• How flawed is life expectancy?

    Life expectancy as a metric is so controversial that I felt it deserved further exploration.  People don’t like it because they think lots of things are getting in the way besides the health care system.  Some of the most commonly brought up examples are how we score miscarriages, or the fact that we have more homicides, car accidents, or suicides.

    Yes, I know Betsey McCaughey made this argument on the Daily Show. She got it originally from an analysis done by Robert L. Ohsfeldt and John E. Schneider (published by the American Enterprise Institute ) for their book, The Business of Health: The Role of Competition, Markets, and Regulation:

    The abnormally high child mortality rate obviously contributes to the abnormally low life expectancy at birth in the United States. But death rates among adolescents and youth can also have a dramatic impact on estimated life expectancy. In that light, it is important to note that some specific cultural aspects of American society largely outside the purview of the health care system contribute to rates of death from injury, both unintentional (accidents) and intentional (homicide and suicide). Rates of death from injury are usually high in the United States compared to other developed countries, which affects the apparent underperformance of the U.S. health system (as measured by life expectancy at birth), because deaths from injury disproportionately affect adolescents and young adults.

    Those are fair points.  But do they alter things slightly or change how we perform greatly?

    First let’s look at homicides:

    Yes, we have more, but the number of actual deaths pales in comparison to total deaths per year (almost 700 per 100,000 population).

    We also have more deaths by accidents, but again, not in huge numbers.

    Our suicide rate is actually such that it should help us.  But again, not a huge factor.

    So let’s think this through.  What Ohsfeldt and Schneider did was calculate a regression to remove the effects from infant mortality, accidents, assault, etc. from the equation and recalculate the life expectancy (making us first).  But there are problems with this:

    Carl Haub, a demographer at the Population Reference Bureau in Washington, D.C., said the method was incomplete. A more-precise analysis would have removed those who died from these causes from overall mortality stats, and then recalculated life expectancy. (For more on how life expectancy is calculated, see this earlier blog post.) “Just because another method is a lot of work, does not mean regression will yield a correct result,” Mr. Haub told me.

    Prof. Ohsfeldt acknowledges that regression was chosen for its relative simplicity for what he called his “little book project.” And he agrees that some deaths that his book attempted to remove from the life-expectancy tables might be dependent on health-care systems.

    If it’s the case that the miscarriages, accidents, and homicides are screwing us, because we lose many more people at a young age, then if we look at the life expectancy of people who make it out of the dangerous young years, things should look better.  In fact, in their book, Ohsfeldt and Schneider make this exact argument:

    In contrast to life expectancy at birth, cross-national comparisons of healthy life expectancy at age sixty are relatively unaffected by differential death rates from unintentional injury and homicide.

    So let’s look at the life expectancy for 65 year olds.  According to the people who did the analysis for AEI, that’s the fairest way to assess life expectancy as a health care system population metric.

    Still the worst in recent years.

    Accept it.  Even if we look at life expectancy for sub-populations relatively less affected by the reasons people use to try and discredit the metric as a quality measure, we still look pretty bad.  Especially when you remember that people in the US over age 65 have much better access to the health care system overall, due to the universality of Medicare.  Moreover, even if you argue that the US is more dangerous, then don’t we really need a much better health system to keep us from dying?

    You can’t blame all deaths on the health system, but that doesn’t mean we couldn’t use a much better one.

    • Seems to me that the charts you are publishing tend to show the U.S. rates of murder and death during land travel have been falling faster in the U.S. relative to other countries. So the change in life expectancy in the U.S. since 1990 would, if anything, improve.
      Said another way – suppose the ONLY way Americans died was to be murdered, and our murder rate was six times the average of other nations. Were we to reduce the murder rate to only triple the worldwide average, fewer people would die every year. Our life expectancy would rise.
      As you point out, the death rate by murder, etc., is small relative to the overall death rate. But even granting the premise that murder rates drive life expectancy, you reach a different conclusion than some would, er, prefer.
      Also, some nations consider murder, auto injuries to be public health problems and devote resources to addressing them – public service announcements, etc.
      Finally, LE after 65 needs to address the obvious – that Americans move into an entirely different health system at that age – single payer Medicare. Perhaps people enter Medicare too weakened to recover Perhaps Medicare isn’t as successful in the U.S. as it is elsewhere. The data you have here, while helpful, can’t answer that.

    • This analysis makes the U.S. healthcare system look like the world’s worst, but there is a factor you’re leaving out.

      “Americans are also more likely to be obese, leading to heart disease and other medical problems. Among Americans, 31 percent of men and 33 percent of women have a body mass index of at least 30, a definition of obesity, versus 17 percent of men and 19 percent of women in Canada. Japan, which has the longest life expectancy among major nations, has obesity rates of about 3 percent.

      The causes of American obesity are not fully understood, but they involve lifestyle choices we make every day, as well as our system of food delivery. Research by the Harvard economists David Cutler, Ed Glaeser and Jesse Shapiro concludes that America’s growing obesity problem is largely attributable to our economy’s ability to supply high-calorie foods cheaply. Lower prices increase food consumption, sometimes beyond the point of optimal health.” (http://www.nytimes.com/2007/11/04/business/04view.html?ex=1351828800&en=7abf86ba1f3f353d&ei=5124&partner=permalink&exprod=permalink)

      How would the obesity factor affect your thinking?

      • @Gary Robinson,
        While the availability of cheap high-calorie food does help to explain the rise in obesity over the past few decades, it can’t be that significant a factor in explaining cross-country comparisons since cheap high-calorie food is also readily available in other developed countries. To take one example, in Japan, where I live, food prices are in general higher than in the US, but this is even more true for fresh fruits and vegetables, so if price were really such a big driver, one would expect Japanese people to consume a higher percentage of their calories from junk food and consequently be fatter, but they’re most certainly not.

    • People have a major misconception about suicide.

      People think suicide is a teenage phenomenon, but, actually, suicide rates trend upward as people get older and are highest in the population of people over 65.

      Yes, there are stresses in being a teenager, but as you get older you feel the walls closing in and might feel that you’ve got less to live for. Disability, the loss of a spouse, or an impending terminal illness can all drive an older to person to end it all; think of Hunter S. Thompson, who shot himself soon after he fell and broke his hip. He just didn’t want to live that way.

      Parasuicidial behavior is also common in older adults; when my father died, my mother stopped taking her blood pressure medication and started smoking. She didn’t live long past him.

      • And suicide is more common in other developed countries, Japan in particular, than in the US, which makes the results for life expectancy at 65 look even worse for the US.

        (ed. note: The claim in this comment requires evidence per the comments policy.)

    • Haub is right–there are two conventional ways to calculate so-called “deleted cause of death” (or counterfactual) life tables, and they depend on alternate assumptions about how to distribute mortality among the “remaining” causes of death. I suspect we’d still have low life expectancy at birth and 65 under these assumptions, and if there’s any demography grad student reading this, go to it! It’s a good exercise…

    • Gary Robinson,

      Although you’re correct that the causes of obesity are poorly understood, they do not necessarily involve lifestyle choices. Obesity has been linked to virus (http://www.sciencenews.org/view/generic/id/63992/title/FOR_KIDS_Obesity_and_the_common_cold), vitamin deficiency ), lack of sleep (http://www.walesonline.co.uk/news/health-news/2010/09/24/lack-of-sleep-can-make-you-fat-say-scientists-91466-27332633/) light at night (http://www.medicalnewstoday.com/articles/204236.php), pesticides in the womb ), hormonal disorder (http://topnews.us/content/226799-hormone-responsible-excessive-eating), among other things. Some of these may be influenced by lifestyle, but are not necessarily “choices”; others are environmental issues; some are metabolic. The idea that obesity is simply a “lifestyle choice” has been repeatedly discredited.

    • I do agree with an overhaul of our health care system, but I also agree that this graph doesn’t factor in the American (and I guess British) lifestyle.

      Sure obesity may have some genetic factors, but I truly believe that if Obese people ate differently they would lose weight.

      Most people’s diets in this country are based on processed and fatty foods. I have some friends that qualify as obese and when they change their diets and exercise, guess what, they lose weight.

      I would suggest to everyone here, (knowing that it’s not practical on a global or even nationwide scale currently) to look into the Paleo Diet. Premise being that evolution takes millions of years to take hold, and the agricultural revolution (that has lead to processing of foods, grains, and domesticating animals) has done a number on our health. The major premise is to basically eat lean meats (including red meat, just not McDonald’s cow fat burgers), fruits and vegetables. No grains, no starchy veges (potatoes), no dairy. Eat like this and the results will be that obesity diminishes and health flourishes. I’ve been doing it for a 5 months now and have more energy than I’ve ever had and have turned most of my fat into muscle. Just a thought….

    • While non-behavioral factors may certainly have an impact on obesity, I know that I lost 50 pounds, moving from obese to non-obese, and have kept off that weight for years, purely by lifestyle choices (eating less fat and exercising)… and I’m pretty sure most other obese people would see the same results if they made the same choices. I just don’t buy that more Americans are obese in recent years because of a new (the last 10-15 years) hormonal disorder that is restricted to the US, for example.

      I can easily believe that our culture, which involves longer work hours than elsewhere, leaving less time to prepare healthy meals, and which also involves insane amounts of marketing dollars spent on extremely calorie-intensive foods (such as most things sold at Starbucks), can be the cause of our greater incidence of obesity relative to many other countries.

      One other note: it may be coincidence, but I think it’s interesting to note that in the “Life Expectancy At Age 65” graphs presented above for men and women, Japan, Canada, and the US are ordered in the exact reverse of the obesity rates given for those countries in the quote I posted above. (I don’t have the rates for other countries handy right now.)

    • Gary, congratulations on the weight loss! Keep up the good work.
      Not sure how your comment is a response to Sapien or steve above. I tend to think if people are unable to do things that are in their best interest, it’s because those things are difficult to do – kind of a tautology, when you think about it.
      Regardless, other nations look upon national health problems as just that – national health problems – and address them through extensive education campaigns.

    • I agree that our government may be doing less than other countries at health-oriented education campaigns. If it’s true that we do much less, I don’t really consider that a failing of our healthcare system, which may be doing a better job than those other countries do at compensating for our bad lifestyles.

      That is, what I want to know for my personal interests is: if I’m sick, can I get health care here that is competitive with what I could get if I moved to, for example, Canada? I think the answer to that is probably Yes.

      That being said, there is one great advantage of fully socialized medicine. If the government is paying the bills, it is highly motivated to save money on those bills by passing laws and funding education campaigns. If it’s the insurance companies that are paying the bills, they don’t have the (direct) ability to pass laws, and they have less ability to do education campaigns (although insurance companies do make efforts in that direction).

      So, I can believe that a fully socialized system would lead to better overall health. But Americans (Republicans in particular), have historically made the choice of more perceived freedom (i.e. absence of socialism) vs. more overall health.

      By the way, using just Japan, Canada, and the US, the inverse correlation between obesity rates and life expectancy has a probability of only 1 in 6 of occurring by chance alone. It would be interesting to consider other countries. As I mentioned above, I don’t have the data handy.

    • The discrepancy islargely driven by race. In 1997, at the age of 65, whites lived an additional 2 years longer than blacks. When you factor that in place, it explains the entire difference.


    • Good lord, why am I not allowed to post?

    • Shweet!

      Why are we concerning ourselves with longevity in the regard?

      The question is: When US women of the “Japanese” profile body mass index X%, non-smoker, eaters of Y food, etc. are compared to Japanese women… how do they do?

      Without that all that we’re really just comparing lifestyles.

    • “Europeans smoke more.”

      The smoking thing can be deceptive because it takes so long to kill. Did more 65 year old Americans once smoke that 65 year old Europeans, would be the pertinent question.

    • “But Americans (Republicans in particular), have historically made the choice of more perceived freedom (i.e. absence of socialism) vs. more overall health.”

      Canadians, me included, tend to chuckle at the above argument. That’s because all the things that “Republicans in particular” are claiming about the Canadian heath care system seem to apply more to the US system. HMOs and health insurance companies seem to put all sorts of restrictions on when and who you can see, whether you can go to an “out of network” facility, whether or not a certain medical issue is covered, and so on.

      I on the other hand, can travel 4500 miles to the other side of the country and make an appointment with any doctor who can fit me in, for any medical cause, and not have to pay any deductible, co-pay, or anything else. Likewise if I have to go to a hospital ER — typically the medical issues are addressed even before the administrative admitting procedures. And once I’ve recovered, I simply leave — that is, after the hospital staff is certain I can make my way home safely.

      To me, “perceived freedom” (particularly in regards to health care choices) is a great deal stronger in Canada than the US.

    • To me, “perceived freedom” (particularly in regards to health care choices) is a great deal stronger in Canada than the US.

      Well, one might argue that “perceived” freedom is more in the US, but actual freedom is more in Canada. 😉 I totally hear your points on the restrictions.

    • An anecdote to Ken’s post re Canada: A couple months ago I attended an actuarial conference in Canada. The Canadian actuaries laugh at the U.S. system. They do not understand why we tolerate what we get.
      BTW, I’ve heard the same about Lloyd’s of London underwriters who take on U.S. health insurance risks.
      These, of course, are anecdotal evidence, but it’s a bit embarrassing being the American in the room during such discussions.

    • I will say one thing about Canada vs. the US. It’s more anecdotal evidence but …

      My wife’s a US surgeon. She occasionally meets Canadian surgeons in her specialty. In my wife’s observation, Canadian surgeons work fewer hours, and patients have to wait much longer to get operated on (at least in her specialty). She gets people traveling from Canada to get timely US treatment. So, her perception is that, if she were a patient, she’d rather have the American system and (again within her specialty), she feels that the US system has to lead to better outcomes on average… for those patients who have insurance.

      Of course, the new laws will give almost everyone insurance, but if doctors end up being paid less because of that, it’s hard to say what the net result will be.

    • The thing that makes obesity more than a matter of individual will is that, across the U.S. society as a whole, obesity rates began to climb rather suddenly around 1980. By the mid-90’s, even the World Health Organization was coming to see it was a global problem, which was an ideological shock to them, having the perspective that malnutrition was the major threat to global health.

      Something changed in society around 1980 or so that led to the epidemic. I find it hard to blame technological developments such as processed foods, automobiles, and television because all of these were ubiquitous by 1970. One of the most interesting clues I see is that stress is strongly linked to obesity: I just finished reading a conference proceeding titled “Stress, Obesity and the Metabolic Syndrome”

      Here are my three crazy theories:

      (1) Environmental chemical: there’s some chemical that’s entered the food supply or general environment that leads to weight gain. For instance, there are quite a few growth regulator fed to meat animals.
      (2) Women entering the workforce: this is probably the largest social change in the last century — it had some good effects but it also had some bad effects. People eat fewer home cooked meals, they’re now more likely to get grease-bombed at a restaurant. Women feel stressed because they’re working but still doing the bulk of child care and housework.

      That s said, men are doing more work around the house, which is now a less stable environment, and are also facing a world with vanishing social mobility: if upper class professions can pool of applicants from upper class backgrounds, there’s no reason to look for talent in the middle and lower classes. Downward mobility becomes easier, and an increasing divorce rate adds additional stress to individuals and families.

      (3) Reagan (conservative politics and globalization.) Once more, upward mobility has disappeared, the social “safety net” is in tatters, people have less job security, etc. It all adds up to more stress, and more stress-driven eating.

    • Gary,

      Great, thanks. We’re talking data here, and you throw out some anecdotal evidence based on conversations between your wife and other highly-compensated surgeons about what extremely wealthy Canadians do to get treated faster. Exciting stuff, thinking about what the richest people in the country can afford to buy.

      Having lived in both Canada and the US, the American medical system doesn’t seem to have much of an advantage even for the insured, unless you consider it advantageous to get a lot of error-filled bills in the mail, which require you to spend hours on the phone with an insurance company’s customer service department.

    • What the analysis leaves out is the high rate of poverty, particularly child poverty in the United States compared to other nations. Even more important than poverty per se is the poverty gradient. The greater the divide between rich and poor, the poorer the health status of both the poor and middle class. The famous study of the British Civil Service showed that people at the top of the hierarchy lived longer and in better health than those at the bottom. Given the availbility of fairly equal medical care since 1947 in the UK, there is obviously something else at work here besides medical care.

    • Between obesity, the accident factor, and the poverty gradient, it sounds to me that there is little evidence that our low life expectancy ranking says anything about our health care system. We could have the best health care system in the world (and might actually have it), and still end up with the relatively poor life expectancy ranking we have.

      Additionally, as far as my wife (a surgeon) can tell, most of the most effective drugs come out of our healthcare system. So the countries that brag about their systems relative to ours are, perhaps, being a little disingenuous because their strong results are dependent on our drugs, for which we pay a disproportionate share of the development costs.

      This view only works if we view “health care system” as an entity that isn’t responsible for persuading people not to eat lots of junk food, etc. As a consumer of healthcare, who is fully free to choose a healthy lifestyle, I do regard it as independent. (But I also think that somebody SHOULD be doing the persuasion work, and that it has to be the government, as happened with cigarettes.)

    • I know this is beside the point of the article, but what’s with the German suicide rate? It seems like you took the total rate prior to 1997 and the male rate post 1998 or something similar. If you didn’t, any idea what the reason for the increase is?

    • “…and patients have to wait much longer to get operated on (at least in her specialty). ”

      What is “her specialty?”

    • “””What is “her specialty?””””

      Retina surgery.

    • “In my wife’s observation, Canadian surgeons work fewer hours, and patients have to wait much longer to get operated on (at least in her specialty). She gets people traveling from Canada to get timely US treatment.”

      It’s only a single province, but here are the wait times for British Columbia (where I live):

      Surgical Median Wait Time Patients Waiting as
      Specialty in Weeks for the 3 of August 31/10
      months ending
      August 31/10

      Eye Surgery 7.3 15,335

      Note however the “significant weakness in these records:”

      “Data Audits: In 2004, the ministry began auditing wait list cases against other ministry databases. Approximately 14,500 cases have been identified that should no longer be on the wait list, as most of these patients have already received their surgery. These cases have been removed from the waitlist for public reporting while hospitals check the outdated cases and remove them from their booking lists. The ministry will continue to audit waitlist data to identify and examine any anomalies.

      Operational waitlists for elective surgery are compiled and maintained by hospitals and physicians. The ministry uses the data they provide solely for analysis and public reporting.”

      It would appear that the numbers are somewhat high as completed cases are not removed from the lists in a timely manner.

      If what your wife does is vision correction surgery (i.e. Lasik type stuff) I don’t think that is covered in Canada, so the choice would likely be paying for it in Canada or paying for it in the US. But for those of us that live close to the border, that’s the case for a lot of things other than medical care.

    • Yech! That formatting didn’t work at all. You’ll probably have to go to the web site to see the numbers properly formatted. But it seems the median wait time for “eye surgery” in BC is 7.3 weeks.

    • And finally, I forgot to add this bit how waiting lists are only for non-emergency (elective) surgeries:

      “In British Columbia, more than 400,000 hospital-based surgeries and treatments are performed each year. If you need surgery or treatment that is not an emergency, you will be placed on a wait list. An individual who needs emergency surgery does not go on a waitlist; they receive treatment without delay. “