
A tale of two covariates: Why OWID and company are wrong about US healthcare - jedharris
https://randomcriticalanalysis.com/2019/11/07/a-tale-of-two-covariates-why-owid-and-company-are-wrong-about-us-healthcare/
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jedharris
Very long and well argued review of sources of excess mortality in developed
countries. Bottom line: Obesity! and other non-medical factors like
automobiles. Big implications about how we should spend money to increase life
expectancy.

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hdlothia
Can you explain the conclusion of this article to me? I don't fully understand
what he is trying to say.what are the implications? That the only improvement
we can make on the american healthcare system is to fight obesity better?

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rayiner
There are two points to the article.

1) Healthcare spending has rapidly diminishing returns, not only comparing the
US to Europe, but comparing countries within Europe (such as the Netherlands
versus Spain).

2) The lower life expectancy in the US can be explained mostly by higher
obesity. US states with similar obesity to European countries have similar
life expectancy.

~~~
smt88
Re: #2, my understanding from friends at the CDC is that lower life expectancy
is due to lower incomes (meaning food, medicine, and doctor visits are
unaffordable even with health insurance), suicides, and the opioid crisis.

Suicides and obesity can also be caused by low income and drug abuse, so it
sounds like the author may be seeing causation where correlation is more
accurate.

~~~
s1artibartfast
Causation isn't mutually exclusive. The relationship between obesity and heart
disease is clearly causative. Any causation between income and obesity does
not negate this..

This is an important distinction.

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smt88
That's true and I agree, but if you're asking why people are dying, you're
going to be most interested in the root cause (which should be the variable
that is least dependent on the others).

While obesity likely does reduce income somewhat (due to stereotypes), income
can be considered an independent variable here.

Relatedly, we know that obesity is very hard to treat, while poverty is
incredibly easy to treat on an individual level. The only reason we don't is
because people see treatment of poverty as unfair, while treatment of obesity
is not seen that way.

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s1artibartfast
I would never claim that income/poverty is the root cause of obesity, as
obesity poorly correlated with income in the US.

Obesity is prevalent in both the middle class and poor, with the middle class
slightly leading the poor[1]

>39% of people ≤130% of the federal poverty line (FPL) are obese.

>40.8% of people 130 to 350% of the FPL are obese.

While individuals should be brought out of poverty for other reasons, it is
not a cure-all for obesity. If anything can be implied by the correlation, it
will make the problem worse, and the healthcare system should prepare for
this.

[1]
[https://www.cdc.gov/mmwr/volumes/66/wr/mm6650a1.htm](https://www.cdc.gov/mmwr/volumes/66/wr/mm6650a1.htm)

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Ididntdothis
This starts with saying that there is a popular telling that the more money a
country spends the better life expectancy will be. Especially looking at the
US I thought most people know that US doesn't get much value compared to the
money spent.

Was that really controversial?

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rcafdm
My point is that there's very little to suggest US healthcare is _uniquely_
ineffective. There rapidly diminishing returns to health spending and US
outcomes are badly handicapped by factors like obesity and homicide.

Maybe try actually reading it though?

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Ididntdothis
"Maybe try actually reading it though?"

Your first sentence is "In the popular telling, there is a strong and
reasonably constant relationship between health spending and life
expectancy.". My comment was that I am not aware of this being the popular
telling. But instead from what I can tell most people agree that the US
doesn't deliver better results despite much higher spending.

Otherwise I think you have dug up a good and useful amount of data although I
think some of your conclusions are debatable. This is probably to be expected
if you analyze such a complex system.

~~~
PunchTornado
it IS a popular thing, only here on hacker news I've read at least 10 articles
on this issue, i.e. that US is wasting money on health.

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atomic_rabbit
The blog Random Critical Analysis has made a good argument that Americans
spend so much on healthcare simply because Americans spend so much on
everything. Healthcare isn't exceptional in this regard. If you replace the
usual GDP per capita measure of income by a measure of actual individual
consumption, the US lies right on the trend line, just with higher healthcare
spending and higher overall consumption than everyone else.

[https://randomcriticalanalysis.com/2018/11/19/why-
everything...](https://randomcriticalanalysis.com/2018/11/19/why-everything-
you-know-about-healthcare-is-wrong-in-one-million-charts-a-response-to-noah-
smith/)

~~~
rgbrenner
The US healthcare system is not a free market. The pricing system--critical to
any free market--is broken when it comes to healthcare. Customers are unable
to shop on price (even for non-emergency care).. but also the AMA limits the
number of doctors; and hospitals require a certificate of need (giving
competitors a veto over new businesses), for example.

It isn't just that we spend more... if that was the only issue, then
everything would be fine because we would be obtaining what we paid for.

But since it's not an efficient free market... the fact that we spend more
only increases the urgency that we reform the system... since those
inefficiencies become so huge in a system that accounts for such a big portion
of GDP.

So while RCA's analysis might be perfectly correct... unless he also proves
that the healthcare market is at least as efficient as a free market system...
then we still need to reform it.

~~~
nradov
Please stop posting misinformation about the AMA. It does not limit the number
of doctors. The actual bottleneck is in residency slots, and the AMA is
actually advocating to increase funding there.

[https://www.ama-assn.org/press-center/press-releases/ama-
fun...](https://www.ama-assn.org/press-center/press-releases/ama-fund-
graduate-medical-education-address-physician-shortages)

Most patients are able to shop on price. The majority of insurers now provide
web sites where their members can obtain estimates of out-of-pocket expenses
for common treatments at network providers. There are still some gaps and room
for improvement but most people are able to do price comparisons for non-
emergency care if they want to.

~~~
koolba
Bullshit. Trying to get prices from an insurance company requires hours of
time, researching individual billing codes, and at best leads to a ballpark
guess.

~~~
nradov
That's not true. Most insurers allow you to search by text and see an accurate
estimate of what you would pay at each provider. Such features aren't
universal yet but the majority of patients have access.

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alexlikeits1999
The best thing I've read about cross-country longevity, and I don't even care
about its main point (ie USA healthcare spending). If you have a Patreon
account or something similar please post it. I want more of this.

~~~
rcafdm
Thanks. I haven't seriously considered that before, but I may put one up!

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pjc50
> The problem is GDP is not even particularly a good proxy for the income of
> households (individuals). GDP is designed to measure how much value add is
> produced within domestic (territorial) boundaries. It usually does a fairly
> decent job of this, but it does not directly tell us about the household
> perspective, as in, the average level of real incomes or real consumption
> enjoyed residents of a country (a.k.a. “material living conditions“). Most
> importantly, it is an increasingly unreliable proxy for this concept.

Would someone care to explain how this works? What's the factor causing
divergence between the two? Is it the proportion of GDP being returned to
overseas investors? Or a mis-counting which includes GDP of US multinationals
produced by workers overseas?

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PunchTornado
one example that I often heard being made is that natural disasters have a
positive outcome to the GDP. Houses and communities get destroyed, people are
objectively much worse off, but due to the money pumped in reconstruction the
GDP grows more than if no disaster had happened.

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hdlothia
Australia has similar rates of obesity and better health outcomes don't they?.

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rcafdm
No, but this is addressed in my post. Australia's obesity rate is
substantially lower, plus they suffer from lower homicide, drug abuse, and the
like. More generally, the diminishing returns to health spending imply there's
very little to believe the higher expenditure the US makes is likely to
purchase appreciably better outcomes (even with different healthcare regimes).

~~~
hdlothia
Are you the original author? Have you done an evaluation on the financial
consequences of both healthcare systems as well? Do people suffer medical
bankruptcies at similar levels in our peer nations?

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rcafdm
Yes, I'm the author of the blog (RCA). No, I haven't studied this narrow
question, though it's somewhat tangential to the arguments I've advanced
(outcomes; prices; aggregate costs; etc). I have, however, seen several
studies that suggest "medical bankruptcies" have very little to do with
medical debt and much to do with the effects of their health on their
employment/earned income (also similar patterns in Canada and some other comps
in the available data...)

[https://www.nejm.org/doi/pdf/10.1056/NEJMp1716604](https://www.nejm.org/doi/pdf/10.1056/NEJMp1716604)

~~~
smcl
Going back to comparison between US and its "peer nations" though - I would
imagine in this group of countries the concept of medical bankruptcy is
largely unknown given that many have socialised healthcare.

For example I'm sure there are people in the UK who have turned to the private
sector for treatment and in doing so incurred debts which resulted in
bankruptcy. But that's such an exceptional unusual concept I'd be surprised if
it occurred more than a handful of times in any given year.

~~~
rcafdm
The point is that almost all of what people have termed "medical bankruptcy"
has approximately nothing to do with healthcare costs. It has to do with
income/career disruption associated with their health, so these issues play
out to a similar degree in other countries for similar reasons.

While I can believe there is somewhat higher variance in the US system in
terms of bills/prices/etc, which sometimes affects people meaningfully, it's
also worth pointing out that out of pocket costs aren't unusually high in the
United States. I mean, we might have a _slightly_ larger problem with these,
but that's much more of an implementation detail in terms of _who_ pays and
how much than the sort of top-down policy proposals some people seem to
believe are necessary (because they've badly misdiagnosed the situation or are
ideologically blinkered)

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xixixao
I feel like this is a great article, but is very hard to digest for someone
without statistical background and working knowledge of its jargon. Pretty
sure it could be amended only slightly, using common language terms, for
larger audience to appreciate it.

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maxerickson
Does the article address quality of life?

No one particularly thinks that artificial knees are life extending.

