For decades, we have seen reports showing that U.S. health costs are greater and outcomes worse than in most other countries. This seemed irreconcilable to me when I considered that the wealthy and royalty from other countries often come to the United States for their care.

Let’s face it. When was the last time you heard of a friend or family member heading to Estonia or Iceland for health care?

The fact that most countries do not have the health care inequality that the U.S. does has undoubtedly contributed to this discrepancy. In a May report, the Commonwealth Fund observed that the U.S. is the only industrialized country that does not ensure health care affordability through universal insurance-based or tax-financed systems.

But inequality does not explain it all. Recent reports from the Commonwealth Fund and the Institute of Medicine shine a light on other contributing factors.

The higher U.S. spending does not appear to be due to higher incomes. Health care spending in Norway, the wealthiest country, was only 9.6 percent of GDP, whereas the United States’ spending is more than 17 percent.

It is not due to an aging population. The U.S. population is relatively young compared with other industrialized countries.

Nor is it due to a greater supply or utilization of hospitals and doctors. In fact, the U.S. has below-average numbers and utilization of both hospitals and physicians, the Commonwealth Fund found.

Here is what the Institute of Medicine reported:

• Although Americans’ life expectancy and health have improved over the past century, these gains have lagged behind those in other high-income countries.

• Americans are dying at younger ages than people in almost all other high-income countries, and this disadvantage is even worse among women.

• Poorer health in the U.S. persists over the course of life.

There are certainly opportunities to improve the health care delivery system, and I have written extensively about many of these opportunities on my blog (www.drpate.stlukesblogs.org). And in keeping with the Institute of Medicine’s conclusions, I have long believed that we will not get health care costs under control until we get into the health business and try to keep people from becoming patients, as opposed to just providing care for ill people.

It appears that much of the U.S. disadvantage relative to other countries is social and cultural. The American health care delivery system is poorly equipped to deal with those, given its current focus on illness.

Americans fare worse than other high-income countries in injuries, homicides, adolescent pregnancy, sexually transmitted infections, HIV and AIDS, drug-related deaths and obesity.

The U.S. health care system is unlikely to be able to address Americans’ very poor health behaviors. Americans consume more calories per person, have higher rates of drug abuse, are less likely to use seat belts, are involved in more traffic accidents that involve alcohol, and are more likely to use firearms in acts of violence than people in other industrialized countries.

No single factor explains why the U.S. spends more and obtains poorer outcomes for its health-care spending. But we can’t blame it all on the health care delivery system. Each of us also must take an honest and courageous look at our families, our society and our culture.

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David C. Pate, M.D., J.D., president and CEO of St. Luke’s Health System. drpate@slhs.org