| September 27, 2009 Addendum Regarding John Tierney’s Times piece on the work of Samuel Preston and Patricia Ho, several points: 1. There’s confusion about the meaning of the word “system” in “health care system.” Preston and Ho seem clear that a “health care system” comprises many things, some related to quality of care, others to access to care. But their analysis is confined solely to issues of quality of care—specifically “screening for cancer, survival rates from cancer, survival rates after heart attacks and strokes, and medication of individuals with high levels of blood pressure or cholesterol” among people over age 50. Since health care systems address the health needs of all people suffering from all conditions, and encompass issues of access and prevention as well as care, Preston and Ho’s findings are not an answer to their question, “Does a poor performance by the US health care system account for the low international ranking of longevity in the US?” (italics added) Thus the title and stated purpose of their work is misleading. On the other hand, “amenable mortality”—deaths of people under age 75 from “treatable” conditions—is a metric that theoretically could be used to compare different countries’ health care systems. One could quarrel with any specific definition of “amenable mortality”—specifically, what conditions should be counted as “treatable”—as Preston and Ho do with that of Nolte and McKee. But a measure that only looks at detection and treatment of conditions wherein the U.S. is known to specialize, and then only when they afflict people 50 and older, is hardly a substitute for a concept that considers all “treatable” conditions afflicting people 75 and younger. And Preston and Ho don’t really argue against the concept of amenable mortality, but mainly against its specific instantiation in the work of Nolte and McKee. Which is fine, but a reasonable response would be to propose a redefinition of the term, not a wholesale abandonment of the concept. 2. The one possible justification for abandonment of “amenable mortality” is a view Preston, Ho and Tierney endorse: that lower life expectancy of Americans is primarily caused by higher disease prevalence in the U.S., i.e., that Americans for some reason are “sicker” than the peoples of other countries. If true this would undermine the use of mortality statistics to assess a country’s health care system since high mortality could then result from factors outside the health care system. Tierney writes: “Americans are more ethnically diverse. They eat different food. They are fatter. Perhaps most important, they used to be exceptionally heavy smokers.” Fatter, yes. But aren’t Europeans (especially when combined with the Japanese and Australians, as is typically done in these comparative studies) also ethnically diverse? Aren’t their diets, ranging from Greek to Spanish to Italian to German to French to English to Scandinavian (and Japanese), at least as diverse as American diets? But as to whether Americans are sicker than people in other countries, that doesn’t appear to be the case. As noted in my previous post, a 2008 study by the McKinsey Global Institute found that “of 122 diseases within 35 medical conditions representing 37 percent of total US health care spending—including heart conditions, trauma, cancer, mental disorders, and diabetes—the United States has a lower prevalence of disease than France, Germany, Italy, Spain, and the United Kingdom” (italics added). As for smoking, it’s true that Americans were once heavy smokers (though now we’re among the lightest smokers in the industrialized world). But going back to the McKinsey report, the authors observe (explaining their finding that Americans have a lower disease prevalence than the citizens of other industrialized countries) that “smoking figures in the United States are far lower than in the comparison countries [France, Germany, Italy, Spain, and the United Kingdom]” and that the U.S. has “a third fewer” cases of chronic obstructive pulmonary disease than the comparison countries. A “third fewer”? Clearly some empirical investigation is in order. Finally, the report notes (further explaining its finding that the U.S. has a lower disease prevalence than other industrialized countries), “the United States benefits from a younger population with an overall lower prevalence of conditions associated with age, such as heart disease, even though incidence rates may actually be higher for some segments of the population.” In any case, if our higher mortality rates really were a legacy of our heavy smoking past, why would Americans’ mortality after age 65 (presumably the cohort of the heaviest smokers or former smokers) be approximately the same as that of other countries? Also, most smoking-related deaths occur after age 65. (One well-known study found that a life-time of smoking reduces life expectancy by ten years. For a summary, see this.) So why should our smoking legacy affect younger age cohorts so adversely? 3. Of the relatively high mortality rates of younger and middle-aged Americans, Tierney writes: “Many of those deaths have been attributed to the health care system, an especially convenient target for those who favor a European alternative.” Since in Tierney’s view many of these deaths are not attributable to our health care system, our high mortality numbers would not be evidence that we should adopt a European-style model (i.e., one of those models that provide approximately equivalent care to ours at about half the cost and cover nearly everyone). It’s not clear that Preston and Ho have the same take on their findings. As noted, they seem to recognize that health care systems comprise not just detection and treatment of a small range of conditions, but prevention of illness broadly. They write:
This would seem like an endorsement of the insurance market reform currently being contemplated by Congress, reform that would move our system closer to that of Germany, the Netherlands, and Switzerland. (Which doesn’t explain the title and stated purpose of their paper.) But Tierney’s take seems to exhibit a reflexive conservative impulse to defend the status quo no matter what. Of course it’s not the quality of care, but access to care wherein the “European” models are superior. As T.R. Reid says in his excellent new book (a must-read for anyone interested in the issue), “the United States does well when it comes to provding medical care, but has a rotten system for financing that care” (p. 225). And it’s access to care that plausibly accounts for our high mortality numbers. One comprehensive study of the relationship between access to care and health outcomes is this one by the Institute of Medicine. Among its findings:
Rocket science it isn’t. Many Americans lack secure access to health care, so Americans on average die younger than people in other advanced industrialized countries. (And if you need to put a name and story to the numbers, read the harrowing tale of Nikki White in Reid’s book (pp. 209-12).) That excellent minds should spend time and resources trying to torpedo the obvious is sad. |
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