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Type in the terms “life expectancy,” “infant mortality” and “health care” into the popular search engine Google, and it will yield about 449,000 results. Clearly, linking these two measures to health care is very popular.
Life expectancy and infant mortality are powerful tools for those who support some form of socialized medicine. On those measures the United States fares worse than all other industrialized nations. Most other industrialized nations have some form of government-run, universal health insurance. Thus, the reasoning goes, America’s inferior performance on life expectancy and infant
mortality is due to its heavy reliance on a system of private sector care.
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Physicians for a National Health Program, a vocal advocacy group, recently examined the health care systems in 16 industrialized countries. The only measures that the study used to compare the different nations were, not surprisingly, life expectancy and infant mortality ... Using expenditure per capita on health care as a proxy for health care system, it shows that America spent more on health care but got less return than countries that had some form of universal health insurance. “The high costs and poor outcomes seem to stem from inefficiencies that are unique to the U.S. health care system,” the Center for Economic and Policy Research claimed.
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Life expectancy and infant mortality are widely used as measures of a health care system because doing so serves an ideological agenda of greater government involvement in health care. However, these measures are useless for trying to determine the effectiveness of a health care system. Even some advocates of government-run health care acknowledge this. For example, Jonathan Cohn of The New Republic states “those statistics are pretty crude measures.”
The next three sections offer an explanation why.
Measuring Health Care Systems
Any statistic that accurately measures health-care systems across nations must satisfy three criteria. First, the statistic must assume actual interaction with the health care system. Second, it must measure a phenomenon that the health care system can actually affect. Finally, the statistic must be collected consistently across nations.
Under the first criterion, the phenomenon being measured must be one in which the individual actually has contact with the health care system. More specifically, he must have contact with a health care professional, be it a doctor, nurse, lab technician, etc. A statistic measuring the rate of cancer survival satisfies this criterion, since diagnosis and treatment of cancer requires health care professionals. By contrast, a statistic measuring the rate of car accidents would not satisfy such a criteria since health care professionals are not essential to identifying car accidents.
Some statistics may assume interaction with the health care system, but the phenomena they measure are not ones on which the health care system can have any meaningful impact. Take, for example, the rate of cancer incidence. While this statistic assumes interaction with the health care system (an incidence of cancer cannot be known without the diagnosis of a health care professional), there is little a health care system can do about the rate of cancer. Rather, cancer incidence is affected by factors such as genetics, diet, lifestyle, etc., over which the health care system has no control. Thus, to be an adequate measure of the effectiveness of a health care system, a statistic must measure a phenomenon that health care professionals can actually affect.
Finally, a statistic must be collected consistently across nations. While this seems simple in theory, in practice it is quite complicated. Nations use diverse definitions of health phenomena. This leads to some nations excluding a segment of their populations from the collection of a statistic while other nations include those segments. In such circumstances, cross-national comparisons are largely meaningless. Thus, for health care systems across countries to be meaningful, there should be little to no variation in how statistics are collected.
As shown below, both life expectancy and infant mortality are poor measures of a health care system because each fails to satisfy at least one of the above criteria.
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Life expectancy is a poor statistic for determining the efficacy of a health care system because it fails the first criterion of assuming interaction with the health care system. For example, open any newspaper and, chances are, there are stories about people who die “in their sleep,” in a car accident or of some medical ailment before an ambulance ever arrives. If an individual dies with no interaction with the health care system, then his death tells us little about the quality of a health care system. Yet all such deaths are computed into the life expectancy statistic.
Life expectancy also largely violates the second criterion - a health care system has, at most, minimal impact on longevity. One way to see this is to reexamine the table constructed by the Center for Economic and Policy Research. The interpretation that the Center for Economic and Policy Research wants readers to derive from Table 1 is that the United States would be better off with a system of universal health care. However, a careful examination of that table yields a more accurate interpretation: There is no relationship between life expectancy and spending on health care. Greece, the country that spends the least per capita on health care, has higher life expectancy than seven other countries, including Belgium, Denmark, Finland, Germany, Netherlands, the United Kingdom and the United States. Spain, which spends the second least per capita on health care, has higher life expectancy than ten other countries that spend more.
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GDP per capita is one of the more consistent predictors of life expectancy.
Yet the United States has the highest GDP per capita in the world, so why does it have a life expectancy lower than most of the industrialized world? The primary reason is that the U.S. is ethnically a far more diverse nation than most other industrialized nations. Factors associated with different ethnic backgrounds - culture, diet, etc. - can have a substantial impact on life expectancy. Comparisons of distinct ethnic populations in the U.S. with their country of origin find similar rates of life expectancy. For example, Japanese-Americans have an average life expectancy similar to that of Japanese.10
A good deal of the lower life expectancy rate in the U.S. is accounted for by the difference in life expectancy of African-Americans versus other populations in the United States. Life expectancy for African-Americans is about 72.3 years, while for whites it is about 77.7 years.11 What accounts for the difference? Numerous scholars have investigated this question.12 The most prevalent explanations are differences in income and personal risk factors. One study found that about one-third of the difference between white and African-American life expectancies in the United States was accounted for by income; another third was accounted for by personal risk factors such as obesity, blood pressure, alcohol intake, diabetes, cholesterol concentration, and smoking and the final third was due to unexplained factors.13 Another study found that much of the disparity was due to higher rates of HIV, diabetes and hypertension among African Americans.14 Even studies that suggest the health care system may have some effect on the disparity still emphasize the importance of factors such as income, education, and social environment.15
A plethora of factors influence life expectancy, including genetics, lifestyle, diet, income and educational levels. A health care system has, at best, minimal impact. Thus, life expectancy is not a statistic that should be used to inform the public policy debate on health care.
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At first glance, infant mortality appears to be a good measure of a health care system. First, it assumes interaction with a health care system since most babies born in the industrialized world are born in a hospital or other health care facility. It also satisfies the second criterion of assuming that health care professionals can affect the outcome, since doctors and nurses have a direct impact on the survival chances of a newborn. If infant mortality were accepted as an adequate measure based on those two criteria alone, then the U.S. health care system is one of the least effective in the industrialized world.
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But infant mortality tells us a lot less about a health care system than one might think. The main problem is inconsistent measurement across nations. The United Nations Statistics Division, which collects data on infant mortality, stipulates that an infant, once it is removed from its mother and then “breathes or shows any other evidence of life such as beating of the heart, pulsation of the umbilical cord, or definite movement of voluntary muscles… is considered live-born regardless of gestational age."16 While the U.S. follows that definition, many other nations do not. Demographer Nicholas Eberstadt notes that in Switzerland “an infant must be at least 30 centimeters long at birth to be counted as living."17 This excludes many of the most vulnerable infants from Switzerland’s infant mortality measure.
Switzerland is far from the only nation to have peculiarities in its measure. Italy has at least three different definitions for infant deaths in different regions of the nation.18 The United Nations Statistics Division notes many other differences.19 Japan counts only births to Japanese nationals living in Japan, not abroad. Finland, France and Norway, by contrast, do count births to nationals living outside of the country. Belgium includes births to its armed forces living outside Belgium but not births to foreign armed forces living in Belgium. Finally, Canada counts births to Canadians living in the U.S., but not Americans living in Canada. In short, many nations count births that are in no way an indication of the efficacy of their own health care systems.
The United Nations Statistics Division explains another factor hampering consistent measurement across nations:
...some infant deaths are tabulated by date of registration and not by date of occurrence… Whenever the lag between the date of occurrence and date of registration is prolonged and therefore, a large proportion of the infant-death registrations are delayed, infant-death statistics for any given year may be seriously affected.20
The nations of Australia, Ireland and New Zealand fall into this category.
Registration problems hamper accurate collection of data on infant mortality in another way. Looking at data from 1984-1985, Eberstadt argued that, “Underregistration of infant deaths may also be indicated by the proportion of infant deaths reported for the first twenty-four hours after birth."21 Eberstadt found that in the U.S. and Canada more than a third of all infant death occurred during the first day, but in Sweden and France they accounted for less than one-fifth.
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Inconsistent measurement explains only part of the difference between the U.S. and the rest of the world. Were measurements to be standardized, according to Eberstadt, “America might move from the bottom third toward the middle, but it would be unlikely to advance into the top half."22 Another factor affecting infant mortality Eberstadt identifies is parental behavior.23 Pregnant women in other countries are more likely to either be married or living with a partner. Pregnant women in such households are more likely to receive prenatal care than pregnant women living on their own. In the U.S., pregnant women are far more likely to be living alone. Although the nature of the relationship is still unclear (it is possible that mothers living on their own are less likely to want to be pregnant), it likely leads to a higher rate of infant mortality in the U.S.
In summary, infant mortality is measured far too inconsistently to make cross-national comparisons useful. Thus, just like life expectancy, infant mortality is not a reliable measure of the relative merits of health care systems.
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Life expectancy and infant mortality are wholly inadequate comparative measures for health care systems. Life expectancy is influenced by a host of factors other than a health care system, while infant mortality is measured inconsistently across nations. Neither of these measures provides the United States with conclusive guidance on health care policy, let alone serve as reliable evidence that a system of universal health care “should be implemented in the United States."24
Do measures that would permit accurate cross-national comparisons of health care systems exist? The most exhaustive source of cross-national data is the Organization for Economic Co-operation and Development (OECD). Yet the OECD notes that in most cases its data is not “internationally comparable” because “there is a lack of international agreement on the most promising indicators and many definitions of each indicator that could be adopted."25
To rectify this problem, the OECD and the Commonwealth Fund have embarked on a collaborative effort to develop comparable measures across nations. Called the “OECD Health Care Quality Indicators Project,” it is taking the “first steps towards a comprehensive reporting system for quality of care in OECD member countries."26 A recent report updating the progress of this project looks promising. For example, one standard that an indicator must meet is its “susceptibility to being influenced by the health care system."27 The researchers pose important questions on this regard, including, “Can the health care system meaningfully address this aspect or problem?” and “Does the health care system impact on the indicator independent of confounders like patient risk?"28 In other words, these statistics will assume interaction with a health care system and measure phenomena that a health care system actually affects. Furthermore, the aim of this project is to assure that data is collected consistently across nations, so that national policymakers have “the opportunity to compare the performance of their health care delivery systems against a peer group"29
While the project researchers have chosen many indicators that measure phenomena that are actually affected by a health care system, comparability issues across nations remain. For example, one indicator measures the fatality rate within 30 days of those diagnosed with acute myocardial infarction (heart attack). However, the report notes that some “countries are able to track patients after hospital discharge, [while] some are not."30
Hopefully such difficulties can be resolved as the project progresses. In the meantime, policymakers, pundits and reporters should stop referring to life expectancy and infant mortality as meaningful comparative measures of health care systems.
“Life expectancy also largely violates the second criterion - a health care system has, at most, minimal impact on longevity.”
The National Center for Public Policy Research (NCPPR) is an interesting organization. Partially funded by Exxon, it opposed the Kyoto Protocol on Global Warming (duh!) and NCPPR has also received funding from R.J. Reynolds, for which it reciprocated by lobbying against FDA regulation of the tobacco industry.
A less objective source would be difficult to find. If I wanted to get advice on evaluation of health care systems, I’m not going to listen to a conservative think tank that lobbies for the tobacco industry.
The OECD is also an interesting organization. And guess what they’re doing? As the paper cited above mentions, they are looking for ways to harmonize health statistics reporting across the countries under their “purview”, so that real (and therefore useful) comparisons and policy recommendations can be made.
To wit, from the OECD Health Care Quality Indicators Project itself:
NOTE: highlights mine.
Aim
To collect internationally comparable data reflecting the health outcomes and health improvements attributable to medical care delivered in OECD countries.
Description
The Health Care Quality Indicators Project (HCQI) responds to the growing interest by healthcare policymakers and researchers in OECD countries in measuring and reporting the quality of medical care. ‘Quality indicators’, here, means: indicators for the technical quality with which medical care is provided, i.e. measures of health outcome or health improvement attributable to medical care (changes in health status attributable to preventive or curative activity). Such measures could be said to represent the ‘value’ side of the ‘value for money’ equation in health care - a key issue in measuring the performance of health systems.
Many OECD countries have already instituted national strategies to begin to collect technical quality indicators often for benchmarking purposes in a performance measurement setting. Those efforts have brought about much progress in implementing quality indicators at the level of providers, such as hospitals or physicians. However, these national activities do not lead, except by accident, to internationally comparable QIs. That is because there is a lack of international agreement on the most promising indicators and many definitions of each indicator that could be adopted. Hence, there is, so far, little possibility of international benchmarking of quality of health care. This deprives national policymakers of the opportunity to compare the performance of their health care delivery systems against a peer group. An aim of the project is to begin to fill a gap in OECD Health Data.
...
As mentioned in the paper cited above, here’s what they themselves have to say about comparability problems in regards to infant mortality statistics:
NOTE: highlights mine.
The reliability of the data, an indication of which is described above, is an important factor in considering the limitations. In addition, some infant deaths are tabulated by date of registration and not by date of occurrence; these have been indicated by a plus sign (+). Whenever the lag between the date of occurrence and date of registration is prolonged and, therefore, a large proportion of the infant-death registrations are delayed, infant-death statistics for any given year may be seriously affected.
Another factor that limits international comparability is the practice of some countries or areas of not including in infant-death statistics infants who were born alive but died before the registration of the birth or within the first 24 hours of life, thus underestimating the total number of infant deaths. Statistics of this type are footnoted. In this table in particular, this practice may contribute to the lack of comparability among
deaths under one year, under 28 days, under one week and under one day.
Variation in the method of reckoning age at the time of death may also introduce non-comparability. Although it is to some degree a limiting factor throughout the age span, it is an especially important consideration with respect to deaths at ages under one day and under one week (early neonatal deaths) and
under 28 days (neonatal deaths). As noted above, the recommended method of reckoning infant age at death is to calculate duration of life in minutes, hours and days, as appropriate. This gives age in completed units of time. In some countries or areas, however, infant age is calculated to the nearest day only, that is, age at death for an infant is the difference between the day, month and year of birth and the day, month and year of death. The result of this procedure is to classify as deaths at age one day, many deaths of infants that occurred before the infants had completed 24 hours of life. The under-one-day class is thus understated while the frequency in the 1-6-day age group is inflated.
A special limitation on comparability of neonatal (under 28 days) deaths is the variation in the classification of infant age used. It is evident from the footnotes that some countries or areas continue to report infant age in calendar, rather than lunar month (4-week or 28- day) periods. This failure to tabulate infant deaths under 4 weeks of age in terms of completed days introduces another source of variation between countries or areas. Deaths classified as occurring under one month usually connote deaths within any one calendar month; these frequencies are not strictly comparable with those referring to deaths within 4 weeks or 27 completed days.
In addition, infant mortality rates by age and sex are subject to the limitations of the data on live births with which they have been calculated. These have been set forth in the technical notes for table 9. These limitations have also been discussed in the technical notes for table 15.
In addition, it should be noted that infant mortality rates by age are affected by the problems related to the practice of excluding infants who were born alive but died before the registration of the birth or within the first 24 hours of life from both infant-death and live-birth statistics and the problems related to the reckoning of infant age at death. These factors, which have been described above, may affect certain age groups more than others. In so far as the numbers of infant deaths for the various age groups are underestimated or overestimated, the corresponding rates for the various age groups will also be underestimated or
overestimated. The youngest age groups are more likely to be underestimated than other age groups; the youngest age group (under one day) is likely to be the most seriously affected.
Care to engage the subject matter under consideration, or would you prefer to continue to make a fool of yourself by, for instance, claiming that the OECD and the U.N. are shilling for Big Oil and Big Tobacco?
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The National Center for Public Policy Research (NCPPR) is an interesting organization. Partially funded by Exxon, ...
Heh. I think minimally funded” would be the accurate description.
Let’s start with Exxon contributions to the NCPPR. These figures, by the way, come from Exxonsecrets.org (self-desribed as “Documenting Exxon-Mobil’s funding of climate change skeptics."):
Now let’s take a look at what proportion of the NCPPR’s funding that represents. Say, in 2005.
From NCCPR’s website, the audited figures (links to PDF docs thereof are available on the web page linked below):
“In 2005, The National Center had income of $7,407,443 ...”
OK. Now, ... dividing $55,000 (2005 figure from above) into $7,407,443 ... it turns out that Exxon contributed a WHOPPINGLY GYNORMOUS ... 7 tenths of one percent of NCPPR’s funding in 2005!
Man oh man! Imagine that! No wonder Exxon has sooooooo much influence on NCPPR’s activities!
LOL!
Where, one may wish to ask, does the NCPPR get the rest of its money? Overwhelmingly, from people like me (yes, full disclosure here, I have been a contributor):
Funding
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Over the last four years alone, over 70,000 Americans have made tax-deductible contributions to National Center programs.
Our audited figures show that most—98% in 2005, 97% in 2004, 73% in 2003, 81.5% in 2002, 93% in 2001, 93% in 2000, 88% in 1999 and 80% in 1998—of The National Center’s funding comes from small gifts from individuals.
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Stop crying. You got busted presenting propaganda from a conservative think tank instead of hard facts. No big deal, just try not to do it next time.
The “success” of the US health care system has been known for years. It’s an excellent system if you have the money to access it. That large segments of the US population can’t access it is the problem. That’s why our mortality numbers are behind everyone else’s. It’s been that way for quite awhile now.
By the way, presenting qualifiers from the UN doesn’t refute the position of the US in the list of industrialized countries. That’s a disingenuous argument. You’re attempting to misrepresent what the qualifier means, implying that because there is a qualifier, then the whole analysis is wrong. Dishonest.
Stop crying. You got busted presenting propaganda from a conservative think tank instead of hard facts. No big deal, just try not to do it next time.
The “success” of the US health care system has been known for years. It’s an excellent system if you have the money to access it. That large segments of the US population can’t access it is the problem. That’s why our mortality numbers are behind everyone else’s. It’s been that way for quite awhile now.
By the way, presenting qualifiers from the UN doesn’t refute the position of the US in the list of industrialized countries. That’s a disingenuous argument. You’re attempting to misrepresent what the qualifier means, implying that because there is a qualifier, then the whole analysis is wrong. Dishonest.
Atlan: I’LL TALK LOUDER SO THAT I DON’T HAVE TO ADDRESS THE ISSUE.
Get a life. The arguments presented in the article are cogent, logical, and worth considering. “Crying” does not seem to be what CG is doing. It seems to be what you are doing. You don’t like where those statements lead, so they must be propaganda. Are you saying that:
The statistics collected on these two parameters are collected in a reliable, standard, reproducible manner by all countries compared? If so, how do you know that. If not, then you are not contradicting the statements, are you.
Stop crying. You got busted presenting propaganda from a conservative think tank instead of hard facts. No big deal, just try not to do it next time.
The “success” of the US health care system has been known for years. It’s an excellent system if you have the money to access it. That large segments of the US population can’t access it is the problem. That’s why our mortality numbers are behind everyone else’s. It’s been that way for quite awhile now.
By the way, presenting qualifiers from the UN doesn’t refute the position of the US in the list of industrialized countries. That’s a disingenuous argument. You’re attempting to misrepresent what the qualifier means, implying that because there is a qualifier, then the whole analysis is wrong. Dishonest.
Atlan: I’LL TALK LOUDER SO THAT I DON’T HAVE TO ADDRESS THE ISSUE.
Get a life. The arguments presented in the article are cogent, logical, and worth considering. “Crying” does not seem to be what CG is doing. It seems to be what you are doing. You don’t like where those statements lead, so they must be propaganda. Are you saying that:
The statistics collected on these two parameters are collected in a reliable, standard, reproducible manner by all countries compared? If so, how do you know that. If not, then you are not contradicting the statements, are you.
You are so reliably pompous. It’s funny, really.
Oscar77,
Typing in upper case doesn’t increase “the volume” of text, unless you have some sort of disability which requires you to use a text-to-voice conversion program.
The National Center for Public Policy Research is a conservative think tank. Think tanks are tasked to present arguments and viewpoints which are consistent with the desires and ideologies of those parties who fund them. No mystery there. Tell me you’re not so naive up there in Boise as to believe that think tanks are objective?? You can’t be that stupid.
I just pointed out just who the source (and biases) of ChicagoGabriel’s source was, that’s all. That appears to have bothered both you and ChicagoGabriel.
The position of the United States in the World Health Organization standings have been consistent for awhile now. It’s a matter of concern.
Thanks CG for giving us a insightful look into this. Never mind Altan, he is just in a snit because one of the liberal memes to try to justify nationalizing healthcare took a hit from what you posted.
Further, his citing of WHO as the standard measure of judging healthcare is laughable. He critcizes your source as politically motivated, as if WHO is not???? WHO is one of the most politically driven organizations in the world.
But the most telling thing was Altan’s avoidence of directly challanging the points put forth in the article. If his position was so strong and correct, he would have been able to directly challange the methodology put forth. This he did not do, choosing instead to make his point by engaging in name calling and blanket statements. He believes that he is making a point by this, but in fact all he is doing is exposing his lack of critical thinking.
Awwww, did I hurt your feelings?? You seem awfully hurt to find out that ChicagoGabriel’s source was a think tank that does whatever whoever pays the bills (Exxon, R.J.
Reynolds, etc) tell it to defend.
(laughter)
Actually, I did address but one of the points put forth in the article and any idiot could have recognized the worthlessness of the article via the statement I criticized alone.
“Life expectancy also largely violates the second criterion - a health care system has, at most, minimal impact on longevity.â€
So what this statement from ChicagoGabriel’s source is telling me is that it doesn’t matter if I have a hospital in the area or not when I have my heart attack / car wreck / neoplasm.
Did you buy that??
(laughter)
The World Health Organization is political?? A hard to refute statement since all organizations are subject to that charge but the World Health Organization is a branch of the United Nations.
Which country has the most influence on the United Nations??
(laughter)
So you mean to tell me that the United States used it’s political power as one of the two Super Powers on the planet to give itself poor mortality ratings??
(laughter)
That is your thesis, isn’t it?? Mortality figures at the WHO can be influenced politically??
Stop crying. You got busted presenting propaganda from a conservative think tank instead of hard facts. No big deal, just try not to do it next time.
The “success” of the US health care system has been known for years. It’s an excellent system if you have the money to access it. That large segments of the US population can’t access it is the problem. That’s why our mortality numbers are behind everyone else’s. It’s been that way for quite awhile now.
By the way, presenting qualifiers from the UN doesn’t refute the position of the US in the list of industrialized countries. That’s a disingenuous argument. You’re attempting to misrepresent what the qualifier means, implying that because there is a qualifier, then the whole analysis is wrong. Dishonest.
Atlan: I’LL TALK LOUDER SO THAT I DON’T HAVE TO ADDRESS THE ISSUE.
Get a life. The arguments presented in the article are cogent, logical, and worth considering. “Crying” does not seem to be what CG is doing. It seems to be what you are doing. You don’t like where those statements lead, so they must be propaganda. Are you saying that:
The statistics collected on these two parameters are collected in a reliable, standard, reproducible manner by all countries compared? If so, how do you know that. If not, then you are not contradicting the statements, are you.
You are so reliably pompous. It’s funny, really.
Oscar77,
Typing in upper case doesn’t increase “the volume” of text, unless you have some sort of disability which requires you to use a text-to-voice conversion program.
The National Center for Public Policy Research is a conservative think tank. Think tanks are tasked to present arguments and viewpoints which are consistent with the desires and ideologies of those parties who fund them. No mystery there. Tell me you’re not so naive up there in Boise as to believe that think tanks are objective?? You can’t be that stupid.
I just pointed out just who the source (and biases) of ChicagoGabriel’s source was, that’s all. That appears to have bothered both you and ChicagoGabriel.
The position of the United States in the World Health Organization standings have been consistent for awhile now. It’s a matter of concern.
You have heard of the World Health Organization, haven’t you??
Am I pompous or are you just out of touch?? I suppose namecalling and ad hominem might get you caught up on your reading but it’s never worked for me.
No, the answer is...........you are pompous. And pretty obtuse, since you didn’t apparently notice that the upper-case letters were me depicting YOU.
“The position of the United States in the World Health Organization standings” is not in dispute here. What is in dispute is how they got to those numbers, how the UN got to their numbers, etc. So try to stay up, will you?
The WHO is quite good when they are doing what they were supposed to be doing. I have several of their publications on various tumor classification systems. When they are talking about diagnosis and treatment, they are fine. What is NOT fine is when they are pontificating about political change. Then, they have transgressed from medical opinion into political opinion, where my opinion is as good as theirs.
I suppose namecalling and ad hominem might get you caught up on your reading but it’s never worked for me.
ROFL!!!! This one is a classic! (uproarious side-splitting, tear-emitting laughter) Nearly your every response includes an ad hominem! That is what caused me to drop you down the list in terms of liberals that I respect in here. You started that way, you have continued that way, and you are currently that way. If your communication didn’t include such a plethora of ad hominems, you’d never hear one from me directed to you. But, it is apparently your language. That and pomposity.
