If U.S. health care's so good, why do other people live longer?

Sacramento BeeAugust 12, 2009 

Ask around for the healthiest country in the world, and the United States won't come close to topping the list.

People live longer in just about every industrialized nation, from Canada to our north, throughout much of Europe, and around the Pacific in Japan, Australia and New Zealand.

New mothers and their babies also face a rockier start here, with U.S. infant and maternal death rates double some of our industrialized peers.

As debate swirls in Washington and at town halls nationwide over health care reform, there is also a more fundamental question — what about health?

Could policymakers change our medical system in ways that would make America a healthier country?

Insuring everyone should help — but less than people might think, according to doctors and public health experts who've studied the issue. Putting more resources into primary care should also make a dent, they say.

Neither one, though, is likely to send America to the top ranks of its global peers.

"If you want to see dramatic changes in health, you're not going to get there even by doubling the efficiency and effectiveness of the health care system," said Dr. Richard Kravitz, a University of California, Davis, professor of medicine whose research interests include quality of care.

"When you need it, you really need it … but in general, the benefits of medical care to populations are a little bit overrated," he said.

When taken all together, the other factors that play a bigger role include education, income, toxins in the environment, crime, violence, family structure, stress, obesity, nutritious food and exercise.

Across large populations, he said, numerous studies suggest that medical care contributes only modestly to overall health, perhaps somewhere between 10 percent and 25 percent.

Health care for all would provide a "very large" improvement for some deprived populations, Kravitz said, but "a surtax on high fructose corn syrup would probably be more effective … than anything we could do for the health care system, just because of obesity."

Researchers who have delved into the effects of medical care on the health of large groups overall have made some surprising and sometimes conflicting discoveries.

An experiment in the 1980s that extended different levels of insurance to otherwise uninsured people found that more coverage fostered more use of the medical system but not necessarily healthier people, said Dr. Peter Muennig, a professor of health policy and management at Columbia University's Mailman School of Public Health.

A 2006 study that compared white people in England with whites in the United States, in an effort to keep different ethnicities from complicating the findings, reached conclusions Muennig found startling. Even the richest white Americans, who are pretty much universally insured, had more diabetes, more high blood pressure, more heart disease and more cancer than the richest white Britons. On most measures they were a little less healthy than middle income Britons.

This points to a vast range of things health care cannot do, from providing mass transit that makes it likelier people will walk more, to providing the kind of education that correlates strongly with better health.

"Education is the fundamental ingredient for what you need to survive in any ecological niche," Muennig said. People with less education are likely to have jobs that are lower paying, higher stress and possibly more dangerous. They're likelier to live in unsafe housing and eat cheap, calorie-dense food. They're less likely to be offered job-related health insurance. Except for the insurance, he said, health care reforms cannot fix that.

Those who examine health across many nations puzzle over other oddities.

In international health care measures, America's ranking improves when life expectancy is measured for people age 65 and older. While still not at the top of the health heap, Americans who make it to age 65 have remaining life expectancies closer to 65-year-olds in other developed countries, and men stack up a little better than women against their peers worldwide.

That might mean that American medicine treats older people more effectively. Or it could mean that Medicare, universal coverage available at age 65, may be keeping older people healthier. Or it could be something called the "survivor effect," suggesting those who have lived past earlier perils are more robust.

While the factors that optimize health are complex, doctors say there are things federal policymakers could do to make America a little healthier.

Among them are strengthening primary care, finding ways to encourage better diet and exercise, and effectively reforming how health care is financed, said Dr. James G. Kahn, a professor of health policy and epidemiology at the University of California, San Francisco.

People do better in nations that encourage them to have a regular primary care provider, Kahn said, perhaps partly because regular, front-line care helps bolster healthy habits.

"Even in the United States, in locations with a higher concentration of primary care providers, people have somewhat better outcomes and also lower costs," he said.

Rewarding and encouraging primary care might also offset an American tendency to do too much, driven by a system that pays for each procedure performed by a doctor, hospital or testing lab, Kahn added.

"We do too many surgeries," he said. "Rates of cardiac surgery are lower in Canada, yet they have better outcomes."

There is hope, too, for "accountable care" groups that would move away from fee for service payments but be held accountable for keeping all their patients as healthy as possible, said Stephen Shortell, dean of the school of public health at UC Berkeley.

Shortell is also pleased that the health legislation being discussed in Washington includes billions for disease prevention and health promotion.

"You can't ignore the health care system, but the big payoff is in lifestyle factors and disease prevention," he said. "A dollar spent on those activities saves $5 in health care costs."

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