We spend one-and-a-half times more per person on health care than any other country, but we aren't any healthier for it.
-- President Obama in his address to a joint session of Congress on health care on September 9, 2009.
If you were seriously ill, what country would you want to be in? That seems like the simple question for comparing health care in different countries. But the numbers being offered by the administration aren't any more useful in answering that question than they were about comparing the cost of health care across countries.
As evidence to back up the president's claims, his press office points to the Commonwealth Fund or the United Nations' World Health Organization (WHO). Both organizations measure the quality of the health care system in fairly similar ways, such as relying on life expectancy.
The "Overall Health System Performance" ranking put out by WHO is intended to show how the health care system "contributes to good health." It ranks the U.S. at 37th out of 191 countries. This places the United States behind countries such as Chile, Colombia, Cyprus, Dominica (a small island in the Caribbean), Malta, Morocco, Portugal, and San Marino. The U.S. is given virtually the same ranking for its health care system as Costa Rica, Cuba, and Slovenia. But would anybody, other than international bureaucrats, consider health care in these countries even close to the health care delivered in the United States?
Fortunately, we can go beyond the "Overall Health System Performance" ranking itself and look separately at the many different factors that go into this index -- some are more closely related to measuring the quality of health care than others. One such factor is the "overall level of health system responsiveness," defined as "a combination of patient satisfaction and how well the system acts." By that measure, the U.S. ranks first. The result squares well with polls showing that about 90 percent of Americans are happy with their health care and that even the vast majority of uninsured are happy with their care.
Admittedly, the U.S. ranks much more poorly on some other measures -- some more closely related to measuring the quality of health care than others. One measure is life expectancy. The WHO measure takes average life expectancy and adjusts it to make a disabled year count for less than a healthy one. The Commonwealth Fund looks at life expectancy without making this adjustment. But both are imperfect measures of the quality of health care because how long people live has a lot to do with lifestyle factors such as smoking, obesity, accidental deaths, and murder. Obviously even the best health care system cannot prevent car crashes.
TABLE 1 shows how lifestyle risks vary across 30 developed countries, as compiled by the Organization for Economic Co-operation and Development (OECD). Obesity and smoking have similar impacts on life expectancy, with, on average, being obese being roughly as risky as being a smoker. Now, Americans are, on average, fatter than people in other OECD countries but they smoke less: over 20 percent more Americans are obese than in the average OECD country AND about 7 percent fewer Americans smoke. The differences in obesity are fairly dramatic across countries, with Americans being about 10 times more likely to be obese than Japanese or Koreans. Americans are about three times more likely to be obese than Austrians, Dutch, Finns, French, Italians, Swedes, and Swiss. As the problem with obesity is so much more extensive compared to our relatively low rate of smoking, on net, Americans are taking greater life-style risks than the average for OECD.
Unlike statistics on most other accidental deaths, data on automobile accidental deaths are readily obtainable across most countries. And automobile fatalities make up a very large percentage of total accidental deaths -- about a third in the United States. The per-person automobile death rate in the U.S. is about 72 percent higher than the average for other countries. Also, at least among the OECD countries, the murder rate in America is above the average, too, and this drives down life expectancy, regardless of any fault in the health care system. Even America's relatively high rate of infant mortality has a lot to do with behavioral differences, including alcohol and drug use. Accidental automobile deaths, murders and infant mortality all involve relatively young people and have a large impact on life expectancy.
The WHO also adjusts downward the ranking of countries when different portions of the population have differences in life expectancy. But here also personal behavior matters. Blacks, particularly black women, are much more obese than other portions of the population. And despite making up only about 13 percent of the population, blacks account for 50 percent of all murder victims. Whatever conditions one blames for these differences, they certainly are not the fault of the local doctor or hospital.
When asked about some of these problems, how to use life-expectancy to measure health care quality, Nicholas Papas, a spokesman for the Department of Health and Human Services did not address these concerns. He would only tell FOXNews.com: "These are the standard and accepted tools used to measure health care outcomes across countries."
So how can we evaluate the quality of health care that Americans receive? An alternative way of measuring health care quality is to look at survival rates after being diagnosed with a particular disease. Take the eight types of cancer shown in TABLE 2 (all survivor rates are age-adjusted). For each type of cancer, an American with cancer has a higher probability of surviving for five years. Overall, men in the United States are 40 percent more likely to survive for five years, American women 13 percent more likely.
TABLE 3 provides a comparison on a country-by-country basis along with the WHO ranking of each country's health care system. Despite having a lower WHO health care rating, the United States has a higher cancer survival rate than any of these other countries. For four of the types of cancer (Colon, prostate, Cervical, and Thyroid), the better the WHO rating for various countries, the lower was the cancer survival rate (FIGURE 1). This weird result suggests that the WHO measures have little to do with measuring what health care makes people better.
Possibly the federal government will soon be taxing soda drinks and dramatically higher proposed gas taxes will reduce energy use. Fewer calories and more enforced walking may reduce obesity. But presumably Americans like to drive because we like living in the suburbs and having yards. We may also drive to save time.
President Obama and the Congress may not approve the choices people make, but individuals are presumably in the best position to make decisions about what they like to eat and where they like to live. In answering the question: If you were seriously ill, what country would you want to be in? The answer is pretty clear. The American health care system is second to none. But you can't blame the health care system for the choices that some Americans make.