Ask around for the healthiest country in the world, and the United States won't come close to topping the list.
People live longer in just about every industrialized nation, from Canada to our north, throughout much of Europe, and around the Pacific in Japan, Australia and New Zealand.
New mothers and their babies also face a rockier start here, with infant and maternal death rates double some of our industrialized peers.
As debate swirls in Washington and at town halls nationwide over health care reform, there is a more fundamental question — what about health? Could policy-makers change our medical system in ways that would make this a healthier country? Insuring everyone should help — but less than people might think, according to doctors and public health experts. Putting more resources into primary care should make a dent, they say.
Neither one, though, is likely to send the United States to the top ranks.
"If you want to see dramatic changes in health, you're not going to get there even by doubling the efficiency and effectiveness of the health care system," said Dr. Richard Kravitz, a University of California at Davis professor of medicine whose research includes quality of care.
"When you need it, you really need it, but in general, the benefits of medical care to populations are a little bit overrated," he said.
From toxins to crime
When taken together, the other factors that play a bigger role include education, income, toxins in the environment, crime, violence, family structure, stress, obesity, nutritious food and exercise.
Across large populations, he said, numerous studies suggest that medical care contributes only modestly to overall health, perhaps from 10 percent to 25 percent.
Health care for all would provide a "very large" improvement for some deprived populations, Kravitz said, but "a surtax on high fructose corn syrup would probably be more effective than anything we could do for the health care system, just because of obesity."
Researchers who have delved into the effects of medical care on the health of large groups overall have made surprising and sometimes conflicting discoveries.
An experiment in the 1980s that extended different levels of insurance to otherwise uninsured people found that more coverage fostered more use of the medical system but not necessarily healthier people, said Dr. Peter Muennig, a professor of health policy and management at Columbia University.
A 2006 study that compared white people in England with whites in the United States, in an effort to keep different ethnicities from complicating the findings, reached conclusions Muennig found startling. Even the richest white U.S. residents, who are pretty much universally insured, had more diabetes, more high blood pressure, more heart disease and more cancer than the richest Britons. On most measures, they were a little less healthy than middle income Britons.
This points to a range of things health care cannot do, from providing mass transit that makes it likelier people will walk more, to providing the kind of education that correlates strongly with better health.
"Education is the fundamental ingredient for what you need to survive in any ecological niche," Muennig said.
People with less education are likely to have jobs that are lower paying, higher stress and possibly more dangerous. They're likelier to live in unsafe housing and eat cheap, calorie-dense food. They're less likely to be offered job-related insurance. Except for the insurance, Muennig said, health care reforms cannot fix those things.
Those who examine health across many nations puzzle over other oddities.
In international health care measures, the U.S. ranking improves when life expectancy is measured for people 65 and older. While still not at the top of the health heap, U.S. residents who make it to age 65 have remaining life expectancies closer to 65-year-olds in other developed countries.
That might mean that U.S. medicine treats older people more effectively. Or it could mean that Medicare, universal coverage available at 65, may be keeping older people healthier. Or it could be the "survivor effect," suggesting that those who have lived through past perils are more robust.
While the factors that optimize health are complex, doctors say there are things federal policy-makers could do to make the nation healthier.
Among them are strengthening primary care, finding ways to encourage better diet and exercise, and reforming how health care is financed, said Dr. James G. Kahn, a professor of health policy and epidemiology at UC San Francisco.
People do better in nations that encourage them to have a regular primary care provider, Kahn said, perhaps partly because regular, front-line care helps bolster healthy habits.
Rewarding and encouraging primary care might offset a tendency to do too much, driven by a system that pays for each procedure performed by a doctor, hospital or testing lab, Kahn added.
"We do too many surgeries," he said. "Rates of cardiac surgery are lower in Canada, yet they have better outcomes."
There is hope, too, for "accountable care" groups that would move away from fee- for-service payments but be held accountable for keeping all their patients as healthy as possible, said Stephen Shortell, dean of the school of public health at UC Berkeley.
He is pleased the legislation being discussed includes billions for disease prevention and health promotion.
"You can't ignore the health care system, but the big payoff is in lifestyle factors and disease prevention," he said. "A dollar spent on those activities saves $5 in health care costs."