HOW GOOD IS THE US HEALTH CARE SYSTEM?
Our national debate has focussed attention on multiple aspects of health care. Much of the debate has involved manipulated and misinterpreted data. One of the “facts” repeatedly posted for us to ooh and aah over is how much shorter our life expectancy is than that of other industrialized nations. National life expectancy is posited as a measurement of health care quality. However, is that a correct assumption?
There is an interactive chart at http://www.worldlifeexpectancy.com/world-rankings-total-deaths#instructions that displays data on mortality rates and causes of death both worldwide and for many nations. One can choose the countries in which one has interest and display them next to each other for comparing causes of death. What is readily apparent is that cardiac disease, stroke, and lung diseases predominate as causes of death in most of the world. Some really striking data show Alzheimers/Dementia as the second leading cause of death in the US versus 22nd in world data. The chart is well worth spending some time interacting and analyzing scenarios. Compare reported data with what your preconception is. In this post, I will mostly be comparing the US and Japan.
If one extracts out just coronary, stroke and influenza (top three causes of death in the world) and compares these as a single rate with the US, Japan and the world, the rates of death are 2.1 per thousand in the US versus 2.8 in Japan and 2.6 in the world. Math is not my strongest point so, if someone finds an error in my analysis, let us know. These three conditions strike me as a better “proxy” for a nation’s health care system than overall mortality. I base this on the following:
- Overall mortality includes a number of causes of death not related to health care systems such as violence, accidents, suicide, poisoning and war. These causes of death tend to occur in younger persons so have a proportionately greater affect on life expectancy, and
- Any impact of the health care system on mortality from number 1, above, would be to lower mortality rate from those causes (i.e., excellent trauma care will prevent many deaths from violence, suicide, and accident), and
- Health management of cardiac disease, stroke, and influenza have direct impact on mortality. Granted, these are also impacted by nutrition and personal life style. Because these illnesses tend to occur in more elderly persons, extending life for their victims will have a lesser impact on population life expectancy. Persons dieing in their 70s will have less impact on overall life expectancy than those dieing in their 20s.
Looking at the aggregate of road accidents, other injuries, suicide, and violence, the rates are 5.37 per thousand in the world, 4.0 in the US and 4.5 in Japan. Note that these data are influenced more by national ethos than quality of health care. For example, Japan has almost as many suicide deaths as the US (31,571 versus 35,441) despite only 40 percent as much population. This is most likely due to the long time ethos related to suicide in Japanese culture.
One could play with these data for a long time and come up with all sorts of conclusions some of which might be useful and many of which would be silly. However, more value can be found by using data such as these in order to create national priorities for impacting death rates and national survival. For example, consider the following:
- Japan can get more value from developing national strategies that lower suicide deaths than they would from lowering motor vehicle deaths, and
- Coronary deaths are the major cause of death worldwide. Further research into prevention will yield greater value than treatment of this disease. Imagine the worldwide impact of delaying progression of coronary obstruction by several years, and
- National strategies directed toward healthier life styles would have major impact on cause of death. Type II diabetes mellitus, lung cancer, hypertension, and violence are among major causes of death that are related to specific life styles, and
- Influenza as a cause of death is very much affected by vaccinations. In the US, there were 57,722 influenza deaths from influenza versus 123,302 in Japan. This article, http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(03)14870-2/fulltext discusses the low rate of vaccination for influenza in Japan and how it came to be so low. Rate of vaccination in the US was about 65 percent (of 65 and older) in 2001-02. Clearly, this cause of death can be impacted through a relatively low cost alternative and will be even more impacted with upcoming advances in vaccine technology (e.g., DNA vaccines), and
- Alzheimer/dementia in the US is the second leading cause of death. More than three times as many die of dementia as breast cancer in the US. Yet the NIH budget discussion mentions significant improvement in breast cancer survival that they attribute in part to NIH actions and investment in research but makes almost no mention of work on or impact on dementia.
- A major impact on life expectancy in the US relates to violence (murder, suicide, risk taking, etc). Lowering these causes of death is more a national ethos issue than a health care issue. I did not do the math but have seen more than one paper documenting that, if one abstracts out data of death due to violence, the US has one of the highest life expectancies.
Health care in the US consumes a major portion of our national productivity. I agree that we should expect better results than seem to be the case. I do not agree that our health care system is second rate compared with the rest of the world. Indeed, in a number of areas, our system excels based on data in this and other charts. Immunization rates in the US are a major success story and something of which to be proud. Our trauma survival rates are close to or superior to those seen in many countries that are more compact (i.e., closer to the trauma centers). Rather than using data to “make” political points, we should be using data to develop strategies for improving quality of life in this nation. Our strategies will not be the same as those of other nations that face different national ethos and different threats to health.
In summary, I have no idea whether health care is better, equal to, or not as good as other industrialized nations. The data found in the chart to which I referred and other sources seem to indicate that the system itself is equal to or more successful than other nations. I do know that our nation and its citizens invest huge sums into what they perceive as health care. Much is expended wastefully, much is on areas not impacting on health or longevity, and much provides major improvement to life and quality of life. There also is clear evidence that a significant portion of our population has poor access to health care. The Affordable Health Care Act was intended to address this as well as a number of other problems with access to care. Even early in its implementation, it has improved access through extended insurance coverage for young adults. Soon, further improved access will come through improved insurance alternatives for those in their late 50s to age 65. I doubt that it will have much impact on homeless and some of the other unserved members of our population. What is unclear is whether the improved access that it will create will impact on the quality of our health care system.
If I were the “health tsar” (a position to which I have absolutely no aspirations), I would direct assets into further improvements in vaccinations, research on prevention of dementias, better education of teens and young adults on risk taking (dangerous activities), better education on self care to prevent chronic disabling conditions, and getting tobacco use out of our national scene. I would work to implement a national primary care program that would provide high quality primary health care based on communities of persons (i.e., design the health program based on the community rather than expect the community to somehow meet the design of the health program). As my primary public health project, I would eliminate every sugar subsidy and maybe even forget my Objectivist aspirations and add sugar taxing in order to cut down the massive sugar load our citizens use.
As an aside, if we as a nation wish to move to the top of the chart of life expectancy, we can do so by cutting in half deaths from violence and other trauma, eliminating use of burned tobacco (smoking), and cutting motor vehicle deaths in half. Those achievements can be made with no changes to the health care system but would require draconian social interventions. Are we really willing to make those changes so that we can brag that we live longer than anyone else?