Thursday, May 04, 2006

The American Malady



This time, in concrete terms. A recent study argues that Americans are sicker than Brits:

The United States spends more than twice as much per person on health care as Britain and yet, according to new data released today, older Americans are "much sicker" than their English counterparts.

The conclusion, in an article in the Journal of the American Medical Association, or JAMA, surprised some in Britain, where American private health care is widely perceived as highly effective, if expensive. It also seemed to confirm mutual stereotypes, tossed across the Atlantic, that Americans are prone to obesity while Britons drink too much.

Sir Michael Marmot, the professor who is a co-author of the report from University College London, said the research showed that the differences in health could not be ascribed to the "usual suspects" such as smoking, obesity or alcohol abuse. Indeed, he said, neither could the disparate nature of health care systems in the United States and Britain be blamed for the difference in levels of health.

"I'm arguing that it's due to the differences in the circumstances in which people live," Sir Michael said in a telephone interview. "Work, job insecurity, the nature of communities, residential communities, et cetera — I think that's the place we should try to look."

There is a small chicken-and-egg problem with the first sentence of this quote: "The United States spends more than twice as much per person on health care as Britain and yet, according to new data released today, older Americans are "much sicker" than their English counterparts." The author seems to argue that the United States is not getting value for money if it spends so much and its citizens are still less healthy than those of Britain. But another way to look at the same relationship is to assume that the United States needs to spend twice as much because Americans are less healthy. The only way this problem could be sorted out would be with the use of time-series data: If the ill-health precedes large expenditures on medical care the second explanation would be correct, for example.

The study results are fairly hard to interpret in any other way than the one suggested by Sir Michael Marmot. For example:


"The researchers found that U.S. citizens in late middle age are much less healthy than their English counterparts for diabetes, hypertension, heart disease, heart attack, stroke, lung disease and cancer," the press release said. For instance, it said, the prevalence of diabetes was twice as high in the United States as in England and hypertension was 10 percent more common in America.

Comparing the habits of older people, the article said "smoking behavior was similar in both countries, with about one in five people between the ages of 55 and 64 years currently smoking."

But it observed: "Obesity rates were much higher in the U.S. and heavy drinking was more common in England."

The article concluded that wealthier and better-educated people in both countries were much healthier than poorer and less-educated people. "Differences in socio-economic groups between the two groups were so great that those in the top education and income level in the U.S. had similar rates of diabetes and heart disease as those in the bottom education and income level in England," it said.

(I believe that the second "groups" in the last sentence should be "countries" to make the sentence meaningful.)

International comparisons have for a long time shown similar findings when mortality rates are used as a very crude measure of extreme ill health. The United States has shorter life-expectancy and higher infant mortality rates than countries such as the United Kingdom, France, Germany or Canada. The advantage of this new study is that it uses measures of illness rather than measures of death. That rules out the influence that higher murder rates have on the American mortality statistics.

If it indeed is the case that Americans are less healthy because of "work, job insecurity, the nature of communities, residential communities, et cetera" we end up smack in the middle of politics. For it is politics that has created a society where workers are expected not to take more than a week or two off out of every year and politics that makes jobs so insecure. Indeed, one recent political strategy tried to strip Americans of their Social Security benefits, too. Imagine how many heart attacks that plot may have caused.