In my last article, I dissected the idea that single-payer healthcare will save the country money. While anything is possible, it’s not possible to do so in the United States for less money while maintaining the quality of care we currently enjoy.
But single-payer advocates often attack the quality of care in the United States, trashing our health outcomes as compared to that of other nations. They point to lack of single-payer as the reason for our struggles. Rather than take it for granted that the U.S. health-care system is barely better than going to a medieval barber for a bloodletting, I did a bit of research to discover how we really compare with the rest of the world, especially the industrialized nations advocates always say we need to be more like. How did we do?
Firstly, I had to come up with a metric. As I’m not a statistician or epidemiologist, I needed to settle on a simple proxy for health outcomes, so I chose average life expectancy. While quality of life is hard to measure and infant mortality, while frequently cited, is not useful since its measured differently in the United States than in the rest of the world, life expectancy works well because it’s clear and objective. Someone is either alive or dead (until we are forced to tweak the definition for live people that “identify as dead”).
On first glance, the United States is not great in this metric, placing 43rd in the world at 79.68 years, nearly a decade behind number one on this list. We are, in fact, behind many other industrialized countries, such as Japan (2), Switzerland (9), Italy (14), Canada (18), France (19), Spain (21), and the United Kingdom (33). Even Greece, which has seen its economy fall apart over the last half-decade, ranks 34th.
So, time to ban insurance companies and turn it all over to the state, correct? Not so fast. These numbers fail to explain why the United States falls where it does. A few comparison points immediately popped out at me: population size, ethnic diversity, and how emigrants from those same nations fare in the United States.
Let’s Examine Population Size
Providing health care for people is not easy. Providing health care for even more people is even harder. Even Sen. Bernie Sanders could agree. So while the United States is just 43 on this list, not a single bigger nation outranks it. In fact, of any nation with 130 million or more people (the top ten countries by population), the next best-performing country is our neighbor to the south, Mexico (which has a single-payer system), at a much lower 75.65 years, ranking 95, with less than half our population. The only nations bigger than ours, China and India, rank 99 and 163, respectively.
Of course, both China and India aren’t just bigger, but much bigger, at more than four times the size of the United States. So if we acknowledge treating and insuring more people is harder, then it’s easy to understand why we struggle to do this comparatively in the United States. It also helps explain why the United States, with 330 million people, fares so poorly.
Looking at some of the places ahead of it on the list, it would be very hard to apply the health care system of, say, Iceland, to the United States , since Iceland has just 334,000 people, about the same as Aurora, Colorado. Many others in the top 10 aren’t nations at all but microstates, such as Singapore (3), Macao (4), San Marino (5), Hong Kong (7), and Andorra (8).
While people often cite the United Kingdom as a country to emulate, nations within it such as Guernsey (10) or Jersey (17) are rarely used as examples despite much better outcomes. And if we are going to emulate other nations, we might as well emulate No. 1 on the list, Monaco, whose life expectancy is a whopping 89.52 years, despite all the premature deaths caused by frequent James Bond visits.
In fact, you can take the cumulative population of about half the places ahead of the United States on this list and the total population is still fewer than California alone. Amazingly, if you have fewer people, you can spend more to keep each alive. But it’s not just the total population that matters, as its makeup is very important as well.
Now for Comparing Ethnic Diversity
Another thing that matters a great deal is how diverse a population is. If a population is more uniform culturally, doctors would know better how to approach and treat their patients. If a population is more uniform linguistically, doctors and health advocates can better communicate with patients. If a population is more uniform ethnically, genetics will be more uniform and doctors will be more familiar with the diseases their patients get and how to treat them.
How diverse is the United States? With about 197 million whites, it has the largest white population on earth by far. But there are also more than 50 million Hispanics, also more than any other nation on earth. There are nearly 38 million blacks, more than all but eight other countries. Even Asians in the United States, who comprise less than 5 percent of the population, still are more numerous than the populations of Sweden and Denmark, two countries often cited as health-care models, combined.
So comparing the United States with many nations above us, such as Japan, Iceland, Sweden, Norway, Finland, Ireland, and Greece, becomes very difficult because of the complexity of health in this country versus those. A doctor in Iceland will treat almost solely Icelandic patients, whereas a doctor here will have a large variety of patients, with different languages, cultures, and genetic differences that make treatment much tougher.
The genetic component shouldn’t be downplayed in life expectancy, either. With four of the top seven countries by life expectancy largely Asian, it’s very possible that genetics may help them live longer despite other factors. With Asians in the United States living a whopping 86.5 years on average, that seems to be supported.
Conversely people of sub-Saharan African descent seem to have shorter lifespans worldwide, with Ghana at 172nd, leading the way among countries with a majority of this population. With African-Americans living just 74.6 years, that theory can’t be discounted. Without the large number of African-Americans counted in lifespan statistics, the average U.S. lifespan rises to a bit more than 80.1 years, or right about the same as the European Union average.
Comparing Emigrants to the U.S. Population
But it’s easy to tease the statistics to make the United States look better. Discounting countries as being too small to matter or taking out populations as being pre-disposed to shorter lifespans are likely factors but certainly not dispositive. So it’d be useful to look at apples to apples, or, in this case, similar populations in different countries. In this, the United States fares quite well.
As mentioned above, African-Americans live, on average, 74.6 years, or about five fewer years than the population at large. While this is too low, it also makes America seem to be a much worse place for African-Americans than it is. Comparing that number to Ghana, which leads all sub-Saharan African countries in lifespan at just 66.18 years, the same ethnic group gains about a decade of life, minimum, living in the United States versus Africa.
But Africa is a country rife with poverty, disease, lack of infrastructure, and other basic needs. So it makes some sense that the United States, despite not having single-payer, may produce better health outcomes than those countries. So, for the same reason, it may not surprise that Hispanic Americans do well in this measure also.
Puerto Rico leads the way in life expectancy among Latin American territories, at 79.25 years, bolstered in large part by being a part of the United States. The next highest Latin American nation in lifespan, Chile, at 78.61 years, is a half year less. Meanwhile, a Latin American in the United States, lives, on average, 82.8 years. So with the largest population of Hispanics in the world, they still live longer by nearly four years on average by living in the United States.
Not only does that beat all Latin America countries, it beats Spain, at 81.57 years, despite it being a Western European country whose health-care system I am told we should emulate. In fact, as a Hispanic, one would die sooner, on average, growing up in Salamanca, Spain than in Salt Lake City, Utah, where Hispanics live on average 82.1 years, which is only 22 best among all states.
I have danced around one nation this whole article: Japan. They rank number two in overall lifespan at an amazing 84.74 years. With the Japanese government entrenched in many aspects of its citizen’s lives, including health care, this serves as a great model on which to base the U.S. system. Or so it would seem, unless you also look at how Asian-Americans do in the United States.
While the U.S. Census doesn’t tease out ethnicity among Asian-Americans, the lifespan of this group is a whopping 86.5 years. With other ethnicities such as Chinese and Koreans, whose average lifespans are much lower, making up most of this number in the United States, it stands to reason that Japanese-Americans have even higher lifespans than this, meaning one is probably statistically likely to live longer as someone of Japanese descent being born in Tuscaloosa, Alabama (85.3 years) than in Tokyo, Japan.
What This All Means
The U.S. health-care system has its faults. But its strengths are largely underestimated as well. Looking solely at average lifespans across the world, the United States fares poorly. But if we try to compare with other nations of similar size, the United States does the best. If we compare with other very diverse nations, the United States performs very well. If we look at it demographically, on average, there is nowhere you will live longer in the world as someone of Asian, Hispanic, or African descent than in the United States.
This is all without accounting for the differences in counting infant mortality, where the United States keeps much more accurate records than international peers. Nor does this take into account other social factors that harm the United States in this category, such as longer commutes leading to more car accidents, violent crime, a more spread-out population, obesity, and other such things that cause Americans to live shorter lives that have more to do with lifestyle choices and distance to trauma centers and very little to do with their access to insurance coverage.
So while the U.S. health-care system has a good deal of flaws, it’s hard to say lack of single-payer is one. To that end, since the Affordable Care Act was passed, average lifespan in the United States actually dropped from 88.9 years to 88.8 years, despite the huge increase in the percentage of the population with insurance.
So next time someone tells you we need single-payer because we have to have universal coverage and that’s why people don’t live nearly as long here, let them know that we aren’t perfect, but for a country with 330 million people, we are doing quite well. And if that person is black, Hispanic, or Asian, let him know he is more likely to live longer here than he would anywhere else in the world.