Is Low Life Expectancy the Fault of Our Health Care System?
A recent working paper by University of Pennsylvania demographers Samuel H. Preston and Jessica Y. Ho considers whether Americans’ low life expectancy, compared to that of other advanced industrialized countries, is the fault of the U.S. health care system. Their answer, based on the health outcomes of people over 50 suffering from such conditions as heart disease, stroke, and cancer, is no.
The problem with the study is its narrowness. It focuses on a narrow class of emergency conditions afflicting one class of patient, the elderly. And of course we know that U.S. health care caters well to this group, particularly with respect to the serious medical conditions considered in the study. So as an answer to the question posed, the paper is wanting.
If Preston and Ho’s measure of health outcomes of people over 50 with emergency medical conditions were, as they claim, a fair measure of the quality of our health care system, then logically the concept of “amenable mortality”—deaths before age 75 from conditions considered amenable to treatment by medical care—couldn’t be. And accordingly Preston and Ho criticize this metric (at least as formulated by Nolte and McKee), on two grounds:
(1) That it’s biased against the U.S. since it underplays or doesn’t include certain conditions (ischemic heart disease and prostate cancer) wherein U.S. care is distinguished.
(2) That the rate of decline in mortality among American males from “non-amenable” causes has been twice that from “amenable” causes, an anomaly that suggests “either flaws in the index or the unimportance of medical care relative to other factors that are operating.”
Two points:
(1) Supposing Preston and Ho’s objections to “amenable mortality” are fair, a reasonable response would be to redefine the concept to take account of these objections. We could then see how the U.S. compares with other countries in terms of the reformulated metric. Wholesale abandonment of the concept in exchange for measures in which the U.S. is known to excel is like throwing the baby out with the bath water.
(2) As to whether the U.S. has a high disease prevalence owing to factors outside the health care system, that doesn’t appear to be the case. A 2008 McKinsey Global Institute study, for example, 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).
Thus I conclude that the mortality numbers are exactly what many health care reform advocates claim they are—an indictment of the U.S. health care system.
But what’s most peculiar is the pattern of mortality in the U.S. For both sexes and at every age level until late in life, the U.S. stands apart from every other advanced industrialized country. (The U.S. is represented by the thick red lines.)
(Data from W.H.O.)
Although these diagrams use raw mortality numbers (not “amenable” or any other specific definition of mortality), they clarify why Preston and Ho get results so different from analyses in terms of amenable mortality. If you consider mortality from age 50 onward and include mainly conditions in which the U.S. specializes, as Preston and Ho do, obviously you’ll get a very different picture from the one you’ll get if you consider mortality under age 75 and include all “treatable” conditions.
Why the peculiar pattern of mortality in the U.S.?
A recent Urban Institute review article, discussed in a previous posting, finds that U.S. health care overall is a “mixed bag,” with both strengths and weaknesses. Since the overall quality of U.S. care appears to be neither exceptional nor terrible, whatever association may exist between low life expectancy and our health care system is almost certainly an access issue rather than a care issue.
Resources not being infinite, health care, like any good or service, must be rationed. The question is how (by decision or by market) and what to ration, or more precisely, what not to ration. All other industrialized countries have decided that, given the existence of care that can effectively address serious medical conditions, no one—rich or poor—will be denied this care. In other words, no one will die or go bankrupt because a medical treatment available to the society is not made available to them. That’s a moral decision, one that I suspect most Americans would endorse.
U.S. policymakers, however, haven’t made that decision (although they appear to be on the verge of making it now), leaving us our de facto brand of rationing, i.e., by price.
We see it in our out-of-pocket medical expenses:*
 |
Broadly there two kinds of rationing: by price (or market) and by decision. The left-hand column below depicts rationing by price, i.e., percentages of repondents that have, over the previous year, foregone attention or treatment because of cost. In this category the U.S. is without peer. The right-hand column depicts rationing by waiting (a proxy for rationing by decision), wherein the U.S. typically, but not always, fares reasonably well.
| Rationing by Price | Rationing by Waiting | ||
 |
 |
||
 |
 |
||
 |
 |
||
 |
 |
How might the different brands of rationing affect life expectancy? In no country with rationing by decision is there a waiting line for emergency care. Which is to say people get their foot in the door, have their medical conditions assessed, and rationing proceeds accordingly. Under a system of rationing by price, by contrast, rationing can occur at any point, including in the initial assessment phase. Unsurprising are the results.
The bottom line is that many Americans lack a product that the citizens of all other advanced industrialized countries have by right: a financial guarantee of access to health care during their working lives. It’s a product that Americans would almost certainly buy were it available, but not one that an unregulated or lightly regulated insurance market (owing to information asymmetries and adverse selection, to be discussed in future postings) can provide. It’s a product that requires a government guarantee.
*These and the following data are from The Commonwealth Fund 2005 International Health Policy Survey of Sicker Adults in Six Countries, released in November 2005. The numbers refer to percentages of respondents. A more complete account would require data from other sources and years. Still a clear and unsurprising picture emerges. Note that these results aren’t cherry-picked. The three categories of rationing by price are the only categories of rationing by price in the survey. The four categories of rationing by waiting are the only categories of rationing by waiting in the survey.
Systematic Wrongness II
Systematic Wrongness
Four Instruments
Where the Economy is and Where It's (Apparently) Going
Some Reality about Deficits
Armageddon: The Aftermath
The Hype
How to Explain It
Is Health Care Reform Popular?
The Point of the Public Plan
The Context of Health Care Reform
Addendum
What Americans Believe
American Health Care: Best in the World?
Is 76.5 Large?
NBC-WSJ Poll
Inside the Asylum
More About Bubbles
Why Did Economists Miss the Housing Bubble?
Why Has Monetary Policy Been so Ineffective?
The Geithner Plan
Is 22.2 Large?
Economics: A Theoretical Divide
The New Deal and the Great Depression
Stimulus By the Skin of Our Teeth
The Interregnum
Postmortem
Obama and McCain on Tax Cuts and Health Care
Religion and the New Atheism
Home