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The Perils of International Health Care Comparisons


“America spends more on its health care system than any other country, but has worse health outcomes.” It’s a familiar tune, a variation on which involves Americans’ relatively lower life expectancy. Think again, says Avik Roy, offering several reasons why life expectancy isn’t a good metric by which to compare national health care systems. For example:

People die for other reasons than health. For example, people die because of car accidents and violent crime. A few years back, Robert Ohsfeldt of Texas A&M and John Schneider of the University of Iowa asked the obvious question: what happens if you remove deaths from fatal injuries from the life expectancy tables? Among the 29 members of the OECD, the U.S. vaults from 19th place to…you guessed it…first. Japan, on the same adjustment, drops from first to ninth.

This doesn’t necessarily mean that the “more costly, less quality” narrative isn’t true in other ways. What it does show is that making cross-country comparisons is a complex process fraught with many opportunities for error and misinterpretation. We can learn important truths about health care policy from studying other countries’ systems closely, but using one-off, decontextualized statistics isn’t the way to do it. Beware anyone trying to argue for a pet health care policy on the basis of a few statistics.

[Photo of stethoscope and money courtesy of Shutterstock]

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  • Andrew Allison

    Another apologist for the world’s most costly healthcare system heard from. The US ranks 30th in infant mortality. How many of those dead are victims of violent crime, car accidents, etc? How much of the death toll is due to lack of access to “the world’s best” healthcare? Let me be clear, I think ACA is an abomination, but the pretense that the excellent healthcare available to those who can afford it is universal is, pardon the pun, sickening.

    • ColoComment

      You need to familiarize yourself with some of the valid criticisms of cross-country healthcare comparisons. Like this one, re: measuring infant mortality.

      • Andrew Allison

        And you a lesson in civility. Parse the data any way you wish, the simple fact is that, for reasons which may be debated, the world’s most costly heath care system has third-world longevity and infant mortality.

        • ColoComment

          Sorry. I did not intend the rudeness that you apparently inferred.

          I simply wanted to note that the ranking that you attributed to the U.S. vis-a-vis infant mortality rests on arguably dubious cross-country data comparisons. And that the OECD studies on which all the country comparisons rely are heavily weighted in favor of European health care systems.

          It’s not a matter of parsing the data — it’s a matter of data comparison integrity.

          Lastly, your reply begs the question of the actual quality of U.S. health care system. If you wish to ignore that information about the OECD study(ies), which to date, so far as I’m aware, is the sole foundation for any insistence that the U.S. has “third world” health care outcomes, what else forms the basis for your assertion?

          • Andrew Allison

            Thank you for your thoughtful response. At least part of the problem is one’s view of “quality”. As others have pointed out, if you have access to US healthcare, it’s comparable (albeit roughly twice as costly) with other OECD countries. Unfortunately, all too many US residents lack access — the problem which ACA was allegedly intended to address (allegedly because the hoofprints of the Pharma, Insurance and Provider Industries are all over it).
            Although I actually used CDC data (“The United
            States infant mortality rate as of 2005 was 6.9 infant deaths out of
            1000 births. According to the United States Center for Disease Control,
            the U.S. ranks 30th compared to other countries. ‘The U.S. infant
            mortality rate is higher than rates in most other developed countries,’
            note CDC researchers Marian F. MacDorman, PhD, and T.J. Mathews. ‘The relative position of the United States in comparison to countries with the lowest infant mortality rates appears to be worsening.'”), the criticism of the OECD study comes from US interests and is long on supposition and short on data. The Quick Take to which I responded is a typical example of such criticism: deaths from fatal injuries are a societal issue; what’s relevant to healthcare is the survival rate of those who were not DOE. Etc.
            In summary, the US has good healthcare for some, OECD has good health care for all at much lower cost.

          • FlyoverGuy

            It is generally understood that infant mortality data are compiled in grossly different ways across countries. Most countries have much stricter standards for what constitutes a live birth. As a result, US mortality rates are much higher than they would be if compiled with other methods. You can choose elide this problem or selectively quote the CDC, but this doesn’t change the fact that you asserted a “fact” that is not true. And everyone who understands and honestly describes intl health comparisons knows that your “fact” is not a fact.

          • Andrew Allison

            Au contraire. It is a fact that CDC concurs with international bodies that US infant mortality is scandalous. Denying the facts is your priviledge, but doesn’t change them.

          • FlyoverGuy

            You answered an argument that I didn’t make. I believe that is known as knocking down a strawman.

            But that doesn’t surprise me as you are here to score political points, not discuss issues.

            I never said that US infant mortality wasn’t in need of significant improvement. That is certainly true.

            What I said was that infant mortality stats are often not comparable across countries, a fact that is still a fact, even if some people who should know better ignore that.

            Please feel free to continue responding to arguments that I didn’t make.

            Perhaps you can refute the idea that the Earth is flat on your next comment.

  • Anthony

    A most salient point of Quick Take is “making cross country comparisons is a complex process fraught with many opportunities for error and misinterpretation.”

  • paridell

    Update to my comment on the Shutterstock illustration to “The British Health Care Scandals in Context” – the illustration (showing the old Beelitz hospital in Germany) was even wider of the mark than I thought. Not only was it not a British hospital, it was the very hospital to which Private Adolf Hitler was sent after he was struck by shrapnel while fighting the British in October 1916. Yes, the story on the British NHS was illustrated by a stock photo of a German hospital from the Kaiserreich era, with a link to Hitler. Nice going!

  • ljgude

    I am forever making the point that the bill for US healthcare is about double the OECD average. I always say that the outcomes are only SLIGHTLY worse despite not having universal healthcare. If you want to graphically SEE the overall trends in World health you can go by Hans Rosling’s talk from about 2008. It is long, but the first thing he covers is the world wide trend toward smaller families and greater life expectancies with lots of caveats about margin of error in the stats. It is very clear that the US healthcare system is very very good in terms of outcomes, It is the percentage of GDP we spend on it that is way out of line with other countries. The key thing Americans need to know is that the ACA caps healthcare spending to 17.5% of GDP by 2017 from the pre ACA level of 16%. The second most expensive healthcare system in Switzerland at 11% of GDP. Here is a comparison chart:

    • ColoComment

      Rosling is wonderful, but I don’t have 20 minutes right now to again watch his TED talk. If I recall correctly, some economist (de Rugy?) whom I read some time ago noted that some European countries’ budgets categorize certain factors of “health care” as social welfare, thereby excluding some of their costs from direct comparison with U.S. spending. As I said, I don’t have time now, but will look for that later.
      Serious Q: if our federal legislators (and their constituents) are comfortable with (and indeed, enthusiastic about) capping health care spending at some % of GDP, why can they not cap aggregated U.S. social welfare programs at some % of GDP?

      • ljgude

        I don’t think reporting differences account for the discrepancy. Rosling shows he is quite aware that his work is only as good as his data. An informal confirmation of US health costs being double is to look at the costs of travel insurance for travelers going to the US. The premiums are double. Any travel agent will tell you you need the top level of coverage to avoid disastrous medical bill in the US. The point of Rosling’s talk is that health outcomes have been excellent and improving not only in the developed countries but but across the world for the past 50 years.

        I too would like to see an honest comparison of social welfare spending as a percentage of GDP. Unlike health, the outcomes are harder to agree on, much less measure. The best article I’ve read on US healthcare spending is Bitter Pill in Time earlier this year.

    • FlyoverGuy

      How does one define “slightly” better outcomes?

      For many serious illnesses, the US has excellent outcomes, especially adjusted for demographics.

      A very large proportion of health care expenditures are on people who might have very little time left –either fairly old people or those with very serious illness. We could easily save a lot of money by simply telling these people they are done and should say goodbye. There would be only a very marginal impact on almost all health statistics and we’d save a lot of money.

      Do you want to do that to your family?

      I will never do that.

    • RonRonDoRon

      “ACA caps healthcare spending to 17.5% of GDP by 2017”

      Are you claiming that the ACA actually caps healthcare spending? Meaning, by “caps,” that it has a legal mandate preventing spending from going above that level?

      If so, that is only possible through explicit rationing or through price controls. If not, then that “cap” is just wishful thinking.

      • ljgude

        My understanding from reading about the ACA is that the cap is in the actual bill. I have not read the bill and I agree without some control mechanism put in place it is just wishful thinking. Perhaps the whole bill is just wishful thinking come to think of it.But the nub of my point is that as a “reform” of American healthcare it is actually going in the wrong direction. It shouldn’t cost us more than the insurance based Swiss system at 11% of GDP. Instead the ACA anticipates it is going to increase by 1.5% over about 5 years. It isn’t just rationing, a lot could be gained by rationally administering the ‘free’ medical we already provide for the poor. We already have de facto socialized medicine but run it irrationally. The patient is billed but they can’t pay. The hospital gets reimbursed or not by various levels of government and it ends up costing all of us more than it should. Again, Time Magazine’s article Bitter Pill identifies where the excessive spending is going.

  • BrianFrankie

    Thanks, VM for covering this topic. Those familiar with the science and statistics are well aware that the two most common metrics used as claims that US health care quality is low – life expectancy and infant mortality – are actually entirely useless for cross border health care comparisons. Confounding data simply make these simple statistics a terribly poor proxy for health care quality. Academic work pretty much recognises this truth, but the popular and non-technical press has not got the message to date.

    The truth is simple. All studies that have attempted to control for extraneous variables to isolate health care system quality factors show that the US system is comparable to, or superior to, all other systems in the world. The issue with the US health care system is one of cost and access, not quality.

    • Andrew Allison

      “The issue with the US health care system is one of cost and access, not quality.” Exactly!

  • stan

    The US subsidizes health care for the rest of the world. It’s ridiculous to compare our costs to those of a country whose drug costs and medical technology development costs we are paying.

  • ColoComment

    This may or may not make it onto anyone’s Disqus alerts, but today’s WSJ (page A11) has an article about France’s underfinanced social welfare programs, including its social security and HEALTH CARE programs. It appears that France transfers that debt to a [off balance sheet?] vehicle named “Cades” which was set up to pay down overdrafts, but which is now pushing against its legal debt ceiling. So maybe the reported costs for French health care do not include ALL cost?
    How can we compare health care costs in different countries when we don’t have accurate numbers? The comparison is doomed from the git-go.

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