Issue No. 8: Is the Problem Health Care, Or Is It Health?

​A disturbing new study, published Feb. 21 in The Lancet, points to a paradox. We spend more of our national output than any other country on health care. A Commonwealth Fund study in 2014 rated us third among 11 rich countries for “effectiveness of care.” The U.S. is probably the best place to live if you face acancer diagnosis, and our access to the best medicines is unmatched. Yet – and here’s the mystery – on average our health outcomes are mediocre, even poor – and apparently getting worse.

The Lancet study looked at life expectancy in 35 large, upper- or middle-income countries in 2010 and then, using sophisticated, Bayesian modeling, made forecasts for 2030. The U.S. ranked 25th out of the 35 for women’s life expectancy in 2010, a rank that is expected to fall to 27th by 2030, just ahead of Mexico and Croatia and behind Poland and Greece. For men, the ranking is 23rd now, falling to a projected 26th.

The Lancet’s researchers conclude that “the poor recent and projected US performance is at least partly due to high and inequitable mortality from chronic diseases and violence, and insufficient and inequitable health care.”  But there is a simpler explanation that may be more powerful: We are less healthy to start with – because of our behaviors. The health care system has to work much harder and invest more money to get Americans well.

Is the Health-Care System at Fault
for Low Life Expectancy?

Samuel H. Preston, a sociologist at the University of Pennsylvania, and Jessica Y. Ho, a research scientist at Stanford, wrote a paper, first published by the prestigious National Bureau of Economic Research, with the intriguing title, “Low Life Expectancy in the United States: Is the Health System at Fault?” Their answer was, “No.” And their summary is worth publishing at length:

We find that, by standards of OECD countries, the US does well in terms of screening for cancer, survival rates from cancer, survival rates after heart attacks and strokes, and medication of individuals with high levels of blood pressure or cholesterol. We consider in greater depth mortality from prostate cancer and breast cancer, diseases for which effective methods of identification and treatment have been developed and where behavioral factors do not play a dominant role. We show that the US has had significantly faster declines in mortality from these two diseases than comparison countries.  

We conclude that the low longevity ranking of the United States is not likely to be a result of a poorly functioning health care system.

It’s not the health care system. It’s the “high prevalence of disease in the US [that] adds considerably to health expenditure,” write Preston and Ho. In other words, Americans spend more not because of health care but because of health. Or, rather, lack of health.

Here is more evidence….

Heart Failure on the Rise

The American Heart Association recently released its annual update on heart disease and stroke and predicted that the “number of people diagnosed with heart failure is increasing and projected to rise by 46 percent by 2030, resulting in more than 8 million people with heart failure.” But we have substantial tools to fight heart disease. For example, cholesterol-lowering statin drugs and high-blood-pressure medicines have been available as generics for years and, for most Americans, are inexpensive. Emergency interventions mean that a heart attack is no longer a death sentence. Yet the threat of heart failure keeps growing, and the culprit isn’t so much poor health care as poor behaviors. 

The American Heart Association developed what it calls the Simple 7: “avoiding smoking and tobacco products, engaging in daily PA [physical activity], eating a healthy diet, maintaining a healthy weight, and keeping cholesterol, BP [blood pressure], and glucose at healthy levels.” For almost everyone, meeting these goals does not require expensive medical intervention. Unfortunately, few are measuring up. Only 16.9% of adults met five or more of the Simple 7 goals in 2007-08; even worse, only 14.6% met five or more goals in the most recent period studied, 2011-12.

Poor Diets, Low Physical Activity,
High Health Costs

The AHA found that 17% of men and 14% of women still smoke cigarettes. Only 22% of adults meet federal physical activity guidelines. The prevalence of obesity among adults has increased from 31% in 1999-2000 to 38% in 2013-14. (We have the highest obesity rate in the OECD, the organization of developed nations.) About 80% of men and 70% of women have unhealthy diets. Nearly 40% of adults have total cholesterol of 200 milligrams per deciliter or higher (above 200 is considered “borderline high” or “high,” according to theNational Institutes of Health ); that’s hard to understand with the prevalence of generic statins. One-third of adults have high blood pressure. 

The AHA reports that a meta-analysis of nine cohort studies, representing 12,2417 patients, found that as little as 15 minutes of daily moderate to vigorous physical activity reduced death rates for adults 60 and older. Exercise reduces mortality not just from heart disease but from cancer, respiratory diseases, and diabetes, among others. In a separate study, the Centers for Disease Control found that 38 million adults (one in six) “consume alcohol excessively,” costing the economy $224 billion a year (that’s about two-thirds of what the U.S. spends annually on prescription drugs.). 

As we noted in the last newsletter , the three conditions responsible for the most health-care spending in the U.S. are diabetes, ischemic heart disease (heart attack and stroke), and low back and neck pain, according to ancomprehensive study in December by JAMA. In most cases, the three can be prevented or mitigated through exercise, good diet, and smoking cessation. 

The U.S. spends nearly 19% of GDP on health care while no other industrialized country spends more than 12%. But those numbers don’t tell the whole story. Unhealthy behaviors cause illnesses, and illnesses can require expensive interventions. 

How to Save $60 Billion a Year

If behaviors improved, the cost savings would be enormous. Blue Cross-Blue Shield, the health insurer, found that annual medical spending for an obese person is up to $1,429 higher than for a person of normal weight. About 80 million adults are obese. Cutting that figure in half would save around $60 billion a year. 

Chronic diseases account for 86 cents of every dollar spent, says the Blue Cross-Blue Shield report. “Chronic diseases and conditions, including heart disease, stroke, cancer, diabetes, obesity, and arthritis are among the most common, costly – and preventable – of all health problems.” 

A 2015 study looked at 13 rich OECD countries and found that Americans had by far the highest proportion of seniors with two or more chronic diseases: 68%, compared with 33% for the U.K. and 49% for Germany. When it comes topremature death (before age 50), U.S. rates for cardiovascular and disease are roughly twice those of an average of 17 rich countries. 

Policy makers and the general public are up in arms about high health-care costs. And they should be. But many of the critics are looking in the wrong places. Lower costs begin at home. The most productive route to cutting national health-care expenses is improving health through better personal behaviors.