How bad is it?
...Analysts often juxtapose the poor ranking of the US in life expectancy and the very high percentage of its gross national product that is spent on health care. The conclusion that is often drawn from this combination is that the United States’ health care system is extremely inefficient. But measures of population health such as life expectancy do not depend only on what transpires within the health care system, such measures also depend upon a variety of personal behaviors that affect an individual’s health such as diet, exercise, smoking, and compliance with medical protocols.
...The health care system could be performing exceptionally well in identifying and administering treatment for various diseases, but a country could still have poor measured health if personal health care practices were unusually deleterious. This is not a remote possibility in the US, which had the highest level of cigarette consumption per capita in the developed world over a 50-year period ending in the mid-80’s. Smoking in early life has left an imprint on mortality patterns that remains visible as cohorts age. One recent study estimated that, if deaths attributable to smoking were eliminated, the ranking of US men in life expectancy at age 50 among 20 OECD 2 countries would improve from 14th to 9th, while US women would move from 18th to 7th. Recent trends in obesity are also more adverse in the US than in other developed countries.
...We have demonstrated that mortality reductions from prostate cancer and breast cancer have been exceptionally rapid in the US relative to a set of peer countries. We have argued that these unusually rapid declines are attributable to wider screening and more aggressive treatment of these diseases in the US. It appears that the US medical care system has worked effectively to reduce mortality from these important causes of death. This conclusion is consistent with other evidence that we have reviewed on the performance of the US health care system: screening for other cancers also appears unusually extensive; 5-year survival rates from all of the major cancers are very favorable; survival rates following heart attack and stroke are also favorable (although one-year survival rates following stroke are not above average); the proportion of people with elevated blood pressure or cholesterol levels who are receiving medication is well above European standards.
...These performance indicators pertain primarily to what happens after a disease has developed. It is possible that the US health care system performs poorly in preventing disease in the first place. Unfortunately, there are no satisfactory international comparisons of disease incidence. Individuals report a higher prevalence of cancer and cardiovascular disease in the US than in Europe, and biomarkers confirm the higher prevalence of many disease syndromes in the US compared to England and Wales. Higher disease prevalence is prima facie evidence of higher disease incidence, although it could also be produced by better identification (e.g., through screening programs) or better survival. The history of exceptionally heavy smoking in the US, and the more recent massive increase in obesity, suggest that a high disease incidence in the US could not be laid entirely at the feet of the health care system. Evidence that the major diseases are effectively diagnosed and treated in the US does not mean that there may not be great inefficiencies in the US health care system. A list of prominent charges include fragmentation, duplication, inaccessibility of records, the practice of defensive medicine, misalignment of physician and patient incentives, limitations of access for a large fraction of the population, and excessively fast adoption of unproven technologies. Some of these inefficiencies have been identified by comparing performance across regions of the United States. Of course, the fact that certain regions do poorly relative to others does not imply that the US does poorly relative to other countries. And many of the documented inefficiencies of the US health care system add to its costs rather than harm patients.
...Just as we are not addressing issues of efficiency on the production side, we are not treating patient welfare as the main outcome. Practices that produce greater longevity do not necessarily enhance well-being. This potential disparity is central to the controversy involving PSA testing, which uncovers many cancers that would never kill patients but whose treatment often produces adverse side effects. The question that we have posed is much simpler: does a poor performance by the US health care system account for the low international ranking of longevity in the US? Our answer is, “no”. http://www.nber.org/papers/w15213.pdf
Wrong system or wrong people?
...The health care system could be performing exceptionally well in identifying and administering treatment for various diseases, but a country could still have poor measured health if personal health care practices were unusually deleterious. This is not a remote possibility in the US, which had the highest level of cigarette consumption per capita in the developed world over a 50-year period ending in the mid-80’s. Smoking in early life has left an imprint on mortality patterns that remains visible as cohorts age. One recent study estimated that, if deaths attributable to smoking were eliminated, the ranking of US men in life expectancy at age 50 among 20 OECD 2 countries would improve from 14th to 9th, while US women would move from 18th to 7th. Recent trends in obesity are also more adverse in the US than in other developed countries.
...We have demonstrated that mortality reductions from prostate cancer and breast cancer have been exceptionally rapid in the US relative to a set of peer countries. We have argued that these unusually rapid declines are attributable to wider screening and more aggressive treatment of these diseases in the US. It appears that the US medical care system has worked effectively to reduce mortality from these important causes of death. This conclusion is consistent with other evidence that we have reviewed on the performance of the US health care system: screening for other cancers also appears unusually extensive; 5-year survival rates from all of the major cancers are very favorable; survival rates following heart attack and stroke are also favorable (although one-year survival rates following stroke are not above average); the proportion of people with elevated blood pressure or cholesterol levels who are receiving medication is well above European standards.
...These performance indicators pertain primarily to what happens after a disease has developed. It is possible that the US health care system performs poorly in preventing disease in the first place. Unfortunately, there are no satisfactory international comparisons of disease incidence. Individuals report a higher prevalence of cancer and cardiovascular disease in the US than in Europe, and biomarkers confirm the higher prevalence of many disease syndromes in the US compared to England and Wales. Higher disease prevalence is prima facie evidence of higher disease incidence, although it could also be produced by better identification (e.g., through screening programs) or better survival. The history of exceptionally heavy smoking in the US, and the more recent massive increase in obesity, suggest that a high disease incidence in the US could not be laid entirely at the feet of the health care system. Evidence that the major diseases are effectively diagnosed and treated in the US does not mean that there may not be great inefficiencies in the US health care system. A list of prominent charges include fragmentation, duplication, inaccessibility of records, the practice of defensive medicine, misalignment of physician and patient incentives, limitations of access for a large fraction of the population, and excessively fast adoption of unproven technologies. Some of these inefficiencies have been identified by comparing performance across regions of the United States. Of course, the fact that certain regions do poorly relative to others does not imply that the US does poorly relative to other countries. And many of the documented inefficiencies of the US health care system add to its costs rather than harm patients.
...Just as we are not addressing issues of efficiency on the production side, we are not treating patient welfare as the main outcome. Practices that produce greater longevity do not necessarily enhance well-being. This potential disparity is central to the controversy involving PSA testing, which uncovers many cancers that would never kill patients but whose treatment often produces adverse side effects. The question that we have posed is much simpler: does a poor performance by the US health care system account for the low international ranking of longevity in the US? Our answer is, “no”. http://www.nber.org/papers/w15213.pdf
Wrong system or wrong people?