Blog: The Health of Nations

Americans die earlier than those in other high-income nations, despite spending twice as much on health care.  This, of course, is old news.

What makes the National Research Council’s January 9 report, U.S. Health in International Perspective: Shorter Lives, Poorer Health, such an interesting read is its comprehensive approach to the tangled question of why, exactly, this remains the case.

A couple of facts first.  Drawing on a substantial body of literature, the report compared the US to 16 other “peer countries,” i.e. developed, high-income nations, mostly in Western Europe.  Among these 17 countries, life expectancy was lowest in the US among men and second lowest among woman, with particularly poor life expectancy for those under age 50.

No particular disease or demographic explained this rather dismal global performance: we had, for instance, the highest infant mortality rate, the highest homicide rate (6.9 times higher) and firearm homicide rate (19.5 times higher), the highest AIDS rate, and the second highest mortality rate when considering all noncommunicable diseases.  Our death rate was worse than average with respect to cardiovascular, respiratory, infectious, endocrine, neuropsychiatric, skin, and perinatal conditions, with notable superiority only in the area of cancer and digestive disease.  This despite spending more than twice as much on health care as other OECD countries (in 2009, $7,960 per capita versus $3,223), which amounts to about 18% of the total GDP.

While the explanation for these outcomes is clearly multifactorial, a couple of interesting points stand out.  For instance, the frequently bemoaned health behaviors of Americans, while clearly a contributing factor, are not enough to explain our poor health.  While we consume more calories, use seatbelts less, and consume more illicit drugs, we also smoke less cigarettes and imbibe less alcohol, on average.  Socioeconomic factors also clearly play an important role, with higher rates of poverty and inequality in the United States, and less availability of safety-net programs.  But interestingly, even when considering advantaged groups only (the insured, upper-income, educated), health outcomes remain inferior.  Indeed, when we look only at “amenable” mortality, a metric of those deaths theoretically preventable with currently available medical therapies, the US performed worst among 16 countries.

Clearly, then, however much we might squirm and squeal, it is impossible to exonerate the contribution of our vaunted health care system.  System factors cited in the study include less overall visits by US patients to health care providers; overall lower physician density; a lower percentage of physicians engaging in primary care; worse continuity of care; greater delays in care; greater financial barriers in accessing care, with Americans facing higher deductibles, copayments and out-of-pocket expenses at the time of health care utilization; and, of course, lower rates of insurance, with the US having the worst rate of coverage of all OCED countries except Mexico, Turkey and Chile.

Everyone therefore now finally acknowledges that the US has worse health outcomes than other high-income nations, and at a much higher cost.  Yet oddly, it remains positively radical to conclude from this fact that perhaps we might benefit from borrowing from our better-performing peers.   It is considered particularly inappropriate to suggest that we take on the one element common to essentially all of these other systems: their truly universal basis, and the advantages with respect to efficiency, coverage, and comprehensiveness that result.

On the contrary, the most commonly proposed solutions we hear involve making our system even less like those of our better-performing peers, and even more like itself.  Our only salvation, it is frequently heard, is to further the commodification of health, to empower patients to become savvier care consumers, to drive down costs and improve quality by unleashing the inexorable power of the market panacea.  More on why this is utter nonsense at a later date.