The US health system was already falling short. Then Covid-19 happened.

Take a long enough lens — say, 25 years — and it seems as though health care in America is inarguably getting better.

People are living longer than they did a quarter century ago. The burden of disease, a metric that includes premature deaths and disability, has dropped. The number of avoidable hospitalizations and hospital errors is lower.

But below those rosy numbers is the truth: American health care has been falling behind other countries in the developed world for decades.

Life expectancy has increased, but by less in the US than in the wealthy nations of Europe and Asia. The improvement in disease burden has likewise been less impressive than that of comparable countries. Meanwhile, to achieve those mediocre results, the United States continues to spend more money on medical care than any other country in the world; while health spending in the US isn’t going up faster than in other countries, it was higher to begin with and continues to increase. We’ve maintained a sizable lead in health care spending while getting outcomes that are worse than countries that spend less.

And all of that was true even before the United States experienced one of the worst Covid-19 outbreaks in the world.

Kaiser Family Foundation researchers recently warned of a “further widening of the gap” between the US and other countries as a result of the pandemic. Life expectancy in the US had already stagnated in the last few years, driven by a rise in drug overdoses and suicides; now Covid-19 will shorten it further. Disease burden had been trending upward in the US while dropping elsewhere; the Covid-19 pandemic is likely to widen that disparity too.

“This pandemic has been a fast pandemic, fueled by a slower pandemic of chronic illness,” Howard Koh, a Harvard public health professor who worked in the Obama administration, told me. “All those streams have converged to cause the public health catastrophe we’ve endured.”

You could say the trajectory of American health care before, during, and after the pandemic is like that of an individual vulnerable patient: It was sicker to begin with, hit hard by Covid-19, and will be dealing with the lingering effects for a long time.

The US was already falling behind the rest of the world on health care

When it comes to getting value for money in health care, America slowly but perceptibly fell behind other developed countries over the last 25 years.

It starts with life expectancy, the bluntest measure of how well people are served by their health system. Life expectancy in the developed world has steadily improved over the past few decades, driven primarily by major breakthroughs in the treatment of heart disease and other cardiovascular problems, which rank near the top among causes of deaths in wealthy nations.

But not as much in the United States as in other countries. According to a KFF analysis of health care trends from 1991 to 2016, Americans saw their life expectancy rise by 3.1 years during that period — a meaningful improvement, to be sure, but substantially less than the 5.2 years gained in comparable countries.

And in the US specifically, that progress has stagnated in recent years. With tens of thousands of people dying of opioid overdoses every year and a sustained increase in the number of suicides, American life expectancy actually started tailing off in 2014, according to a 2019 analysis published in JAMA. The gap between the US and other wealthy countries was already growing before Covid-19 struck.

Likewise, disease burden had steadily improved until a recent downturn separated the US from other countries. The reasons for the improvement were the same: better medical treatment for chronic diseases. But once again, America did not improve to the degree that comparable countries did, seeing a 12 percent improvement versus an average of 22 percent elsewhere. In the United States, the burdens from disease of the heart, lung, kidney, and liver — as well as from diabetes — remain stubbornly high compared with the rest of the developed world.

And the reasons for America’s recent stagnation are the same, too: Suicides and drug overdoses, plus a rise in the number of young people with chronic health conditions, are robbing people of years of healthy living.

The same pattern holds for medical errors. They have been declining in the US over the last 25 years but are still more common in America than in comparable countries. Avoidable hospitalizations and adverse drug events are down, but not as much as in wealthy European or Asian nations. Americans are roughly twice as likely to experience an error in their medical care as their counterparts the world over.

One metric — known as mortality amenable to health care — combines all of these characteristics and grades a country’s health system on how well it prevents deaths from conditions that should be treatable with timely access to health care. The US ranked behind the biggest countries in Europe, as well as Japan, as of 2016.

A country like Taiwan, which performed much worse than the US on the same metric 30 years ago, is now nearly its equal.

And for those middling outcomes, the US still spends more on health care than other countries: nearly 18 percent of its GDP versus about 11 percent, on average, in comparable nations. Health spending has been rising at the same rate in the US and its peers over the last few decades, and yet those other countries have seen more improvement in their health outcomes.

They are, in other words, getting more value out of their health systems than the US.

“One could conclude that the comparable … countries’ value improvement was greater,” the KFF researchers wrote in 2018, “even though they started at a higher threshold in terms of better outcomes and a lower percentage of GDP consumed to achieve it.”

One possible explanation for America’s poor performance: We underinvest in social spending and overspend on medical care compared with other developed countries. If you combine social services spending and health spending, the US and its peers actually spend about the same amount of money, a little more than 30 percent of their GDPs. But spending in those other countries is more slanted toward social services, while America spends more on medical care.

America’s underinvestment exacerbates disparities between haves and have-nots: 18 percent of Americans live in poverty versus 10 percent in other wealthy countries. We know that people with lower incomes have structural challenges — access to healthy food, clean water, and fresh air, for starters — that lead to worse health outcomes. When they get sick, they have a harder time finding a doctor and affording their medical care.

“Economic inequality is increasingly linked to disparities in life expectancy across the income distribution, and these disparities seem to be growing over time,” wrote the authors of a 2018 review of relevant research in Health Affairs. Poor health also tends to lead to lower incomes, creating a feedback loop known as the “health-poverty trap.”

And those disparities — between rich and poor, white and Black — only worsened during the Covid-19 pandemic.

Covid-19 will have long-term consequences for American health

The gap between the US and other wealthy nations is expected to grow because of the pandemic. America has lost more than 600,000 people to Covid-19, the highest confirmed death toll in the world. Adjusting for population, the US has lost more people on a per-capita basis than most of the European and Asian countries to which it is compared.

Official death counts can be somewhat arbitrary because they depend on testing to identify cases. Excess deaths — the number of deaths from all causes above what would be expected in an ordinary year — are considered by experts to be a more reliable gauge. On that metric, too, and adjusting for population, the United States is one of the worst performers among wealthy nations.

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“The outsized effect of the pandemic on the U.S. will likely widen the existing gap in mortality rates between the U.S. and peer countries,” wrote the authors of an October 2020 analysis on Covid-19 death rates and life expectancy.

America is also likely to experience a higher disease burden (that’s the years of quality life lost to premature death and disability) as a result of its pandemic failures. People under 65 in the US have died from Covid-19 at higher rates than their peers elsewhere.

A prolonged mental health crisis may linger after a year of disrupted social lives and isolation. More than 4 in 10 Americans reported experiencing symptoms of anxiety or depression in 2020, according to US census surveys.

Health spending actually slowed down in 2020, a historic aberration, as people postponed medical care during the pandemic. But medical spending did not slow down as much as the rest of the economy: As of October 2020, it had fallen 0.5 percent versus a 1.8 percent contraction overall. So even as spending dropped, health care likely consumed an even greater share of America’s GDP than in years prior.

And the short-term drop in spending could have long-term consequences. Last year, 24 percent of Americans said in a census survey that they did not get needed medical care during the pandemic, with 33 percent saying they delayed care. To give one example, cervical cancer screenings dropped about 80 percent from normal levels in spring 2020, and while they rebounded later in the year, they were still 25 percent down by the end of September.

While patient volume generally has recovered, we still don’t know what the long-term effects of people missing care or receiving belated diagnoses will be. And there are tens of millions of people recovering from a Covid-19 infection; as many as 15 million of them may struggle with “long Covid” for the foreseeable future, according to a new analysis in the New England Journal of Medicine that called long Covid-19 “our next public health disaster in the making.” Those direct health aftershocks from the pandemic will be yet another burden on the US health system long after the coronavirus itself starts to subside.

Long-term spending trends were already prompting health plans to push more of the cost of health care onto patients. Deductibles and worker premiums have been increasing for years.

Post-Covid-19, at least as a relative share of the economy, health care is eating up even more of the country’s resources. America’s health outcomes have been set back by the pandemic, and the spending crunch is intensifying.