Why Does Health in the United States Lag Behind Other Countries’? Becker

A more than 400 page recent report from The National Research Council and The Institute of Medicine of the National Academy of Sciences (“U.S. Health in International Perspective: Shorter Lives, Poorer Health”) finds that children, men, and women all have shorter life expectancies in the United States than in Japan, Canada, Australia, and 13 European countries. Some of the media comments on the report blame what they consider an expensive and inefficient American healthcare system. Yet the report shows that many, perhaps most, of the reasons behind why American life expectancy is lagging relates to lifestyle decisions, and not to medical care.

The U.S. fared worse than these 16 other countries in 9 health categories:

1.     Infant mortality and survival to age 5.

2.     Deaths from car accidents and homicides.

3.     Adolescent pregnancy and sexually transmitted infections.

4.     Prevalence of HIV infection and AIDS.

5.     Deaths from alcohol and use of illegal drugs.

6.      Chronic lung disease.

7.     Obesity and diabetes.

8.     Disability due to arthritis and other factors.

9.      Heart disease.

Most of these categories relate to lifestyle decisions rather than medical care. For example, American deaths from car accidents is greater mainly because Americans drive more since the report shows that fatalities per mile driven is not higher in the U.S. Guns are far more common and violence is much greater, in America than in these other countries. Deaths from lung disease are more common in America because smoking was more common here in the past. Americans are much more likely to use cocaine and other drugs. That Americans are much fatter than individuals in these other countries contributes to the greater incidence of diabetes and cardiovascular diseases.

The higher incidence of child mortality may be partly due to poorer health care for disadvantaged pregnant mothers. However, this mortality difference is also likely mainly due to the personal behavior of these pregnant mothers than to any limited access to good health care.

The age pattern of American mortality rates also implies that most of the higher mortality of Americans is not due to low quality health care. The elderly are the recipients of a large fraction of health care spending in all rich countries. In particular, over 35% of health care spending in the United States is on persons aged 65 and older. The National Research Council study shows American mortality rates are among the very highest up to ages under 55, but mortality rankings begin to change quickly then. American mortality is in the middle of the pack by the mid-seventies, and it is already relatively lower by age 60.

To be sure, since the US spends a lot more per capita on medical care than does any other country, the fact that American life expectancy looks good at older ages does not imply that these expenditures are wisely allocated or efficient. Ways to improve the efficiency of America’s spending on health care are discussed in several of our past blog postings (the most recent one is on January 6).

Even though most of the difference in life expectancy between the US and these 16 peer countries are due to difference in personal behavior, public policies should try to change some of this behavior. For example, stiffer punishments for driving while drunk would reduce the incidence of drunk driving, a major cause of American traffic fatalities. Greater punishments for illegal possession of guns and for the use of guns to commit crimes, and judicious tighter gun controls are likely to reduce deaths from shootings, although there would be some compensating increases in stabbings and other types of violence. Decriminalization of drug use would reduce the rate of drug addictions and possibly even the number of drug addicts, increase visits to clinics by those addicted to drugs, and lower the incidence of AIDS from using contaminated needles (see the essay by Kevin Murphy and me “Have We Lost the War on Drugs?” Wall Street Journal, January 5, 2013).

It is more challenging to decide what to do about the fact that many Americans are overweight and obese. A recent survey of the evidence in a number of countries shows that being overweight, as measured by BMI (weight divided by height squared), does not lead to higher death rates except at very high and very low BMI values (dissertations at the University of Chicago under Robert Fogel’s supervision had already shown this). These studies imply that taxes and regulations on fast foods that discourage their consumption would mainly affect individuals whose eating patterns do not reduce their life expectancy, although overweight individuals do make modestly greater demands on the subsidized health care system.

The lower life expectancy for young and middle aged Americans than in peer countries is a matter of public policy concern, but wise policies require accurate knowledge about their causes. The comprehensive National Research Council study suggests that the major causes lie in differences in lifestyles between American and individuals in other countries. Poorer access of some Americans to adequate healthcare seems to be of  relatively little importance.

 

Comments

[Disisdkat]

Except for auto accidents all of these issues are related to our not having a national health care system and even that could be part of our health care if we were a smart country. We as a nation are shamefully neglectful of our people by not having safe means of bicycle or pedestrian travel which would improve both the quality and quantity of life and that is part of the myopic view of what our health care should be, what the 'general welfare' of a people should be. Get people out of their automobiles and you will improve their lives. Surely you do not think that infant mortality would not drop if women were more likely to seek prenatal care. Do you truly think that suicides would not drop if mental health care were something everyone had access to without worry of cost and shame? Part of a good health care system is education. Why do you think that the teen pregnancy rate is so shockingly high in this country when compared to other 'advanced' nations?

This is a sadly uninformed article and lacks understanding of what health care could be in our country.

[ezz201]

Just to respond to @Disisdkat, I think you're confusing welfare and healthcare. Definitely everything marginally impacts everything in some way, and it is at times and art rather than a science at determining what counts as healthcare. But there is a difference between education and sex ed, for example. There is a difference between things that affect health and are part of the healthcare system, and that is really part of what makes evaluating healthcare systems so difficult. So maximizing health and efficiently running the healthcare system are two different tasks, I'd say.

[Neilehat]

The analysis of Health Care outcomes and its concerns is a good reportcard on general American Health. As for the statistical anomaly in the improvement in the aged population health, this is simply due to the weaker members in the study dying off and skewing the results. As for the nine health categories, all of them appear to have a "lifestyle and choice" component, but this should not preclude some form of Health Care intervention. Perhaps, another analysis would ferret out a more powerful root cause as opposed to "lifestyle" choices. May I suggest a much more powerful and insidious root cause. Such as Mass Marketing and Modern Advertising of unhealthy lifestyles and the control of human behaivor. Now, how do we roll this idea into Health Care intervention?

[Terry Bennett]

I agree that our choices drive the stats; I don't see why anybody is worked up about that. This is what we do with our freedom. Judge Posner has a point that much of this individual choosing takes place in the absence of good data, but that data is freely available, and if one recklessly chooses to proceed with one's choice and not do the research, that is also a freddom Americans currently have.

I am not convinced that stiffer penalties for drunk driving would help. We've cut way down on it in the last few decades already, but I am still flabbergasted at the self-inflicted misery I see at the bi-weekly session of my local municipal court. People are still driving drunk, and I can't figure out why. Among teenagers it carries a certain cachet, sort of an initiation to be able to say you've faced your first DUI arrest, but I see people in their 50's facing a fourth offense ten years after their third offense. I conclude that some segment of the population is unteachably stupid, and if we can't take them out and shoot them we are stuck with them and their consequences upon us.

How would decriminalization reduce drug addiction? I expect that some people are predisposed to addiction and others are less so. My father more or less died of alcoholism, but I've never had a drink so I don't know if I would be overwhelmed by a thirst for it were I to open that door. If drugs are decriminalized, virtually everyone will try it, just like alcohol currently. If more people try it, more of those people who are predisposed to really, really like it will be found, and we will end up with a larger population of addicts. Furthermore, those same people who are already willing to defy the current law and use drugs are probably not going to forego a clinic on the grounds that it's socially embarrassing.

I own one gun, I've never fired it, and I don't care if I ever do. (I find it much more satisfying killing my enemies with my bare hands.) Having said that, we may already be at the optimum balance on the gun issue. Let's suppose that of Chicago's 500 murders last year, one a day was gang competition. In three years, that takes over a thousand gangstas off the streets. If they each would have lived another 5 years on average before finally receiving their inevitable life sentences, and if conservatively we assume they would have each committed two crimes a month, the presence of guns has prevented 120,000 crimes, and no doubt lowered the proliferation of venereal diseases as well. The obvious human cost is negligible; the cost to society is that every so often a child gets caught in the crossfire, but the next time that happens we should all remember that we probably were saved from a mugging by the same forces that hurt that innocent victim.

[Neilehat]

Bennett, "Bare Hands" you say? Really...?! Do you eat them as well? Perhaps the "powers that be" need to put the University on a Werewolf, Vampire and Zombie alert...

[Amanda Purcell]

This is a really interesting perspective. I think the effect of lifestyle choices on health are significantly talked about in the US. Here is a discussion based on this article trying to find the main arguments on whether lifestyle or medical care is the biggest culprit for the lower than expected life expectancy in the US: http://www.the-counterpoint.com/discussion/2O

[Justin Van Hoose]

"However, this mortality difference is also likely mainly due to the personal behavior of these pregnant mothers than to any limited access to good health care"

Are you suggesting Europeans are more caring mothers? Or just that they are smarter?

[Bill Drissel]

The US measures infant mortality differently from the rest of the world. US doctors cut themselves no slack. If a baby breathes in the US, he is born alive. If he subsequently dies, that's an infant death. In the OECD nations, a baby less than 30 cm long or less that 1kg at birth is recorded as stillborn if he dies within 30 days. On an equivalent definition, the infant mortality of the US is about that of Switzerland See:

http://www.opinionjournal.com/best/?id=110006161 There is more at:

http://debate-central.ncpa.org/topics/2002/book2.pdf around p 22.

Outside of OECD and the English-speaking countries, much of the public data on infant mortality needs heavy discount. 41 nations have better reported rates than the US incl Azerbaijan and Cuba.

Life expectancy isn't a very good measure of health care systems unless deaths that aren't influenced by the systems are controlled. If controlled for accidental death and homicide, US life expectancy is the best in the world (although to my statistician's eye, the differences of the first dozen or so look insignificant). See
Table 1-5 of: http://www.aei.org/docLib/20061017_OhsfeldtSchneiderPresentation.pdf

Regards,
Bill Drissel
Grand Prairie, TX

[Justin Van Hoose]

"If controlled for accidental death and homicide, US life expectancy is the best in the world (although to my statistician's eye, the differences of the first dozen or so look insignificant)."

There is a bit of a logically fallacy with this statement. "Accidental death[s]" and "homicide" do not occur independent of the healthcare system. Look at battlefield medicine for proof. Quick and timely access to emergency response is a major factor in whether a victim dies or not.

If there is a smart and intelligent way to control for this that may or may not make a difference in the comparision-I don't know. I am not a statistician, but I would think that it would a mistake to just dump out of the denominator anyone who dies from a "accidental death" or "homicide."

[Abigailenagle]

They should do another survey for this year because some people change their eating habit yearly. They should really reduce that number of people that are obese.

-Abigaile Nagle

[Lafjohn Wify]

Determine what programs and services are currently available or lacking in the community. This may involve contacting your local health department, nonprofit organizations or physicians specializing in reproductive health. Thanks.
Regards,
http://weightlosspunch.com/garcinia-cambogia-extract-dr-oz-calls-weight-loss-holy-grail/