06 November 2013

Trauma Is The Main Factor Driving Down U.S. Life Expectencies Relative To Wealthy Peers

From Avik Roy: 
A few years back, Robert Ohsfeldt of Texas A&M and John Schneider of the University of Iowa asked the obvious question: what happens if you remove deaths from fatal injuries from the life expectancy tables? Among the 29 members of the OECD, the U.S. vaults from 19th place to…you guessed it…first. Japan, on the same adjustment, drops from first to ninth.
From Marginal Revolution.

A few observations, however, illustrate that health care quality and underlying economic issues that drive health care quality disparities still have something to do with the disparities.

1.  As used in the above quotation: "fatal injuries" appears to mean what I usually describe as "trauma", i.e. accidental deaths, homicide and suicide combined, not just accidental deaths.

2.  Surely, the U.S. has a much higher homicide rate than many of its peer countries for reasons including its cultural propensity to violence (at least in some geographical regions such as the South and large urban centers) and its lax gun control.  Even after years of declining homicide rates, this remains true.  The U.S. homicide rate has gone from about 9 per 100,000 people to 4.7 per 100,000 people.  Many of our economic peers have homicide rates under 2 per 100,000 people, comparable to the homicide rates of U.S. states with the consistently lowest homicide rates (mostly in the rural North).

3.  The U.S. probably has more accidental deaths as well.  High motor vehicle use due to low population density and weak public transit is one factor - the U.S. has one of the highest rates of traffic deaths among developed countries per population, but is closer to the middle of the pack measured by vehicle miles traveled.  Serious problems with prescription drug abuse is another big problem in the U.S.  There may be other public safety/accident prevention issues as well.  For example, the U.S. has quite high rates relative to many of its peers, by international standards, of mechanized farming, commercial fishing and construction activity, each of which has much higher than average workplace mortality rates associated with it. But, U.S. workplace deaths are dominated by traffic deaths and homicides with deaths from other sources that are particular to work activities making up absolute numbers of accidental deaths that are pretty small relative to the total number of accidental or trauma deaths in any one year (1,198 deaths in the year 2011, which is less than 5% of all accidental injuries and a smaller percentage of all trauma deaths).

4.  U.S. suicide rates aren't particularly exceptional relative to other developed countries (18th out of 34) and some populations with high homicide rates like African-Americans have below average suicide rates.  Japan, for example, has far more suicides than the United States, per capita, despite its overall high life expectancy and very low rate of firearm related deaths.

5.  The United States has universal single payer health care for senior citizens (age sixty-five plus).  Also private insurance rates are highest, and complete lack of health care (including lack of Medicaid enrollment) is lowest, among late middle aged Americans and highest among the young.  Thus, the age associated diseases that account for most non-trauma deaths impact mostly the populations with the best access to health care, while trauma deaths impact, on average, the populations with the least access to health care.  This is true not just on age measures, but on socio-economic measures.  The less well off have the worst access to health care (either inferior Medicaid coverage or not at all) and the most exposure to trauma mortality risk.

6.  The measurable and significant differences in outcomes between Level I trauma centers and less specialized emergency care illustrate and quantify the potential mortality improvements that could be secured by better funding and organization of trauma care.  A transfer of a patient from a Level II trauma center to a Level I trauma center reduces mortality risk by about 10%.  And, many trauma victims receive health care below the standard of the Level II trauma center, or receive no professional health care at all (e.g. due to fear of implication in criminal activity).

7.  The United States also doesn't fare well compared to its peers in infant mortality statistics, again, a category of deaths that occur disproportionately in populations with poor access to health care, or access only to inferior care through Medicaid in the U.S.  The U.S. ranks 34th out of 40 OECD countries by this measure between Lithuania and Chile.

8.  The U.S. just ended a long period of time during which its homicide rates fell dramatically together with almost all other forms of serious crime.  The decline from 1994 to early 2012 was almost 50%.  Given that the study cited is a few years old, these reductions in homicide rates may not be fully reflected in the statistics cited.

9.  Likewise accidental deaths other than prescription drug overdoses are at near record lows and have been falling steadily for several decades.  They have declined (on an age adjusted basis) about 16% over the last 50 years, more or less steadily.  The decline would be considerably greater were it not for an immense surge in prescription drug overdoses since 1999 that masks improvements mortality associated with most other forms of accidental deaths (and a pretty clear failure of the U.S. health care system itself) in that time period.

10. To the extent that the U.S. does get good outcomes in non-trauma health care, it pays far more for that non-trauma health care than its developed country peer nations by any measure.  There is absolutely an overpayment problem with U.S. health care even if the quality problem may not be quite as bad as it seems in most kinds of care.

11.  Both trauma victimization and poor health care availability are very closely linked to economic inequality and racial inequality in the United States in a manner not nearly so pronounced among its developed nation peers.  Economic inequality among the non-elderly is a root cause of low U.S. low expectancy relative to its peers.  Racial and gender gaps in life expectancy in the United States have narrowed significantly in the last twenty years, however.

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