• Life expectancy and health care spending

    Yesterday, I threw up a chart that graphed life expectancy and health care spending. I didn’t put in any context, nor did I spend a lot of time explaining that life expectancy is an imperfect metric, because I’ve done that many times before.

    OECD LE Spending

    My point is this. As a number of people pointed out to me on Twitter and in emails, life expectancy may not be a good metric of public health, but as a friend put it, “it seems like one of the central goals of health care is to keep people not dead longer. Not the ONLY goal..but a big one.”

    Plus, this. Our system has to have some impact on life expectancy.  Anyway, here are a few of the many thoughts I had reading your comments and tweets yesterday:

    -Even if you dispute that life expectancy is a good metric of the quality of a health care system, can we agree that the life expectancy in the richest, most resourced country in the history of the world is a problem? Even if you don’t think it’s “the health care system”, do you think it’s OK? How can you defend this, period?

    -Please stop with the “we define life differently at 24 weeks” thing. That’s been tested, and found not to be the cause of the infant mortality differences. Plus, we give the OECD this data. They don’t steal it in the middle of the night. If we really thought we were being measured unfairly, we could fix it.

    -Please stop with the whole “it’s all violence thing”. I don’t care how big a blog said it. I already went through that one, in detail, and everyone who keeps saying it has never once acknowledged the arguments made in that post.

    -Please stop telling me that we should spend this much because we’re so rich. All I hear about is how we’re spending too much as a country, and can’t afford things like SNAP and infrastructure.

    What bothers me most is not that we’re all the way on the right, or even that we are lower than we should be. It’s that we are all alone. We are spending so, so, so much more than everyone else. It’s not an even spread. I don’t want to get into arguments about the fit of the line, or about the fact that there’s a cutoff. It’s that those countries – representing lots more people than the US, by the way – are all in a reasonable relationship of more spending correlated with more life, to a point. Then there’s us. The difference is so large, it must be defended. It must be justified. What are we spending the money on, if not extending life?

    This question is especially important given the fact that we have so many people uninsured and barely able to access the system at all. We have so many people who don’t feel like they spend enough time with their doctors, or feel like they have to avoid care because of the cost.

    What are we doing?

    You want to spend this much money, fine. But I would love to see some similar charts showing the United States in a class by themselves, on some metric of actual quality.** Then, this might all make sense. Until then, this seems like a lot of waste.


    **Don’t you dare show me survival rates.

    Comments closed
    • The US is not as unique as this chart suggests. If we plot spending on a log scale as seen in this chart: http://www.bit.ly/1i1DVfY , you can see that there are a few others that share company with us: AID’s-ridden and massively unequal South Africa, Alcohol-soaked petro-kleptocracy Russia, famously disfunctional Nigeria and other sub-saharan nations.

      Still, not a comforting club to be a member of.

      • The point is that spending goes up exponentially in relation to life expectancy (which is clearly not a direct cause-effect relationship); and that the U.S. spends far more than other countries with equivalent life expectancy (roughly 3x more).

        This doesn’t change if you log the prices, it only distorts the picture.

    • Excellent post and I agree with your rebuttals to the usual rejoinders, and our isolation on the graph does indeed show more than anything else.

      However, to dovetail with your point here, what other countries don’t spend on health, they spend on their social support system — and that is where we lack. We have serious politicians here who criticize government support for breakfast for impoverished kindergardeners because freedom, and then we give huge bags of money to the medical industrial complex to provide services we know don’t help anyone. And then we are surprised when that doesn’t make things better.

      The problem isn’t that we spend too much or too little — it’s that we clearly spend money in the wrong places for the wrong reasons.

    • OK, longshot, but… it’s plausible that it’s a cultural problem, not related to spending at all. The US may be simply spinning its wheels spending more on healthcare in the literal measurable sense, but not spending enough time caring for one another in economically-immeasurable ways.

      That sounds kind of touchy-feely and out of place where normally we’re all about numbers, but there’s plenty of evidence that the US behaves differently than other cultures (http://www.psmag.com/magazines/pacific-standard-cover-story/joe-henrich-weird-ultimatum-game-shaking-up-psychology-economics-53135/)… can we attribute none of the disparity of life expectancy to our eccentricities in other areas?

      China, for example, apparently has laws requiring people to visit elderly family members ), while in the US we, anecdotally, have much lower respect for the elderly. There’s been recent articles about foods used in the US that are banned in other countries (http://articles.mercola.com/sites/articles/archive/2013/07/10/banned-foods.aspx).

      I’m not saying any one of these answers the question, but healthcare spending focuses mostly on reactive spending, or targeted prevention… not cultural prevention. I have no idea how to set up studies to measure this effect, but it probably accounts for something.

      Or, of course, it could just be bad diet and greedy economics. Just throwing ideas out, don’t yell at me too much.

      • I think China is one of the few countries we beat.

        We smoke less and drink less than lots of these countries. Please don’t try to tell me it’s all obesity, either. Lots of countries have obesity problems.

        • I think you missed a point: health care spending for elderly people (long-term care) could be reduced by a significant amount had we have laws requiring people to visit elderly family member.

          • No, I didn’t miss the point. There’s just no evidence for this!

            • I feel like we’re off topic a bit, because I feel like I’m defending a point that I didn’t mean to emphasize (I even indicated that I didn’t know how to build a good study)… Still, this article, being the first I found on google — http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3016701/ — which references numerous studies that may have plenty of their own flaws, indicates “A study by Max et al. (2005) revealed that the presence of perceived loneliness contributed strongly to the effect of depression on mortality,” among other things. So there is at least a hint of evidence that zero-“cost” cultural issues may play a part. Coupled with the WaPo charts on “social” care spending, we may just be telling an incomplete story.

        • We beat China in terms of raw life expectancy, but, if we take the curve from the chart as the norm, we do so at a rather exorbitant cost. I wasn’t trying to imply that how China treats their elderly makes them live longer, but that cultural decisions affect where each country lies on both axes of the curve. Nursing home care may extend life due to the availability of medical professionals and equipment, but my point was there are large cultural divides that are not primarily driven by money or the desire to live as long as possible that still affect both measures, and are reasonably explainable.

          I found this article on Wapo (I rarely use them as a source): http://www.washingtonpost.com/blogs/wonkblog/wp/2013/09/19/the-two-most-important-numbers-in-american-health-care/ and their second chart may explain what I mean better than I’m doing… we in the US may spend in a particular _way_, focusing on direct rather than indirect health care. It’s not just that life expectancy is an imperfect metric, health spending is as well.

          And I’m sure I didn’t mention obesity or smoking or violence… 😉

      • @Chipmonkey: “China, for example, apparently has laws requiring people to visit elderly family members ” … “while in the US we, anecdotally, have much lower respect for the elderly.”

        So the often referred to communist nation requires families to take care of their own while the often referred to capitalist nation relies upon government spending to take care of the elderly.

        A bit of historical reference. In decades past NYC used to require the children of those on welfare to compensate the government. With increasing socialization that type of requirement no longer exists.

        Does that mean that less political socialization creates more respect for the elderly? 🙂

    • You should start a regular “time machine” post with links to previous posts where you’ve covered topics that keep coming back up. I think that might help against some of the zombie ideas that you keep having to kill over and over again.

    • “can we agree that the life expectancy in the richest, most resourced country in the history of the world is a problem?”

      Life expectancy is most definitely a problem, but has little to do with our health care system and a lot to do with our society. Drug and violence related deaths among teens causes life expectancy to plummet. Take a kid that died at age 14 from drugs and an adult that died at 100. Add and divide by two. That provides a 57 year lifespan. (simplistic example to make the point). Auto accidents and other accidents lower lifespan. Young men lost in battle lower lifespan. Genetics play a very big part in disease and can lower lifespan. Suicide lowers lifespan. Counting anencephalic deaths and other deaths where survival rates were extremely low or non existent lowers lifespan in comparison to those nations that don’t count those deaths.

      Do we need to work on improving our lifespan and wellbeing of society? Of course, but every dime spent inappropriately trying to increase lifespan where the healthcare system is not at fault is a dime wasted. Those dimes add up and the wellbeing of the nation falls. We are not alone as all nations are facing the same problems we are. We do spend more, but our incomes are much higher than most so we are not really that far out of line.

      Can we improve? Yes.
      Should we improve? Yes

    • it would be interesting to see this broken down by income levels as well.

    • Isn’t one of the common responses that our massive expenditures subsidize the lower expenditures of the rest of the world?

      I know why that’s not the case (scale – the amount we’re overpaying is way more than could be accounted for by those effects) but that could be useful to go into, or link to.

      e.g. the TIE FAQ post on pharma costs, that shows that the amount we overpay, itself, could fund all of pharma R&D, twice.

    • Can any of this gap be explained by immigration? We have a large number of Latin American immigrants that are becoming a greater share of our population. I see several lat am countries below us (all on the line). Can you control for place of birth?
      *note: I am one of these immigrants and like our porous borders.

    • So I think people skeptical of this plot would probably say it’s not as bad as people make it out to be. Yes, in your other post you argue against violence explaining this difference. But does it shift things the US to a place closer to trend? Even if it doesn’t explain everything, doesn’t mean it can’t explain a portion. Then just slap a little ‘american spends more on innovation to improve quality of life, and other countries reap the benefits’ and you might get to a decent counter-response.

      I doubt these are reasons why we shouldn’t be under a single payer system, or at least spending less. The marginal benefit we get from this spending in the form of the latest Asthema drug just isn’t worth it when we could be helping some at-risk kid get into college.

      But for the same reasons (single-cause thinking) I’m skeptical of the counter-response, I am still skeptical, to some degree, in this plot. At least when you throw it up there with no caveats.

      • Joe, I’m not an expert by any stretch, but I did experimentally try to see what the effects on life expectancy from murders, car crashes, and “excess” (excess for whatever reason) infant mortality, and of course it moved us in the right direction, but not a lot.

        The calculation I used was

        adjusted = (78.37 – 25 * 0.006 – 30 * 0.0135 – 0*0.003) / 0.9775 = 79.6.

        average age of murder death is 25, 0.6% of deaths.
        average age of car crash death is 30, 1.35% of deaths.
        average age of infant mortality death is 0, “excess” is 0.3% of deaths
        (that is, excess infant mortality is 3 per 1000)

        0.9775 + 0.003 + 0.0135 + 0.006 = 1

        Feel free to disagree with my assumptions, plug in your own, and redo the math to get a different number. The average age of death for car and murder victims I pulled completely out of the air, but I thought I should aim young. (Hah, Bureau of Justice says “27” for murder victims, but good luck finding the average age of a car crash death).

        In the rank order of life expectancy, that adjustment (which is crude, but I think also pretty generous to the US) moves us from #49 to #37 — but it’s extra-generous because I’m not erasing car crash deaths or adjusting infant mortality in other countries (Portugal, Belgium, and South Korea are cases where this might matter).

        I’m pretty sure I’m doing this slightly wrong, that “life expectancy” is calculated in some other way (the guys dying today at age 30 had their “life expectancy at birth” calculated 30 years ago), but these numbers move slowly so I don’t think I’m a lot wrong.

        • Yeah, I don’t have the time to go over the numbers myself. But I don’t think it really matters. The criticism is relying on a single plot without context to say what one wants to believe. Unfortunately, people are doing this far too often these days.

          I take the basic point of the plot–America spends a lot and doesn’t have a lot to show for it–but that really only is evidence against the naive arguments you find on WSJ comment threads: that the U.S. system is best in everything. The sophisticated counterargument is that the extra spending *IS STILL* worth it, and violence, demography, and other factors, while not explaining everything, explains some of the fact that the U.S. doesn’t match trend. And that’s why just showing this plot isn’t helpful. Both sides (reformers and sophisticated current-system backers) see what they want in the plot.

          The proper argument for pro-reformers is to push back against people like Tyler Cowen. It is completely reasonable that a single payer system with cost controls would produce a better outcome. The market has optimized to a point that it is bankrupting the nation, provides little justice, and all because healthcare is EXTREMELY different than other goods–no one wants to skimp on health care, and reasonable people think people have a right to some level of it (since it is crucial for ones self-determination). Maybe a new system would cost some innovation, but that may be completely acceptable. It’s like Tyler Cowen wasn’t an economics professor and doesn’t know about marginal benefits and opportunity costs.

    • Only thing I could ever come up with was our inordinate love of automobiles and cheap gasoline. Lack of exercise from walking and biking looks like a multi-year hit on life expectancy — fair larger than the bogus explanations of “violence” and “infant mortality”.

      But do people in other countries get that much more exercise, taken as a whole? Half the Dutch population rides bikes a lot — but there’s a fraction that rides them a lot less, and another fraction that rides them not-at-all.

      • Those issues are probably almost identical in Canada — so much so that Canadians often drive to the US to buy cheap gas.

    • What I don’t understand is why the defenders of the American healthcare system line up the way they do. Obviously, those of us on the inside are not above feathering our own nest, but what are the motivations of others? I frequently hear strongly voiced defenses of our system from upper middle class people. That stratum of society is otherwise pretty prudent about money matters. Paying first-class fares for a ride in tourist class would seem to be against their practice in life. Even if you look at survival for age 65 on (which excludes much trauma, violence, drug life styles, etc), the US is the big spender getting mediocre value.
      For working class Americans, health outcome statistics should include bankruptcy rates. We have 1.2 million personal bankruptcies annualy; reportedly 50-60% are due to medical bills. This means healthcare is financial Russian roulette with maybe half a million people a year getting hit.
      I just don’t understand the search for finding some way of massaging the data. Do Bernie Madoff’s clients keep expecting a big check from their accounts?

    • I see it as two separate unrelated problems:

      1. Life expectancy is low in the USA. If you compare Italy with Denmark you will see that we have this problem in common with Denmark. Maybe the below is why the Danish lag the Italians by so much.

      An unusual Dutch initiative aims to put an end to one of Amsterdam’s worst nuisances — those bawdy, loitering alcoholics — by employing them in a kind of street cleaning corps. The problem, though, is that the state-financed Rainbow Foundation behind the project pays the self-professed chronic alcoholics in beer for their labor.

      2. Healthcare costs way to much in the USA. Deregulation or price controls might help.

      BTW Healthcare is mostly regulated at the state level in the USA and Colorado and Utah do OK in the 2 areas. Draw your own conclusions.

    • Chipmonkey beat me to it with the reference to the Washington Post article.

      Are we really measuring health care spending if we exclude spending on social services that arguably affect health outcomes?

    • A better measure would be a comparison of life expectancy by country and economic class. Obesity is a problem. Heart disease and diabetes are huge killers both are prevalent in lower class. Nutrition habits amongst the lower class are awful.


    • Aaron, I think you’re showing some bias with facts. You wave off the point about obesity, saying many countries have obesity problems. The fact is that the US has the highest obesity rate in the world, and obesity is clearly going to reduce life expectancy.

      You claim that because the death rates for these US-specific factors are low, then the effect on life expectancy will be small, but these aren’t numbers. We’re about 4 years below Japan and less than a year behind UK. Is the increase in life expectancy going to be less than 1 year? Do you have evidence.

      Also, you criticize others for not having evidence to back up their claims. Is there evidence that the health system is responsible, which seems to be your view?

      Here’s a paper saying it’s not the health system’s fault. http://www.nber.org/papers/w15213

      • My argument isn’t that it is the health care system’s fault. My argument is that the huge amount of spending we are doing doesn’t seem to be paying dividends. My argument is that there is a lack of evidence to support the spending. In light of that, why not spend much less?

        And I didn’t dismiss obesity. I said it can’t be the total cause (and I’ve done the prevalence post/cost post already). If you can’t be bothered to read the other posts on the topic here, I can’t help you.

        • As you suggest, you chart speaks for itself. Something’s wrong here.

          On what, then, should we be spending less?

          Saying that “we” are spending too much suggests that someone is being overpaid for something. Who is being overpaid, for what, and who’s doing the overpaying?

          I’ve just stumbled on the blog — this is the first post I’ve read — so forgive me if you’ve already addressed these questions elsewhere. Maybe you could point me in the right direction.

        • Aaron Carroll: “My argument is that the huge amount of spending we are doing doesn’t seem to be paying dividends. My argument is that there is a lack of evidence to support the spending. In light of that, why not spend much less?”

          Dr. Carroll, you are 100% correct at least according to my thinking. However, the spending isn’t due to market place ideas rather it is due to all the rules and regulations along with third party payer. This doesn’t mean that government shouldn’t be involved. It only means that the involvement to date has been too expensive.

          If we got rid of some of the craziness I believe we would save a ton of money and have lot left over to adequately care for those in need and still have money left to return to the taxpayer.

        • I don’t think anyone in health policy thinks a benevolent planner would allocate so much money for treatment and so little to behavior modification and public health (ie banning cigs, trans fats, big sodas) but both parties in America are both much more interested in high tech treatments than behavior modification because let’s face it, Americans hate the idea of being told to eat their broccoli.

          If anything Democrats push high tech treatment harder by trying to community rate health insurance. Republicans don’t want to tell people to eat their broccoli but they are somewhat open to letting people suffer the consequences of their options which would do a little bit to deter suicide by ingestion.

      • Any paper that uses “survival rates” isn’t worth the paper it’s printed on.

        (That point has been repeatedly addressed in this forum. Search for “survival rates” and you’ll find dozens, if not hundreds, of posts on this very issue.)

    • Aaron, I agree with your last comment implying that some more precise charts on the US would be useful to see. For instance, breaking down the amount spent by socioeconomic classes versus life expectancy within those classes.

      It would also be informative to know what factors go into the concept of “spending” — does this include, for instance, the inordinate amount of money spent on TV advertising of prescription drugs (an insidious practice that is not permitted in certain countries, including the one where I live (Australia).

      Does it include, for instance, the amount spent on health insurance by corporations as part of employee benefits, including those monies that aren’t ever used because the employee isn’t sick? Malpractice insurance premiums paid by doctors and hospitals? How is the monetizing all accounted for?

      So — you’re right. There’s a lot of $$ disappearing somewhere, and into what…?

    • Here’s a monkey wrench for this discussion.

      Maybe it’s the lack of quality of the US educational system.

      We do way worse than a lot of countries on math and science ability in grade and high schools. In all of my interactions with medical systems, both Japanese and US, it seems that one has to take control of one’s care, or have someone with a decent science background, strong logical thinking, and willingness to take the time to do the internet searches making sure the system doesn’t mess up.

      Could someone with better statistics than mine check for the correlation?

      This would also explain poverty being correlated with shorter life expectancy, since the US does worse in education for it’s poorer citizens.

    • Life expectancy might not be a perfect measure at all. But, it the comparison in your figure is helpful. For some additional suggestions, see
      Note slide 22.

    • >This question is especially important given the fact that we have so many people uninsured and barely able to access the system at all. We have so many people who don’t feel like they spend enough time with their doctors, or feel like they have to avoid care because of the cost.

      I’m a bit confused why you bring this up. I’m aware this blog has a unique perspective on the Oregon Health Experiment. But even after cherrypicking and focusing on self-reported effects rather than medical observables, it’s pretty clear that the effect of increasing access to health care was very small.

      So why bring up things like uninsurance and people’s feelings when we know they don’t come anywhere near explaining the gap?

      (Incidentally, one explanation for this graph is simply that we are way past the point of diminishing returns and can simply cut spending to move closer to the trendline. That’s my preferred solution – cut until we can unambiguously measure some pain. )

    • A few questions:

      How much of what we pay in the US is because we are developing much of the new technology? If we eliminate the premium, what is the opportunity cost to the world in terms of less developed treatments and drugs?

      If a major cause of shorter life expectancy in the US is because of lifestyle, should we do anything about it besides educate people? If we established a totalitarian feeding and exercise regime, we could probably dramatically reduce deaths from unhealthy lifestyles, but it wouldn’t be a great place to live.

    • A good post, and thank you for the pre-rejection of the arguments that you have already heard, understood, and found wanting – it saves a lot of time. Admittedly at the risk that you might foreclose something that actually is material, but you’re both honest and well-informed, so I doubt that is the case.

      1) Why is our life expectancy lower?

      This one is easy. Largely, because about a sixth of our population is African American, and we’re comparing it to countries where none of the population is African American. For a variety of reasons, including racial oppression and the lingering/transmitted deficit of care caused by it, African Americans have much lower life expectancies than do Americans of Caucasian or Asian heritage. The exact figure varies by geography, social class, etc., but its 5 years less at minimum, 10 years for some largeish subgroups. That takes 1 to 2 years off the national number, which puts us squarely into the middle of the Europack.

      There are other reasons that contribute, but dollars to donuts, this is the one that contributes the most.

      2) So why the hell are we spending 2 to 4 times as much as the Europack, for the same outcome?

      Here I’m less definitive but here’s a few hypotheticals, all of which I think have plausibility, in descending order of how much money I would bet that they pan out as having at least some truth to them.

      a – we spend a lot of money on useless care, which we spend because it’s our choice rather than someone with a more rational assessment of the situation’s choice. Sometimes, this saves grandma; more often, it just churns a lot of money and useless procedures through the system but has no impact on outcome: grandma dies anyway.

      b – we carry the lion’s share of the R&D load for medical science and we pass the cost back to the American consuming population as a whole. Europe does a lot too, but we do more. This is then compounded by European regulatory controls on pricing which means that the American biotech firm can’t rely on its ability to extract big money from the Irish in Ireland, so they gotta get fully repaid here.

      c – we didn’t lose an enormous chunk of our population in World War II, meaning that the generations that have just finished dying off (at enormous medical expense) were larger, relative to population, than they were in Europe. We lost 0.3% of our men; Britain lost about 1%; Germany lost 10%. Since the number of women killed was not nearly so large, subsequent generations (you and me!) were about the same size as they would have been anyway, but many European countries had a huge reduction in effective expense for old-age medical care because the men in question never got to old age.

      d – Related, we lost a lot more people in the wars of the 1960s and on than Europe did, though nothing like the figures from WWII, but we also had a huge number of survivors who require(d) very expensive care, sometimes for life. Medical care for Iraq and Afghanistan war veterans is expected to cost the VA $6 TRILLION over time. Vietnam figures are probably worse; a lot more guys got hurt.

      e – I’m putting this one last even though I am morally certain that it is a cost, I am not sure what the European equivalent is, so I don’t know how much of a difference it makes. Every system pays the cost of capital; our system pays much of it in profits to insurance companies. I don’t know enough about the European systems to guess at their cost of capital; wouldn’t surprise me to find out that private insurers get it cheaper than big eurosclerotic bureaucracies, nor would it surprise me to find out that greedy capitalist overlords extract way more for their financing services than need be. So I dunno how it comes out net-net, but cost of capital is a relevant comparison.

      • Wow, Robert:

        As far as I can tell, you’re saying the health of one sixth of Americans is unimportant to how our health system performs?

        High African American infant mortality is a part of their lower life expectancy. Yet, infant mortality is strongly correlated with pre-natal care. So high African American infant mortality is a FAILURE on the part of the American health care system, not an exogenous fact.

        Ditto care of chronic diseases. African-Americans who are dying ten years too soon aren’t dying because of slavery and Jim Crow. They are dying prematurely because of the quality and access to health care in the system that we have to day and in the last 20 years.

        I’d say one of the biggest problems with the American health care system is that all the people who have decent access and care are so willing to dismiss those who don’t as being unimportant or undeserving.

        But I hope you appreciate that the only thing keeping you in the group with good health care is money, not your white skin. If you have the money, American health care is the best in the world. But God help you if you lose your job or run though your assets dealing with a chronic disease.

        • Sorry it took me a long time to answer you, SAO, haven’t been on this site for a bit.

          I am not sure how noticing that a large ethnic subgroup of Americans has a lower life expectancy, and noticing that the nations we are comparing ourselves too do not have significant populations of that ethnic subgroup, and doing some kitchen arithmetic is tantamount to saying that the members of that subgroup are unimportant to how our health system functions.

          Life expectancy is a pretty important statistic, but at the national population level it can be misleading, If we look at the US vs. Denmark and conclude “oh my heavens, middle-class people of European ancestry in the States are dying years and years before middle-class people of European ancestry in Denmark, what are the Danes doing right or what we doing wrong? Oh! The Humanity!”, then we are (a) wrong about the comparison between the majoritarian subgroups, (b) wrong about the identity of the people who are being less well-served and (c) going to focus our effort on fixing problems that may not actually in fact exist. We may compare the countries, notice a huge difference in senior spin classes for 70-year old women, and launch a crash old-geezer-spin-class initiative in the retirement belt, doing jack/shit to the actual mortality problem. Whereas if we focused on the African-American population, including in the ways that you list in your comment, we could move the number up a lot faster since we would be doing something relevant to the problem.

    • Few have mentioned that in the US the business of health care gets more attention than health itself. From the point of view of the maximizing earnings and income for those in the health care business, we’re doing fine.

      Low-cost solutions to our diet and exercise problems would not help the GNP, and it’s the GNP that ultimately drives US policies.

    • I find it interesting that the focus of the comments is the metric used and not so much on why the US spends so much on its healthcare.

      Canadians want your gas with significantly lower taxes on your side of the boarder but plenty of Americans cross the boarder for Canadian health care because what we charge for non-residents is still a fraction of what the US systems charges.
      The American healthcare system is a for profit system in all aspects and that is the biggest problem.
      The American system doesn’t have the bargaining power within the industry that other countries have that providing health care nationally which saves money when dealing with providers.
      eg. un-name country needs to purchase multiple MRI machines/drugs/medical supplies for the nation they can bargain for the best price with the manufacturers, in the US there is no large scale bargaining and each provider pays what the manufacturer wants to charge – and this is rampant problem within the American system because you are being charged multiple times more what other nations pay for the exact same things.

      You also have a fixation on un-needed procedures for convenience, look at the national level of caesarian sections and inducing labour, over 30% and climbing, and from a medical stand point caesarians should be at 8%. Caesarians and inducements cause a lot of complications which if looked at closely would no doubt contribute significantly to the maternal mortality rate. But it’s a money maker $30,000 for the average caesarian in the US – note they are around $10,000 in Canada for non-residents, also the doctors then don’t have to spend hours waiting for labour to progress normally and safely, instead perform an un-needed surgery that in the end actually causes a lot more risks for both mother and baby.

      Then you also have the county run hospitals that are under the gun to provide services to those who have no where else to go and if they cannot pay – the government ends up footing the bill for those people – so you pay already over inflated prices for individuals and then have to foot the bill. The ACA is suppose to help eliminate this but it will not help with the over inflated costs to begin with and still providing government run insurance to cover the over inflated prices – so it’s kind of ridiculous to think the ACA will in fact save you money when it really won’t help reduce the inflated rates you pay to begin with — it just helps get people the access they need which is really important but really won’t save money in the end because of the costs of your healthcare.

      Why do you think the medical industry lobbies against government run healthcare so badly – because they will lose their biggest and most profitable client — and this again just shows yet another corporate machine that is profiting off of a really messed up system.

      Good luck America

    • “What are we spending the money on, if not extending life?”

      I thought you’d had plenty on this before – the hospital, salary/fees technology and drug costs in the in the US are far higher than elsewhere.

      As Ezra Klein says: “There is a simple reason health care in the United States costs more than it does anywhere else: The prices are higher.”

      What you have in the US is a massive cartel that’s been immune to regulation and negotiation.. When you have the CEO of a hospital earning millons of dollars vs say about $200,000 in Europe you know you’ve got problems.

    • I don’t agree with the fitted curve. To me, it looks like there should be a peak around $4000 but then a decline in age expectancy after that.
      That would suggest that, above a certain dollar amount, medical care becomes counter-productive. More money, die sooner?

      • Or perhaps it says that those with moderate incomes buy medical care and an increase in years but, beyond a certain dollar amount, they can’t let the doctor do it – they have to start taking better care of themselves. The wealthy, on the other hand, think they can just pay the doctor to keep them healthy but actually find that if you don’t pay attention to your own health, no amount of money will help.
        In other words, as you transfer the responsibility for health from yourself to the doctor, the shorter you will live. Keep that responsibility and use the doctor as an adjunct, not a replacement, and you live longer.

    • What are spending money on?

      Mostly the same stuff other countries spend on but with much higher prices. What do those higher prices buy?

      They give doctors, hospitals, malpractice lawyers, drug developers and healthcare technology firms higher incomes. That buys us (and the rest of the world which free rides) better treatments in the long run.

      We also buy care for the big time screw-ups without having to give them insurance, and the ability to eat like pigs without dying younger. And of course we get longer lifespans conditional on being sick with terminal illness. But the main thing is rents for providers and innovation the rest of the world free rides on.

      • It’s not true that private healthcare in the US is funding the rest of the world’s medical development, certainly not in drugs and in much day to clinical evidence building. Europe now does about as much R&D as the US, and in both the US and Europe government funds a large slice of development. The US does have a lead in machines such as proton beam.

        There’s little significant evidence that the US has better treatments and outcomes than western/northern Europe.

        Tort reform in the US has been shown not to be a big factor.

    • I’d like to see 10 of these graphs.

      — one drawn for the bottom income decile in each country, one for the 2nd to bottom, and so on, through to one for the top income decile..

    • I think the answer is to get the Gov’t OUT of healthcare, not in deeper. However, even if it could be proven that socialized medicine increased lifespans at a reduced cost, I would STILL be against it because freedom is more important and nobody has a moral “right” to take another person’s property by force. SIMPLE AS THAT FOR ME…

      • JC writes:”even if it could be proven that socialized
        medicine increased lifespans at a reduced cost, I would STILL be
        against it because freedom is more important and nobody has a moral
        “right” to take another person’s property by force. SIMPLE AS THAT
        FOR ME…” Nothing could be simpler, I agree. This is the right wing
        argument in a nutshell and hard to find in so pristine a form.
        Rarely does anyone argue in public that private property will
        outweigh life in a cost-benefit analysis. But this is a notion of
        private property accepted by no nation on earth, however convincing
        it may be among pirates, robber barons, and other lawless but
        powerful people. Its weakness is in thinking that a tax is simply
        redistributing money from Mr Rich to Baby Poor. Actually, taxes
        take money from the public in lawful amounts—one does have to
        assume the legitimacy of government, more specifically of
        democracy, and not be a total anarchist to accept my argument. That
        legitimate power of government to tax was ceded by the people in
        the Constitution. (“We the people….”) That makes it a moral
        exertion of power. There is implied force in taxation, but not all
        force is illegitimate, everyone agrees. The taxing power (federal,
        state or local) uses the money for public policies approved by
        legitimate representatives. Government revenue is no longer the
        money of Mr Rich. It is the nation’s money for health, education,
        war, etc., and no individual may prevent the sovereign people from
        acting. Whether the money is raised equally from all citizens or
        spent equally are political decisions validated morally and legally
        by elections. Mr Rich does not own the public schools, army or
        government hospitals or the cash in the Treasury, however much he
        might have contributed. Far from being an immoral taking, group
        decision-making thru legitimate process is the essence of any
        civilized social behavior. See you on election day. Simple as that
        for me.

    • I wonder what the chart would look like if only Red States
      were included. Would they have actually won the race to the

    • Let me just make one more comment These posts on
      comparative life expectancy give the impression that you think that
      if the USA or Denmark had the Italian health care system they would
      have Italian life expectancy. I do not think that anyone including
      you believe that is correct.

    • the US gov under PBO, tackled healthcare from the wrong end
      of the money. starting with the little guy [who frequently gets
      caught in a financial vise…fitting punishment since we are deemed
      to be the problem] rather than starting at the top…with insurance
      companies, drug companies and corporate hospitals. it’s no wonder
      the graph doesn’t make sense. the money and how it’s used/justified
      is a more important investigation by far.

    • Dr. Carroll, You permitted a misstatement of fact and an accusation of fabrication to stand. I have posted my reply several days in a row and it wasn’t posted. It contained data along with respected citations to demonstrate that the claim of fabrication was erroneous. Ken entered a portion of the thread where he wasn’t even involved. Please correct the error so that established scientific research doesn’t play second fiddle to one not familiar with the scientific data.

      Ken Hammer: “this is quite simply a fabrication.”

      So says an individual that in another posting states:

      “Any paper that uses “survival rates” isn’t worth the paper it’s printed on.”

      Absolutely laughable! Survival rates/mortality rates are used by scientists all over the world even in Canada. What does he think Canadians use for comparisons? Apples? Read a scientific study. Take acute leukemia and compare two drugs. The metric will be survival rates/ mortality rates along with other metrics such as the complication rate.

      As far as the fabrication goes you have been provided with reliable citations previously provided on this blog:


      Nicholas Eberstadt, The Tyranny of Numbers: Measurement and Misrule, (Washington: The AEI Press, 1995), p. 50.

      That will demonstrate a difference in data collection. It documents that in Switzerland an infant must be greater than 30 cm at birth to be considered a live birth for purposes of tabulating infant mortality.

      You do add a bit of humor to the blog.

      • Emily, my comment is only on your use of “survival rates/mortality rates”. These two concepts are not the same thing and provide different information.

        See this post for a more detailed discussion:

      • Ken was misinterpreting Carroll’s statement. He wasn’t saying that you can never use survival rates EVER. He was saying that you can’t use them for cross-country comparisons. The problem with cross-country comparisons inflate survival rates with no benefit to the patient. However, an intra-country time series to compare quality is acceptable. (However, even these sorts of studies mention the possibility of lead-time bias and earlier screenings.)




        For further explanation of the many types of bias that have yet to be disconnected see:

        Also Aarron is right to call out your claims without evidence. You cite two non-peer reviewed books by conservative publishing houses, that site one or two countries on the list. It seems to be the best argument you make is that France and Switzerland should be taken out of the list, but that still leaves 10 other countries better than the US in infant mortality. I agree that one shouldn’t read too much into these numbers, but you’ve got a long way to go to show that the U.S. does better in IM.

      • If you don’t hold detection rates constant, survival rates are crap stats. I know statisticians where I went to school decades ago were worried about this even then; as diagnoses were getting ever more effective and we detected cancers at ever-smaller and ever-earlier stages, we inflate the pool of “sick” people with those who might otherwise overcome their cancer on their own or die of some other cause before it would have been detected using old diagnostics.

        Differences in infant mortality definition don’t make a large difference. I tested all those claims myself once, it’s not very hard arithmetic, and the “corrections” did not move us to anywhere near the front of the pack (from #49 to #37, +1.2 years leaves us still below the 80-year line). Your claim is true in the literal sense of “yes, that does improve our standing slightly” but misleading in the sense that all these “corrections” combined do not change the basic picture — we spend a lot, and get sub-par results, even if we discount all our murder deaths, even if we discount all our car crash deaths, and even if discount half our infant mortality.

        So what’s your point, really? Someone on the internet was rude to you, therefore they’re wrong? Math doesn’t work like that.

        • +1.2 years is a lot, that get us to average

          Presumably diet explains another couple years, stress from work could explain more, and who knows what else and then all the sudden the US might be at the top.

          Remember, no one is claiming there is a large increase in LE from spending on medical care. The claims about the benefits of medicine are about a few 0.01 increments in LE * $200,000+ value of life-year = plausible justification for spending $4k extra.

          • +1.2 years does not get us to “average”, unless you decide you want to include a lot of countries that I would not normally think we wanted to be compare to (Mexico, Brazil, China, Russia). That increment gets us to not quite 80 years, which is still bottom of the pack among countries that spend much money at all.

            And my correction was entirely kind to us and unkind to every other country. I tossed ALL of our murder deaths and ALL of our traffic accidents. We’re unusually violent, but that’s only about half the effect of traffic accidents, and lots of countries have traffic accidents. Car crashes are good for .6 of the +1.2 adjustment. You can’t actually use my estimate to show that we’re doing well, only that we’re doing badly, because I skewed the results heavily in our favor and did not apply the same adjustment uniformly to other countries.

            Looking only at the countries “nearby” in the expectancy rankings, I spotted 3 others that might benefit from the same visit to the data salon for a makeover (Belgium, Portugal, South Korea), and the same special pleading might apply to many countries further down the curve, and that would lift the “average” even if we decided to include the low-spenders. Among the other countries doing better than us, removing their own anomalous deaths will only raise the average that we lag.

            And these other causes that you propose — where’s your math? Can you show your work, or explain your methodology? And you do know, that smoking is surprisingly prevalent in other countries, and others drink quite a lot? We don’t have a monopoly on bad habits.

            (For reference, “showing my work”, with bonus political insults, because I get really tired of people who make bullshit claims: http://dr2chase.wordpress.com/2012/12/13/democrat-math/ )

            • Methodology: I pulled some numbers out of my ass based on my prior.

              Alternative methods: Put garbage data into a regression, use point estimates of causal effect (for smoking, alcohol, diet, etc.) + massive selection bias term.

              Note: You’re arguing that all this stuff doesn’t explain why the U.S. sucks on LE so you’re argument only works if you round up. That’s why I have to round up too.

              The regression estimated effect is that obesity decreases life expectancy of young people by 10 years (give or take A LOT) and about 20% more people in the US are obese compared to the healthier European countries. You do the math.

              Other people who have used the regression BS method have estimated effects around 1.5 years give or take, what, 5 years?

              Also, the U.S. clearly does have a big problem with bad behavior and environmental factors . . . you can see the large residual in the graph. Russia does too.

      • “Look at the Concord study and use that for your arguments.
        That is one of the few good cross national studies ever performed.
        If you want to say that early diagnosis increased survival based
        upon solely early diagnosis you can, but when you look at the raw
        data you will find things that don’t fit neatly into what I
        interpret your scenario to be.” I have, and you’re wrong. The
        critique still stands. If you wish to present evidence instead of
        statements I’m ready to evaluate them. I provided 3 citations, you
        provided 0 (since Concord actually helps my case). “By the way if
        early diagnosis doesn’t help in increasing survival rates then why
        do mammograms, colonoscopies, pap smears etc.?” Of course early
        diagnosis helps survival rates. No one said it didn’t. But the
        point was that early diagnoses INFLATES *5-YEAR survival rates’
        “What are you talking about? You cannot just assume that those that
        agree with you are appropriately peer reviewed and those that do
        not aren’t. That is what is what your comment sounds like.” I
        didn’t make that assumption, you did. I cited VERIFIABLE peer
        reviewed studies. You cited two **NON PEER REVIEWED BOOKS**. I
        actually have no problem including those books as evidence of
        justification of a claim, but the point is that research by a
        single individual, that has not been confirmed, and has never been
        evaluated by any other individual *IS NOT STRONG EVIDENCE* FOR
        JUSTIFICATION* Please provide evidence that either of those books
        were peer reviewed. “No it doesn’t. Look at the statistics in the
        various weight classes. When you look at them you find out how good
        the US is in treating low birth weight deliveries. These statistics
        are not questioned. They are simply left out of the argument. You
        can say what you wish, but I think even the WHO is recognizing
        things you have yet to envision.” Look, you can’t just say things
        without evidence. I looked into those statistics and I found out
        that you are 100% wrong. Not only are you wrong, but the data
        actually proves the OPPOSITE of what you’re saying. Just look at
        the data! See what I did there. I can say something too without
        backing it up. (Of course, that’s just an example, I try my best
        *NOT* to do that.)

    • Oncodoc, that Himmelstein bankruptcy study has been debunked so many times I am surprised you bring it up. If a billionaire goes bankrupt and he had $1,000 in medical expenses that year the cause of the bankruptcy was blamed on healthcare costs. The same type of craziness is found with a whole bunch of other metrics he used. The statistics on life span though valid don’t have much merit when used to determine the quality of a health care system.

      We do spend a lot on healthcare, but you know what? We spend a lot on TV’s, Lattee’s and all sorts of things so it really isn’t that much out of proportion even though we all find such spending undesirable.

      I’m not going to rehash the quality argument for when outcomes are used we do pretty well. When we lump in violence, genetics, drug use, auto accidents, etc. then our numbers fall, but that is more a result of societal problems not the problems of a health care system.

    • I haven’t read all the posts, sorry if this is a duplicate.
      Have you factored in that our healthcare spending includes medical
      research that is widely used, tested, and then adopted around the
      world? Are we bearing a disproportional cost to develop the care
      used in other countries, thus in effect inflating our spending vs

    • Hi Aaron, I am a little slow gathering data but I found this that you might find interesting:

      What are the causes of early death? This study seeks to rank different causes of death according to “years of life lost”–that is, a cause of death that affects people at younger ages is counted more heavily than a cause of death which affects people at older ages. Here’s the comparison from 1990 to 2010. Notice that the top six causes of years of life lost change their order a bit, but are otherwise unchanged: heart disease, lung cancer, stroke, chronic obstructive pulmonary disease (COPD), road injury and self-harm. But after that, there are some dramatic changes. For example, the years of life lost because of HIV/AIDS, interpersonal violence, and pre-term birth complications are ranked lower. However, cirrhosis, diabetes, Alzheimer’s disease, and drug use disorders now rank much higher.

      It looks like road injury is the 5th leading cause of years of loss of life in the USA. Impersonal violence is number 12 and drug use is number 15. These are quote significant. Add to them the early deaths due to more use of fertility treatments in the USA and the low birth weights and higher than average incidence of natural multiple births among people of sub-Saharan African decent and combined they can be quite significant.

      Cirrhosis is number 8 and that alone might narrow the gap between Italy and Denmark significantly.

      You might want to address these in a post.

    • Thank you for this graph. I actually draw great comfort from the reality implicit in these numbers. The US is the world’s greatest outlier in health care expenditures and does not perform as expected with regard to health outcomes. The statistical principle of ‘regression to the mean’ alone means we will see improvements in both metrics. The ACA is all about empowering this nation to perform the ‘medical hat trick’ of lowering % of GDP for healthcare, improving quality, and broadening coverage. How can this be possible? Let me give you three vignettes:

      A 26 year old juvenile diabetic has better access to primary and specialty endocrinology care under the ACA and does not go into diabetic ketoacidosis, avoiding a week in the ICU and $100,000 in costs…

      A 24 depressed co-ed finds solace talking to a counselor and help from the medications an ARNP provided, mental health benefits assured by the ACA, and does not take a tylenol overdose, saving a liver transplant and $300,000 in costs…

      A 90 year old comes to her primary care internist with her daughter, and as per the recommendations of the ACA, discusses her wishes for end of life care, making clear to her daughter she does not want futile attempts at resuscitation, saving a week in the ICU on a ventilator with anoxic brain damage, followed by 9 months of semi-conscious existence in a local nursing home, followed by death anyway.

      We don’t count non-events. My best work as a physician is often helping a patient avoid the MI, the colon cancer, the OD, the futile medical misadventure. American policy makers have never properly understood all this and structured the health care system to deliver such sensible opportunities before.

      I believe the next 5-10 years will be the most remarkable for American medicine since the advent of general anesthesia or aseptic technique. Medicine advances in waves, usually of discovery. This wave will be through developing improvements in the delivery system, from computerization to accessible and effective mental health services. Your graph illustrates the opportunity and hope we have to really accomplish the Hat Trick of Medicine.

      • Bruce,

        No objection to real data that would prove the ACA is working as promised. That would be desirable.

        But, talk about anecdotes not being a good way to prove policy is or is not working, here we have anecdotes that haven’t even happened. This stretches one’s belief out into the stratosphere.

    • Robert, you provided a thought provoking post. Another interesting factor to add to your high life expectancy for Asians and a lower life expectancy for African Americans is that Hispanics in this nation have a higher life expectancy than caucasians despite the fact that they are poorer as a class. Asians are immigrants as well and have rapidly moved up the economic ladder. Also take note of the differences in lifespan and poverty level of those blacks that come from the islands vs the group that have existed here for generations.

      Then look at violence, those that are dependent for generations and those without jobs. Also compare specific genetic populations (races) with high lifespans outside the US and then compare them to concentrated groups of the same race in the US. One finds that for many of these groups lifespans are much more narrowly matched.

      In business if one area of a company is falling apart we don’t level the entire company rather fix the parts that need fixing for whatever reason. SAO doesn’t seem to know the studies on pre-natal care. All should have pre-natal care, but the quantity needed varies and the way it is provided should vary as well. If targeted to those most in need Pre-natal care programs appear to be quite beneficial. However, for other populations I don’t believe these programs have had a significant effect on infant mortality.

      Drugs, violence, lack of appropriate care when young has dramatically affected certain population groups. All the care in the world will not have as much positive impact as changing the social environment. Access depends upon the patient as well as the system. Even if totally free and available the patient has to have a desire to be seen, a desire to live in a fashion conducive to long life spans, has to follow the advice given etc. This reliance by some on the health care system to cure all evils is pure foolishness.

    • I think the data in the chart supports and confirms the hypothesis:

      (H) The single biggest factor determining average life expectancy rates of a group of people is the percentage of having easy access to affordable quality of healthcare.

      If so, the chart supports the claim that the US offers less decent affordable healthcare access to its population than the other advanced economies, but pays at least twice the price of the same degree of healthcare delivered in those same advanced economies.

      As a corollary: Genetic, cultural, and infant mortality factors are jointly or individually significant factors.

      US Data supporting (H)

      Hypothesis (H) predicts:

      (P1) The 15 US states with the highest percentage of uninsured will likely have lower average life expectancy than the bottom 15 states with a lower percentage of uninsured—especially within the same cohort (uninsured whites vs. insured whites, etc.)

      Results confirm (P1):

      Compare the top and bottom 15 states of these two categories: the state average white LE’s, and the state percent uninsured whites:

      here: http://www.worldlifeexpectancy.com/usa/life-expectancy-white


      here: http://kff.org/uninsured/state-indicator/rate-by-raceethnicity/

      Prediction Strongly Confirmed—And that’s exactly the across the board result:

      None of the 15 worst LE states have a white uninsured rate of lower than 13%, and 13/15 have 14% or more. Whereas none of the 15 best LE states have a white uninsured rate of greater than 13%: only 3 of those states have a 13% uninsured rate, and 12/15 have a 12% or lower uninsured rate.

      Of the 15 states having the lowest average white LE, _zero_ had less than 13% uninsured whites; whereas of the 15 states having the highest average white LE, _zero_ had greater than 13% white uninsured.

      Fact: There is a direct correlation between US household income and lack of insurance (US Census Bureau).
      See: https://www.dropbox.com/s/dyecyd3khp4ldwq/US%20uninsured%20by%20household%20income.png

      Which means that there is a significant correlation between white household income and LE—exactly what (H) predicts given the above Census Bureau fact.

      Then do a domestic comparison of average white LE in the 15 states with the highest median household income with the 15 states having the lowest white male household income: (ranging from LE’s of 80.78 in DC to 72.26 in West Virginia.)

      See: http://en.wikipedia.org/wiki/List_of_U.S._states_by_income#States_ranked_by_median_household_income



      Prediction confirmed: 13/15 states having the highest incomes also had the longest white life expectancy, whereas 10/15 with the lowest household income correlated with the lowest life expectancies. (This from US sourced government data.)

      Moreover if making affordable access to quality healthcare is the single most important factor in predicting LE globally. Then the original LE/spending chart we began with is pretty much what one would predict: countries with lots of uninsured and lacking in access to decent affordable healthcare will tend to have a lower average LE than countries that provide universal affordable, decent quality care.

      So on hypothesis (H), what explains why the US is such an outlier? Well it’s not such an outlier on the scale of average LE (78 including men and women). There is about a 10% lower LE for the US than the average for the advanced economies. So while most Americans have access to decent affordable care we have approximately 15% of the population uninsured, but not completely without access to medical care. That scenario goes a long way to explaining why the US has a lower average LE, but not a dramatically lower LE.

      But why then the dramatic difference in cost? No mystery there: the other high performing advanced economies are more than twice as cost efficient in the provision of healthcare than the same care in the US.


      • The greatest leap in lifespan came from sanitation not healthcare. We ought to remember that as we see incremental increases or decreases in lifespan. Thus the argument linking lifespan to the quality of healthcare is faulty.

    • Surely the healthcare issue we should be addressing is why the US performs so poorly vis a vis the rest of the developed world in infant mortality and longevity. The former could possibly be explained by access to pre- and post-natal care, the latter by violent death unrelated to disease (crime and vehicles). These data should not be too hard to come by, and might suggest where we should be spending the money.