A week or so ago, a fascinating health care study ricocheted aroundtheblogosphere, comparing death rates among 19 industrialized nations—and looking in particular at deaths that could have been prevented with “timely and effective” medical treatment.
Not too surprisingly, the study found that the US was the worst of the lot, with higher rates of medically-preventable deaths, and slower reductions in such deaths, than any other country studied. (No wonder we’re one of the developed world’s laggards on life expectancy.)
But when I dived into the data a bit, it looks to me as if our leaky health insurance system isn’t the only story behind our comparatively high death rates. In fact, medically preventable deaths aren’t even half the story of why people under 75 die.
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By the numbers:
At last count, the authors concluded that some 110 out of every 100,000 US residents under the age of 75 die each year from causes that, in the study’s words, “should not occur in the presence of timely and effective health care.” Canada does much better, with just 77 such deaths per 100,000 residents. France, however, leads the way, with just 65 “medically amenable” deaths annually for every 100,000 residents. If the US had France’s “amenable mortality” rate, about 101,000 fewer Americans would die each year. (Ezra Klein’s take on this is just right: if an enemy nation targeted that many American lives—say, by blowing up a city the size of Boulder, Colorado, or targeting 30 World Trade Centers—we’d be at war in a heartbeat. But in this case the killer is a mixture of apathy and systemic political failure, so we let the deaths pile up, essentially unnoticed.)
That’s all interesting (and depressing) enough. But what I found most fascinating in the study was the variation in deaths that are not considered “amenable” to medical care. Just what are these “non-amenable” deaths? Well, obviously, some are homicides and suicides; others are caused by car crashes, firearms accidents, and the like. A lot are heart attacks. Some are inoperable and untreatable cancers. The list, I’m sure, goes on and on.
But the bottom line is that these non-amenable deaths are almost 3 times as important in determining whether we’ll live past 75 than are the small subset of deaths that medical care has a prayer of preventing.
There are at least 2 ways of looking at this:
Non-amenable deaths predominate: The highest non-amenable death rate (Denmark’s 311 per 100,000 residents under 75 per year) was about 2.8 times as high as the highest amenable death rate (110 per 100,000 per year, in the US). Similarly, combining data from all 19 nations studied, the average non-amenable death rate (243 per 1000,000) was roughly 2.8 times higher than the average amenable death rate (87 per 100,000).
Non-amenable deaths are more variable: The gap between the best- and worst-performing nations for amenable death rates—deaths that could be prevented with effective medical treatment—was 45 deaths per 100,000 residents. But for non-amenable deaths—the ones that even the best medical care couldn’t prevent—the gap between the best (Japan) and the worst (Denmark) was about 125 deaths per year. So among industrialized nations, there’s nearly 3 times as much variation in the deaths that medical care can’t affect than there is for deaths that a good doctor can forestall.
This last point bears repeating: nations differ far more in their non-amenable deaths—the ones medical care currently can’t prevent—than in amenable deaths. If you want to improve health, medical care is certainly important; but in the aggregate, it’s more important to look at deaths that medical care can’t affect.
To illustrate further: in the figure below, the blue bars represent the “excess” non-amenable death rate for each country—that is, how much worse each country does than Japan, the nation with the lowest “non-health-care” death rate. And the red bars represent the excess “amenable” death rate—that is, how much worse each country does than France, the nation with the lowest amenable death rate. Quite obviously, the blue bars—the deaths that medical care couldn’t prevent—dominate the picture, both in absolute numbers and in variability.
What do I take away from all of this? Well first off, there’s a lot more to health than health care. Improving our health insurance system is clearly important, but even a wildly successful health system reform is no guarantee of good health. In fact, if you waved a magic wand and improved the US “amenable” death rate to France’s, we’d still have the industrialized world’s third-highest death rate for residents under 75. We have just too many deaths from other causes for medical care alone to save us.
Second, public health (writ large), rather than health care per se, may be the key to living longer, healthier lives. It’s the subtle forces—the way our suburbs and cities discourage walking and encourage driving; the lack of healthful food (and the low cost of junk food) that disposes us to eat poorly; the pervasive poverty and economic inequalities that dampen our spirits and our sense of community—that truly affect how healthy we are as a society. We could have the best medical care in the world, but it still wouldn’t make us a truly healthy nation. For that, we need not only a better system to cure us of our ailments, but more importantly, smarter ways to keep us from getting sick or injured in the first place.
A little confused that France seems to have 0 deaths amenable to health care in the chart and Japan seems to have 0 deaths *not* amenable to health care. Must be some kind of typo (or would this be a “grapho”?—ha.).Japan, I know, has one of the world’s highest suicide rates. http://news.bbc.co.uk/2/hi/asia-pacific/5082616.stm That’s got to count for something.
ps- but, still the comparison to the US is remarkable.
I wonder why Denmark is so different from the rest of Europe. I can think of all sorts of reasons to explain the higher numbers in the USA. Higher violent crime, poor diet, lack of exercise, lack of education, overworked lifestyles, etc. Black males have the lowest life expectancy of any group. Both amenable and non-amenable deaths are likely high amoung black males. Maybe even hispanic males also. So could that be affecting the overall numbers significantly in the USA? Or does Europe have similar issues with minority populations? Or is that too touchy of a question to ask? I don’t want to be accused of being racist or anything for simply posing the question.
Andrew –Yeah, the graph’s a bit confusing in that respect. It represents “excess” deaths above the world’s best performers.France is the world’s best performing nation on “amenable” deaths. So it has no red line at all—no deaths “in excess” of the world’s best performer (itself).Jeapan is the world’s best performing nation on “non-amenable” deaths. It has no blue line at all—no deaths in excess of the world’s best performer.All the red & blue lines are comparisons with those 2 countries’ respective rates.Oh, darn, it all makes sense inside my head. I guess I’ll just have to work harder on the explanation….
Jay -As I understand it, Sweden has a surprisingly high percentage of immigrants. I don’t know what accounts for Denmark’s lackluster performance, but you see it in health-stats across the board: life expectancy, mortality, etc.
Immigration will affect these statistics in rather complicated ways. I don’t presume to know the overall effect, but one issue would be that immigrants tend to be young and healthy, so that aspect at least would suggest that high immigration ought to improve this statistic.Going by the chart, I’m not convinced that the overall effect of immigration is predictably one way or the other: countries listed there which have high rates of immigration include not only the US, Britain and Ireland (all fairly poor performers), but also Canada, Spain and Australia, all of which perform considerably better.
Canadians indulge in a North American lifestyle quite similar to that of Americans, yet there is a sizeable gap in excess non-amenable deaths. While gun-related deaths must account for some of the difference, I wonder whether a further portion may be attributable to the effect of universal health care. Perhaps poor and lower middle-class Canadians are more likely to seek earlier medical intervention for cardiovascular conditions and cancers, enabling them to be treated before they reach non-amenable status. Not that public health in general isn’t important, but perhaps not quite as much as you seem to be suggesting.
Kevin -It’s hard to know what to make of the US/Canada divide. There’s obviously a big gap in health care & amenable deaths—but I don’t really understand how “medically amenable” deaths relate to preventive medical care. Is a death “amenable” if it could have been forestalled by early medical intervention? I’ll have to understand the paper & its methods a lot better before I know the answer to that.However, Canadians lead US residents in a lot of health-related behaviors & conditions: smoking, car crashes, homicides, obesity, etc. Plus, there’s a lot of research on the links between economic equality and population health—and Canada’s economic structure isn’t as wildly unequal as ours is.So there’s probably some element of preventive care that keeps Canadians healthy; but (a) I’m not sure how much of that shows up in amenable death rates, and (b) I’d bet that the other health determinants are also pretty important.
I’m not willing to pay to read the article, but the commentaries on it make it clear that the intent of the amenable/non-amenable distinction is to separate deaths preventable by health-care from those that are not. So I must be wrong to have used “non-amenable” in my above comment. At least one commentary did refer to the list of conditions considered amenable as “subjective,” suggesting that there’s no standard list of such conditions.