Explaining these two graphs should merit a Nobel prize

Reposting from The Incidental Economist Blog

What happened to US life expectancy?

Posted: 07 Jan 2014 03:00 AM PST

Here’s another chart from the JAMA study “The Anatomy of Health Care in the United States”:

life expectancy at birth

Why did the US fall behind the OECD median in the mid-1980s for men and the early 1990s for women? Note, the answer need not point to the health system. But, if it does, it’s not the first chart to show things going awry with it around that time. Before I quote the authors’ answer, here’s a related chart from the paper:

ypll

The chart shows years of potential life lost in the US as a multiple of the OECD median and over time. Values greater than 1 are bad (for the US). There are plenty of those. A value of exactly 1 would mean the US is at the OECD median. Below one would indicate we’re doing better. There’s not many of those.

It’d be somewhat comforting if the US at least showed improvement over time. But, by and large, it does not. For many conditions, you can see the US pulling away from the OECD countries beginning in/around 1980 or 1990, as was the case for life expectancy shown above. Why?

The authors’ answer:

Possible causes of this departure from international norms were highlighted in a 2013 Institute of Medicine report and have been ascribed to many factors, only some of which are attributed to medical care financing or delivery. These include differences in cultural norms that affect healthy behaviors (gun ownership, unprotected sex, drug use, seat belts), obesity, and risk of trauma. Others are directly or indirectly attributable to differences in care, such as delays in treatment due to lack of insurance and fragmentation of care between different physicians and hospitals. Some have also suggested that unfavorable US performance is explained by higher risk of iatrogenic disease, drug toxicity, hospital-acquired infection, and a cultural preference to “do more,” with a bias toward new technology, for which risks are understated and benefits are unknown. However, the breadth and consistency of the US underperformance across disease categories suggests that the United States pays a penalty for its extreme fragmentation, financial incentives that favor procedures over comprehensive longitudinal care, and absence of organizational strategy at the individual system level. [Link added.]

This is deeply unsatisfying, though it may be the best explanation available. Nevertheless, the sentence in bold is purely speculative. One must admit that it is plausible that fragmentation, incentives for procedures, and lack of organizational strategy could play a role in poor health outcomes in the US — they certainly don’t help — but the authors have also ticked off other factors. Which, if any, dominate? It’s completely unclear.

Apart from the explanation or lack thereof, I also wonder how much welfare has been lost relative to the counterfactual that the US kept pace with the OECD in life expectancy and health spending. It’s got to be enormous unless there are offsetting gains in areas of life other than longevity and physical well-being. For example, if lifestyle is a major contributing factor, perhaps doing and eating what we want (to the extent we’re making choices) is more valuable than lower mortality and morbidity. (I doubt it, but that’s my speculation/opinion.)

(I’ve raised some questions in this post. Feel free to email me with answers, if you have any.)

@afrakt

5 Comments

robert posted on January 8, 2014 at 11:54 am

I don’t have JAMA access and have been searching for an answer to something that’s bugging me …

If ‘all causes of death’ in the US are 10-20% higher than those of the OECD median from 1960 to 90 … how can the US life expectancy possibly stay on par with the OECD median for those 30 years? 10-20% worse is a LOT worse.

If there is an un-gated version of the paper or a PDF I can look at via email I would gladly look into this myself.

robert posted on January 8, 2014 at 11:56 am

… I note that the mix of males and females over the years is a clear first line of inquiry (and may help explain the deterioration after 1990 as well), but I don’t have the data in front of me and it’s unlikely that it would change so drastically between 1960-1990 and then stop after 1990 to cause the deterioration we see there.

Randy Ellis posted on January 8, 2014 at 12:09 pm

Note that this first chart is life expectancy. Most people die when they are old. Even if older people die at twice the rate of young people the LE will not differ by that much.

If infant mortality was 20% higher in the US than in the OECD, and people only died when they were infants or at age 80, then we would see a 20% reduction in life expectancy. Otherwise the difference will be less than 20%. Work it out.

The second chart is of years of productive life lost. It would also have a different pattern.

Randy Ellis posted on January 8, 2014 at 12:19 pm

I want to correct the second paragraph. The LE will always go down by less than the magnitude of the percent reduction in the P(dying). Suppose infant mortality was an implausible 10%, and 90% died at age 100, so LE was .1*0 + .9*100=90. A 20% increase in infant mortality (to 12%) would only reduce LE to 88 years, a ~2 percent reduction, not 20%. This percentage effect on LE will be even smaller if mortality at any age greater than 0 is reduced.

robert posted on January 8, 2014 at 1:04 pm

Agreed, and thanks Randy. I went straight to P(death) on the the second chart and had not considered YPLL. I’ve never done that particular calculation though I think it seems fairly straightforward; I’ll read the PDF for more details!

Thanks again.

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