Comparative Longevity—Posner

I am guessing that inequality of income is a major factor in the poor health and reduced longevity of Americans compared to inhabitants of our peer countries. Fifteen percent of the U.S. population lives below the poverty line, which is defined as an income of $23,000 for a family of four. The median income of American households is only $50,000 a year, rising to $65,000 for a family of four, which nowadays is only a modest income—and half of families of four make less (what is what “median” means). Life expectancy is 5 years longer for rich than for poor Americans. There is a safety net of sorts, but more porous than in the peer countries. Private insurance is expensive, and unaffordable by many families not poor enough to be eligible for Medicaid. A family of four with an income of say $25,000 can’t afford adequate health insurance. And there is a scarcity of primary-case physicians in many parts of the country. 

But I agree with Becker that the main cause of the nation’s poor health and longevity statistics relative to our peer countries is not deficient medical care but “lifestyle” choices. And there is nothing wrong in principle with people wanting to trade off life expectancy against the pleasure of engaging in activities that happen to be risky, or with society allowing them to do so provided they agree to bear the cost. That is not an irrational tradeoff. But when one compares people in the upper part of the income distribution with people in the lower part, one is made doubtful that the people in the lower part just happen to be the people who want to trade a long life for a short one full of thrills. Probably most of the people in the lower part of the income distribution have poor health or will become unhealthy early because of lack of information about nutrition and other dimensions of healthy living, of a good education, of a responsible family, of exercise, and in general of good opportunities at home or at work for leading a safer, healthier life. Many of these people probably underestimate the riskiness of riding a motorcycle with but especially without a helmet, mistakenly believe that owning guns makes one safer rather than less safe, do not know what a healthy diet is or can’t afford it, and do not know how to obtain free or cheap medical care. 

If incomes were more evenly distributed, and if more public money were spent on services for lower-income people, probably the U.S. population would have better average health and higher average life expectancy. A program of income redistribution beyond what we have now, coupled with more public spending on social services, would increase the overall level of public spending, and in turn require cuts in other public spending plus in all likelihood higher taxes as well, but the net economic effect could be positive if a healthier population increased employment and output. 

A curious aspect of the international comparisons is that America is tops when it comes to the life expectancy of persons 75 years old and older. That, at least, may seem a triumph of American health care, and partial justification for our spending more per capita on health care than any peer country, with seemingly little to show for it. But the higher life expectancy of our old people may be, in part anyway, a survival-of-the-fittest phenomenon. Suppose there are two types of person: those genetically predisposed to long life, and those not. If there is no or poor medical care, the members of the latter group will tend to die young, so that mostly only members of the former group, the genetically predisposed to long life, will reach 75--and being a genetically select group they can expect a long remaining life. If medical care enabled almost everyone to live to 75, many of those still alive then would not live much longer, because they don’t have good genes for longevity, and so average longevity of 75 year olds would rise. 

Moreover, it’s an ambiguous achievement, at least from a public finance standpoint, to prolong the life of the already elderly. The more people who live to very old ages, the higher the average cost of medical care, because people require more care the older they are. Rising costs of medical care are creating pressures to economize on the cost of such care, but not to economize on the cost of medical care of old people, because they are both a powerful and rather single-minded voting bloc and able to pay for extensive care through Medicare, often supplemented by private health insurance.

Comments

[Terry Bennett]

If people want to live a long time, they need to use more years productively to earn their keep. Especially in the public sector, a teacher for instance can work 35 years and then live another 40 on a public pension. If you accomplish this with private enterprise and private investment, good for you, but I believe the compensation of public employees is grossly misunderstood and undervalued. Even in the private sector, large numbers of people will take more from Social Security and Medicare than they put in. We are told that unemployment is "insurance", and you pay a premium so you can be entitled to collect if you lose your job. However, the premium you pay is nowhere near sufficient to underwrite the costs of the insurance pool; it's just another form of welfare / wealth redistribution.

When a minimum wage worker retires and then needs a liver transplant or a few years in a nursing home, I would paraphrase the President - You didn't earn that. Your productivity in the private sector and your contributions to the public sector are in no way sufficient to offset the public cost of your health care. It is welfare, pure and simple. Perhaps the highest cost of our socialism is the obscuring of that once-central value in our culture, the imperative to pull one's own weight. Most people are now oblivious to what their own weight even is, and we are a less noble people for it.

[Eric Rasmusen]

Surely the problem is not that too little is spent on the health care of poor people. Recall that the US government spends more per capita than the British government--- but we spent it on just the poor and the elderly, whereas they're spending it on everyone. More is spent on health care for the poor in America than on health care for anyone in most of the world.

It would be interesting to know how death rates compare for the US poor vs. rich at ages above 75. Perhaps by that age the lifestyle differences don't make much difference.

[James Binkley]

I agree that "there is nothing wrong in principle with people wanting to trade off life expectancy against the pleasure of engaging in activities that happen to be risky." Indeed, this can also explain part of the mortality-income difference. It makes more sense to give up current pleasures for future lifetime if that future is well-financed than if it is one of possible penury. See "Low Income and Poor Health Choices: The Example of Smoking" American Journal of Agricultural Economics 2010 92(4)

[Qariwa]

I want to focus mainly on one of Judge Posner's points, on which he agrees with Prof. Becker, namely that differences in lifestyle CHOICE helps to explain Americans' shorter longevity than citizens of other countries. The main examples Posner and Becker cite are traveling more by car, being on average fatter, being more likely to be an alcoholic or drug addict. Apart from my suspicion that the last claim is not true (European countries tend to have proportionally more alcoholics than we do), I seriously question whether these differences can be attributed to individual choices. People here travel more by car because we have far less available public transportation than Europeans and Asians do. Americans eat more garbage because good food is relatively less available (try foodshopping in the slums!), and owing primarily to working longer hours, Americans are too tired (and uninformed) to cook food from scratch. Higher rates of diabetes are also attributable to the far greater rates of poisons such as modified corn starch in our food, and overrefining of food products. People do not choose to drive more and to get fat. Posner is way the hell out in left field when he goes a step further and suggests that Americans make the choices they do because they are more inclined to take pleasure in taking more risks than citizens of other countries: "there is nothing wrong in principle with people wanting to trade off life expectancy against the pleasure of engaging in activities that happen to be risky." Judge Posner, do you really believe that citizens of other countries are more risk averse than Americans and that explains why they are healthier??? Oh, and by the way, when Americans stay in foreign countries (e.g. as exchange students), they tend to lose weight because they eat like the locals, and take as much public transportation as them (my daughter actually did a BA Thesis on the eating issue). What people do is only partly a matter of individual choice. It is also a matter of the availability of choices, and the surrounding social and cultural environment. Among other things, as some commenters have intimated (in different words), both Becker and Posner need to construe "health care" more broadly than they do, to include inducing people to take better care of themselves (e.g. exercise more), promoting preventive measures (such as engaging in safe sex), pushing for healthier food, and improving sanitation (I would add reducing the amount of advertising people are bombarded with, which would reduce depression, attention deficits, and, generally, stress). Some other countries are far more effective in their policies on these matters.

A comment on another aspect of what Posner and Becker write about: I suspect that our health care system (narrowly construed) does not in the aggregate compare very unfavorably with those of other industrialized countries mainly because we have superior medical training and technology compared with most (if not all of them). In other words, controlling for doctors' proficiency and technological level, our system is indeed worse than those of other countries. The relatively higher level of our doctors and our technology compensates for the poor administration of our health care system.

[Terry Bennett]

Q - intriguing thesis. Some of Europe's social differences from the U.S. can be compellingly derived from other more fundamental differences, such as geography and population density. I think the car v. train mentality comes back to the American need for the reassurance of autonomy - which may itself have something to do with geography. A car offers more freedom than a train, and maybe we need that - or maybe we sometimes just think we need it. I was stopped at a traffic light outside a large company site at closing time, and sat watching car after car exit, each with one person, all going the same direction. We pay a premium for this granularity, and when the reduction in efficiency from traffic congestion is factored in we may not benefit as much as we think, but for Americans who are not accustomed to using public transportation, a car is both a mental health issue and a symbolic exercise of the freedom we cherish - for better or worse.

The American food machine has not infiltrated Europe with anything near the ubiquity of its success here. Still, one doesn't have to buy the french fries. The major chains all offer various salads. It's a start.

I've been a guest at a number of hospitals in the Philippines over the years (usually for dehydration), and I have been consistently impressed with the doctors. They don't have the more elaborate machines, and it forces them to actually know something about what is going on in the body. Those encounters have left me with the sense that we have maybe been throwing out at least a sliver of baby with our bath water.

[Chandan_jes]

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