Live and learn

I've long been a skeptic about the relative contribution of health care to health and longevity. I haven't changed my mind in the slightest that social determinants of health are ultimately more important - I'd rather not have diabetes or lung cancer or heart disease in the first place than get medical treatment for any of them, obviously. We should spend less on health care and more on other good stuff.

What I am about to tell you doesn't challenge that, in fact it supports it, but it does put health care front and center in the story of the poor health of Americans compared with people in other wealthy countries. Meunnig and Glied in Health Affairs (sorry, I'm not sure whether you have full text access because I'm permanently signed in via cookie)* use trends over time to sort out the effect of health care from other determinants in explaining our poor life expectancy.

This is a complicated story so I'll have to be fairly elliptical for this blog post. As the banner at the top of this page says, we spend far more on health care than other countries but we get less for it. As M&G tell us, the U.S. now ranks 49th for life expectancy at birth - a severe decline since the 1950s, and we now spend more than twice the median of other wealthy countries. But some people object that the life expectancy comparisons are flawed because of differing definitions, e.g. fetal deaths might be counted as an infant death. Others attribute the gap to social determinants, such as smoking, obesity, motor vehicle crashes, etc. and argue that it's even possible our higher spending on health care reduces the gap that would otherwise exist.

Well, it turns out that if you just look at 15 year survival of people age 45 and 65 -- eliminating the infant mortality problem, getting to ages where medical care becomes more important, and eliminating problems with coding of death for the very old -- the story looks pretty convincing. In 1975 we were already in last place for 15 year survival of both sexes at age 45, but we did pretty well for survival of older people. Our health care spending was above average but not an outlier.

Over the next 30 years survival rates and health care spending went up everywhere, but our performance in both categories grew dramatically worse in comparison to other nations: "By 2005, . . . the United States had become a high outlier in spending and a low outlier in 15 year survival." They find that non-Hispanic whites taken separately did worse in survival gains than people in any other country, so it's not just our racial inequality that drags us down.

They also rule out some of the usual suspects. Smoking rates in the U.S. are actually lower than in comparison countries and also fell faster over the period than in most of them. Yes, we are more likely to be obese than people elsewhere but our obesity rates haven't been growing faster, which would be necessary in order for obesity to explain the trends. And the share of deaths in the U.S. attributable to motor vehicle crashes, while comparatively high, has been falling.

They conclude that maybe we should actually blame high health care spending for the mortality gap:

It is possible that rising US health spending is itself responsible for the observed relative decline in survival. There are three reasons why this might be so. First, as health spending rises, so, too, does the number of people with inadequate health insurance. Notwithstanding the uncertainty surrounding the impact of lacking insurance on the health of the US population, higher spending could be reducing survival by decreasing the number of insured people.

Second, rising health spending may be choking off public funding on more important life-saving programs. Health spending now constitutes a sizable proportion of the federal budget. At current spending levels, investments in public health, education, public safety, safety-net, and community development programs may be more efficient at increasing survival than further investments in medical care.

Finally, unregulated fee-for-service reimbursement and an emphasis on specialty care may contribute to high US health spending, while leading to unneeded procedures and fragmentation of care. Unneeded procedures may be associated with secondary complications. Fragmentation of care leads to poor communication between providers, sometimes conflicting instructions for patients, and higher rates of medical errors. For example, two separate physicians are probably more likely than a single primary care provider to prescribe two incompatible drugs to a single patient.

Talk about your death panels.




*And apologies for the bad link yesterday -- my university's computer network is so powerful that it gets me into JAMA without having to log in or go through our library proxy server, so I didn't know it was closed access. I'll have to find a way to descend among the mortals.