I received this E-mail after participating in a panel discussion hosted by Warren Olney on his program, "To the Point" on NPR affiliate KCRW in Los Angeles ("Healthcare Reform: Should Obama Have Fought for Single-Payer?"). [You can listen to the broadcast here.] The writer brought up important points regarding America's public health ranking against other countries. Here is the E-mail followed by my response.
Thank you for listening critically to the NPR broadcast, "To the Point," on October 3rd and specifically to my comments. I will do my best to respond.
Data demonstrating our public health rank near or at the bottom of industrialized countries come from multiple sources. They all concur regarding our dismal results [1-6].
Correcting our health care statistics for smoking, obesity, traffic fatalities, race, and homicides makes no perceptible difference in our relative ranking .
Some of the criteria stand on their own without requiring correction for equally sick patients with comparable diseases. These include maternal mortality [8,9], foot amputations per 100,000 diabetics , and lives lost to treatable diseases .
The clinical efficacy aspect to which you refer compares clinical outcomes for patients receiving treatment. This presumes citizens receive treatment. This is mostly true in other industrialized nations but unfortunately not in the US. A participant on the broadcast, Dr. Schoen, is co-author on one article documenting compromised access to health care in the US [12,13].
Compromised access, not provider ineptitude, is the principal factor responsible for our poor health [14,15]. Once Americans get through the door of a hospital or physician's office, their care compares well to other countries. Unfortunately only relatively wealthy Americans have sufficient money to get through those doors. The 44% of Americans who do not receive health care in a timely manner or, in some cases, at all, make our overall statistics poor .
Some statistics show longer survival rates in the US for certain kinds of cancer. These conflict with other statistics, confounding the claim . Additionally, similar mortality rates for these cancers suggest differences (if any) are attributable to earlier diagnosis rather than longer life expectancy [17,18].
You are correct that differences in the definition of "live birth" affects statistics on infant mortality and life expectancy at birth. Here is a statement from the OECD (italics in the original):
"Some of the international variation in infant mortality rates is due to variations in registering practices of premature infants (whether they are reported as live births or not). In the United States, Canada and the Nordic countries, very premature babies (with relatively low odds of survival) are registered as live births, which increases mortality rates compared with other countries that do not register them as live births." 
Correcting for this different definition does not improve our rank. "The United States has … the highest infant mortality rate among the eight countries that report this metric similarly." (Canada, Denmark, Finland, Iceland, Japan, Norway, Sweden, and the United States [20,21]).
This is presented in a graph with data from the CIA :
Some contend American neonatologists make humanitarian (and usually futile) efforts to save premature or underweight neonates, efforts not made in other countries. If so, we expect a lower life expectancy at birth than these other countries. This is true. However, after these desperately ill neonates die young, we expect a rise in comparative life expectancy at ages five years and above. We do not see this. The relative life expectancy ranking of the US compared to other countries does not change at any age (until age 65, suggesting an effect of Medicare on health care access).
This is presented in graph form below :
You are not alone in suggesting our health care must be better than statistics indicate. Many Congressional leaders make similar statements [23-30]. As these members of Congress are in the top 10% income bracket, it is unlikely they encounter the access failures plaguing Americans in lower income brackets. They also have political agendas served by publicizing their unsubstantiated beliefs.
If you have additional studies that should be included, as your last paragraph suggests, please share the citations and I will include them in future discussions.
1. Organization for Economic Cooperation and Development (OECD)
2. Preker AS. The introduction of universal access to health care in the OECD: lessons for developing countries. In: Achieving Universal Coverage of Health Care. Nitagyarumphong ES, Mills A (editors). Ministry of public health, Bangkok, 1998, p.103
3. The Central Intelligence Agency (CIA). The World Factbook.
4. The World Health Organization (WHO)
5. The Commonwealth Fund
6. The Kaiser Family Foundation. www.globalhealthfacts.org/bytopic.jsp
7. Muennig PA, Sherry A. Glied SA. What changes in survival rates tell us about US health care. Health Affairs 2010;29, no.11:2105-2113. doi: 10.1377/hlthaff.2010.0073
8. Hogan MC, Foreman KJ, Naghavi M, Ahn SY, Wang M, Makela SM, Lopez
AD, Lozano R, Murray CJL, Maternal mortality for 181 countries,
1980-2008: A systematic analysis of progress towards Millennium
Development Goal 5. The Lancet. 2010;375(9726):1609-23.
9. Deadly Delivery: The Maternal Health Care Crisis in the USA. Amnesty International, March 2010. Index: AMR 51/019/2010. http://www.amnestyusa.org/sites/default/files/pdfs/deadlydeliverysummary.pdf
10. Health at a Glance 2009: OECD Indicator
11. Wilper AP, Woolhandler S, Lasser KE, McCormick D, Bor DH,
Himmelstein DU. Health insurance and mortality in US adults. Am J Public
12. Schoen C, Doty MM, Robertson RH, Collins SR. Affordable Care Act reforms could reduce the number of underinsured US adults by 70 percent. Health Affairs, 2011;30, no.9:1762-1771. www.latimes.com/health/la-fi-health-insurance-20110908,0,343767.story
13. Consumer Reports. Health Insurance Survey Reveals 1 in 4 People Insured But Not Adequately Covered, ConsumerReports.org, September 2007. September 12, 2007, www.consumerreports.org/cro/cu-press-room/pressroom/archive/2007/09/0709_eng0709ins.htm.
15. Mark Pearson, Head Health Division, OECD, Written statement to Senate Special Committee on Aging, 30 September 2009. Disparities in health expenditures across OECD countries: Why does the United States spend so much more than other countries? www.oecdwash.org/PDFILES/Pearson_Testimony_30Sept2009.pdf
16. Paul Krugman. Cancer Survival. New York Times, March 24, 2011. krugman.blogs.nytimes.com/2011/03/24/cancer-survival
17. Aaron Carroll. Senator Johnson's odd dislike of the PPACA. The
Incidental Economist. March 23, 2011
18. Aaron Carroll. Survival rates are not the same as mortality rates. The Incidental Economist August 31, 2010. theincidentaleconomist.com/wordpress/survival-rates-are-not-the-same-as-mortality-rates
19. OECD Health Data 2005. www.oecd.org/dataoecd/15/23/34970246.pdf
21. Congressional Research Service, Peterson CL, Burton, R. U.S. Health Care Spending: Comparison with Other OECD Countries. 9-17-2007
22. WHO, World Bank, UNESCO, CIA, individual country databases from 2008. www.worldlifeexpectancy.com
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