• The state of US health ain’t so good

    There’s a ridiculously fantastic manuscript over at JAMA that you should go read right now. “The State of US Health, 1990-2010: Burden of Diseases, Injuries, and Risk Factors“:

    Importance  Understanding the major health problems in the United States and how they are changing over time is critical for informing national health policy.

    Objectives  To measure the burden of diseases, injuries, and leading risk factors in the United States from 1990 to 2010 and to compare these measurements with those of the 34 countries in the Organisation for Economic Co-operation and Development (OECD) countries.

    Design  We used the systematic analysis of descriptive epidemiology of 291 diseases and injuries, 1160 sequelae of these diseases and injuries, and 67 risk factors or clusters of risk factors from 1990 to 2010 for 187 countries developed for the Global Burden of Disease 2010 Study to describe the health status of the United States and to compare US health outcomes with those of 34 OECD countries. Years of life lost due to premature mortality (YLLs) were computed by multiplying the number of deaths at each age by a reference life expectancy at that age. Years lived with disability (YLDs) were calculated by multiplying prevalence (based on systematic reviews) by the disability weight (based on population-based surveys) for each sequela; disability in this study refers to any short- or long-term loss of health. Disability-adjusted life-years (DALYs) were estimated as the sum of YLDs and YLLs. Deaths and DALYs related to risk factors were based on systematic reviews and meta-analyses of exposure data and relative risks for risk-outcome pairs. Healthy life expectancy (HALE) was used to summarize overall population health, accounting for both length of life and levels of ill health experienced at different ages.

    I’m a health services researcher, and I’m obsessed with outcomes. One of the first major projects of this blog was a two-week series on quality in the US health care system. I’ve written numerous times about what kills us. This study specifically looked at the burden of disease, injuries, and risk factors in the US versus other countries. The methods are amazingly detailed.

    So how did we do compared to other countries? Not well. Between 1990 and 2010, among the 34 countries in the OECD, the US dropped from 18th to 27th in age-standardized death rate. The US dropped from 23rd to 28th for age-standardized years of life lost. It dropped from 20th to 27th in life expectancy at birth. It dropped from 14th to 26th for healthy life expectancy. The only bit of good news was that the US only dropped from 5th to 6th in years lived with disability.

    There’s a chart I’d like to highlight. This is the rank of age-standardized years of life lost rates among the 34 OECD countries in 2010.  The numbers in each cell show the rank of the country in years of life lost for each cause (1 is best). The countries are sorted overall on age-standardized all-cause years of life lost.  The colors show if the age-standardized years of life lost for a country is significantly lower than the mean (green), indistinguishable from the mean (yellow), or higher than the mean (red) for all OECD countries (click to enlarge):

    Ranks

    Things don’t look so good for the US. There’s an awful lot of red there. A little bit of yellow. One green. Best in the world, my ass.

    Some of you will feel the urge to blame this on the racial or ethnic makeup of the US. I encourage you to look at the variety of causes of years of life lost. They don’t favor just one group. They’re all over the place. And we do pretty badly in most of them.

    I want to highlight one more table. It’s the deaths and years of life lost for the 30 leading diseases and injuries that contribute to overall years of life lost in the United States in 1990 and 2010. They’re ranked by the size of the relative contribution to overall years of life lost. In other words, those at the top cause the most years of life lost in the US, and those at the bottom the least (click to enlarge):

    YLLWhat we have here is a prioritization issue. We spend a lot of time worrying about colon cancer. It’s ranked 11th in 2010. We spend a lot of time worrying about breast cancer. We have walks, and ribbons, and whole months dedicated to it. It’s ranked 13th. Prostate Cancer? Men are obsessed with it. It’s ranked 27th. But more years of life are lost to lung cancer than to prostate cancer, colon cancer, and breast cancer combined. Ischemic heart disease causes four times as many years of life to be lost each year as prostate cancer, colon cancer, and breast cancer combined. Stroke is 3rd. COPD is 4th. Traffic accidents are 5th. Suicide is 6th. None of these things get the national attention, or resources, that they deserve.

    We could have the best health care system in the world. We’ve got the money and the necessary pieces to get really, really good outcomes. But we need to be much smarter about it if we’re going to do so.

    @aaronecarroll

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    • Aaron
      Having read the paper, and I commend everyone to scan the accompanying editorial, one cannot but be impressed with the task accomplished by the investigators. Methods off the charts.

      Still, I am left wanting with I see #1 cause of disability in US = nutritional deficiency.

      Knowing how clunky data reads–obesity, or at least BMI <30, as contributor to M&M; macro vs micronutrients; and interplay with Rx, exercise, SES, etc., makes interpretation almost impossible. So many observational trials give us a mixed pic, yet a study of this magnitude presents so conclusive a finding.

      Saying "nutritional deficiency" seems like a proxy for DM, HTN, etc as they all rest in a similar bucket, more or less. Might as well say the sky is blue.

      Yeoman's work, and certainly serves us a slice of humble pie, but in the end, tell me something I dont know. And if you can, what do with we do with findings we did not know yesterday.

      Brad

    • Aaron can I ask you a question as a pediatrician?

      The top 10 conditions by YLL almost exclusively kill people in their later years (w/ the exception of traffic accidents + self harm). However, it seems obvious that a lot of cases of lung cancer/COPD were really results of actions started around age 16. Similarly, stroke/diabetes/heart disease are conditions that accrue over time, starting on day 1 of life depending on how the mother feeds a kid.

      The question is this: As a Pediatric intern beginning a career – how much of my duty is keeping kids alive to the age of 18 and how much of my duty is getting kids on trajectories where they don’t die at 52 of lung cancer or MI? And, if I do preoccupy myself with keeping events from happening decades in the future – how can I possibly be reimbursed in any sustainable way? It seems like the financial incentives in peds are all geared towards fixing problems that are happening RIGHT NOW.

      Just hoping to hear an opinion from someone who’s had a ton of time to mull it over.

      • It’s important to remember that most kids don’t even have abstract thought yet. You’re not going to convince them to change behavior based on things that will occur decades later. :)

        But older adolescents? You can start talking about that to them, likely.

        • On a somewhat related note, I wonder if we will see a natural correction in the COPD and lung cancer rates over the next decades simply because the smoking rate has declined. I believe that it is now close to the published rates for many of the higher-ranked countries in that report.

          Plarry

      • Will’s question is an important one, namely how much of the problem is started by habits well before adulthood.

        For kids under the age where they can understand these things, the obvious choice is to focus on their parents. If the only snacks available in the house are fresh fruit, then there’s a good chance the kid will eat more fresh fruit than they will potato chips, for example.

        And yes, as a doctor it is your role to give kids the drug talk if their parents haven’t obviously done so. Not in the sense of “cigarettes are bad mmkay” but in the sense of “I’m responsible for keeping you healthy, and these things will hurt you” kind of way. Just make sure what you’re saying is medically accurate, or the kid won’t believe you. Ditto for unsafe sex: It’s not “You’re a bad person for having it”, it’s “Here’s what you need to know about the risks”.

    • Here we go again – more bashing of U.S. healthcare. Of course, Christopher Conover already outlined the myths about quality in the U.S. (when compared to Europe) in connection with Steven Brill’s Time article. When adjusted for social and cultural factors for which doctors and hospitals cannot reasonably be held responsible, U.S. medical care is the best in the world.

      The liberal wonks who find the U.S. lacking when compared to Europe confound behavior with medical care and their criticism is better viewed as an objection to our relative lack of authoritarian government. No wonder the wonks don’t so much as blink at plans to place 315 million Americans under the thumb of a single, central authority.

      • Yeah, cause “liberals” hate the health care system and won’t be satisfied until democracy is destroyed! You figured it out.

        This was your last factless freebie comment.

      • I would believe that this is a fair criticism and a fruitful avenue to travel down if the Republican Party didn’t reflexively shoot down every effort to improve those social and cultural factors by calling them government tyranny. Exhibit A: Michelle Obama’s Let’s Move! campaign to get kids working out and eating healthier foods that has been endlessly criticized as evil or worse.

      • What in the world is Alsan talking about? A compilation and interpretation of health statistics is “bashing” U.S. health care?

        Why do so many people feel personally insulted when these issues are pointed out? What sort of black and white world do we live in when discussing the shortcomings of the health system is perceived as an attack on America and freedom? This is truly perverse and until we can get through this, we will never be able to collaborate/compromise to solve problems.

        To paraphrase “The Godfather:” It’s business, not personal . . .

        • Sheldon W: You are right, no one should feel insulted, but others are entitled to their own opinions. If competing arguments and statistics are censored out or delayed then one is looking at only one side of the coin. Things are not as black and white as some expect so we should respect each other’s position. Those in need don’t need ideologues to help them, they need concerned citizens.

        • As Americans, we want to win EVERY race. We won the Tour de France (multiple times), the space race, and the arms race, and, heck, we’re undefeated World War champs!

          So we just don’t like coming in 27th place. In anything!

    • Although heart disease is by far the biggest killer it seems that road injury would be the most tractable. I think that it would yield more lives saved per effort spent to work on road injury. Replacing CAFE with a gasoline or carbon tax might cut driving and also reduce lung disease (and heart disease now that I think about it). Of course it could backfire by getting more people to ride motorcycles and bikes. You could also use the tax receipts to fund self driving car research.

    • Road injury YLLs declined by 33% from 1990 to 2010. Nevertheless, road injuries remained the second and fifth disease or injury contributing to YLLs for males and females, respectively, in 2010. Age-standardized YLLs related to road injuries in the United States are exceeded only by those of South Korea, Greece, and Mexico. Compared with Sweden and Iceland, which have the lowest road injury death rates in the OECD, mortality from this cause in the United States is 3-fold greater

      I wonder if you take out Road Injury and Interpersonal violence out how close the USA gets to the mean.

      It is interesting to me that a state like North Dakota can get very close to the European mean life expectancy even while the rest of the USA is so far off. I am sure that it is not a matter of the other sates doing what they do in ND.

      • Other examples of higher than mean rates with substantial potential to reduce YLLs include interpersonal violence, COPD, preterm birth complications, and diabetes, followed by drug use disorders, Alzheimer disease, and poisonings.

        One reason for more preterm birth complications in the USA is that more people in the USA get fertility treatments leading to multiple births.

    • To focus on the list of killers, I think you touch gently on some of the underlying social and personal issues that motivate response. For example, people are afraid of breast or prostate cancer because they see it as affecting them simply because they’re female or male. But lung cancer? They see that as more a behavioral issue because people know smoking causes lung cancer. And heart disease, particularly coronary artery disease? Isn’t that to people a series of personal choices one makes to eat this, not that and to drive, not walk, etc.

      In other words, some of the results seem to reflect an underlying issue of American ideology and thus may reflect the cost of that ideology. People want to believe the market generates the best results. You and I may believe “best” implies lower mortality, better health outcomes, etc. and use this data to argue the market is obviously not very good at identifying and correcting these problems. But believers in markets as an ideology see a benefit – call it “liberty” – to which they attribute value. The amount of value attributed to the ideology seems to be whatever is necessary to overcome the costs associated with the ideology … so you can’t win arguing with them. We can, however, use this data to quantify in certain ways the costs of ideology. (But of course we already do that by, for example, counting the number of gun deaths, the number of children killed by guns left lying around, etc.)

      An associated problem is that ideology has a need to proclaim its virtues. America has the best health system, bar none. Repeat. The issue isn’t that this is wrong but that there is a need to say it. We can attribute that to ignorance but certainly experience looking at the internet, TV, etc. shows that you can stuff people with facts and they’ll ignore them, deny them, distort them, etc. I have learned over time to consider this fact denial as a form of argument, one which rather inchoately includes other values and considerations that trump facts. See above: if you argue we have the best system, you argue for a form of “liberty” that to you has more value than quantifiable contrary evidence. Don’t want to be told to get health care, then you must argue that lots of people dying, lots of pain and lots of wasted money is not worth as much as your perceived “liberty” interests.

      This raises the long-term question: do these people believe over time their ideology will in fact generate better quantifiable results that don’t need to include “liberty” to be the best? I don’t know. I think they do. I think they tend to believe God or something else smiles on them and on us if and only if we achieve a certain standard of “liberty”. This enables them to make these arguments from the safety of knowing we’ll never achieve this standard and thus they can commit to perpetual struggle for their ideology without ever having to judge its failure.

      • Real humans have differences in values, preferences, habits, norms, and behaviors that result in variations in health status and life expectancy. What percentage of the deviations in real human being’s deviation from a theoretical optimum with regards to, say, diet and exercise are the consequence of deliberate choices motivated by an ideology derived from a personal commitment to *any* political ideology relative to personality type, family environment, local culture, etc? Do you honestly believe that people in the South – white and black – tend to eat more fried foods and exercise less because commitment to a particular ideology inspired them to do so? Are people with dangerous outdoor hobbies like mountaineering risking their lives to satisfy an ideological imperative arising from a set of political convictions?

        • My point was that people defend the current system, with all its problems so they have to attribute a value to defending rather than changing. The question is what that value is and I don’t think the issue is really in question: given the massive amount of distortion and rejection of factual evidence that shows problems in US healthcare, they must be including an extrinsic value. I call that “liberty” but you could label it “ingredient blah”.

          The point can be summarized as saying that you or I look at the health system’s endogenous concerns while many people are bringing exogenous concern into the health system.

          This has nothing to do with the bad choices individuals make. It speaks to the inability of the system to address these bad choices. So for example, motorcycle riders don’t want to wear helmets for a variety of personal and social reasons, but our inability to enforce helmet laws in many places is due to exogenous concerns like how these laws infringe on personal choice.

    • After looking up Ischemic heart disease, I was left wondering to what extent the approaches we have taken towards treating this condition go towards explaining the lack of progress..

      Stenting and bypasses are common and expensive – but some doubt their effectiveness…

      https://acountrydoctorwrites.wordpress.com/2013/07/01/fifty-fifty-propositions/

      I think this loops back to Dr. Carroll’s point in a perverse way. Because we have come to standardize how we deal with coronary artery disease – and some other things – we tend to assume that we have “fixed” the problem – know need to search further for a cure – just do more expensive – but limited effectiveness procedures…

      • LL, Though I have many similar thoughts to yours mortality is not the only way of looking at things. One has to look at quality of life and that is determined by the patient and his particular life not the average life of everyone else. Physicians can distinguish the risks of mortality caused by coronary artery disease simply by looking at which arteries are affected and their dominance. So of course many times stents are put in place where it can be well appreciated that the stent itself is not likely saving a life rather preserving heart tissue, thus exercise tolerance, and reducing pain. It is a value judgement that hopefully will improve in the future. Many people have disease of the arteries, but no intervention is performed so what we are concerned about are the gray areas.

        The question is whether some of these procedures should be paid with pooled funds. Unfortunately it seems most of the discussion is trying to promote one idea over another sometimes leading to censorship, not about separating what expenditures should be pooled and what should not.

        • Emily – not disagreement on the quality of life stuff. But here I think we have some of the same issues. My brother underwent bypass surgery a couple of years ago and is very angry today that he finds himself with a variety of mental issues. He was never told that these are “sometimes” normal outcomes from heart procedures. He tires easily – still and complains of “just not feeling right”.

          Alternatives to bypass surgery are seldom considered – or offered.

          Prostate cancer is also dealt with more agressively than many thing is necessary – and almost always results in a lower quality of life post surgery.

          So I think I would basically agree with Dr. Carroll – we have lots of room for improvement – my only quibble is that it needs to be a bit broader than just pouring more resources against the problem. Better informing both Doctors and Patients on risks and benefits and alternatives should be part of the effort.

          • LL, along with success comes failure. I am sorry about what happened to your brother, but I don’t know what to say about him or even why he had the surgery. I do know that on the whole the country has benefited from similar interventions. We should, however, strive for more transparency so that the patient and physician always have access to as much information as possible.

            Prostate surgery: I don’t think anyone has clear answers especially as to the selection method of who should have the testing. There is too much ideology injected into health care and that is influencing science. One thing I do know, but off hand cannot remember the citations. We have seen a decline in deaths from cancer of the prostate. There was also a cross comparison made with the UK where the US decline in death from cancer of the prostate was startling when compared to the British. This is of interest to me because that difference in death rates coincided with our greater use of the PSA. Correlation does not mean causation, but physicians cannot always rely upon absolute proof.

            No one disagrees on this issue with Dr. Carroll. We can always do better and in this case we should, but that requires more science and less ideology and also the understanding that we are dealing with people and complex things that cannot be managed as if they are widgets.

            • Addendum:

              LL, in the interim I ran across one of many articles that discuss cancer of the prostate and this article might be of interest to you and others.

              http://www.ncbi.nlm.nih.gov/pubmed/18424233

              Lancet: Prostate-cancer mortality in the USA and UK in 1975-2004: an ecological study.

              Interpretation: “The ***striking decline*** in prostate-cancer mortality in the USA compared with the UK in 1994-2004 coincided with much higher uptake of PSA screening in the USA” (***mine)

              Take note that I accept this as evidence but do not draw firm conclusions. The reason I hesitate to draw any conclusions about prostate cancer and the PSA is that we haven’t done any direct studies, nor do I think we can. This study and others like it are the opposite side of the coin.

              This is not something I am casually studying. I have had to deal with this exact problem thousands of times.

    • Maybe it’s my Canadian inferiority complex but in these league tables and similar exercises, I’m quite satisfied with “average” because the competition is strong and many of the “top” countries are smaller than any Canadian province (other than PEI) – the most eastern and most western provincial capitals are nearly 8,000 km apart by road/water.

      The three inexplicable results are the heart disease cluster, including stroke, hypertension and other cardiovascular, which I would have expected to be much more similar to the U.S. Is it because pre-crisis treatment is free and Canadian doctors are aggressively treating hypertension? Is it because post-crisis treatment is the same as the U.S. but poor patients in Canada get the same level of care as the wealthy (at the same price)? Both countries have the disadvantage of getting rural and semi-rural heart attack and stroke patients to treatment over long distances and Canadians are quickly becoming as obese as Americans.

      I was going to make a point about Alzheimers but forgot what I was going to say….(we really do need an effective treatment/cure).

      • You make a very important point about people in the US avoiding necessary care due to the disabling cost! My father is a classic example. He played Russian roulette with his diabetes and hypertension for decades.

        In large measure due to the suffocating costs of medicines and clinic visits, he never got the treatment he needed. During his last decade of life, he could afford the office visit or the prescription, but not both.

        Until his kidneys finally failed completely and he got on the federal ESRD program. Jackpot! His diabetes was never better managed in the prior three decades than in the last 3 or 4 years of his life.

    • I can’t help but point out that a lot of money is being made by giving people lung cancer and COPD, and that a serious effort to reduce the incidences thereof would put a dent in corporate profits.

    • On a positive note, it’s striking that deaths from the Number 1 and Number 3 killers (ischemic heart disease and stroke) declined strikingly from 1990 to 2010, reflecting an increased national awareness of blood pressure control, and of other risk factors.

      I worked for a large HMO during those years, and would note that as a quality-improvement measure we HMO physicians got better and better at double-checking on ourselves, to prove that we were documenting blood pressure elevations, and then promptly treating the patients for hypertension, and not procrastinating. After a decade or so, our outcome data also began to show a nice signal about better medication compliance, and fewer strokes and MI deaths among our patients, to reassure ourselves that we were making progress.

      Considering the US Health Care system overall today, where as many as 25% of Americans still don’t have health coverage, or where care is often fragmented, episodic, and not quality-checked, it will be interesting to see in 10 or 20 years if broader coverage and better quality incentives might lead to even more improvement in these numbers.

      . . . not to mention of course the wonderful prospect that ACA will deliver FREE clinical preventive care to most Americans.

      I sure hope in another decade that we American doctors won’t have to be ashamed that–public-health wise–America is no better than Number 27 in the world. We know we can do better.

    • Hmmm,

      Looks like my comment was moderated out – what did I say that made you do that.

      I have tried to be a good commenter…

      My question about how we treat heart issues was honest and fairly worded – I thought

      Too many stents and too many bypasses that lead to too little effect seems to be on topic and worth considering.

    • When discussing outcomes and comparing healthcare systems internationally one must be aware of what they are comparing. Are they comparing health care system quality or are they comparing things external to the health care system?

      This is extremely important for if one makes the wrong assumptions one might be spending money in the wrong place.

      Take infant mortality. I believe the US is number one with regard to low birthweight infant survival. Thus our placement (as stated above) must mean that things external to the health care system’s quality is a significant part of the cause. We count all low birthweight infant deaths as infant deaths. Do all other countries we are compared to do the same or do some call many of these deaths miscarriages. That would significantly alter our placement as far as infant mortality.

      Why do I find this so important? Because the factors that cause low birth weights frequently are external to health care quality. We need to focus our efforts at the cause and not the correlation. Some causes are data collection, drug addiction and teen pregnancies. Thus we have a lot of experience with low birthweight infants and have become quite good at managing the problem, but low birth weight infants significantly impact infant mortality statistics perhaps misleading people as to how the US should be rated.

      • You are repeating a zombie argument, that has already been answered… on this blog:

        http://theincidentaleconomist.com/wordpress/the-zombie-infant-mortality-explanation/

        But even then, you’re cherry picking. Infant mortality is just one of the many, many, many areas where we are underperforming.

        • That is your opinion, but to many others that opinion is quite valid. There is no doubt or question that we are excellent at saving low birth weight infants. It has also been shown that some western nations do not try to save infants born with low weights or of short stature and call those deaths miscarriages NOT infant mortalities. No one disputes the fact that our place on the scale of infant mortality would dramatically improve if we didn’t have so many low birthweight infants due to drugs etc. I won’t repeat the other valid data I mentioned.

          Why you wish to stifle valid discussion and valid statistics is unknown to me. I simply want the money being spent to do the most good and I am not convinced that is being accomplished. I am happy to debate any parameter, but since my primary concern is the overall well being of the nation and not ideology sometimes we will agree. I would think that you would feel secure enough about your positions to let other positions exist just to demonstrate where different perceptions lie whether you agree with them or not. As I have said more than once in one form or another the important issue is not whether or not the US is better than another country rather whether the US can be better than it is. That is the issue and that consideration requires the discussion of trade-offs.

          • I’m not giving you an opinion. You made a factual claim, and it’s either right or wrong. I’m explicitly reprinting the methods of a study that show how they counted deaths, and it explicitly states that what you say is not the case. Go read what I wrote in the link I posted above.

            Moreover, you write “It has also been shown that some western nations do not try to save infants born with low weights or of short stature and call those deaths miscarriages NOT infant mortalities” without any evidence that this is the case at all. Link to a credible source. We won’t keep approving posts that don’t do that.

            You’re not debating. You’re talking past us. You bring up a point, and I refute it with evidence. Then you just reassert it, without evidence. That’s not how this blog works.

            • One has to be careful about the variables they are looking at and I think you are looking at different variables than I am.

              I am actually looking at the survival rates of low birth weight infants and the US is great at treating the least likely infants to survive. That has to do with a health care system’s quality. I am also looking at the number of low weight infant births in the US due to drugs and other social problems. That is quite high. In the past I noted in the OECD records a little asterisk next to some nations, France and Switzerland come to mind. That asterisk informed us that infants smaller than a certain size or weight were not included in their infant mortality reports. On and on we see data reporting problems so that based upon the data used to create a figure is where countries will rank, but that number might be more representative of social economic problems or other things than health care quality.

              I am not talking past anyone. I am simply providing statistics that are left out of the discussion. As far as sources, I believe one can find the asterisks I mention on the OECD site if one has a subscription, but as an alternative one can go to anyone of numerous authors. I’ll give two:

              1) Nicholas Erbstadt, “The Tyranny of numbers: Mismeasurement and Misrule”. I provide this source because I believe he did original research on this.

              2) John Goodman, “Lives at Risk”. I provide this source because along with being an expert and called the “father of HSA’s” you featured his newer book on this blog. Specifically you can refer to page 53, the last paragraph.

              I have never intentionally provided any data that I did not believe had a good source and when asked to provide it I have provided an adequate response. Reports: Take note of the Hoenig and Heisey article with regard power calculations. Statistics: Take note of the Concord study I provided as evidence and now take note of these two references above. Your attempt to unfairly marginalize what I say is inappropriate.

    • Small correction: Colorectal cancer is ranked 10th in 2010.

      Plarry

    • Sheesh. Now _no one_ is going to listen to my cheap shots from the standpoint of my country of residence (Japan)….

      (I do try to keep my comments reasonably on topic. Really. I do.)

      It’s a good thing neuroses aren’t fatal: the Japanese are seriously neurotic (i.e. overly worried) about diabetes and Alzheimer’s disease; there’s something on them on prime-time TV every month, it seems. Of course, being insanely overly concerned with diabetes is why they have the lowest rate of lost years due to diabetes. Which is, I claim, on-topic _good_ news: it means worrying about it helps.

    • This article may now replace the Banks Marmot Oldfield and Smith article in my Intro Health Econ reading list, though I will miss BMOS.
      I am struck by how many of the comments on Austin’s post are in one way or another about where to draw the line between health and the rest of society.
      The countries that look really good in the new BOI study are generally countries with high levels of income, low levels of poverty and high levels of support for those in trouble. Pediatricians in those countries can give credible advice to any child on how to build a good life. That is not so easy to do in the USA. On the other hand, the Ayn Rand folks are going to claim that important freedoms are compromised in those countries.
      The question is not just what kind of health system we want, but what kind of society we want. Yes, there is plenty of inefficiency in the U.S. healthcare system, but even some of that is due to the stories, frequently inconsistent, we want to tell about the kind of society we live in. We are not going to have Swiss or Japanese or Swedish health outcomes in a Wild West society.

    • Does this article look at areas where the US is clearly a leader like the provision of robotic prostatectomies to men with a Gleason score of 6 or less?

    • Interesting that the increase in Alzheimer’s mortality is so high (nearly 6x the number in 1990). I’d surmise that much of that increase is due to better diagnosis of the condition. The interesting question is in which categories most of those earlier, undiagnosed Alzheimer’s cases were placed.

      The corollary question is whether, like diabetes, there are some long term nutritional/environmental/other causes that are contributing to this explosion in Alzheimer’s deaths.

      • I was also interested in the Alzheimer’s death numbers, since Japan (sorry. it’s the only other country I’ve ever been to) has a higher percentage of elderly than the US may ever have and the lowest number of Alzheimer’s deaths. I suspect, though, that it’s more a practical pathology issue than a real (or at least as large as a) difference as stated: if you look, I suspect you could find another cause of death for most US Alzheimer’s “deaths”. The aunt that my wife cared for for the last 5 years of said aunt’s life was _diagnosed_ with Alzheimer’s, but died of a stroke (the day after we took her to get checked out by her PCP). I’m not sure she really had Alzheimer’s, though, since she only had really bad short term memory and became depressed for the good reason that she was no longer able to participate in her previous activities. (She perked up a lot when we found day care for elderly that picked her up, kept her entertained, and returned her to us at the end of the day.) My point is that it’s hard to definitively diagnose Alzheimer’s without a serious autopsy, and I doubt that happens in real life in most of those US Alzheimer’s deaths. In our case, a death of a person who had no history of serious illness forces the police to look into it, and the massive stroke was easily detected. So they tried to find a cause, and found one that wasn’t Alzheimer’s.

    • -Speaking of zombie arguments, “best healthcare in the world” as presented here is a zombie red-herring. The people who are claiming that we have the best healthcare in the world are not, as a rule, arguing that the US has the healthiest citizens in the world. Far from it. A trip to the local mall will quickly disabuse *anyone* of that notion.

      They are arguing that on average, our doctors and hospitals can take care of and treat sick and wounded people as well or better than any other country, on average. Since the metrics above are the product of both health status, which is largely determined by choices and habits – and to a much lower extent, the health-care that people get, the health status end-points catalogued above tell us little or nothing about how well a given person with a given disease is likely to fare when they are treated by doctors and nurses in the US vs another country.

      -The argument that the patterns in this data can be attributed solely, or even primarily, to specific deficiencies in the health care that people receive in the US would be far more convincing if it cohered across all of the geographic, cultural, economic, etc boundaries that persist in the US. They don’t – not even close. They vary *massively* from state to state, county to county, city to city, and even within the populations treated by the same hospital.

      Look at, say, life expectancy at the state level and the variations are massive. It’s 81+ years in Hawaii. It’s 76 in Kentucky. 81 is well above the OECD average, and light years above Kentucky’s. Are you seriously prepared to make the claim that doctors and hospitals in Kentucky are so inferior, or in Hawaii are so superior, that discrepancies in the clinical efficacy of the care they deliver account for all, or even some of the differences in life-expectancy or any other health-status metric? Really?

      -What is the clinical value of this geographic variation data unless it can actually be definitively proven that a variation in, say, heart attack survival rates in area X vs Y can be attributed to either variations in a) clinical practice or b) access or both? I can appreciate the political utility of ignoring confounding factors and arguing that country X has better health outcomes because country X has single-payer and arguing that correlation equals causation, but how does this variation cataloging approach help anyone who wants information that will actually help improve the way they treat patients in concrete ways?

      • Now that’s an interesting point, but I don’t think I agree. I think most people are not just referring to capability, but also to the fact that it’s widely available. And that I dispute.

        And actually, I would make the argument that poverty, insurance, and resources do differ in Hawaii and Kentucky.

        • Doesn’t Hawaii essentially have a single payer system? It has at least an extremely high rate of insurance. There is also a low obesity rate.

      • @ JayB
        Two comments:

        –I agree with your assertion on what “best care” should mean. However, not everyone defines the phrase similarly. In fact, I find the saying rather malleable and can be a proxy for whatever folks want it to mean.

        –In the aggregate, all nations have variation, but we analyze them as a whole. See NHS:
        http://www.rightcare.nhs.uk/index.php/nhs-atlas/

        You could find many quibbles with my generalization, but every country will have relative differences province to province. Perhaps US absolute variation more profound, but I am not certain top performers dont manifest the same incongruity.

        Brad

    • “It has also been shown that some western nations do not try to save infants born with low weights or of short stature and call those deaths miscarriages NOT infant mortalities.”

      WHERE has it been shown? I don’t believe this is the case in *any* western nation, and I’ve never seen any evidence of it.

      I’ve heard lots of *claims*, but then that’s not evidence, is it?

      • Ken H. I provided three separate sources including one page number. That response has yet to be posted, but in brief the sources were:

        OECD
        Erbstadt Tyranny of numbers
        John Goodman Lives at risk.

        I won’t repost right now because I am sure that it will be posted later.

    • (1) People, rather than nations, seek health care. If I live in a nation where competent health care professionals practice in first-rate facilities with modern equipment, but I lack access to all of this, I have something other than the best health care in the world. Tens of millions of us in the US lack such access, so the “we” of “We have the best health care in the world,” is a circumscribed we far smaller that the population to which this comment is typically at least implicitly applied.

      (2) Given the acknowledged importance of health education and preventive care to health outcomes, a health care system designed to be the best in the world will include these in amounts that reflect their relatively high benefits:costs. The current pandemic of lifestyle-related disease is evidence that we fall short of this level of investment.

      • David S., is it true you lack access? There is no question that access can be a problem if one doesn’t have the requisite funds or insurance. We really need to make sure even if we have to subsidize people that everyone has reasonable access to reasonable health care. However, is it your belief that should you become ill and require hospitalization that without insurance or money you cannot get that hospitalization? If that is your belief then the belief is wrong. By law everyone with or without insurance, money, citizenship etc. must be admitted to a hospital for care even if it is known to the hospital in advance that the hospital will never be paid should that necessary hospitalization takes place. The ER must treat as well under these circumstances.

        I would urge similar cautions in the term “preventative care”. Aside from vaccination much of preventive care and early diagnosis is very expensive unless appropriately targeted. “Preventative care” wastes huge amounts of pooled money that could be better used.

        • Emily, I feel you’re missing the forest for the trees.

          The EMTALA requires for hospitals to stabilize patients. And in the maybe week before your death, you will get to spend it in the hospital getting intensive care. So all in all we don’t deny people heroic efforts to save their life.

          But 99% of life is spent out of the hospital, and for all those times you aren’t lucky enough to expire, you collect medical bills that will cripple you.

          The EMTALA has two huge caveats:

          “A hospital cannot delay treatment while determining whether someone can pay or is insured but that does not mean they are completely forbidden from asking or running a credit check. If the patient doesn’t pay the bill, the hospital can sue the patient and the unsatisfied judgment will likely appear on the patient’s credit report. A 3rd-party collector for a hospital bill would be covered under the Fair Debt Collection Practices Act.

          Hospitals and affiliated clinics are not required to provide continued outpatient care, drugs, or other supplies following discharge. ”

          In practice this is how it works out for uninsured: A 50 year old man w/o insurance has a myocardial infarction, shows up in the ED & will have been seen. He will get a large work-up, and maybe a cardiac catheterization. Upon discharge he receives a massive bill, which due to inability to pay leads to getting sued. Finances are tight.

          When he was discharged he was prescribed three important medications: An anti-hypertensive, an ACEi, an aspirin. These cost a lot of money, but there is no obligation to provide outpatient care or drugs. For the next 15 years he rarely pays for these medications. At 65 his PCP immediately starts these medications, cursing the fact he didn’t take these meds in the 2 years after his MI.

          Also, he was likely hospitalized at least once more between 51 and 65, making the chance of ever getting out of debt nearly 0.

          But no it is true – every American has some form of access. They can access the medical system, accrue massive debt and be bounced out. What tens of millions of Americans don’t have is ongoing access to a high-quality, available medical system.

          • “The EMTALA requires for hospitals to stabilize patients.”And in the maybe week before your death, you will get to spend it in the hospital getting intensive care. So all in all we don’t deny people heroic efforts to save their life.”

            Will, tell me what happens to a person who is in the process of having a vessel closed in his heart or brain. Does the hospital just wait until it closes or does it provide the needed treatment like it does with other patients? How about appendicitis? Does the hospital simply give the patient an antibiotic and send him home? Does the hospital openly risk a large malpractice case, very significant government fines and exclusion from all government health care agencies?

            “But 99% of life is spent out of the hospital”

            … and 99+% of the time people don’t need health care.

            Before you make a statement about the views of another you really ought to stop and think about what you are saying and make sure you read their complete statement.

            My words on the subject were as follow:

            “… access can be a problem … We really need to make sure …that everyone has reasonable access to reasonable health care.”…you cannot get that hospitalization? If that is your belief then the belief is wrong. ”

            Without discounting the costs to the uninsured and our need to help them, statements like this “An anti-hypertensive, an ACEi, an aspirin. These cost a lot of money” call for correction. Check out Walmart’s free drug list or generics at $4. How much do you think aspirin costs? The cardiac drug you talk about at one of the box stores is $4 per month. Many antibiotics, asthma and arthritic medications are free. Additionally for those with low incomes and no insurance many of the pharmaceutical suppliers will send their expensive top of the line pharmaceuticals for free or $15 even if generics are available.

            No one is denying that we have problems in the health care sector that require correction, but one needs to get their facts straight before jumping to conclusions.