• US life expectancy after 65: Why so low?

    Matt Yglesias cited Aaron’s post and figures on mortality after age 65 and commented,

    Strong evidence of systematic underperformance in the American system. And yet since we’re talking about Medicare-eligible people here that also suggests that the issue can’t be solved by messing with who has insurance or how insurance-provision is organized. You need to actually delve down into the delivery of health care services.

    That’s one conclusion, and I’m inclined to think the delivery system is part of the problem. But it could be an insurance issue too. Seeing it that way requires going deeper in another direction.

    Michael McWilliams did just that in several articles that examined how previously uninsured Medicare beneficiaries fared. In his 2007 NEJM article co-authored by Ellen Meara, Alan Zaslavsky, and John Ayanian he found that such beneficiaries had “greater morbidity, requiring more intensive and costlier care over subsequent years, than they would if they had been previously insured.” The same authors found in a 2007 JAMA article that Medicare “improved trends in self-reported health for previously uninsured adults, particularly those with cardiovascular disease or diabetes.”

    That is, there is evidence that Medicare improves health outcomes (no surprise there), but also that previously uninsured individuals who become beneficiaries of that program require a lot more care (not such a shock either). They’re less healthy than they would have been had they had insurance before turning 65.

    Thus, another way to interpret poor post-65 U.S. mortality relative to peer nations is that we do a worse job of providing access to coverage and the care it facilitates before individuals become Medicare eligible. In short, even mortality for Medicare beneficiaries could be related to the health insurance system. This is not really surprising since many causes of death are related to life choices made and health care received over many years. It is not inconceivable that better care at an early age can prolong life even for those who make it to 65.

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    • It could be really simple. People who didn’t have insurance before Medicare could simply be poorer.

      Do poor people have other factors which make their health worse, quite apart form access to medical care?

      Dirtier, more dangerous jobs, perhaps? Poorer diets? Greater stress?

      Do other countries with cradle-to-grave health care find that the difference between the health of rich and poor differs less?

      Are poor but insured people in the USA that much healthier? Does their health approach rich-people standards?

      It wouldn’t surprise me if you’ve done the math on this one already

      • @headbank8 – Come on! It’s so simple don’t you think reviewers of the articles would have brought that up? The article texts are public. Take a look. The authors controlled for a wide variety of things, all reasonable measures available (not everything because we don’t have data on everything). It isn’t trivial to get a paper in NEJM and JAMA you know.

    • One potential issue is the way McWilliams et. al. treated death – they did not include any observations of individuals who died at all during the study period, which could significantly bias the results.
      Polsky et. al. did a study in Health Services Research (“The Health Effects of Medicare for the Near-Elderly Uninsured”) that used the same data but did not throw out individuals who died. This study did not find a statistically significant difference in health trajectory between the previously insured and uninsured after age 65. Subsequently, a fascinating commentary and reply appears in HSR between the two author groups on the methodologies.

      • @Sunita Desai – Yours is a very valuable comment. Thank you!

        I saw the back-and-forth in HSR. As is typical, we can’t be certain we know why post-65 mortality is lower in the US vs. other countries. Is it the delivery system, as Yglesias suggests, or is it due to factors preceding Medicare eligibility, like insurance, as the work of McWilliams et al. suggests but others using different methods does not? Or is it both? Or something else?

        It’s one thing to observe something that looks problematic (which doesn’t itself prove it is problematic) and another to discover why. The former is far easier than the latter. And so we keep banging away at the data …

    • The United States does need life prolonged for those who cannot pay for it and take care of themselves.

      We need life extended only for our leaders, bankers, and industrialists with the wherewithal, common sense, and patriotism necessary to finance their own lives and health care.

      Anything else is communism.

    • http://www.aihw.gov.au/mortality/life_expectancy/indig.cfm
      Life expectancy is not uniform across populations within Australia. An issue of particular public interest is that Aboriginal and Torres Strait Islander peoples have a much lower life expectancy than the general Australian population. Indigenous Australians born in the period 1996-2001 are estimated to have a life expectancy at birth of 59.4 years for males, and 64.8 years for females.

      Aboriginal are about 2.3% of the total Australian population.

      It is a similar situation in Canada with Native Americans, the Native Americans. Native Americans in Canada live about 7 years lass than the average for all Canadians but they are only 3.7 percent of the population.

      Blacks and Native Americans in the USA live about 6 years less than the average for all Americans but are about 13% of the population.

      Further people of east Asian decent live longer a lot than average and are a higher percent of the population in Canada and Australia. Interestingly as noted Hispanics a little longer than average despite having less access to health care.

      BTW I know how the USA can win this silly race and the silly international standardized tests of education. Allow anybody in China, Korea or Japan to freely immigrate into the USA and we will win both silly races.

      All that I am saying is life expectancy is all but useless measure of health care.