The Health Of NationsIf you listen to left–leaning critics attack U.S. health care, some version of this complaint from New York Times columnist Paul Krugman invariably surfaces: "Americans spend more on health care per person than anyone else... Yet we have the highest infant mortality and close to the lowest life expectancy of any wealthy nation."
Paul Howard, Ph.D.
December 7, 2007
But as Canadian physician David Gratzer has pointed out, health outcomes like infant mortality and life expectancy aren't always a reflection of health care; instead, they represent a "mosaic of factors such as diet, lifestyle, drug use and cultural values." For instance, in The Business of Health, economists Robert Ohsfeldt and John Schneider show that once you factor out U.S. accident and homicide rates (which are abnormally high in the United States), Americans actually live longer than their counterparts in other wealthy Western nations.
Gratzer's argument got another big boost recently when economist and former Congressional Budget Office director June O'Neill and her husband, economist Dave M. O'Neill, released a study comparing U.S. and Canadian residents' health status, health care and access to care.
The study makes for compelling reading. First, the authors point out that infant mortality and life expectancy are poor proxies for health–system performance. Take infant mortality, which averages about 6.8 deaths per 1,000 live births in the United States, compared with 5.3 in Canada. Advantage Canada?
Not so fast. Infant mortality strongly correlates with low birth weight and pre–term births, both of which are likelier among teen mothers. And the United States has nearly three times Canada's rate of teen births, and about seven times Japan's and Sweden's. If you break down infant mortality rates in the United States even further, by race, you find that both "the pre–term infant mortality rate and the teen birth rate are considerably higher for blacks than for whites." This means that America's diverse ethnic mix plays against it in comparisons with more homogeneous countries. Once you factor in America's high rate of low–weight births, an interesting statistic emerges: "If in Canada the distribution of births by birth-weight was the same as in the United States, their infant mortality rate would rise to 7.06." Conversely, if the United States had Canada's distribution of low-weight births, its infant mortality rate would drop to 5.4.
This means that access to health care probably isn't to blame for America's higher infant mortality. Education, diet, smoking, and other cultural factors are likely to play powerful roles in fetal health that aren't captured in infant–mortality rates. And those rates affect life expectancy, making it another poor metric for measuring U.S. health–system performance.
Perhaps the most surprising findings in the O'Neills' report come from their analysis of the Joint Canada/United States Survey of Health, which asked the same questions of U.S. and Canadian respondents. American patients had higher rates of chronic diseases, partly because of the high incidence of obesity in the U.S.—not a problem that you can lay at the feet of Big Insurance, by the way. But they also had greater access to treatments for those diseases. And American patients had much better access to cancer–screening programs—for instance, mammograms, Pap smears, colonoscopies, and PSA tests for prostate cancer. Unsurprisingly, though the incidence rates for breast, lung and colorectal cancer were higher in America than in Canada, the likelihood of dying from the disease was lower in the United States. (Cervical cancer was the sole exception to this trend.)
Fine, critics might say: Canadian patients don't get as much high–tech care for cancer, but at least every Canadian, regardless of income, has equal access to health care, right? Wrong again. When it comes to this relationship, called the income/health gradient, the O'Neills found that, after taking into account America's greater income variation, the United States actually did somewhat better than Canada among 18–64 year olds. Income typically acts as a proxy for education and other social advantages that make it easier for wealthier patients to navigate any health–care system. In Canada, where care is rationed, poorer patients have fewer connections and less ability to "jump the queue" to get needed care abroad or from private (and often questionably legal) clinics.
The most enduring lesson here is that broad metrics like infant mortality and life expectancy are heavily influenced by behavioral factors for which no health–care system can take the credit or blame. But if a serious disease like cancer is threatening your life, there's still no place on Earth you'd be better off than the United States.
Paul Howard is the managing editor of MedicalProgressToday.com, and a senior fellow at the Manhattan Institute's Center for Medical Progress.