Stand by for another round of partisan warfare, as Senate Republicans grapple with a replacement for Obamacare. You can expect to hear a lot about access to health insurance and coverage for pre-existing conditions. Those are important issues, for sure. But there are much deeper problems with health in America, which the current fight will do little to address.
Since the early 1970s, most developed countries have followed a similar trajectory: They have increased spending on health care and seen some impressive gains in life expectancy.
But one nation stands out for profligate spending and poor outcomes: The US has spent more than any other nation on health care, while its citizens still die fairly young. Among 23 nations who have been members of the Organisation for Economic Co-operation and Development (OECD) since the early 1970s, only Turkey — which spends a tiny fraction of what Americans lavish on health care — lags behind the US on life expectancy. Japan leads the OECD with a life expectancy of 83.7 in 2014, almost four years longer than the US.
While some OECD countries, including the UK, have single-payer, government-run health care, this isn’t what separates the US from the rest of the pack. Switzerland, for instance, delivers almost universal coverage in a system that relies on competing private insurance companies.
In America, how long you are likely to live varies dramatically from place to place. As this map shows, life expectancies by county in 2014 spanned a range of more than two decades. Residents of Summit County, Colorado, live even longer than those in Japan, while those of Oglala Lakota County in South Dakota die younger than the typical citizen of Cambodia or India.
Look at these outlier counties, and the reasons for this massive variation start to come into view. Summit County is about 90% white, with only about 14% of people below the poverty line. Residents of Oglala Lakota County are more than 90% Native American and more than half of them live in poverty.
In a study published earlier this month, researchers at the University of Washington’s Institute for Health Metrics and Evaluation in Seattle weighed factors that influence life expectancy across the US. Access to health care played a role, but the main drivers of bad outcomes were the intertwined effects of poverty, race, and behavioral factors like poor diet and infrequent exercise.
“We have very wide disparities, more than other countries,” Ali Mokdad, a member of the research team, told BuzzFeed News. In most countries, geographic variations in life expectancy are decreasing, he added. “But ours are increasing.”
The influence of socioeconomic and behavioral factors explains the pink stain of low life expectancy across much of the poor rural South and Appalachia, hit hard in recent years by an epidemic of opioid abuse.
In a series of studies, researchers led by Elizabeth Bradley of the Yale School of Public Health have analyzed public and private spending on health versus social programs like unemployment benefits, job training, old-age pensions, and housing subsidies.
Over the OECD as a whole, Bradley’s team found that all nations spend more on social programs than health care — except the US. Spending more on social services, the researchers found, is associated with longer lives and lower infant mortality.
“We should think of health spending as education, housing, transportation, food, and jobs,” Shannon Brownlee, senior vice president of the nonprofit Lown Institute in Brookline, Massachusetts, which advocates for community health, told BuzzFeed News.
Spending more on social programs might sound like a classic liberal cause. But some conservatives are banging a similar drum about America’s misplaced priorities — although they tend to focus on reducing inefficiencies in government health spending.
“I’m interested in acknowledging that we have finite resources, and looking at where you put your next dollar,” Oren Cass, a senior fellow with the free-market Manhattan Institute and formerly domestic policy director for Mitt Romney’s 2012 presidential campaign, told BuzzFeed News.
The big problem with US efforts to alleviate the effects of poverty, according to Cass, is that they are dominated by Medicaid, administered by the states but largely financed through federal tax dollars. Conceived in the 1960s as a modest program to cover the medical bills of the poorest Americans, Medicaid has today grown to provide health care for about 74 million people — including about 11 million added to its rolls under Obamacare.
Evidence from an unusual experiment in Oregon, which in 2008 expanded its Medicaid program through a lottery, paints a mixed picture of its benefits. Compared with people who remained on the waiting list, those enrolled into Medicaid were less likely to be depressed and said they felt healthier. They were also protected from the catastrophic medical bills that can bankrupt people who lack insurance.
Still, two years after the experiment began, the people on Medicaid were not physically healthier than those on the waiting list. “We did not see any detectable improvements in blood pressure, cholesterol, or diabetic blood sugar control,” Katherine Baicker of the Harvard School of Public Health, one of the lead researchers, told BuzzFeed News.
Shifting people into Medicaid also proved more expensive than expected. Many policymakers had predicted that it would reduce the number of costly emergency room visits, as newly insured patients would instead seek help from regular family doctors before their conditions worsened. Although Medicaid patients did make more routine doctor visits, they also seemed to go to the ER about 40% more often than those on the waiting list.
There have been few attempts to measure how social programs affect citizens’ health. But between 1994 and 1998, the federal Department of Housing and Urban Development ran an experiment called Moving to Opportunity, in which some families in public housing in poor areas were given housing vouchers that could only be spent by moving to a low-poverty neighborhood. When followed up 10 to 15 years later, women in the families that moved — mostly single mothers — were less likely to be obese or depressed and had a reduced risk of diabetes. Their children’s health wasn’t much better, however.
Don’t expect Trumpcare to divert money from Medicaid into other programs that might alleviate the influence of poverty on health. The version of the American Health Care Act that passed the House of Representatives would reverse Obamacare’s Medicaid expansion. But instead of redirecting the money saved to social programs, it would deliver tax cuts of $600 billion, mostly to people who make more than $200,000 a year. Senate Republicans are reportedly considering a compromise plan that would retain the Obamacare expansion of Medicaid but impose new spending limits. Meanwhile, President Donald Trump’s budget plan, unveiled on Tuesday, calls for deeper long-term cuts to Medicaid and would slash social programs including food stamps.
Not only is the US out of whack with the rest of the developed world in its low spending on social programs, it also spends way more on procedures and drugs.
According to the latest survey by the International Federation of Health Plans, a global network of health insurers, the price of drugs, surgeries, and diagnostic tests was consistently higher in 2014 in the US than in other developed countries.
What’s more, the Commonwealth Fund in Washington, DC, which has compared the health systems of leading developed nations, has found that Americans use more expensive medical technologies like MRI scans. This is partly due to a payment system that reimburses doctors and hospitals directly for the procedures they perform — creating a perverse incentive to order tests and treatments that may not be necessary. Despite some efforts to link payments instead to patient outcomes, this “fee-for-service” model still dominates.
Another big difference between the US and the rest of the developed world is that other countries exert stronger central control over costs and the delivery of care. Even though the Swiss system relies on private insurance companies, for instance, all residents are required to have coverage and the government imposes limits on drug prices and the fees charged for medical procedures.
With no such controls, prices in the US are not only higher on average, but also vary wildly from provider to provider. “You have the same imaging scan costing twice as much three blocks down,” David Squires of the Commonwealth Fund told BuzzFeed News.
One consequence of these high costs is that they are often not fully covered by insurance, leading to high copays and deductibles. “In general, Americans are much more exposed to the costs of their health care,” Squires said.
That, unfortunately, means that even people who have insurance cannot always afford to seek the care they need. “Congress is still talking about health care as if coverage was the only issue,” Brownlee said. “If that deductible puts you into bankruptcy, then having insurance doesn’t help you that much.”
Peter Aldhous is a Science Reporter for BuzzFeed News and is based in San Francisco. His secure PGP fingerprint is 225F B2AF 4B8E 6E3D B1EA 7F9A B96E BF7D 9CB2 9B16
Contact Peter Aldhous at email@example.com.
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