Americans Die Earlier and Live Sicker than Everyone Else: Why?

I was just reading a recent op-ed in the Journal of the American Medical Association, “The US Health Disadvantage Relative to Other High-Income Countries
Findings From a National Research Council/Institute of Medicine (NRC/IOM) Report.”

Well, at least it’s an op-ed on a paper from the afformentioned NRC/IOM. The paper digs through data from 17 OECD countries and tracks trends in disease and mortality.

Americans fare worse than other OECD countries in:

• infant mortality and low birth weight
• injuries and homicides
• adolescent pregnancy and sexually transmitted infections
• HIV and AIDS
• drug-related deaths
• obesity and diabetes
• heart disease
• chronic lung disease
• disability

We also tend to die earlier than everyone else (75.64 years) but really can expect to live about as long as Finns (75.86), Portuguese (75.87) and Danes (76.13).

I’m not surprised that we ended up on the bottom of the list. We certainly have much to be ashamed of in terms of social violence, access to means to kill one another when enraged, and a fractured and inefficient health care system (or lack thereof).

What struck me is how varied the list is. Some elements (accidents, homicides and drug-related deaths) have nothing to do with access and quality of health care. Infant mortality and birth weight shouldn’t be so low in a well fed country like the United States.

The JAMA article sums a lot of the systematic problems of US health care and its potential impact on human welfare:

What could explain a health disadvantage that involves conditions as varied as motor vehicle crashes, heart disease, preterm birth, and diabetes? The NRC/IOM panel explored this paradox and found clues in almost every class of health determinants it considered. The United States lacks universal health insurance coverage, and its health system has a weaker foundation in primary care and greater barriers to access and affordable care.4 Care coordination also is a problem. In multiple surveys of patients with chronic illnesses in up to 11 countries, The Commonwealth Fund has shown that US patients are more likely than patients elsewhere to report lapses in care quality and safety outside of hospitals.1 US patients appear more likely than those in other countries to require emergency department visits or readmissions after hospital discharge, perhaps because of premature discharge or problems with ambulatory care. Confusion, poor coordination, and miscommunication between clinicians and patients are reported more often in the United States than in comparable countries.

But we know all this. Continuing:

Health is determined by more than health care, and the NRC/IOM panel explored differences beyond health care to explain the US health disadvantage. It considered individual behaviors and found that although US adults are less likely to smoke (due to successful tobacco control efforts) and may drink less alcohol than adults in peer countries, they have a greater propensity for other unhealthy behaviors. People in the United States consume more calories per capita, are more likely to abuse drugs, are less likely to fasten seat belts, have more motor vehicle crashes involving alcohol, and own more firearms than do people in other high-income countries. US adolescents seem less likely to practice safe sex than adolescents in European countries. These problems are not products of the health care system

But what I’m seeing here is a pattern. All of these problems are concentrated in the poorest strata of the American population. Drug abuse, violence, poor diets, lack of access to health care.. these are all problems non-existent in all but the most troubled areas of the country.

This is, of course, an unforgivable condition. However, given the plurality of the United States, evaluating Americans as a group masks the true problems. Life expectancies are presented as averages. That is, all deaths are recorded, even those in the top 50% of American households, those with health insurance, those who go to the gym, those who eat relatively well, those who won’t kill one another during a family fight, those who won’t use coke, crack, heroin, meth or even abuse oxycontins. All of these households bring the average up.

If we were to only look at the bottom 50%, a much more homogeneous group than that of all Americans, we would find that the average life expectancy to be frighteningly low. We would find that the incidence of avoidable disease is extremely high, the chances of getting shot high, access to health care minimal and a general state of un-health among them all. We already know that African Americans die about four years earlier than white Americans. In total, though, we’d probably find socioeconomic worlds within the United States as different as that of countries like Somalia and Germany.

Note: Ezra Klein also wrote something on this report.