Uncovering Some Really Bad Science
This makes it entirely possible that this mortality difference is entirely due to lifestyle differences and disease incidence rates rather than the relative merits of health care systems.

Unless 18 countries with very different cultures, diet habits, exercise habits, etc all have a healthier life style than the U.S., you are going to have hell of a time convincing anyone beyond a wingnut that this is due to lifestyle choices.

People really noticed. But they were devastated from grief, and couldn't be sure what went wrong, and the hospitals and system seemed so monolithic they decided not to break themselves against it.

They noticed, though.

This makes it entirely possible that this mortality difference is entirely due to lifestyle differences and disease incidence rates rather than the relative merits of health care systems.

Because 'lifestyle differences and 'health care systems' are entirely independent variables.

Right. Of course, people like coyote (in that Drum discussion) really want you to believe that.

Unless 18 countries with very different cultures, diet habits, exercise habits, etc all have a healthier life style than the U.S
So progressives say that the US has a "obesity epidemic". But that has no effect when determining effectiveness of Health care.

What do you expect from the fattest and laziest country on the planet. Ban the Big Mac and make gas 10 dollars a gallon and see what happens.

"We have the best health care in the world" invariably means "we have the best health care in the world for affluent white people".

Remember that these national- level stats include places like Indian reservations and inner cities, along with the nice comfortable suburbs.

"Remember that these national- level stats include places like Indian reservations and inner cities, along with the nice comfortable suburbs."

Yes, because the stats do not include the poor or urban dwellers in other countries. And morally, not just economically speaking, it's always a sign of a healthy society that walls off its issues into ghetto enclaves that are out of sight, out of mind.

You need to get a brown paper bag to breathe in.

If the numbers were the real issue, you would be all over tobacco which is the largest preventable cause of death coming in a more than four (4) times the population of Boulder.

Again because people in other countries do not smoke. Only Americans. If this is the best you people can post then you really are going to be consigned to the same place you once expected to consign us liberals.

Regarding tobacco, big macs and too-cheap gasoline:

People are working on those issues. Similar forces (i.e., conservative, free-market, anti-science, libertarian) are working to sabotage progress on those fronts.

Others of us are working to reform the perverse and deadly U.S. health care system.

Perverse, deadly and insulting as well, since you can choose not to smoke, choose not to be with people who smoke, choose not to eat fast food, and choose not to drive — or at least choose to drive as little as possible and do it in a Prius.

But you sure don't want to choose not to pay the rapacious and deadly protection racket we call the health insurance industry. Although you can be forced to that position — as more and more Americans are.

Lots of work to be done, each to his passion.

What is OECD? Please spell out the first usage of an acronym.

This makes it entirely possible that this mortality difference is entirely due to lifestyle differences and disease incidence rates rather than the relative merits of health care systems.

I've been arguing for the inherent genetic weakness of Americans, but haven't gotten much traction. Perhaps I'll email Saletan & see what he thinks.

"I've been arguing for the inherent genetic weakness of Americans, but haven't gotten much traction. Perhaps I'll email Saletan & see what he thinks."

Good one. It seems however you will only convince the wingnuts us black folk are to blame for all their woes even more.

I swear were it not for us weighing you down all those centuries first and slaves and now as cheap labor you would probably be much further ahead now.

Ezra,

Good to see a nice health care post-- you're better than the political horserace blogging.

Anyways, a few thoughts on the piece:

-- Let's not demagogue the issue of comparative quality, as the article did provide some other interesting nuggets beyond what you mentioned. One particularly striking is that the best states in the US compare favorably with the best countries in the world. As they suggest, if the whole US had health care as good as our best state, then 90,000 of the 101,000 deaths you cited could be avoided.

Which begs the question-- why is our health care so divergent in different regions (they claim a two-fold difference between best and worst) and what could be done about it?

-- Not to beat a dead horse, but this article explains precisely why I was so disappointed with your overemphasis of the mandates issue. Because the reality is while the pundits claim that the big 3's plans are "all the same" except for mandates, that really isn't true.

There are differences offered in policy and in degree of emphasis between the candidates that address the quality issues laid out here.

Hillary has wrapped her quality ideas around Wennberg himself, who obviously has great ideas that explain the state-by-state variation mentioned above. Her key solution though, is pretty top-down/government-driven: quasi-federalization of the physician qualification and credentialing process. That's a pretty big step-- no attention to date.

Obama, on the other hand, has a greater emphasis on data transparency of quality outcomes to help drive quality improvements-- potentially focusing on some of the same variables analyzed by the authors in the Health Affairs article.

You could argue that these differences are small-- the same could be argued about the incremental difference between their actual percent "covered" (still waiting for someone to actually provide an estimate of Hillary's plan).

The point is-- given that it looks like this race could last a little longer, how about a second look at the differences offered on improving quality/reducing cost, neither of which have gotten any real attention to date?

Is federalizing physician credentialing a good idea? is this politicall feasible?

Is reliance on data transparency to drive improvements unrealistic? Consistent with Obama's perceived "less details, more big picture" or does he adequately address the issue?

There is good discussions to be had-- if only to inform people more about the real difficult challenges that lie ahead-- funding coverage is frankly the easy part.

OECD

Organization for Economic and Community Development.

Basically a number-crunching outfit, consisting of the industrialized countries

Regardless of the cause of this difference in death rates, Ezra understated the impact in that it isn't just 100,000 people dying....it's 100,000 people dying every year. Imagine Boulder CO getting annihilated in 2006, Green Bay WI getting wiped out in 2007, Allentown PA getting destroyed in 2008, etc.

But I partially agree with Coyote's point. The methodology appears to blame these "preventable" deaths entirely on the health care system, when we know that lifestyle is a major factor for some of them.

But this only brings us back to the same place we always end up: even if the US medical system performs about as well overall as other systems when presented with the same patient mix, what the hell are we doing paying twice as much money to get the same result?

Those liberals at Health Affairs' are so political. Why do they always do studies in health in which they know the U.S. will do badly? I think they should measure the health across nations of white people making over 250,000 dollars a year. That would be a lot more fair and we would rock! Just to be safe though, it seems clear that France is an outlier in any case and ought not be included.

Oh gnos!

As long as the health insurance companies are allowed to do what they please - which is not what's good for their customers - we're going to do badly in studies like this.

Health care coverage is not the same as health care, no matter what some politicians (and most insurance executives) want you to believe.

Unless 18 countries with very different cultures, diet habits, exercise habits, etc all have a healthier life style than the U.S., you are going to have hell of a time convincing anyone beyond a wingnut that this is due to lifestyle choices.

Thank you, akaison.

And Ezra, this is an excellent post. Just excellent. Bravo.

Here is a 2003 paper by the authors discussing similar work. It seems to me that the discussion of "amenable mortality" is meant specifically to exclude what might be called "lifestyle factors," as the authors say:

High levels of health attainment in well performing countries may be a consequence of good fortune in geography, and thus dietary habits, and success in the health effects of policies in other sectors. When assessed in terms of achievements that are more explicitly linked to health care, their performance may not be as good.
.); maybe that would be affected by

Ugh, I don't know what happened at the end there, but I meant to link to the table of causes of amenable mortality. One of them is hypertensive disease, which may be aggravated by obesity. But even if the U.S. is more obese than other countries, I doubt that this is causing the entire amenable mortality gap.

Great post, Ezra. But I have one quibble. Would it really be a tragedy if a weapon was detonated on Boulder. I mean, Boulder. Seriously. Think of all the trustafarian hippies we might rid ourselves. This is something worth looking into...but yeah, I agree, America is a disastrously troubled country and HC is the truest indicator of that.

This raises the issue of why, which--I believe--is fundamental issue plaguing this presidential election. There are invested groups--Pharma, insurance etc--that have a stake in this death, to put it ever so lightly. They will not give up their stake. Thus, Edwards approach that allows for a competitive, evolutionary HC system to put them out of business based on the merits of cost is best. This is truly a stark difference in the candidates stances, and cannot be glossed over as some detail.

Unless 18 countries with very different cultures, diet habits, exercise habits, etc all have a healthier life style than the U.S

That doesn't seem particularly implausible. Somebody's got to be last; why not us?

It still doesn't mean our health care system isn't shitty, though.

You all can take yourself or any of your family to any of the countries listed if you get sick, but there is no place Bar None, I'd rather be if me or my family happened to be sick.

If you think our lifestyle has nothing to do with our health go to any of the countries listed then comeback to ours. Get off the plane and go directly to a Cici's Pizza and just think about it.

Unless 18 countries with very different cultures (Yes), diet habits (Yes), exercise habits(Yes), etc all have a healthier life style than the U.S.(No question the answer is Yes), you are going to have hell of a time convincing anyone beyond a wingnut that this is due to lifestyle choices.(No, you won't)

If anyone is having difficulty getting the document via Ezra's link, here's another one:
http://www.canada.com/ottawacitizen/pdf/Nolte_article.pdf

jenga, a while back, at the old Ezra blog, he linked to a terrific graphic showing obesity rates in different nations. Specifically, it ranked various countries in terms of the percentage of citizens over the age of 15 with body mass indexes in excess of 30. At the top of the list, the US was first, at 31%. Then Mexico (24%), UK (23%), Slovak Republic, Greece, and Australia (22%), and New Zealand (21%). I can't compare these numbers to the 19 countries in Ezra's cited study because the linked article is subscription only, but for those who would remove the blame for amenable mortality from America's disgraceful health care system and place it (as usual) on the individuals born here--in other words, they got fat, or smoked, or didn't exercise, so that's why so many of them got sick compare to elsewhere in the world--I do have a question:

Why do you suppose the infant mortality rate is so high in this country? Are all these sick and dying babies emerging from the birth canal holding a cigarette in one hand and a scotch in the other, their plump, unfit and supersized bodies already needing XXXL diapers?

Am I imagining things, or have Ezra's appearances on TV brought a wave of wingnuts to the blog?

Or could it be TAP that attracts them?

I usually swim too deep in the pool of healthcare debates.. maybe light wading at best. ;p but this study sounded like it had a decent viewpoint so I was curious...

Some are lamasting the study because it doesnt attempt to parse out unavoidable deaths from these causes from the truly avoidable ones. Catastrophic heart attack that a hospital couldnt even treat for instance.

Some of these are clearly lifestyle related. IHD, CAD, diabetes (which is highly aggravated and linked to obesity), and infectious disease. The last since the immune system is somewhat suppressed in the obese. (University of North Carolina at Chapel Hill School of Medicine)

But nonetheless this divide we have between lifestyle and healthcare is an artificial one. It isnt really a part that government policy is able to deal with too well, but they are not separate. Kinda like blaming the mechanic when you take your Lexus out mudding. He may still be able to help you, but what he can fix is going to be expensive. Blaming him for the broken parts is just shirking responsibility.

Smoking is looked at in a few of the blogs, and in the above comments. However smoking rates are pretty similar in the developed world. Look at a place like France which is famous for its smoking, and they still beat us hands down in this study. ..would it be good for us to stop smoking, almost certainly. Is it the only cause out there when it comes to health, or even lifestyle disease? no.

Its an interesting look. I still dont think universal insurance is in any way the answer here. Just lower the cost.. Lower the cost and even the middle income people can go in and get treated.

Yes this may mean only 2 beemers for your surgeon. But I think he can tough it out.

You all can take yourself or any of your family to any of the countries listed if you get sick, but there is no place Bar None, I'd rather be if me or my family happened to be sick.

A dear friend, a musician, was touring in Sweden when he came down with a respiratory infection that turned into pneumonia. He was in a hospital in Stockholm for a week, given all the standard meds and therapies, and upon his release, he asked for the bill. The hospital told him there was none. "But I'm an American, I'm not a Swedish citizen--I'm just visiting," he said. They told him he was visiting their country, yes, and they took care of him, and that was that, go and be well.

Based on numerous tales of traveling relatives and friends, along with my own experiences, I'd say Sweden gets the nod for my choice of where to be if a loved one or I were to fall ill.

If you're madly fond of getting writers' cramp from filling in form after repetitive form and signing enormous cheques and permission-to-take-my-firstborn-son-should-I-be-unable-to- pay documents, however, definitely go with the US.

lilbrit, God bless, but you do know Jenga is fucking nuts right?

I looked at the state by state breakdown, which is very illuminating. The top 10 performing states in the US for amenable mortality: Minnesota, Utah, Vermont, Wyoming, Alaska, Colorado, New Hampshire, Maine, Washington, South Dakota. Amenable mortality ranges from 70.2 to 80.2 per 100k - for reference Canada is 76.8. Looking at these ten states for some commonality, I notice that they are very white. Average percentage of African-Americans in these states 1.8%.
The 10 bottom performing states in amenable mortality: North Carolina,Kentucky,West Virginia, Oklahoma,Alabama, Georgia,South Carolina,Tennessee,Arkansas, Louisiana,Mississippi (last) ranging from 114.4 to 150 per 100k
Average African American population in the bottom 10 is 22.4%.
The correlation between percent of African Americans and amenable mortality is 0.84. A large part the US's deficiency in healthcare outcomes is a reflection of our failure to adequately address issues of race and poverty, not our health care system.

A large part the US's deficiency in healthcare outcomes is a reflection of our failure to adequately address issues of race and poverty, not our health care system.

Upper-middle-class and wealthy people can afford top-drawer health insurance.

Poor, working-class and even middle class Americans--of every race--cannot.

Ergo, these three groups, particularly the poor, who are disproportionately represented by African Americans and Hispanic Americans, don't get the same access to "our health care system"--in fact, many don't get any access to it at all. Hence the amenable mortality rates.

Race and poverty, then, mean there are many Americans who can't afford medical care, or enough of it. But our failure to address issues of race and poverty is a separate problem, not an alternate explanation for the US's dismal rate of amenable mortality.

akaison, yeah, based on his or her peculiar logic, I suspected as much but did not know with certainty. Now I feel kind of bad.

(Very well, not that bad.)

lilbrit,

I appreciate what you are doing, but reasonable people wouldn't take this information and do what the people are responding to are doing with it. Ie, the whole thing about race is bullshit. the stuff about poor people is bullshit. the whole point is that looking at each country as a whole with each having its associated problems, cultures, etc- some of which are worse than the US- we still are dead last. Sure people who are trying to justify whatever will dispute this. But those people don't give a shit about honest evaluation in the first place. if they were they would realize that each country has its own separate complexities- the fact we rank dead last is an absolute that can't be parsed into anythin gother than we rank deadlast. i mean is the rest of the planet homogenous and wealthy? for that matter lets say they are 100 percent correct, is the point that well its just those colors and poor white trash? whats the point fo the parsing ? for that matter how can we possibly know or understand that parsing when compared to other countries which again aren't perfect with their own cultural, diet, etc problems and yet still rank higher than us. The problem is in absolute terms when we don't turn this into a relativistic cultural study- (ironic i know) there is no way a reasonable person can justify these numbers unless they are like jenga- in other words fucking nuts.

akaison, agreed--in toto--and for some reason I keep coming back to this: the US is the only developed nation in the world that does not provide health care for its citizens. Even the proposal (for reforming the US healthcare system) of most progressive presidential candidate in the current race falls rather well to the right of the most right-leaning foreign country. Everywhere else, people view universal healthcare as a birthright, as something too fundamentally important to the well-being of all, and too vulnerable to abuse and corporate greed, to be left to the private sector to dole out to those who can cough up (pun intended) enough money. Here, you're on your own, out in the cold; so you spend what you can afford--if that's anything--for what these people think is only deserved, in their view, by those who work hard enough (or inherit money hard enough).

Never mind the caprices of fate, fortune, accident, virus, or tumor, though. Never mind that in those other countries to which you refer--which are all indeed heterogenous in terms of race, wealth, lifestyle, and circumstance, just as we are here--do not leave their citizens to fend for themselves and do without if they can't pay the bill. Never mind that healthy people are better equipped to go to school and work--essentially, to improve their lot--in the first place. Never mind that save the extremely wealthy, most of us in America, whether we want to admit it or not, may well be one catastrophic illness or accident away from bankrupcy and ruin.

To the dyed-in-the-wool wingnut, "giving" us universal health care here in America is perceived as something that would turn us into the dreaded commie nation of their nightmares. Further, it would render superfluous the powerful but threatened and (obviously) deeply worried corporate sector that is the insurance industry. And neither the wingnuts nor said corporate sector will stand for such fair, humane policy, even if nations with longer records of, well, being nations have proven, with hard numbers, that it's infinitely more beneficial--to the individual and the state.

Other countries are not as heterogenous as ours. I support universal health care. This issue is that access does not adequately explain the difference in these statistics. Are you saying there are no poor, working class folks in Minnesota, Utah or Colorado? Their amendable mortality rates are comparable to Canada's. 12.4% of whites are uninsured. 20.1% of African Americans are uninsured. The amenable mortality rate of the US is
103.4/100k. For whites it is 93.6/100k. For African Americans it is 194.1/100k. Studies indicate that adjusting for socioeconomic status only accounts for about 34 to 49% of the difference in amenable mortality between whites and African Americans.

The amazing thing here is that if this is true it seems to affect health very little.

"Which begs the question-- why is our health care so divergent in different regions (they claim a two-fold difference between best and worst) and what could be done about it?"

I went to the State Scorecard on Health System Performance, cited in the article as the source for the data that said, "if all states achieved levels seen in the best-performing state on this measure, about 90,000 premature deaths might be avoided annually."

The top performing quartile are Hawaii, Iowa, New Hampshire, Vermont, Maine, Rhode Island, Connecticut, Massachusetts, Wisconsin, South Dakota, Minnesota, Nebraska, and North Dakota. With the exception of CT, MA, and RI, all the other high-performing States are among those States that spend the least amount of money per Medicare beneficiary.

This means that spending more money on health care doesn't correlate with better outcomes. (And yes, Medicare spending per beneficiary does correspond to overall health care spending in the State on other populations.) Hawaii gets the best rating, and spends the least per Medicare beneficiary ($4,454) at the same time. NJ is the most expensive State, ($7,834 per enrollee, 76% more than in Hawaii) but ranks 26th in health system performance. The worst State in health system performance is Oklahoma, but they still spend $6,152 per beneficiary, 38% more than in Hawaii.

The average cost per bene in the 13 States with the highest performing health systems is $5,306, far less than the national average of $6,271.

Even within the US, higher costs don't produce better results. More health care spending doesn't necessarily mean better health care which has policy implications allowing universal health care proponents to promise better care for everyone at lower overall costs, just like in other countries.

Got to love the strawmen arguments. Look, try to parse with in the US borders until your heart is content- it will never address the over arching point of this diary- namely our care sucks compared to 18 other countries. So long that's true- you are bullshiting.

Akaison-Go Fuck yourself, Go do something in the healthcare field, then have an opinion. In that order preferably, otherwise shut the fuck up.

I say that this is the only place I would want to be because I have worked firsthand in 3 of the countries (US, UK and Canada). Here if I don't like my doctor or what he or she has to say I can go to someone else. If I have a problem with the hospital there are countless patient advocate groups in the hospital or I can go elsewhere. In Canada, Don't like it, Go Fuck Yourself and go to the back of the line. In Britain, Don't like it, Go Fuck Yourself and go to the back of the line. Here patients are revenue and consumers, Great Britain and Canada a number to be knocked off the list while they chalk another day up on the time card.

As far as infant mortality, we save babies other countries don't even count as births.

I agree more spending doesn't equate to better care, but who of you is going to be the first to tell your grandmother she's too old for the ICU.

akaison,

Let me try to make my point simply so you can understand. You say "the over arching point of this diary- namely our care sucks compared to 18 other countries. So long that's true- you are bullshiting." You say "Our care sucks" But the average amenable mortality figure that is 18 out of 18 does not represent the experience of the vast majority of Americans. If 90% of Americans have slightly above average care and 10% have horrible care it has different political and policy implications than if all 100% have health care that sucks equally.

let me make myself clear so that you understand me. Parsing up americans so that you can ether be racist or whatever else you are trying to do to justify our being 19 out 19 is bullshit. So you can keep trying to parse up Americans all you want- I still know what you are doing you racist piece of shit,

jenga- like I said- you are fucking nuts. luckily your crazy is in the extreme minority.

"Why do you suppose the infant mortality rate is so high in this country? Are all these sick and dying babies emerging from the birth canal holding a cigarette in one hand and a scotch in the other, their plump, unfit and supersized bodies already needing XXXL diapers?"

1) Poor black folks and illegal immigrants dont seek out prenatal care, which inevitably leads to far worse outcomes. The Deep South and West have notoriously high infant mortality. Prenatal care is covered at no cost in virtually every state thru a combination of CHIP and other programs. People simply arent utilizing their services appropriately.

2) France and other euro nations have much more lenient criteria for what constitutes a "live" birth. 24 weekers with APGARs of 1 and 3 in France are not counted. They are not intubated. They are not sent to the NICU for aggressive resuscitation. They receive no intervention, and 99% of hte time they die. The doctor tells the mother that the baby is dead and thats the end of the story. In the USA, all births in which the infant has respirations and some kind of heartbeat (no matter how slow or irregular) is counted as a live birth. We send them to the NICU where they spend weeks on a ventilator receiving "state of the art" care which costs upwards of $5,000 per day. 95% of them die within 2 months, but only after incurring enormous costs.

joe blow, how is what you're claiming (in point 2) in conflict with what I said? If, as you say, more babies die in France--and if they're not resuscitating low APGARS, it would logically follow that there are significantly more infant deaths, yes?--then France's infant mortality rate would be higher than ours. It isn't.

And as for your first point, I don't believe it's quiet as simple as walking into a clinic and saying, "I'm pregnant and I'm too poor to afford health care: can you help me?" In the rural area of Florida, where I live, poor women who wish to avail themselves of what little free or low-cost health services are offered have to wait, sometimes all day, to see a nurse. Hell, they have to wait to even get an appointment in the first place. Bear in mind that some of these women are working during the times the clinics are open, and some have other children to care for. At the local clinic in my town, there is a massive room filled with metal folding chairs, and it fills up early in the morning--a woman with small children couldn't possibly sit with them all day (and if she was concerned about germs, wouldn't want to, given that many of the other patients waiting alongside her will be quite communicably sick, coughing and sneezing, especially this time of year.

There are nowhere near enough such free and low-cost services to help the many, many women who need them. And in our state at least, the funding seems to get cut every year--even as more people move here (and they're not all wealthy types escaping the cold, either); even as more people fall below the poverty line.

Further to the above comment, joe, I can see that if infant mortality is defined as not including babies that die shortly after birth, but rather, after a certain period of time (and the low APGAR babies in your example would, instead, be deemed stillborn), the US rate would be higher.

I still don't see how the US has a higher rate than the UK, where there are plenty of poor, especially in urban centers. Also, the main difference between giving birth in England and doing it here is that in England you aren't kicked out of the hospital 24 hours post-partum because your insurance won't cover a longer stay. Also, and my mother confirms this, the NHS sends nurses to visit new mothers at various points after she returns home with the newborn. Obviously beneficial in terms of education as well as noting any early problems with feeding or neonatal illnesses , and any issues like postpartum depression suffered by the mother.

akaison,

You have called me a racist piece of shit, and that you "know what I'm doing." Instead you demonstrate that you know very little.

1) I am an advocate of universal coverage. Any of one the Edwards, Obama or Clinton plans is a good start.
2) I am advocating additional social change to address the problems of African-Americans in terms of health. The disparities are not simply because African-Americans are more likely to be poor, as litbrit reasonably suggests. Racism, unfortunately is deeper than that, unfortunately. I'm saying we will need to do more to correct the inequities of racism on health than to provide universal coverage. wisewon asked what was different about the best performing states - this was the answer.
3. Part of my work is at a NYC public hospital working with the poor and uninsured, as well as going out in a van once a week, providing healthcare to the homeless. That is "what I am doing."

As a citizen of the UK, I would like to take this opportunity to point out that when jenga says you can't change your doctor in my country, he's just lying. Which also means he's probably lying about having worked in my country.

I don't know why he thought nobody outside the USA would be reading this blog and call him on it.

Friends, Americans! This regrettable record on the management of preventable deaths should come as no shock to the chain-smoking, obese, gun-toting populace that occupies much of that swath of the American continent that bears the title "Land of the Freebooter, Home of the Slave," or words to that effect.

And the Great Decider's government has done little to stop their wholesale slaughter of, well, themselves. (But it's not that bad - after all only 10 times as many Americans have been shot in America in the course of the Iraqi conflict as have been shot in Iraq.)

There are a couple of errors in this story. The study says there would have been 101,000 fewer deaths PER YEAR during the study period if the US had the AVERAGE AMENABLE MORTALITY RATE of the top three performers, not if we had the same degree of improvement they had. Achieving the same rate is a good deal more difficult that matching their pace of improvement. But then again, 505,000 preventable deaths is a lot more than 101,000.

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