk of lung and other respiratory organ cancers.

The U.S. has the highest prevalence of obesity among comparable countries

Poor dietary intake and insufficient activity levels present a risk of adverse health outcomes including obesity, identified by the World Health Organization as the percentage of people with a body mass index (BMI) at or above 30 kg/m2. The most recently available data from both the OECD (2014) and the WHO (2014 estimates) indicate that the U.S. has the greatest prevalence of obesity among high-income countries. Over a third of the U.S. is obese, compared to just over a fifth on average in comparable countries.

More adults in the U.S. have a sedentary lifestyle than in most comparable countries

Sedentary lifestyle increases the risk of heart disease, obesity, and other health problems, and is associated with low socioeconomic status. Data from the World Health Organization indicate that 32% of adults in the U.S. have insufficient physical activity, compared to 26% on average in comparable countries.

The U.S. has a higher than average disease burden caused by cardiovascular diseases

The higher-than average rates of obesity and inactivity in the U.S. may contribute in some ways to the U.S.’s higher than average disease burden from cardiovascular conditions. Though rates of disease burden caused by these conditions have improved across the U.S. and other countries, the U.S. has not seen as rapid improvement.

In the U.S., white, black, and Hispanic women have a higher prevalence of obesity than men

Hispanics and non-Hispanic blacks in the U.S. have a significantly higher prevalence of obesity than non-Hispanic whites in the U.S.  As obesity is one of the most important risk factors for several diseases and mortality in general, improvements in obesity among blacks and Hispanics could reduce other disparities in health outcomes. Even so, it is worth noting that whites in the U.S. have higher obesity rates than the prevalence for comparably wealthy and sizable countries for which data is available.

In the U.S., obesity is more prevalent among lower-income groups than those with higher incomes

In the U.S., lower-income groups have higher rates of obesity than higher-income Americans.

The U.S. has consistently had lower average alcohol consumption than most comparable countries

In terms of liters per capita, people in the United States consume less alcohol on average than those in comparable countries. However, research has shown that in countries where alcohol consumption is more restricted and less frequently integrated into meals and other daily activities – as is the case in the U.S., Canada, and much of Scandinavia – more people tend to abstain from drinking, but those who drink alcohol do so more heavily and are more likely to become intoxicated.

Disease burden from alcohol use disorders is higher than average in the U.S.

When we consider disease burden, alcohol use disorders have a higher than average impact on years of life lost to disability and death in the U.S. compared to other high-income countries.

The U.S. has higher than average disease burden for liver cirrhosis due to alcohol use

Compared to similarly wealthy countries, the U.S. has a higher DALY rate per 100,000 population for liver cirrhosis and other chronic liver diseases due to alcohol use, but has a lower average rate of disease burden for liver cancer attributed to alcohol use.

The U.S. has the highest environmental burden of disease compared to other high-income countries

The World Health Organization quantified the effect of environmental factors, such as pollution, occupational risks, agricultural methods, climate change, and food contamination. Taken together, these factors present a higher burden of disease in the U.S. (2,896 DALYs per 100,000 capita) than in comparable countries, whose average environmental burden of diseases is 2,498 DALYs per 100,000 capita.

Poisonings, car accidents, and falls are the leading causes of accidental death in the United States

External causes (such as accidents, suicides, and violence) are the fourth leading cause of death in the U.S., and are more common than in comparable countries. According to data from the Centers for Disease Control and Prevention, unintentional poisonings (often due to prescription drug overdose) are the leading cause of accidental death in the United States, followed by motor vehicle accidents and falls.

Accidental poisonings lead to nearly twice the years of disability in the U.S. than in comparable countries

In the U.S., the DALY rate per 100,000 population for unintentional poisonings is the highest of all comparable countries. Thirty-two years of life per 100,000 people are lost to disability and death from accidental poisonings in the U.S., as compared to 17 years in comparable countries.

Relative to comparable countries, the U.S. has higher rates of death from accidental poisonings, such as drug overdoses

The U.S. had a higher than average mortality rate from accidental poisoning in 2000. Over time, the U.S. has become an outlier, now with far higher death rates from accidental poisoning than any comparable country. According to the CDC, in 2013, opioid pain killers were involved in 37% of drug poisoning deaths

Disease burden from drug abuse disorders is higher in the U.S. than in comparable countries

Data from the Institute for Health Metrics indicate that the U.S. has a higher rate of DALYs per 100,000 people due to drug use disorders than the comparable country average. Opioid use disorders in the U.S. result in over four times the rate of disease burden than in comparable countries.

56 percent of people in the U.S. report having a personal connection to prescription painkiller abuse

Prescription painkillers have recently been brought to nationwide attention as the leading cause of accidental poisonings and thus of accidental deaths. A November 2015 Kaiser Family Foundation poll found that 56 percent of people in the U.S. report having at least one personal connection to prescription painkiller abuse, either through taking one not prescribed to them or experiencing addiction to one themselves, or through knowing someone who has done either or has died from prescription painkiller overdose. Sixteen percent report knowing a family member, close friend, or someone else who has died from such an overdose.

The U.S. has the highest disease burden from motor vehicle road injuries

After poisonings (which includes drug overdoses), the next leading cause of accidental death in the U.S. is motor vehicle accidents. The DALY rate per 100,000 people due to motor vehicle road injuries is 517, almost three times the average rate for comparable countries on average.

The U.S. has the highest rate of years of life lost to disability and premature death due to firearm assaults

In addition to accidental death, violence is another type of death due to external causes. In the U.S., 225 years of life per 100,000 people are lost to disability and premature death as a result of assault by firearm – almost 19 times the comparable country average of 12 years of life per 100,000 people.