Why Don’t Americans Live Longer?

President Obama and his supporters have consistently pointed to the fact that for our extra costs of healthcare, some 30-50% more as a per cent of our GDP than any other country on earth, mortality rates in the United States put us in the middle of the pack of industrialized countries. The President suggests that what we need is a government run plan or possibly a single payer plan that will improve outcomes. Paul Krugman has written, “We spend far more on health care than other advanced countries—almost twice as much per capita as France, almost two and a half times as much as Britain. Yet we do considerably worse even than the British on basic measures of health performance, such as life expectancy and infant mortality.” He further states that, “Many people in this field believe that in the end America will end up with national health insurance, and perhaps with a lot of direct government provision of healthcare, simply because nothing else works.” The assumption here is that government run health insurance would solve this dilemma of poor outcomes.

These data have always evoked confusion in the minds of physicians. We know that our patients are generally well cared for and that our healthcare system generates more innovation in medications and medical devices than any nation on earth. We also know that the malpractice risk has led to defensive medicine and substantial efforts to avoid medical errors. While the large number of medical errors cited by the Institute of Medicine study suggested great room for improvement, there is no data to show that other countries had achieved healthcare delivery with fewer errors than purported to occur in the U.S. We know that we have a very well educated medical corps. We also know that we have a highly regulated healthcare system with oversight by literally hundreds of professional, state, and federal agencies. So why the poor outcomes and high mortality rates?

Some physicians believe that the increment in mortality rates in the U.S. is due to a high rate of auto accidents and murders. But a recent study by the Organization for Economic Cooperation and Development (OECD) removed these so called “external causes” from the calculations and still found a higher mortality in the U.S.

Do we not properly care for the elderly? Do we not properly care for pregnant women and infants? Is that why the poor outcomes? Actually, the genesis of the increased mortality rates turns out to reside in the very groups of patients who currently have good access to government funded health care – pregnant women, infants, and the elderly.

Infant and maternal mortality has a major impact on measurements of life expectancy. A few countries, the U.S. included, count those unfortunate infants who are unlikely to survive extreme prematurity as live births. If these premature infants do not survive, they count towards the overall calculation of mortality rates for the entire population. While this approach does exacerbate U.S. mortality rates, other countries, like Canada and Japan, use the same criteria for determining infant mortality yet have better overall mortality rates than found in the U.S.

Superficially this outcome seems to suggest that lack of access to good healthcare is the cause as life expectancy at birth increased by 3.4 years between 1980-1982 and 1998-2000 (to 79.2 years) for the most affluent tenth of the US population, but by only 1.4 years (to 74.7 years) for the most socioeconomically deprived tenth of the population. Is this not proof that our “unfair” healthcare system is failing?

But the United States has a public program called Women, Infants, and Children (WIC) that specifically targets this group of socio-economically deprived individuals. WIC provides nutritious foods, nutrition education, and referrals to health and other social services to participants at no charge. WIC serves low-income pregnant, postpartum and breastfeeding women, and infants and children up to age 5 who are at nutrition risk. WIC is a federal grant program for which Congress authorizes a specific amount of funding each year for program operations. Congress appropriated $6.86 billion for WIC in FY 2009. By comparison, the WIC program appropriation was $20.6 million in 1974; $750 million in 1980; $2.126 billion in 1990; and $4.032 billion in 2000.

High infant mortality rates in the U.S. among the poor is a major driver of our higher overall mortality rates. Yet the government has been providing the form of support to this population that should have made a difference, but fails to do so. It turns out that even a specific clinical trial of more intense prenatal care carried out by investigators from Harvard and published in the American Journal of Public Health showed that specific and intense prenatal care in a Medicaid population did nothing to improve the risk of preterm infant births. Such premature births are a major factor in increased infant mortality. The Harvard investigators could not explain the basis for the failure of intense prenatal care to improve outcomes and no single study proves anything definitively, but this and other studies have called into question the explanation for the poor infant mortality in the U.S. Inadequate medical care is apparently not the cause.

What about the other end of the spectrum, the Medicare population? The President said in his town hall meeting in Colorado that ,”Medicare is a government program that works really well for our seniors and has protected people”. Most Americans would agree with this point, but, again, the data from Europe, as reported in a comprehensive report by the OECD, show that the elderly also have not had an improvement in life expectancy to the same degree as seen in the European Union. The increase in life expectancy in the United States at age 65 has been less than the European Union average for both women and men. Since the early 1960s the U.S. rank among OECD countries has fallen slightly for men but markedly for women. However, this older population already has access to health insurance through Medicare. Again as for the high infant mortality rate, absence of government supplied health care cannot explain the high mortality rate in seniors.

What does all this mean for healthcare reform? Clearly, any assumptions about causes of high mortality rates are highly speculative. Despite the proposition forwarded by President Obama and Dr. Krugman, guaranteeing that 100% of the population has insurance coverage is no guarantee that our mortality statistics will improve. It is unclear why the portion of our population that has government supported and subsidized health care has such a high mortality rate compared to that of other nations that are our economic peers. I think most would suspect that social, geographic, economic, educational, and other non-health care related issues underlie these statistics. It is a bit hard to accept the promise that providing healthcare insurance more widely, particularly to the young adult uninsured will lead to lower mortality rates for the nation. Better jobs, better schools, better personal responsibility, and perhaps, better utilization of existing programs might make the difference.