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Why is life expectancy in the US lower than in other rich countries? (ourworldindata.org)
129 points by troydavis 52 days ago | hide | past | favorite | 188 comments



Last time I looked closely at infant mortality in the US, it looked like the US was doing horribly. However, after talking with some doctors at a neonatal ICU I found out that in the US, we will often identify an unborn child that is in trouble and get it out of the mother in an attempt to save it. Since these types of cases are considered a birth, they count against the mortality rate whereas in some other countries they would be stillborn and not count against infant mortality statistics.

That isn't to disagree with the causes given in the article, but after talking to those doctors it made me realize how complicated it is to get accurate comparisons between countries.


Another statistic that's difficult to compare is homelessness.

On first glance, New Zealand (0.94%) and Australia (0.48%) top the OECD for rate of homelessness, as they include people living in temporary accomodation (sleeping on a couch, motels, etc.) or cars as homeless. Whereas Japan (with the 0.00%) only counts people sleeping rough). Comparing unemployment rates has similar issues.

Comparing these kinds of rates between countries on an absolute basis is largely useless. However, the change in these rates can give insight on how events (political, economic, etc) have changed the demographics and socioeconomic status of countries.


Comparing stats is fraught. There was a really good thread here on HN about how the US calculates its unemployment rate, it is vastly different to how I naively imagined it was calculated.

https://news.ycombinator.com/item?id=24836422


U-3 is used specifically because we have so much historical data - it lets us compare how we're doing now to the great depression, for example, and up until a few decades ago it was fine because all the various unemployment metrics were strongly correlated.

Politicians eventually gamed the metric so hard that it's almost worthless now, so economists today mostly use U-6.


Note that the current calculation is also what's used almost everywhere else in the developed world; the US figure was changed to be more comparable to other countries in the 2000s.


That's interesting, but for 'life expectancy' my understanding is that it's the expectation for an X year old, where X is something like 12 or 20 that I can't remember - designed to eliminate such effects, and instead indicate the environmental impact.

Edit: apparently I'm wrong, Wikipedia states that 'life expectancy at birth (LEB) is the most commonly used measure'.


Just to confirm, if it's not qualified, it's implied "at birth".


Similar gaps between the US and comparable countries are apparent at age 40 too: https://www.healthsystemtracker.org/chart-collection/u-s-lif...


As far as I recollect discussing this before one will actually save younger children in most of Nordic countries e.g. than in the US, and infant mortality rate is still much lower.

There are several reasons the US rate is so much higher than in other developed countries. The US does not have universal health care, which means large sections of the US population does not get adequate follow up during pregnancy.

If you look at health care for the poor in the US, it is generally geared towards emergency care. They will stitch you up if you are about to die. However it generally does not cover regular doctor visits and checkups. Hence in the US a lot of expensive effort goes into saving babies when born, when the problem could far more easily have been resolved early in the pregnancy with better checkups.

The US system is simply not very geared towards simple preventative care. Where other health care systems tend to focus on simple cheap system. American health care is overly focused on advance equipment, complicated procedures and basically anything which gives a lot of prestige or profits.

Problem is that such a health care system does not perform very well in the real world. You end up with very high costs and poor results.

E.g. a lot of health problems in the US is actually caused by over-treatment. That is the irony of the US system. Poor people who need help don't get it. People with expensive health care plans OTOH are subject to invasive procedures they don't need because it brings in profit. E.g. the US has overuse of surgery. So basically people who don't need surgery are cut open in the US. And that does take a toll on your health.

The opioid crisis killing Americans is a variation of this. Basically it is overmedication for the sake of profits. The health care system is actually a contributor to the bad health problems in the US.

It really should lead people to question for-profit health care, but it seems impossible to question anything about capitalism in the US. You speak to deaf ears.


Re: universal healthcare. Latinos in the US have the highest rates of lacking health insurance (20% versus 5% for non-Hispanic whites). But they have the second highest life expectancy (81.8 years—longer than people in Denmark). And they have the lowest maternal mortality rates: https://www.cdc.gov/media/releases/2019/p0905-racial-ethnic-...

> If you look at health care for the poor in the US, it is generally geared towards emergency care. They will stitch you up if you are about to die. However it generally does not cover regular doctor visits and checkups. Hence in the US a lot of expensive effort goes into saving babies when born, when the problem could far more easily have been resolved early in the pregnancy with better checkups.

That’s absolutely false. Medicaid covers preventative services: https://www.kff.org/medicaid/issue-brief/coverage-of-prevent...

CHIP also covers pregnant women and children under 19 and covers pre-natal checkups and delivery.


According to the link, the maternal mortality rate for Hispanics in US is 11.5, which is almost 4x higher than in Finland.

For non-hispanic black women, the death rate is a staggering 40.8 — that's over 13x higher than Finland!

Large parts of America are a third world country.


The maternal mortality rate in the US is about 50% higher than in the UK for white mothers (8 versus 12), and the same for Black mothers (about 40): https://www.bbc.com/news/uk-england-47115305.

Asians, meanwhile, in the US have a maternal mortality rate of about 13, which would be 4x higher than Finland, but a life expectancy of over 86 years—several years longer than Japan or Korea, and 4 years longer than Finland. Indeed, the life expectancy of Hispanics in America is about the same as people in Finland.

It would be odd to see such disparities between maternal mortality on one hand and life expectancy on the other. Likewise it would be odd for Finland to be so much better than the UK. So I suspect there is more to the story than “large parts of America are a third world country.”


Could this really be a difference in fertility rate? The fertility rate in Finland is 1.46 children per women. The fertility rate of hispanics in the USA is 3.08, more than double that of Finland. The third (or more) child born to a woman is not equal in maternal mortality rate as the first child. The rate goes up with each child born. I don't know if we would expect it to go up to 4x higher, but certainly 3x higher wouldn't be unreasonable.


IIRC both higher life expectancy and lower infant mortality are considered likely to be due to community support systems being much better and more pervasive in Latinx communities in the USA. Home births among Latinx are much safer than among most other subpopulations - reduced medicalisation and strong preservation of cultural knowledge about birth are major factors.


Any chance you have a citation or article for this? I’m not trying to critique here, it’s just that this hits close to home as a black woman. I see that modern midwifery is largely restricted to affluent, white, women, while the art of midwifery has largely been lost in the black community. It’s a cultural tragedy that the knowledge was lost.


Except that US does have universal healthcare for pregnant women. Most pregnancies and births in United States are covered by Medicaid. And Medicaid pays well for that.


Technically true, however, like much of the US safety net there are significant gaps, like co-morbidities, bureaucratic hurdles, restrictive time windows, delayed care, etc.

ProPublica, Vox and Texas Tribune did a great in depth article on this last year, "The Extraordinary Danger of Being Pregnant and Uninsured in Texas". Most of what they found is applicable across the country, Texas just happens to be particularly horrific.

https://www.propublica.org/article/the-extraordinary-danger-...

edit: "And Medicaid pays well for that."

> In Texas, as in other parts of the U.S., providers are paid only about half as much for Medicaid patients as for privately insured ones.


It really isn't the same though. In most developed countries you don't have to worry about turning up to a hospital, for pregnancy or any reason. When a pregnant woman turns up to hospital in the UK (for example) she is absolutely not stressed about the potential cost of the care. If something goes wrong, she gets world class care at no cost to her. If some other medical problem is discovered while she's there, it will be diagnosed and treated and she doesn't have to stress about the cost.

Not so in the US. It would be surprising if that alone didn't account for a significant number of adverse outcomes.


Health care is not free at the point of use “in most developed countries.” The UK NHS is an exception. Also, you’re comparing apples and oranges a bit. In the US, an epidural is standard, which requires the expensive services of an anesthesiologist. Meanwhile, the UK NHS is famous for steering women away from epidurals. In the US, getting a private room after giving birth is standard, while in the NHS you’ll be in a maternity ward.


I think the exception for the NHS is that it is a single government organisation fully paid for by regular taxes. Think about your armed forces, for comparison.

While there are many that don't have this kind of setup I don't know any country where care isn't free at the point of use. (Except for maybe your deductibles).


Many countries have cost sharing and co-insurance: https://www.sciencedirect.com/science/article/pii/S016885101...


> The UK NHS is an exception.

Also, Canada.


> Not so in the US

Yes so in the US. That's literally what the person you replied to just told you: For pregnant women, children, and poor people, it's all fully covered.

It's really only the middle class that has it hard (i.e. expensive).


No, it isn't literally what they told me. In many other countries, there is no possibility of being charged for any medical treatment you require when you visit hospital to give birth. It is free as in you don't need to have any money or any way to pay and you can be diagnosed and treated for any medical condition that might become relevant while you're there giving birth, and give birth and have any related issues handled, and you never have to pay anything at all. In the US, that is just not true [1].

1: https://www.theatlantic.com/health/archive/2020/01/how-much-...


this is a common pattern I see in discussions, the idea of "going to the hospital and not worrying about bankruptcy" is just unintelligible and so you end up with discussions like this, about how "pregnancy-related-costs are often covered by Medicaid" which completely ignores the conditioning and fear and logistics that means that loads of people in the US simply don't go and get routine preventative care, even if they have what they consider to be "good" insurance.


That link talks about people with employer provided health insurance. For those on Medicaid I would not expect them to pay anything out of pocket for pregnancy and birth. Do you have information that says otherwise?


I wish they would report on life expectancy from 1 year at birth to eliminate the variance in what each country considers a live birth.


Just like @TuringNYC,I spent the early part of my life in the lower half of socio-economic ladder. With a bit of luck (and yes, work), I extracted myself from this group. I'm not rich, but I have zero debt. I own a house, multiple vehicles, and an 4 season expedition camper - free and clear. I have a rewarding and unusual career.

By contrast, the entirety of my close and extended family lives in poverty. Bankruptcy, car repos, eviction, and mortgage default are almost a game. MY father died at the age of 40. My grandfather: 36. My brother died at 42 (after a lethal encounter with police after speeding).

I'm 56 (The oldest of any male in two generations). I have multiple retirement accounts. First class healthcare. I take care of my Mom. I can't predict the future, but I suspect my economic success will allow me a longer, more fulfilling life.

I'm convinced that access to healthcare, decent work, and basic housing would have allowed my short lived male family members to live longer with a better quality of life.


I don't agree that "access to healthcare, decent work, and basic housing" would have changed the outcome of a "lethal encounter with police after speeding". Doing that in a Bugatti Veyron is still lethal.


It’s not hard to imagine why someone might take a risk and run from the police if they have outstanding warrants, unpaid fines etc. The level of stress that comes from living like that has all sorts of negatives that exacerbate the problems. Having a safety net in terms of safety, health and shelter doesn’t seem too much to ask in my view.

I’m pretty sure ZDurmphoto has a good idea of their brothers situation.


That depends on the cause of death. If a "lethal encounter with police after speeding" is gunshot wound whilst being detained, a Bugatti veyron might allow you to avoid that outcome. No police vehicle could keep up, unless they brought in air support.

Also, the police are less likely to violently arrest you if you're driving a supercar, I'd wager


There really are two Americas - wealthy america and the rest of america. I'll bet if you split America into two sets of counties, the graph would be much different -- one would be a super-outlier and the other a super-laggard.

I know this personally, as I've spent 21yrs of my life in one half, and another 20 in the other half.

I've also lived overseas for several years, and they also have stratas, but much less pronounced than here in the US.


But even that isn't even true. The US system doesn't even benefit the wealthy. For profit health care means a lot of over-treatment which causes several problems in US health care which kills people:

- Something like 2x as much surgery done in the US than in other countries, because it is profitable, not because it is needed. So perfectly health people are cut open, because they got a good insurance which can pay for it.

- Opioid crisis. Again having health insurance is a problem, not a benefit in this case. That turns you into a money bag, they can push opioids on.

- Antibiotic resistance. America is all about getting more of everything. Quantity over quality, which unfortunately also means excessive use of antibiotics making Antibiotic resistance a major problem.

The US system really isn't working for anyone. It means those who cannot pay get too little treatment, and those who can pay get too much. If only there was a way to even it out...


>The US system doesn't even benefit the wealthy.

That's a ridiculous statement, it benefits the wealthy massively. We can argue over whether or not these benefits would be even more massive without over-treatment, but there is no doubt about the overall benefits to the wealthy.

>A Harvard analysis of 1.4 billion Internal Revenue Service records on income and life expectancy that showed staggering differences in life expectancy between the richest and poorest also found evidence that low-income residents in wealthy areas, such as New York City and San Francisco, have life expectancies significantly longer than those in poorer regions.

https://news.harvard.edu/gazette/story/2016/04/for-life-expe...


If you're wealthy maybe you're also savvy enough to deal with the system. When a few second opinions with doctor friends are only a phone call away it's not hard to imagine better outcomes better. I recall an article on HN where a dev quit his job to do cancer research when he was diagnosed, and spent the next year getting to top 1% level in cancer analysis for his subtype. That's disposable income in action.

Fatal opioid use is less common with wealthy folks, and great diet + exercise + friends (easier if you're rich) are all good prevention mechanisms against antibiotic resistant bacteria.


Going further, many wealthy people hire services (either part of their concierge medicine practice or a la carte) which helps them navigate the system, evaluate doctors, get appointments at the best medical practices, avoid bad doctors, evaluate the gestalt of the recommendations across all doctors, fight incorrect insurance copay/co-insurace bills, etc.


Do you have any citations / resources that can be used to read more about your perspective here?


For healthcare, you can probably segment America a little more generously into insured vs uninsured. If you are insured in America, your healthcare is reasonably good. Lower quality plans may have more restrictive networks or higher deductibles and maximums, but these are manageable and neither are truly barriers to care.


You could segment them in three sets: well insured, people with catastrophic health plans, and uninsured. Many employers are switching to high deductible health plans and that deductible may be thousands of dollars, i.e. catastrophic plans.

When going to a doctor for a simple diagnosis or bloodwork can easily cost $400 to $1000, many put off doctor visits unless it's an emergency. It can easily become a choice between a doctor visit or a car repair. Preventative checkups are gone and insurance is only something one uses with an emergency room visit or major health issue.


That's a great explanation. It also shows how short-sighted such plans us at a national macro level -- because an ounce of prevention can prevent hundreds of thousands in future future bills.

A perfect example is vitamin deficiency and the very serious effects such deficiencies can have, and how inexpensive the preventative care is.


It is getting better. The ACA mandates coverage for some preventative care.


$400 for just a bloodtest at a GP? That's insane. All free in Australia, from the initial visit, to the blood taking, to the follow up.


Maybe a more accurate description of Australia is that it can be free, but you may have to wait for a dr appointment. Or you can go to one of the non bulk-billing doctors and a nice lounge to sit on whilst you wait.

Generally necessary pathology/radiology or routine blood tests are covered by medicare which is paid for by a levy of about 1% on income.

Likewise pharmaceuticals are generally fairly low cost (there are exceptions), being subsidised by the government and for low income or people with ongoing requirements can be free.

Private health insurance is available and encouraged by a decrease in your medicare levy, but a lot of people are finding that it doesn't provide any financial benefit and as we have a very good public health system, does not provide any better health outcome.

Health Insurance is not a major concern in Australia. It certainly is not tied to an employer and doesn't rate on the list of things to worry about when getting a job.


This isn't inflated, really -- Quebec doctors are allowed to charge about the same to the province (depending on several factors, but it's within 2x even for the cheapest option), so it's a reasonable approximation of the costs involved, it's just who pays for it and when.


I have long been against employer provided health insurance. Obama promised if you like your insurance you can keep it. He was mostly correct (if you squint just right there are some minor changes to everyone's plan which you can count as not keeping it), but I don't like my health insurance - but to get a different plan means throwing away the large subsidy I get from my employer to take their plan.


Even if you're insured in the US, you often can't afford care anymore. My private insurance plan costs $6,000 a year and has a $5,000 deductible. It was very bad pre-ACA. I paid over $8,000 a year on the private market and never let it lapse so my kidney donation wouldn't become pre-existing. Under the ACA it dropped a ton. But it's gotten much worse over the past years as it was weakened.


I disagree, a combination of cost of health care even for insured people, enormous worst case out of pocket costs and terrible wages means that people are conditioned to not go to the doctor (and conversely that some people are conditioned to go to the doctor to get "use" of their insurance) even when they are "insured".


I would rather be uninsured and take my chances than work a low waged job and pay for Obamacare. $500/month for a single person, highest deductible plan is ludicrous. Thats fucking 80-90% rent for many people where I live...if not 100%+.


> I would rather be uninsured and take my chances

So you won't seek medical treatment at a hospital if you get injured or become severely ill? Or do you plan to go to the hospital and pay out of pocket? Or, like some other voluntarily uninsured people, will you ask for medical treatment and then just not pay?

> than work a low waged job and pay for Obamacare.

Why would a "low waged" job be a requirement, unless that's the only job you can get? You can pay for Obamacare with a middle or high wage job too. You can also pay for it if you are self employed (which is a lot of people on Obamacare).


I would absolutely do the same if I worked a low wage job. Despite our messed up insurance situation, US laws regarding access to emergency care and bankruptcy are very progressive.

Someone making $15/hr is likely does not have any assets that would be surrendered in chapter 7 bankruptcy. A lot of people would gladly crater their credit score for a few years to delete an $80,000 bill. Plenty of people crater their credit scores over dumber stuff.


this may be the most depressing post in the whole thread - healthcare is fucked, insurance is too expensive for normal people, but hey, bankruptcy is pretty easy!


You don’t even need to declare bankruptcy. Most hospitals will just write it off if you talk to them and work it out.


I think he is saying that for many people it's just too much money. And that if they would be denied care, then so be it.

This is where it gets uncomfortable, isn't it? That their lives are so miserable, that they would gladly trade away years and years of expected lifespan for higher quality of life.


It’s illegal to turn anyone down in the ER for their ability to pay (at most hospitals). If you show up with an emergency, you will get treated, and the bill comes afterwards. Now, you’re definitely not going to get a luxury treatment, but they will patch you up so you’re not dying.

https://en.m.wikipedia.org/wiki/Emergency_Medical_Treatment_...

It isn’t the way we should want this to work, but it is certainly something that people actually do.


The ER isn't going to offer you cancer treatment, pay for costly prescriptions or provide the medical care, routine and otherwise, that is often required to live a long life.


Yeah, anything that requires long term treatment would be a problem, because EMTALA is only good until you get stabilized enough to discharge, and when you come back, it’s scheduled care and not an emergency.


I expect any reason for me to go to a hospital to basically cost me $30k+ without insurance. My plan is to go to the hospital and then declare bankruptcy and hope I don't need to go to the hospital again for another 7 years. I deliberately make lifestyle changes to avoid hospitalization. I don't ride bicycles or motorcycles. I don't play sports. I don't do manual labor or work with saws. I don't drive at night (not sure if this is any real difference but it makes me feel safer).

This is the life I have in capitalist America. I'm afraid to do basic things like ride a bicycle in fear of it financially crippling me to the point that I'm incapable of paying rent and becoming homeless


Well seeing as a sizable majority of human history has gotten by without health insurance for...I don't know, 10k years plus, as I've said, I'll take my chances. As for paying out of pocket, there are plenty of local urgent care centers where their business model is basically only cash. They do things from popping cysts, removing hangnails, to stitches. Lots of stuff that if you went to a hospital, would cost triple or more simply because of insurance.

I'm saying low waged as in I make $14/hr or less. I mean it boggles my mind that you'd even say that because there frankly, is a large portion of the US who don't make Silicon Valley salaries.


For a long part of the sizeable majority of human history, the average lifespan varied from 25 years to 30 years tops.


The reason mortality rates were so high was primarily due to child mortality from disease, virus, or bacterial infection. Not because people just dropped dead after 30 years. Once people got outside of the age of 20+, the average lifespan drastically improved for the individual since they survived the most difficult portion of life in terms of survival.


Actually, one of the leading causes of death, apart from early child mortality was bacterial infection caused by bad dental hygiene. Not to mention a host of other diseases that waited for them such as cholera, Typhoid, TB, etc. People didn't magically live off till their 60s and 70s and 80s after becoming 20 years old. Your statement of average lifespan "improving" for individuals is simply nonsense.


> Your statement of average lifespan "improving" for individuals is simply nonsense.

It’s factually correct. For example [0]:

Life expectancy increases with age as the individual survives the higher mortality rates associated with childhood. For instance, the table above listed the life expectancy at birth among 13th-century English nobles at 30. Having survived until the age of 21, a male member of the English aristocracy in this period could expect to live:

1200–1300: to age 64

1300–1400: to age 45 (because of the bubonic plague)

1400–1500: to age 69

1500–1550: to age 71

17th-century English life expectancy was only about 35 years, largely because infant and child mortality remained high. Life expectancy was under 25 years in the early Colony of Virginia, and in seventeenth-century New England, about 40 percent died before reaching adulthood.

During the Industrial Revolution, the life expectancy of children increased dramatically. The under-5 mortality rate in London decreased from 74.5% in 1730–1749 to 31.8% in 1810–1829.

[0] https://en.wikipedia.org/wiki/Life_expectancy#Variation_over...


Where are you? Here in Maryland gold level plan for a single person age 36 making $35,000 a year is about $250/month, with $1,750 deductible. In France or Germany, you’d pay about 10% of your income in health insurance tax, so this is quite comparable.


In Germany, the figure is 14% of your gross salary, and in France it’s over 20%.


It should be noted that in Germany if you are employed, half of those 14% is paid for by your employer, so you only pay 7% of your gross salary yourself. And there are no deductibles. I think the closest thing to a deductible is having to pay for ambulance (about 20 euro for the trip, probably free if you can't afford it) and for hospital stays (10 euro per day, up to a maximum of 280 per year).


> so you only pay 7% of your gross salary yourself.

Tax incidence doesn’t not depend on who writes the actual check to the government.

When you get your monthly paycheck, your employer had already withheld the income tax and sent it to the government treasury. Does that mean that you pay no income tax, and the employer kindly covers it for you? No, of course not.

When you buy a new phone, 19% VAT tax is paid. Who pays it? The retailer is responsible to send the money to government, does it mean that he pays full tax, and consumers pay no VAT? Of course not, VAT is reflected in price, and if there was no VAT, the prices would fall down. Suppose that government said that half of VAT is paid by buyer, and half by seller. Would that make any difference at all to anyone involved? No, the final price paid by the customer would be the same, the amount of revenue received by the seller after VAT would be the same, and the government would receive the exact same amount of money. Of course, the outcome would be exactly the same for any other government mandated “split” in who pays VAT.

Similarly, any split in who nominally pays healthcare tax does not in fact matter in the slightest with respect to who actually bears the burden of the tax. Government cannot mandate that half of the burden is on employer and half on employee, because it simply has no power to do so: tax incidence depends on relative elasticities of supply and demand, and not at all on what the government claims the incidence to be. In case of taxing labor, almost all of the incidence is on the seller, that is, on the worker. So, government might say that half of tax is paid by the employer, but the only result of it is that some people are tricked in actually believing that.


I don't know about Germany, but in france, the 20% include retirement plan and something else untranslatable, but think financial help for familly with children, youth camp and childcare founding, association founding, financial help for college students. I think the "secu" (health care) take around 30% of our blocked slaray, so it more like 7-8%.


Your premiums will be capped at a certain percentage of your income if you make around $51K or less.


Which half made you happier?


Due to work, I spent:

- 3 months in Japan - 3 Months in Germany - 3 months in the US - 3 months in India

The transition was alarming. I see bits of both Germany and India in the US. Unfortunately (having grown up in America) I see the trend as towards India. I don't mean this as a cultural slight, but as a cultural observation. I've seen high-trust vs low-trust societies brought up many times on HN. Traffic was most pronounced. In Germany, they obeyed the rules to the extent they wouldn't J-walk even if there was no traffic. In America, you'd look both ways then cross. In India might makes right, big cars get the right of way, pedestrians have to be aggressive and just make their way, eyeballing cars down with a death stare of determination.

Anyway all this is to say, it seems like there are two types of wealth:

- In India, you can found a startup, make money, buy a Ferrari, but that would be a terrible move because if you drive it anywhere on public roads you will go max 30kph, and it will get destroyed on the roads - In Germany, you can have a modest Skoda and still hit 200 kph on their impeccable freeways with confidence that the person in the right lane will never, ever change lanes without a signal and mirror check

So, my personal take, and I realize that this is highly reductionist, but I hope, relevant is that there are two types of wealth:

1. a type where society is wealthy, and that translates into well being for the individual and the whole 2. a type where wealth is relative, and the wealthy take joy not in having an absolute sense of wealth (as in compared to a German), but as in "my neighbor lives in a shack and I live in a gated tower high rise"

I fear America is at a cross roads and will make a choice that makes us poor in a global sense.


Another way to describe the difference between Germany and India is that's the difference between a rich society and a poor society that has (a few) rich people in it. This distinction also correlates with multiple factors of collective well-being, including life expectancy, and income inequality.

America made the choice in the 1980s, with the arrival of Reagan, to transition from being a rich society to being a poor society that has a fair number of rich people in it. Income inequality has deteriorated since then, the quality of public services/public infrastructure has severely degraded, and social trust is rapidly eroding. It's almost certainly too late to change course.


I found your take thought provoking. HN is always a surprise.


I love how you described wealth not only in a financial sense, but also in a sense of civic responsibility.


Side node: Just to prevent any life expectancy changing surprises:

> with confidence that the person in the right lane will never, ever change lanes without a signal and mirror check

Always expect someone to sleep at the steering wheel and switch lanes at an instant without so much as using the signal. Especially when you are going 200kph.


Having also spent some time in all 3 of those countries, I agree with your take. It's very well-elucidated.


What did you think of Japan?


TLDR: i'd take unhappy-rich over hungry-poor any day. But the best thing would be the happy medium where you are comfortable enough to afford food/schooling but not in a social class where there are obscene social expectations to spend -- so your question is a fair one.

I think the key thing was getting past the lower rungs of the Maslow hierarchy. It is very difficult to concentrate on schooling (or anything) when you are hungry or sick. I was constantly hungry when we didnt have free public school meals. A close relative had TB, due to poor healthcare where the hospital/system didn't seem to give a darn. The worst thing is how horrible normal people treated you (even teachers at public school.) I was constantly sick, probably due to poor nutrition.

College was great, I will still poor, but the prospects were getting better and all the basics were covered (no longer hungry; decent healthcare). This allowed more happiness because you knew it would be over soon.

With better jobs comes more stress -- the expectations (perhaps justified) that one should have a home, that one should have a school for children w/o crime/gangs -- and bigger mortgages, bigger spending. I live fairly conservatively despite decent career success, but I can see how I could "become unhappy trying to reach happiness" ... all that said, i'd take unhappy-rich to hungry-poor any day.


Yeah, that's exactly it- once you have safety, food, shelter and good health and the expectation those will remain, that's amazing.

Personally I've decided to forgo as many personal luxuries as possible (ie don't fly first class, no boat besides a shitty canoe, no peasant steel case rolex, no car worth > $20k in an effort to retire with a few million in liquid assets on top of my house by my early 40s. Having no worries is the ultimate luxury.

Alternatively, if I lived in California where the weather is mild perhaps I would just go full Diogenes.


My goal is to retire to Germany and become a German citizen if I can't get rich here. At least I won't die in my 60's because I can't afford healthcare.


Coastal America and rest of America might be a better way to cut it.


Not really, there’s countless cities with tons of well off upper middle class people in the middle of the country.

Metro-Denver, Metro-Austin/Dallas/Huston, Metro-Atlanta, Metro-Nashville, Metro-Chicago, Metro-Detroit, Metro-Minneapolis, etc. etc. etc.

I’d say it’s more city/suburban vs rural. This doesn’t account for the poor & homeless in all of America’s inner cities, but does a better job explaining.

Maybe “Fortune 500 headquarters adjacent” is the better indicator. The towns with big global companies almost always have affluent suburbs surrounding them. Even Cincinnati has tons of affluent people due to P&G.


I think you have to go even finer grained than that.

Chicago, for example. My old stomping grounds. The inequality within that city is stark. Glaring. The South and West sides are a world apart from the North side.


One side of the street is Little Italy, the other side is not someplace to hang out after dark.


That Andersonville to Uptown transition can be a shock.


I guess the easiest way to slice it would be knowledge labor vs. unskilled labor. Regardless of where you live.


I know a few multi-millionaires in Idaho and Utah that live very nicely.

In SF or LA they'd be middle-class.

It's not just about wealth in dollars, it's about purchasing power.


Hell of a lot of farmers buying $75k diesel trucks for cash, rotating quarter million dollar equipment through the inventory, sitting on 100 head of cattle and 1000+ acres and wearing carhartts, wranglers and beat up boots. Every now and again a friend of a friend posts a pic on facebook from their 40' boat up on the lake.


It's a bit more intermingled. For example, Williamson County, TN (Nashville suburbs) is one of the 10 highest-income counties in the entire country. The Dallas, Atlanta, Chicago, and Denver suburbs are also very affluent.

Wikipedia's collected some of the recent per-county census data here, although that isn't a perfect metric since states vary a lot in county size: https://en.wikipedia.org/wiki/List_of_highest-income_countie...

In general there's a good/bad outcomes split within (almost?) every major American city between the affluent and the poor neighborhoods. I haven't verified this with the life-expectancy data, but I would bet it differs more between rich vs. poor areas within each state, than it does between coastal and non-coastal states.


Tennessee is a tax haven for the wealthy who don't want to be in Florida. These states have a more regressive economy because the un-wealthy have to shoulder more of the burden of financing their government.


I don't think its so geographically aligned like that. Plenty of rich areas in Chicago, Houston, Dallas, Phoenix etc.



At the county level I dont think it neatly lines up to coasts vs interior. There's definitely a serious problem of the interior southeast though


While that is true, I think that some of these things are tied to local culture too, which is why the Coastal distinction does have some merit.

If you generally are in the Bay Area or LA you rarely see the level of obesity you see in say Houston despite the fact that both areas despite being rich have their fair share of the poor too.

Similarly for smoking. It's exceedingly rare to see public smoking in the Bay Area.

Similarly for diets. When traveling in the South I was amazed at just how ridiculously unhealthy the average food eaten by the average person there was. Everything deep fried, laden with calories, consumed along with sugary drinks.


It's still regional rather than simply everyone vs. coastal. Not sure if it's fair to lump in the wealthier Rocky Mountain states like Colorado or Utah in with say the butter and cornfed Midwest.


Not really, no. Many of the coastal cities are more stratified and economically segregated than many of the non-coastal ones, but they still have a sizable lower-class population. So the precarious people in the high-poverty areas are much more hidden from the "typical" view of someone with some money.

Food deserts and gang violence - both accelerated by concentrated poverty - are a couple of ways this manifests in some of the "elite" cities.


I lived about 1.5 years in the US several years ago. Ironically I had planned on settling but instead came to realize what a great country I came from, Norway. America has many qualities but I had to see America to realize all the qualities of my own home country.

Health care was one of them. I never really liked health care in Norway. I didn't think doctors was all that eager to help often. In the US I kind of experience the opposite, but I slowly realized there was a very dark side to this. All too often I saw that it was just a show to please the "customer."

Basically in the US I saw little patient and health thinking and much more of a profit and customer thinking in health care. So often suggestions and procedures where obviously followed for pure profit motive. I discovered on may occasions how I would be given useless drugs and suggestions just to drive profits.

I think all health care systems are flawed in some way. Norwegian health care is no exception. But in the US I saw that it was possible to do much worse. The sad irony of this is that this happened while US doctors from my impression are exceptionally skilled. Problem is that they are in a system which push them to think about money rather than health care.

A US system where incentives go realigned to serve people rather than profits could quite possibly turn into one of the best health care systems in the world.


For those short on time: “smoking, obesity, homicides, opioid overdoses, suicides, road accidents, and infant deaths. In addition to this, deeper poverty and less access to healthcare mean Americans at lower incomes die at a younger age than poor people in other rich countries.” Still a good article


I wonder what someone's life expectancy would be without the personally-avoidable things such as smoking, obesity, overdoses, and suicides.

Homicides, road accidents, and infant deaths are harder to control as an individual.


There's a causal relationship between the things you're calling "personally-avoidable" and the class wealth gap. People are emotionally predictive; if they don't see an ideal prosperous future outcome, they settle for prosperity where they can get it because it beats a lifetime of suffering, even if the end result is additional suffering.


Personally avoidable, yes. Product of society, also.


Basically, I'm wondering: if someone makes good decisions, or the best of their circumstances, how does their average life expectancy stack up to other developed nations?


I also thought it was interesting to see when the US branched away from the rest of the rich countries. For example:

1. All the other rich countries have steadily increased health expenditure per capita, and for some reason this really accelerated in the US around the early '80s. But the money looks like it mostly went to things that didn't increase life expectancy. Maybe this was a Reagan thing?

2. The US had the highest cigarette sales until the mid '70s, but is now one of the lowest per capita. This is actually one of the things that the US has done better than its counterparts, e.g. Japan and Germany have higher cigarette sales per capita. However the death rate from smoking remains the highest, probably due to a combination of other factors such as poor healthcare.

3. Around the late '90s, the US really started to pull away from the rest of the rich countries in terms of death rate from opioid overdoses. Some of this spilled over into Canada, but they were able to keep it somewhat under control.

4. For deaths from both obesity and road accidents, the US just hasn't made the same sort of gains as the others since 1990.


About point #2, I wonder if the deaths caused by smoking remains high in the US because it's measured effect can be really delayed. Even if sales of cigarettes went down in the mid-70's, they were probably still high for quite a while. On top of that, the effects of smoking can take decades to appear. I could imagine somebody starting smoking in the mid 70's and not seeing effects until recently.

EDIT: It turns out reading even not-so-carefully results in fruit! From the article:

> But the chart also shows that smoking peaked earlier in the US. Since there is a lag of two to three decades between the peak of smoking and the peak of smoking mortality, this should be positive news for the US going forward. The country is over this mortality peak and we should expect the decline in lung cancer death rates in the US to continue in the coming years.


I am always curious how data are compared between countries which will pretty much always have different reporting standards. For example, how does one doctor in Germany attribute a death to smoking vs. a doctor in the US?

The reason why I bring this up is I know of at least one metric where the definitions being used are quite disparate: child mortality. The US is very inclusive in counting pre-mature births as infant mortality whereas a lot of other countries would conclude these were not viable births and thus are not counted in the statistic.


This is something I've seen called out before when these comparisons are trotted out but I don't see it mentioned in this article.

Here is a blurb I found quickly (from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4856058/)

> First, many countries also have reporting requirements related to birth weight and may not report infants under 500 grams as live births (MacDorman and Mathews 2009). Second, the presence of assisted reproductive technologies has increased the frequency of multiple births, which have higher mortality rates.


Wow, the difference between the US and Canada is a surprise, in particular the opioid overdoses and road accidents.

I am a US->Canada transplant, and the cultural and economic differences here just don’t seem that stark. Yes, there is universal health care, obviously…but there is definitely not an abundance of easily available mental health care here, especially outside the major metro areas. And the health care in the most economically disadvantaged areas (First Nations reservations) certainly isn’t platinum care.

Really, the road deaths chart stands out to me. Canada is very car centric, and huge, and full of plenty of large animals to hit. I simply cannot hazard a guess as to why it’s that different.


There are dramatically more high density, high risk driving environments in the US versus Canada. I could also make some questionable generalizations about Canadian drivers versus US drivers.


Is this true? It seems like Canadians drive less than Americans do, which I'm guessing is because Canadians live and drive in higher-density environments where they can make shorter trips and kill fewer people along the way:

https://internationalcomparisons.org/environmental/transport...

Just eyeballing it, it looks to me like the death rate from road accidents in each country correlates strongly with vehicle-kilometers driven per capita. Americans die at a higher rate because they spend more time on the roads covering more distance.


Excellent catch.

And that makes some sense. A huge percentage of the country lives in a fairly narrow band near the US border in large cities. With not a lot of driving to other cities. Because they’re too far away.


And Torontonians could make questionable generalizations about Brampton drivers.

Though, now that I think about it, residential street speed limits are way lower here.


Is the need for Mental Health care in Canada reduced due to a more relaxed, less frantic lifestyle?


The US has around 9x the population of Canada.


For some reason, I have a PhD in Health Policy and clinical practice, so, I'm inclined to look at the healthcare system when thinking about this question.

IMO it's simple (and this is of course a common view): healthcare in the United States is a failed market. It's not about free market fundamentalism vs socialism, it's just that in this case, this market is totally broken. Costs are completely out of control, and accordingly, access, that is, access without incurring crippling debt, is a huge problem.

Obama tried to address both cost and access. He went up against the insurance companies, and lost. He got somewhere on access, but even that is just access to insurance; insurance that may leave you with thousands of dollars to pay out-of-pocket if you walk into the ED with a complaint. So maybe you don't go.

Socialized medicine, it seems, certainly won't fly in this country. But socialized insurance, "Medicare for all"? We, the little people, have many reasons to support a multi-decade experiment with that.

There's no ideology here. It's just insane (unless you're profiting!) given history for us to continue imagine that in this case the Invisible Hand is going to fix things.


> Socialized medicine, it seems, certainly won't fly in this country. But socialized insurance, "Medicare for all"?

The same endless propaganda and sloganeering brought to bear against socialized medicine in every medium and from every mainstream politician to make us think that it's obviously an impossibility in the US (because reasons), is used against Medicare for all. The possibility of changing US healthcare has never had a relationship with any potential improvement in health outcomes or lowering of costs - the chance for any new plan relies on how well it preserves the profits of an industry that consumes twice the proportion of GDP here as it does in any other country.

One of the reasons M4A is criticized has been that it doesn't directly lower anything except administrative overhead (which is massive, but trivial in comparison to the difference between US health care costs and the costs of the civilized world, which would have kept the US in budget surpluses year after year.) It relies on government to put pressure on prices. As the industry's only customer, it would obviously have the leverage, but with most individual politicians being funded by the industry, there's no expectation that it would suddenly have the will. M4A is criticized for not being socialized medicine (i.e. an NHS-like program) by interests who are also against socialized medicine.

The reason Obama passed ACA is because it preserved industry profits, stalled the growth in the rise of healthcare costs, and would hopefully delay the next mass challenge to the status quo. At the beginning of the 2020 election cycle, popular pressure led to virtually all of the early Democratic primary lineup to feign support for M4A, and by the end of the cycle it wasn't even in the platform as an aspirational goal, despite the VP-elect owing her entire initial media presence from her (later-reversed) support of Sanders' bill.

Getting M4A passed will likely be as difficult as getting socialized medicine passed, and would require immense and focused public pressure. We had the most popular candidate in the country run on it as a central issue twice, and during the second time, a new virus changed everyone's daily lives in the middle of the election. Still, through the media, it became a referendum on the personality of a reality show host, Russian spies, and secret pedophile networks. Rational healthcare policy has no hope.


"It's a poor nation with rich people in it."


I suspect that trend will continue until the wealth inequality is so rampant that the taxes needed to secure and defend the wealth of the rich can't be extracted from the rest of us because we no longer obtain enough wealth for our taxes to matter. At that point, wealth will need to retreat to their next most stable country to bunker down.

At some point, people may identify many of these people and entities for what many of them really are: leeches of society--not value creators. Let's not confuse your entrepreneur innovating and improving life with profit maximizing corporatism.

We continue to play this experiment under a rhetoric that claims this is progress, all while we continue to play the song of failed promises of trickle down economics. To me, our current direction seems a lot more regressive than progressive, but who am I.


Yet the median disposable income per person, after adjustments for government provided healthcare and education is enormously higher than any other nation, according to the OECD.

https://data.oecd.org/hha/household-disposable-income.htm


Yes, hence the quip about "rich people in it".

A more serious way of putting it might be that the US is in raw dollar terms one of the richest countries in the world (certainly by far the richest large one), yet in many ways (infrastructure, quality of administration, political culture, etc.) it feels more similar to a middle-income one.


Yes but that quip doesn't work when we're comparing the median. The US does have an absolutely nosebleed wealthy 0.1%, yes, but if you split the population exactly in half, and pick the bloke in the middle, he has really rather a lot of assets, relative to most anywhere else.

"The richest poor country in the world" might be closer to it. As the rest of the threads under this post will reveal, we mostly agree that something is wrong with this country — but putting our finger on what that is can be challenging.


But at middle income in the US you don’t get the healthcare or vacations that a lower 25% gets in any Western European country. It’s hard enough when you’re top 10%.


Vacations, absolutely.

But healthcare? 50th percentile US healthcare is pretty good. It's 25th and under who get shafted.


It doesn't work when you're comparing incomes, but it does work when you compare incomes minus costs.

Having a higher median income is all well and good, until you find it all eaten by education, healthcare, and transportation costs... In addition to less financially denominated costs. [1]

But eh, if you didn't need to take care of your kids, or yourself, you could theoretically afford more iPhones.

[1] Having lived in Canada, and the US, I can't put an exact dollar value on the stress of, for example, having to deal with the American healthcare system, but its non-zero.


that is precisely one reading of the original quote. Americans are rich, but even rich Americans often life in perpetual financial insecurity. THe average American is rich but cannot cough up a thousand bucks for an emergency, which in the US, can be life threatening.

It's a new sort of poverty, affluent and insecure at the same time, and it's probably not a stretch (given the content of the article we're commenting on) to say it's bad for health.

The average Dutch citizen might take less money home, but they also work 30% less, they won't face the threat of not having healthcare or a roof over their head, and they don't need to inhale car exhaust on a highway for an hour per day but take the bike instead. More money is evidently not the solution to everything. American society seems to be optimised around creating economic activity for its own sake.

edit: not really sure what the reflexive downvotes are for, the links between precarity, inequality, stress and biological harm in populations are well documented, see Sapolsky: https://www.scientificamerican.com/article/how-economic-ineq...


It's the inequality that correlates with poor outcomes, not absolute wealth (per capita or median).


This is an interesting study, but there are so many influences that the article can't cover (probably due to its length) that it is a struggle to even draw questions from it.

Everyone dies of something. The fact that US people die from things at a different ratio from other countries is interesting, relevant and uninformative on the topic of life expectancy. Picking out obesity - the fact that US obesity rate deaths are higher than the comparison countries doesn't tell us anything about life expectancy. Are they old fat people, or young fat people?

The article also can't rule out Simpson's paradox style effects. Hypothetically, say the US is just much better at bringing sickly babies into the world and nursing them on into their 70s it would have better care and worse life expectancy. I doubt that theory could even begin to explain what is going on here, but when comparing average statistics of huge and diverse populations effects like that can creep in very subtly. Statistics can be completely misleading if the treatment is short and only deals with part of the picture.

I'm feeling good about reading an article with lots of data, but this didn't do a good job of addressing the title matter.


It does a good job. It asks “why?” and then shows the causes, with numbers for each cause.

Of course, there’s a deeper and more contentious kind of “why?” and it doesn’t go as deeply into that, other than to show some things that seem to correlate.

But I think it is useful, because one can’t defensively say the US doesn’t have a problem compared to other rich countries. The Nordic countries save early, sickly babies and nurse them along just as much as the US does, for instance.

The only thing I wish they’d have changed would be to indicate relative weight of the causes. Because obesity is an order of magnitude more lethal than homicide, for instance.


> Are they old fat people, or young fat people?

Do old obese people exist in the first place? What is the longevity record for an obese person?


Page missed #hrs worked, holidays/vacation days.

Actually just the general stress that you have to work hard your whole life just to get-to/stay in middle class. Maybe that is related to the inequality part.


So what is the average number of days holiday for an American full-time worker? Is anybody aware of any studies that compare hours worked per year against life expectancy?

Is this valid: https://www.openaccessgovernment.org/long-working-hours-shor...


saved you a search: https://www.cnbc.com/2018/08/15/statista-how-far-behind-us-i... . includes this depressing factoid, "American workers took an average of just over 17 days of vacation in 2017, the highest level in seven years".


That's higher than I'd expect. Lots of people get zero days off.


It’s interesting to break this down by state: https://en.wikipedia.org/wiki/List_of_U.S._states_and_territ.... As a benchmark, life expectancy in Germany is about 81 years, while Sweden is a bit over 82. In Minnesota, it’s 80.9, which isn’t far off. New York is over 81, Massachusetts is 80.5. Even less wealthy states like Arizona, North Dakota, and Utah are at 79.9.

It’s also interesting to break this down by ethnicity. Asians in the US are longer lived than people in rich Asian countries like Japan. Asians in California and New York have life expectancies over 87, even though they have slightly higher than average rates of lacking health insurance.


Probably more immigrants in the Asian subgroup that brings good eating habits and if they could move there it probably means wealth. Have been quite a few studies showing that if you move to any country, you get quite a lot of positive effects comparing to staying as you select for a driven personality.


I wouldn't call Arizona, ND and Utah less wealthy. Sure they may not have NY/SF style wealth, but their purchasing power still exists.

I would use the South or Rust Belt as a better reference.


Life expectancy vs healthcare expenditure isn't a good measure. I find it interesting that Smoking is way down and in the conclusion it's first as an important factor. Smoking clearly not impacting life expectancy at all.

In fact if you look at their data. Obesity/Overweight is the only factor. Not surprising given >70% are overweight.

Flipside, nothing here surprises me. The US governments actively subsidize unhealthy foods. Not to mention outright inform their people to eat unhealthy diets.

Worse than that, just look at your options for food in the USA. If you banned unhealthy foods and all current unhealthy food workers are banned for life from working in the food industry. You would be left with >90% of their food industry unemployed and practically unemployable.

What do you do with those >20 million people? Welfare system cant handle them. You might say unsubsidize these unhealthy foods and what happens? Fast food prices go way up and more people go unemployed. Same problem.


Did we lose a smaller percentage of our population in WWII and that somehow goofs up our death rates which then somehow feeds bad data in to life expectancy because the way they calculate it is off?

I’m asking because this is the sort of thing which gets discovered all the time. Even, or especially, because it sounds so implausible.


If you dig into the statistics, the reason is not what most people assume. The US has anomalously high death rates due to unintentional injury (accidents) in the young adult age groups, which skews the average for the overall population. If young people died in accidents at similar rates to the rest of the world, the average life expectancy would look quite good. This is the 3rd most common cause of death in the US, generally.

The primary source of injury in young people creating this situation? Car accidents. And remembering how me and my friends were behind the wheel at that age, this is completely unsurprising. Young people in many other countries do not drive nearly as much.

Everyone looks for medical reasons but it is largely fatal accident rates.


Sorry, car accidents won't cut it. Here are the life tables: https://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_03.pdf which link to this spreadsheet: https://ftp.cdc.gov/pub/Health_Statistics/NCHS/Publications/...

Here are traffic deaths by age group: https://www.cdc.gov/mmwr/volumes/68/wr/mm6806a8.htm. Let's pad those numbers up by a significant amount and assign 20 per 100,000 from birth, and remove those deaths from the life tables (ie let's say noone dies from traffic accidents in the USA). That still only lifts life expectancy by 1 year (from 78.6 to 79.6)

You can keep adding other parts of accidental deaths but: 1) they don't fit the story of USA dying more from driving 2) the leftovers are already below the accidental death rate from countries with much higher life expectancy 3) a big chunk of the rest is accidental falls which predominantly affects very old people so doesn't have a big impact on life expectancy


Even if this is a fundamental part of the explanation, there are features of US culture and geography at work. Most of the rest of the wealthy countries have smaller geographies and denser population centers, and a corresponding lower rate of car travel. With our huge suburban sprawl, many youngs find their entry into adulthood coupling excessive commute responsibility for entry level jobs with the new freedom and responsibility of a vehicle. (I grew up in the DC suburbs, this was my life.)


People vastly underprice the mortality/morbidity costs of driving in the US (or mostly anywhere).

I wince when I hear 1 hour commute times. The risk of injury and death from driving 10k miles per year versus 25k miles per year is material in my opinion.


I guess people in other developed countries take more time to relax than people in US. In US, most people work more than 40 hours a week.


US residents have a huge obesity problem, and very little has been done to improve the situation


In fact we've even started celebrating it. The "Body positive" movement [1].

[1] https://en.wikipedia.org/wiki/Body_positivity


We spend double, as a percentage of GDP, what any other rich country spends on health care, so that's not it.


A random blogger who no one's ever heard of explains this in excruciating detail and very persuasively:

https://randomcriticalanalysis.com/why-conventional-wisdom-o...

He agrees with the linked article that lifestyle factors are what drives the worse health outcomes in the US relative to other wealthy countries. They're not primarily driven by differences in access to or effectiveness in health care. He also makes the case for a few other very unintuitive points:

* Health care spending is a direct function of national wealth. If a country gets richer it spends more on health care, and every country at every time in modern history spends about the same amount on health care as a function of its wealth.

* The US looks like an outlier in health care spending because GDP is not a perfect measure of wealth. Actual Individual Consumption is a less well-known but much more relevant measure of national wealth. AIC shows the US is more of an outlier in wealth, which makes its high health care spending less remarkable.

* There's no magic bullet. Single payer nations pay less than the US mostly because they are less wealthy and health care spending is a function of wealth. Other countries have better health outcomes mostly because of demographics and culture, which can't be fixed by the health care system. And even though finding obvious waste and inefficiency in the US health care system is easy, at a macro level it doesn't look like the US is remarkably less efficient than other rich countries, and most spending goes towards things that patients want.


> lifestyle factors are what drives the worse health outcomes

So in addition to healthcare reform, the US needs public policy reform - to tackle obesity, prescription drug abuse and to tackle unskilled driving creating traffic deaths.


Your employer picks a plan for you, which isn't what you need.

You go to your doctor, who then tries to treat you. But then has to fight an insurance company who wants treatment that isn't in your best interests or isn't covered by the employer plan.

You get home and discover your Doctor is out of network. Pay up. You spend a million years fighting the insurance company.

OR your insurance is good, so the doctor says, what the hell I will order that test that is nice to have. They'll cover it. Costs increase.

Or you go to the emergency room, run up bills for the hospital and leave without paying. The taxpayer foots the bill.

And the doctors pay through the teeth for their degrees and want a big return. They earn more than other countries in a significant way.

All the incentives are out of whack and not in the public's interest.


Not to mention squads of clerks at every single doctor's office doing battle with entire armies at the insurers in a many-to-many clusterfuck of epic proportions over every single bit of care delivered.


Also America is the most litigious society in the world [0], making medical malpractice suits an ever-present threat in everyone's minds; but tort reform does not help taxpayers, and hurts patients [1].

[0] https://statmodeling.stat.columbia.edu/2015/12/03/why-us-lit...

[1] https://www.citizen.org/wp-content/uploads/medical_malpracti...


I'm not super educated on this but I thought that malpractice insurance basically "handled" the problem at a reasonable overhead compared to other gross inefficiencies.


The costs of malpractice insurance vary a lot based on specialty and location:

https://www.leveragerx.com/blog/medical-malpractice-insuranc...

A few years back I was reading articles on how doctors were changing specialties or retiring entirely due to the high cost of malpractice insurance. I'm not sure if the situation has changed since, however.


I recently had a surgery done and we weren't sure it was going to be covered by insurance. I wanted to make sure I knew how much of a liability I was taking on by moving ahead before knowing about insurance. I was told the insurance was going to be billed $150k, but if they didn't pay, they would only charge me $15k as the cash price. I was ok with that since the surgery was important and insurance did pay, but that type of pricing variation is why healthcare is so expensive in the US.


There are places where they don’t use insurance, it’s cash only. The Surgery Center of Oklahoma does cash only and will tell you the cost before you even contact a surgeon or specialist. It’s on their website.

You can also get mri images done for very low cost of you pay cash.

https://surgerycenterok.com/

https://affordablemri.com/


Other first world nations spend half of what we do, and they have better outcomes and quality of care[1]. They are able to insure all of their citizens with it while the US doesn't.

[1] https://www.healthsystemtracker.org/chart-collection/quality...


Well, the US has better outcomes for employed, insured and non-overweight folks; dramatically lower wait times, better cancer survival rates and less competition for care. Expense is also a nonissue on employer insurance.

Unfortunately the US aggregate outcomes are dragged heavily down by an unhealthy population and high barriers to care for the uninsured.


> Expense is also a nonissue on employer insurance.

My impression was that many if not most Americans would have to pay an excess (not sure of the American term; money paid by an insured party on using insurance) for any medical care with their work insurance. Is this not the case?


This is true but complex. It depends on the type of service you receive. As a general rule, you'll need to pay a yearly deductible before receiving insurance benefits for non preventative care. This can be anywhere from $500 to $8000. High deductible plans are commonly referred to as "catastrophic" plans, because the deductible is so high, and the kind of people who purchase them are typically not wealthy, that their owners would only seek care in a true emergency where the service would exceed the cost of the deductible. After paying your deductible you will often also have a "co-pay" which is typically a flat rate based on the type of service. Something in the realm of $25 to $500. After that, many plans have something called "co-insurance" which is a percentage of the bill you are responsible for even if you have met your deductible. Say, 20%.

Add all these charges and fees up, you'll keep paying them until you hit your "maximum out of pocket." So as an example, I was hospitalized a few years back in December while on what would be considered a "good" healthcare plan. I paid my $1000 deductible, a $250 co-pay for emergency room care, and co-insurance of several hundred dollars. I stayed a single night in the hospital and received a CT scan. I was given Tylenol, released the next day, and referred to a specialist. I wound up seeing the specialist in January, so my deductible reset. I was given another CT scan, so I had to pay my $1000 deductible again. The total bill for the entire process pre-insurance was in the realm of $80,000. After insurance, I paid $5000, which was my entire life savings at the time. I didn't hit my maximum out of pocket for either year, so I got lucky in a way. I could have had to pay double what I did.


> This is true but complex. It depends on the type of service you receive.

I feel this is never adequately priced into these discussions. everything about healthcare in the US is expensive and complicated, even if you "have insurance", even if you have expensive, seen-as-good-insurance.


> dramatically lower wait times, better cancer survival rates and less competition for care. Expense is also a nonissue on employer insurance.

Do you have a source for those statements?


Your source combines access and quality in order to put the US at the bottom. If you go further down the page you’ll see that the US is sometimes better and sometimes worse. (Apparently Canadian doctors have trouble delivering babies.) If you seek out other sources of information you’ll find that the US has the best survival rates for certain types of cancer. Supposedly the US also produces 50% of the new pharmaceuticals that reach the market.


I mean, any country could jump to the top of that league table by just building endless hospitals and immediately setting fire to them. There is still a question of value for money.

There may also be an aspect of funny cost accounting there. One reason given for the rather high medical salaries in the US, for instance, is the fact that trainee doctors, dentists, etc tend to incur truly horrifying levels of student debt.

> Now, [US] physicians graduate with a median $194,000 in student debt.

This generally isn't the case in most developed countries, but in that case the state may be spending more on _education_.


The amount the US spends on healthcare is more than offset by the high proportion of people who have no cover.

The % of US population covered by health insurance is around 84%, compared with most other rich countries, which are all at 100%.

Additional, much of what you count as US health care spending is really health care administration - i.e. billing and finding reasons to deny care to the sick.


>The % of US population covered by health insurance is around 84%

That was pre-Obamacare. 91-92% of Americans have medical insurance, whether through their employers, or government programs like Medicare/Medicaid.

>compared with most other rich countries, which are all at 100%.

Nope. That's compared to 95-97% in other developed countries because there are always some people who fall through cracks, like (say) a Canadian who doesn't get a new provincial health care card after moving, or a German who neglects to buy into a new sickness fund after changing careers. The only such systems with actual 100% (or as close to it as possible) coverage is something like the UK NHS, which does not have a requirement to show a membership card (because, well, there isn't one) to receive treatment.


It's not spent efficiently.


Or health care (the wrong type) is the problem...


Maybe it's because of the US spending a lot chasing diminishing returns for rich people but little on impactful interventions for the poor.


Compare wealth and life expectancy of any ethnicity living in USA with the population living in their previous habitat, and the US population comes out on top.

Japanese Americans for example have higher life expectancy than Japanese in Japan, and I expect the same would be true for Ethiopians.

This shows the superiority of the American system.

I need to second the previous comment that this article is either based on deception or ignorance.


But any black person coming legally from the Nigeria/Mali Area to the US will have a lower life expectancy than if he came to Europe?

Maybe this is crazy, but here is an explanation: legal immigrants are richer and more educated than average in their country of origin and thus have better outcomes after having immigrated.

My grandfather is living in Lincoln county WV (since before i even knew him), i know a lot of people in Huntington and Charleston, in fact most Americans i know live between there and Fayetteville, WV. I would be shocked if life expectancy there is higher than 70, especially if you're not in a fringe group.


>Compare wealth and life expectancy of any ethnicity living in USA with the population living in their previous habitat, and the US population comes out on top.

>Japanese Americans for example have higher life expectancy than Japanese in Japan, and I expect the same would be true for Ethiopians.

Similarly, Americans do well on PISA compared to their ethnic relatives. (https://www.unz.com/isteve/the-new-2018-pisa-school-test-sco...) Asian Americans do better than Asians; whites do better than Europeans; Latinos do better than Latin Americans; and blacks do better than Africans.

Hispanics and especially blacks' scores drag the US average down. Both white and Asian Americans score higher than Canada (and white+Asian is essentially Canada's racial makeup), and higher than New Zealand, Australia, the Netherlands, Belgium, Germany, France, Norway, and the UK; Estonia is below US Asians but above white Americans. Norway is by far the wealthiest Nordic state but its average is only two points higher than the US national average, despite not having a demographic that is 13% of the population and scores 85 points below the white American average.


> Americans do well on PISA compared to their ethnic relatives

That analysis is not by an expert, but by an MBA who is selling his own brand of "analysis" to the alt-right crowd.

In this case, he compares the white part of the US against their "ethnic cousins" without taking into account that just about every single western European country has 20% non-European immigrants who (as opposed to underprivileged US blacks) often aren't even native speakers...


Immigrants are a heavily selected group. What's the life expectancy of American-Japanese people compared to Americans in America?


It's not just wealth and life expectancy, it's pretty much every metric. Homicide rate and test scores are two big ones in my eyes, given the prevalence of firearms and a (seemingly?) subpar public school system. That being said, I think it's less so the American system, and more that the US "steals" the best of every other country.


wow - wasn't expecting that chart to be quite that pronounced


Obesity


[flagged]


West Virginia is 92% non-Hispanic white (2018) and has the lowest life expectancy of any US state (74.8). Which clearly disproves that common hypothesis. https://en.wikipedia.org/wiki/List_of_U.S._states_and_territ...

Life expectancy and overall heath in the US is strongly correlated to wealth. It’s a feedback loop, being poor directly results in worse access to healthcare etc, but also because it’s much harder for sick people to hold down a job etc.

Edit: Bottom 5 states by life expectancy vs their median household income rank (#). West Virginia 74.8 years (#50) Mississippi 74.9 years (#49) Alabama 75.4 years (#44) Kentucky 75.4 years (#43) Arkansas 75.9 years (#48). It’s not perfectly correlated but the relationship is very strong.

PS: Great Britain actually has significantly more ethnic diversity than WV and lower median household income than WV yet life expectancy is more than 5 years longer.


I suppose you could be charitable to gp and think they were making the reverse racist good genes argument for Black people?

At least it’d be a new twist on an old racist trope.


Are other races somehow not American? I never understood this argument.

"If it weren't for all those black people and immigrants we'd actually be really good! Those other countries are just too 'homogenous'. "

And then somehow this fact apparently dismisses other countries efforts at providing universal/preventative healthcare and initiatives that the US simply does not.


Genetics are about 2/3s of life expectancy. If you wish to compare ethnically inhomogeneous populations versus those that are homogenous, your comparison is not useful for anything. Urbanized (or rural) Asians in the US live longer than Asians elsewhere. The same is true for Blacks.


That doesn't hold up. A lot of the countries compared aren't that ethnically homogeneous either. In fact, Australia, New Zealand, Spain, Switzerland, Canada, and Sweden all have a higher ratio of migrants per 100k population than the US...


Did you mean to point out that Asians, Hispanics, and Blacks, all have substantially higher life expectancies than their co-ethnics in the relevant home countries, while White life expectancy is substantially lower, and has in fact dropped precipitously in the last twenty years?

Because a) that's how it works and b) most people replying to you are drawing the opposite conclusion. Either way, you've done a poor job of expressing yourself here.


Having a look at how people with various ethnic background fare is interesting and can be essential to optimise the effectiveness of health policies by targetting the right groups.

However, they are still all US Citizen, there is nothing misleading about the article or their analysis unless you want them to start splitting the stats by 'race', which would be a strange starting point (why would ethnic background be a better way to group people than socio-economic brackets anyway?).


can't this variance be explained more accurately by relative income? the US is more ethically diverse than many western nations, but also has high income inequality. This inequality, unfortunately, is distributed ethically


> US is more ethically diverse... inequality, unfortunately, is distributed ethically

Trenchant, if unintentional, observation :)


Is there any research that suggests such a dramatic effect as you're implying? It's obviously plausible that there is some genetic component to longevity but I have a hard time believing that isn't dwarfed by quality of healthcare and nutrition.

That said, it doesn't really invalidate what the article is talking about.


Nothing about the chart you showed supports your argument.


unhealthy diet, drug addiction, wealth disparity.


TLDR: The tree of liberty must be refreshed from time to time with the blood of patriots and tyrants.


Blood is blood.




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