The United States faces a growing paradox between its declining levels of population health relative to other wealthy nations—and even to some developing ones—and its burgeoning spending on health insurance and medical care. By an increasing margin each year, the United States spends a larger percentage of its gross domestic product (GDP) on health care than any other nation, with health care expenditures now totaling $1.9 trillion per year and large increases projected over coming decades (Chernew, Hirth, and Cutler 2003).

Scholars, policy makers, and citizens debate the marginal value and cost-effectiveness of these expenditures. Specific advances—for...

There is a well-known large and persistent association between education and health. This relationship has been observed in many countries and time periods, and for a wide variety of health measures.¹ The differences between the more and the less educated are significant: in 1999, the age-adjusted mortality rate of high school dropouts ages twenty-eight to sixty-four was more than twice as large as the mortality rate of those with some college (Lyert et al. 2001, table 26).

Substantial attention has been paid to these “health inequalities.” Gradients in health by education are now systematically monitored in many countries (the United...

A growing body of evidence documents the substantial effects on health of social policies whose focus is not on health per se, such as those that explicitly target social policy arenas such as human development. Here we focus specifically on the health effects of early-childhood development policies. Because human development policies have typically played a minor role in policy discussions about health, it is important to define their scope and outline a general conceptual framework to support their relevance before reviewing evidence to illustrate their connection with health.

Human development policies include leave policies; labor laws that determine work conditions,...

There is increasing evidence that health care accounts for only a modest fraction of the variation in individual and population health (McGinnis, Williams-Russo, and Knickman 2002). At the same time, there are strong and well-documented associations between health and socioeconomic factors. This suggests that “non-health” factors (that is, social and economic determinants) and related policies deserve heightened attention, alongside biomedical factors, in determining individual and population health. Although researchers and policy makers increasingly recognize the general importance of social and economic factors for health, the peer-review research literature includes very limited research on or discussion of the health effects of...

Do welfare programs that raise the income of poor mothers affect infant mortality? Over the 1960s, United States infant mortality fell dramatically. The rate for whites fell from twenty-three to seventeen per one thousand, while the African American rate fell from forty-three to thirty-two per one thousand. These declines are coincident with the introduction of federal transfer programs including Medicaid and the Food Stamp Program (FSP). But it is not clear whether there is an actual link between welfare programs and improvements in infant mortality.

While there is little doubt that improving maternal nutrition can lead to healthier babies, it...

Based on literally thousands of studies carried out over many decades, it is increasingly accepted that socioeconomic conditions act as important determinants of both individual health and the health of populations (Kaplan et al. 1987; Kaplan and Lynch 1997). Wages, income, wealth, the nature of work, investments in human capital, and the levels of resources and risks in communities are now recognized by many as arguably the most critical determinants of health (Kaplan 2001; Evans, Barer, and Marmor 1994). It seems possible that social and economic policies, in their ability to alter these determinants, might also impact health even if...

Many government policies influence short- and medium-run economic performance. Some, such as the monetary and interest rate targets, are explicitly designed to stabilize the economy. Fiscal policy has the potential to play a similar role, although it is not aggressively used for this purpose in the United States. The unemployment insurance and federal income-tax systems act as “automatic stabilizers” because they make government spending more expansionary during economic downturns and less so during booms. Other programs, such as the Earned Income Tax Credit (EITC), increase incomes during expansions when work is easier to find, and so operate in the opposite...

Historically there have been three arenas of policy debate in the United States relevant to the health effects of employment for workers and their families. First, thephysical environmentof the workplace and its health impact has been a major arena of policy debate. The pathways from the physical environment to health include exposure to chemical and biological hazards leading to disease, as well as physical risks to safety. Second, thedemanding nature of work activitieshas also been the topic of policy debate. The pathway from work activity to health most often implicates work stressors involving too little task...

Beginning in the early 1990s, many states used waivers to reform their Aid to Families with Dependent Children (AFDC) programs. This state experimentation resulted in landmark legislation that eliminated AFDC in 1996 and replaced it with Temporary Assistance for Needy Families (TANF). TANF—like the earlier AFDC program—provides cash grants to low-income families with children and is a key element of the nation’s economic safety net. The roots of this reform lie in long-time concern that AFDC led to reductions in work, decreases in marriage, and increases in nonmarital births among low-income women.

These important policy changes, known collectively...

In 1996 the U.S. Congress passed the Personal Responsibility and Work Opportunities Reconciliation Act (PRWORA), substantially reducing a family’s rights to income support. PRWORA removed the entitlement to government-provided cash assistance and increased states’ incentives to reduce welfare caseloads. At the same time it increased private responsibilities by encouraging greater work effort from mothers and more child support payments from nonresident fathers.

The PRWORA provisions raised concerns within the medical community and among other advocates interested in the health and well-being of at-risk families. The changes to cash welfare and child support policies had potential direct and indirect consequences for...

Do policy initiatives that are aimed at changing physical or social features of the residential environment have measurable impacts on health?¹ It has become an increasingly popular view in the field of public health that physical and social features of the residential environment can affect health either directly (through contaminants in the air or water supply) or indirectly, by influencing behaviors related to health (such as physical activity, food intake, substance use, and utilization of medical care) or psychosocial factors (such as stress and social relationships that help cope with stress) that may be related to health through more complex...

It is believed that the neighborhoods in which children and youth live are associated with their health and well-being. The underlying premise of this belief is that living in more affluent and safe neighborhoods results in better health (as well as increases the likelihood of doing well in school and obtaining better jobs and housing). While this assumption, on its face, seems obvious, it is incredibly difficult to substantiate from a social-science perspective. The primary reason is that families have some choice as to where they live. Consequently, when neighborhood influences are reported, individual-level variables may be accounting, wholly or...

The evidence presented in the prior twelve chapters suggests that social and economic policies substantially influence individual and population health, and it begins to draw out the many policy domains in which this occurs. These chapters consider health effects of education, income-support, civil-rights, macroeconomics and employment, welfare, and housing and neighborhood policies. This not-so-thin volume justifiably could have been expanded to consider still other domains: environmental, law-enforcement, agriculture, and transportation policies, as well as others. Human health is too multifaceted, its determinants too varied, and the current state of our knowledge too limited, for any one volume to capture the...