Why Does Health in the United States Lag Behind Other Countries'?

A more than 400 page recent report from The National Research Council and The Institute of Medicine of the National Academy of Sciences ("U.S. Health in International Perspective: Shorter Lives, Poorer Health") finds that children, men, and women all have shorter life expectancies in the United States than in Japan, Canada, Australia, and 13 European countries. Some of the media comments on the report blame what they consider an expensive and inefficient American healthcare system. Yet the report shows that many, perhaps most, of the reasons behind why American life expectancy is lagging relates to lifestyle decisions, and not to medical care.

The U.S. fared worse than these 16 other countries in 9 health categories:

1. Infant mortality and survival to age 5.

2. Deaths from car accidents and homicides.

3. Adolescent pregnancy and sexually transmitted infections.

4. Prevalence of HIV infection and AIDS.

5. Deaths from alcohol and use of illegal drugs.

6. Chronic lung disease.

7. Obesity and diabetes.

8. Disability due to arthritis and other factors.

9. Heart disease.

Most of these categories relate to lifestyle decisions rather than medical care. For example, American deaths from car accidents is greater mainly because Americans drive more since the report shows that fatalities per mile driven is not higher in the U.S. Guns are far more common and violence is much greater, in America than in these other countries. Deaths from lung disease are more common in America because smoking was more common here in the past. Americans are much more likely to use cocaine and other drugs. That Americans are much fatter than individuals in these other countries contributes to the greater incidence of diabetes and cardiovascular diseases.

The higher incidence of child mortality may be partly due to poorer health care for disadvantaged pregnant mothers. However, this mortality difference is also likely mainly due to the personal behavior of these pregnant mothers than to any limited access to good health care.

The age pattern of American mortality rates also implies that most of the higher mortality of Americans is not due to low quality health care. The elderly are the recipients of a large fraction of health care spending in all rich countries. In particular, over 35% of health care spending in the United States is on persons aged 65 and older. The National Research Council study shows American mortality rates are among the very highest up to ages under 55, but mortality rankings begin to change quickly then. American mortality is in the middle of the pack by the mid-seventies, and it is already relatively lower by age 60.

To be sure, since the US spends a lot more per capita on medical care than does any other country, the fact that American life expectancy looks good at older ages does not imply that these expenditures are wisely allocated or efficient. Ways to improve the efficiency of America's spending on health care are discussed in several of our past blog postings (the most recent one is on January 6).

Even though most of the difference in life expectancy between the US and these 16 peer countries are due to difference in personal behavior, public policies should try to change some of this behavior. For example, stiffer punishments for driving while drunk would reduce the incidence of drunk driving, a major cause of American traffic fatalities. Greater punishments for illegal possession of guns and for the use of guns to commit crimes, and judicious tighter gun controls are likely to reduce deaths from shootings, although there would be some compensating increases in stabbings and other types of violence. Decriminalization of drug use would reduce the rate of drug addictions and possibly even the number of drug addicts, increase visits to clinics by those addicted to drugs, and lower the incidence of AIDS from using contaminated needles (see the essay by Kevin Murphy and me "Have We Lost the War on Drugs?" Wall Street Journal, January 5, 2013).

It is more challenging to decide what to do about the fact that many Americans are overweight and obese. A recent survey of the evidence in a number of countries shows that being overweight, as measured by BMI (weight divided by height squared), does not lead to higher death rates except at very high and very low BMI values (dissertations at the University of Chicago under Robert Fogel's supervision had already shown this). These studies imply that taxes and regulations on fast foods that discourage their consumption would mainly affect individuals whose eating patterns do not reduce their life expectancy, although overweight individuals do make modestly greater demands on the subsidized health care system.

The lower life expectancy for young and middle aged Americans than in peer countries is a matter of public policy concern, but wise policies require accurate knowledge about their causes. The comprehensive National Research Council study suggests that the major causes lie in differences in lifestyles between American and individuals in other countries. Poorer access of some Americans to adequate healthcare seems to be of relatively little importance.