Last week, the Organisation for Economic Co-operation and Development (OECD) released its latest report comparing a number of developed countries’ health care metrics. As always, the data are hotly contested. That doesn’t mean we can’t learn something.
Aaron Carroll, MD, MS
According to the report, the United States fares extraordinarily poorly. Let’s start with the fact that in 2011, US life expectancy at birth was 26th lowest among the 40 countries profiled. Some will argue that this is because of things like traffic accidents or suicide, which can’t be entirely blamed on the health care system. And those people are right, to a point. The rate of US traffic accident deaths is high (with a rank of 7 among 36 countries assessed), and so is the rate of suicide deaths (ranking 13 among 36 countries). But the US health care system could help prevent some of those deaths. Moreover, almost all the research used to justify this as the cause of our low life expectancy is flawed.
The US infant mortality rate (deaths per 1000 live births) was higher than in all but 9 of the 40 countries included in the rankings. Some will try to explain this metric as the result of differences in how different countries measure premature birth. Research has examined whether standardizing definitions changes the results much, and it doesn’t. At some point, we have to own this.
Even when the United States does better in some rankings, it’s certainly not “best-in-the-world” bragging rights. The OECD report says the nation has the tenth-lowest rates in cancer mortality overall, fourth-lowest rates in deaths following a stroke, and sixth-highest rates of influenza vaccination for the elderly. It also comes in 12th place in the number of hip replacements per 100 000 population—which is still shocking given how often US consumers are told that rationing is rampant in the rest of the world.
It’s easy to try to blame this poor showing on “lifestyle,” but the data suggest such an assumption might be at least partly off the mark. Among 15-year-olds, those in the United States had the second-lowest rate of smoking (after Iceland) and were the least likely to have “experienced drunkenness” at least twice. Among adults in 40 countries, those in the United States have the sixth-lowest rate of daily smoking and rank 17th in the amount of alcohol they consume. On the other hand, obesity is clearly a problem: of the 40 countries ranked, the United States has the highest adult obesity rate.
The US health care workforce is small, ranked 28th in the number of physicians per population and 29th in the production of medical graduates. The United States also has relatively few hospital beds (ranking 27 of 40) and doesn’t use them much, as reflected in a 24th-place ranking (of 25 countries) in the occupancy rate of acute care beds.
What the United States does have is lots of technology. The nation has the second-highest number of magnetic resonance imaging (MRI) scanners and the third-highest number of computed tomography (CT) scanners available per million population. Those machines aren’t idle, either: on a population basis, the United States ranks number 1 in MRI examinations and number 2 in CT examinations.
Of 31 countries assessed, the United States had the second-highest rate for avoidable hospital admissions for asthma and the tenth-highest rate for chronic obstructive pulmonary disease. Avoidable admissions for diabetes in the United States were the ninth highest (of 25 countries assessed).
The point is that the United States clearly isn’t close to the “best-in-the-world” rhetoric we hear so often. This is especially problematic given that the one category where we are clearly, totally, unequivocally number 1 is health care spending.
The United States is spending up to 4 times more per person than some of the other countries in the OECD report. We spend more in public money than most of these other countries do in total.
That’s a problem. Because given that many keep harping on the fact that the United States doesn’t have enough money to spend on the things we find important, it seems silly to spend this much on health care without seeing better results.
I concede that some of these things can’t be fixed by the health care system. But they could be fixed by more public health spending or spending in totally different areas. And that can’t occur if so much is spent on health care.
At some point, one must acknowledge that this type of spending can only be justified by incredible quality that places the United States first (or at least near the top) in most metrics. The amount of money being spent has to be justified with clear and consistent population-level data, not anecdotes.
Otherwise, we’re just deluding ourselves—and that may be borne out by evidence, too. According to this report, US consumers believe everything is fantastic. The one metric where we absolutely shine is perceived health: we’re number 1 when it comes to the percentage of adults reporting to be in good health. That may not be supported by the rest of the report, but that hasn’t seemed to make a difference before.
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