Comparative Longevity

I am guessing that inequality of income is a major factor in the poor health and reduced longevity of Americans compared to inhabitants of our peer countries. Fifteen percent of the U.S. population lives below the poverty line, which is defined as an income of $23,000 for a family of four. The median income of American households is only $50,000 a year, rising to $65,000 for a family of four, which nowadays is only a modest income—and half of families of four make less (what is what "median" means). Life expectancy is 5 years longer for rich than for poor Americans. There is a safety net of sorts, but more porous than in the peer countries. Private insurance is expensive, and unaffordable by many families not poor enough to be eligible for Medicaid. A family of four with an income of say $25,000 can't afford adequate health insurance. And there is a scarcity of primary-case physicians in many parts of the country.

But I agree with Becker that the main cause of the nation's poor health and longevity statistics relative to our peer countries is not deficient medical care but "lifestyle" choices. And there is nothing wrong in principle with people wanting to trade off life expectancy against the pleasure of engaging in activities that happen to be risky, or with society allowing them to do so provided they agree to bear the cost. That is not an irrational tradeoff. But when one compares people in the upper part of the income distribution with people in the lower part, one is made doubtful that the people in the lower part just happen to be the people who want to trade a long life for a short one full of thrills. Probably most of the people in the lower part of the income distribution have poor health or will become unhealthy early because of lack of information about nutrition and other dimensions of healthy living, of a good education, of a responsible family, of exercise, and in general of good opportunities at home or at work for leading a safer, healthier life. Many of these people probably underestimate the riskiness of riding a motorcycle with but especially without a helmet, mistakenly believe that owning guns makes one safer rather than less safe, do not know what a healthy diet is or can't afford it, and do not know how to obtain free or cheap medical care.

If incomes were more evenly distributed, and if more public money were spent on services for lower-income people, probably the U.S. population would have better average health and higher average life expectancy. A program of income redistribution beyond what we have now, coupled with more public spending on social services, would increase the overall level of public spending, and in turn require cuts in other public spending plus in all likelihood higher taxes as well, but the net economic effect could be positive if a healthier population increased employment and output.

A curious aspect of the international comparisons is that America is tops when it comes to the life expectancy of persons 75 years old and older. That, at least, may seem a triumph of American health care, and partial justification for our spending more per capita on health care than any peer country, with seemingly little to show for it. But the higher life expectancy of our old people may be, in part anyway, a survival-of-the-fittest phenomenon. Suppose there are two types of person: those genetically predisposed to long life, and those not. If there is no or poor medical care, the members of the latter group will tend to die young, so that mostly only members of the former group, the genetically predisposed to long life, will reach 75--and being a genetically select group they can expect a long remaining life. If medical care enabled almost everyone to live to 75, many of those still alive then would not live much longer, because they don't have good genes for longevity, and so average longevity of 75 year olds would rise.

Moreover, it's an ambiguous achievement, at least from a public finance standpoint, to prolong the life of the already elderly. The more people who live to very old ages, the higher the average cost of medical care, because people require more care the older they are. Rising costs of medical care are creating pressures to economize on the cost of such care, but not to economize on the cost of medical care of old people, because they are both a powerful and rather single-minded voting bloc and able to pay for extensive care through Medicare, often supplemented by private health insurance.