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9
Low Life Expectancy in the United States: Is the Health Care System at Fault?

Samuel H. Preston and Jessica Ho


The United States falls well behind the world’s leaders in life expectancy at birth. Some of the discrepancy is attributable to relatively high infant mortality and some to high mortality from violence among young adults. But the bulk of the discrepancy is attributable to mortality above age 50, an age to which 94 percent of newborns in the United States will survive according to the 2006 U.S. life table. Life expectancy at age 50 in the United States ranked 29th highest in the world in 2006 according to the World Health Organization (2009). It falls 3.3 years behind the leader, Japan, and more than 1.5 years behind Australia, Canada, France, Iceland, Italy, Spain, and Switzerland. About 4 million Americans reach age 50 each year, so an average loss of 1.5 years of life years per person means that some 6 million years of potential life are being lost annually. At the conventional value of $100,000 per additional year of life (Cutler, 2004), the relative loss of life in the United States above age 50 is valued at roughly $600 billion annually. Using Japan as a standard, the loss is $1.3 trillion.

The U.S. medical system is often blamed for this poor life-expectancy ranking. But measures of population health such as life expectancy do not depend solely on what transpires within the health care system—the array of hospitals, doctors, and other health care professionals, the techniques they employ, and the institutions that govern access to and utilization of them. Such measures also depend on a variety of personal behaviors that affect an individual’s health, such as diet, exercise, smoking, and compliance with medical protocols. The health care system could be performing exceptionally well in identifying and administering treatment for various diseases, but a country could still have poor measured health if personal health care practices were



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9 Low Life Expectancy in the United States: Is the Health Care System at Fault? Samuel H. Preston and Jessica Ho The United States falls well behind the world’s leaders in life expectancy at birth. Some of the discrepancy is attributable to relatively high infant mortality and some to high mortality from violence among young adults. But the bulk of the discrepancy is attributable to mortality above age 50, an age to which 94 percent of newborns in the United States will survive according to the 2006 U.S. life table. Life expectancy at age 50 in the United States ranked 29th highest in the world in 2006 according to the World Health Organization (2009). It falls 3.3 years behind the leader, Japan, and more than 1.5 years behind Australia, Canada, France, Iceland, Italy, Spain, and Switzerland. About 4 million Americans reach age 50 each year, so an average loss of 1.5 years of life years per person means that some 6 million years of potential life are being lost annually. At the conventional value of $100,000 per additional year of life (Cutler, 2004), the relative loss of life in the United States above age 50 is valued at roughly $600 billion annually. Using Japan as a standard, the loss is $1.3 trillion. The U.S. medical system is often blamed for this poor life-expectancy ranking. But measures of population health such as life expectancy do not depend solely on what transpires within the health care system—the array of hospitals, doctors, and other health care professionals, the techniques they employ, and the institutions that govern access to and utilization of them. Such measures also depend on a variety of personal behaviors that affect an individual’s health, such as diet, exercise, smoking, and compliance with medi- cal protocols. The health care system could be performing exceptionally well in identifying and administering treatment for various diseases, but a country could still have poor measured health if personal health care practices were 

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0 INTERNATIONAL DIFFERENCES IN MORTALITY AT OLDER AGES unusually deleterious. This could be the case in the United States, which had the highest level of cigarette consumption per capita in the developed world over a 40-year period ending in the mid-1980s (Forey et al., 2002). Smoking in early life has left an imprint on mortality patterns that remains visible as cohorts age (Haldorsen and Grimsrud, 1999; Preston and Wang, 2006). One recent study estimated that, if deaths attributable to smoking were eliminated, the ranking of U.S. men and women in life expectancy at age 50 among 21 countries of the Organisation for Economic Co-operation and Development (OECD) would improve sharply (Preston, Glei, and Wilmoth, Chapter 4, in this volume). Recent trends in obesity are also more adverse in the United States than in other developed countries (Cutler, Glaeser, and Shapiro, 2003; Organisation for Economic Co-operation and Development, 2008). This chapter begins with a review of previous international studies of the comparative performance of health care systems in disease identification and treatment. The review is focused on the major diseases of adulthood, cancer and cardiovascular disease, in the belief that disease-level analyses are more likely to reveal the forces at work than more highly aggregated studies (Garber, 2003). In 2005, cancer and major cardiovascular diseases were responsible for 61.0 percent of deaths in the United States at ages 45+ (National Center for Health Statistics, 2008). Because our concern is with mortality per se, the criterion we employ is effectiveness at preventing death, rather than cost-effectiveness or efficiency of resource deployment. These latter criteria have been used in several other recent comparative studies describing features of the U.S. health care system that appear inefficient by international standards (Garber and Skinner, 2008; McKinsey Global Institute, 2008). A comprehensive evaluation of the U.S. health care system would need to consider patient physical and emotional welfare, a much broader concept than survival, which is the sole focus of this chapter. Health care systems can prevent death from a particular disease ei- ther by preventing it from developing or by effectively treating it once it has developed. A key element in effective treatment is accurate diagnosis. However, almost no internationally comparable data exist on the actual incidence of various diseases, which is the appropriate measure of the success of prevention. While cancer appears to be an exception because “incidence” data are published for various cancer registry sites (e.g., at the website of the International Agency for Research on Cancer), the data refer not to the origin of a disease but to its detection, a process that combines actual patterns of incidence with the mechanics of identification. And even if pure measures of it were available, actual disease incidence reflects not only features of a health care system but also many other factors of behavioral, social, and genetic origin. Disease prevalence—the proportion of the population that has been diagnosed with a disease—is even more difficult to interpret. The United

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 LOW LIFE EXPECTANCY IN THE UNITED STATES States has a higher prevalence than Europe of the major adult diseases, in- cluding cancer, heart disease, and diabetes (Avendano et al., 2009; Thorpe, Howard and Galactionova, 2007a). But higher prevalence could reflect higher incidence, better detection, or longer survival resulting from more successful treatment. Because of these limitations of data and interpreta- tion, our review focuses primarily on disease identification and treatment, elements that are customarily considered to be the provenance of health care systems. A valuable but not unimpeachable indicator of the effectiveness of treatment is the comparative survival rate of individuals once a disease has been detected. Relatively high survival rates imply either that the disease has been detected unusually early or that treatment is unusually success- ful. Early detection is valuable to the extent that it permits better therapy. However, if early detection did not alter the clinical course of a disease but only increased the expected length of time from detection to death (so- called lead-time bias), then it would not be associated with reductions in mortality at the population level despite raising 5-year survival rates (e.g., Gatta et al., 2000). Because they are not subject to this potential bias, we pay special at- tention to mortality rates. In particular, in the second half of the chapter we investigate comparative mortality trends for prostate cancer and breast cancer. We document that: • effective methods of screening for these diseases have been developed relatively recently; • these diagnostic methods have been deployed earlier and more widely in the United States than in most comparison countries; • effective methods are being used to treat these diseases; and • the United States has had a significantly faster decline in mortality from these diseases than comparison countries. INTERNATIONAL STUDIES OF CANCER The United States does well in international comparisons of the fre- quency of cancer screening. The OECD (2006, 2007) provides 2000-2005 data on the percentage of women ages 20-69 in 15 countries who had been screened for cervical cancer during the preceding 3 years. The United States has the highest percentage of women who have been screened in both tabulations.1 We present evidence below that the United States also 1Ages vary somewhat, but the variation is thought to be a “minor threat” to the validity of comparisons (Organisation for Economic Co-operation and Development, 2006, p. 69). The 15 countries include 6 for whom the recall period is greater than 3 years, the period used in the United States.

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 INTERNATIONAL DIFFERENCES IN MORTALITY AT OLDER AGES has exceptionally high screening rates for prostate cancer and breast cancer. Quinn (2003) reports U.S. colorectal screening rates that are “quite high” in comparison to Europe but does not provide comparative data. Gatta et al. (2000, p. 899) also suggest that access to and use of sigmoidoscopy, colonoscopy, and fecal occult blood tests are more common in the United States than in Europe. This difference is supported by the finding that colorectal cancer patients in the United States have less advanced disease at diagnosis than patients in Europe (Ciccolallo et al., 2005). A higher rate of screening for cancer would produce a higher prevalence of ever-diagnosed cancer in the population, ceteris paribus. The elevated prevalence would occur simply because a higher fraction of the population would know about their disease. An additional boost to prevalence would be provided if early detection resulted in reduced mortality. Thus, in view of the higher frequency of screening in the United States, we would expect its reported prevalence of diagnosed cancer to be higher than in Europe. That expectation is confirmed by data from the Health and Retirement Survey and its English and European counterparts. Thorpe et al. (2007a) found that 12.2 percent of Americans over age 50 reported having been diagnosed by physicians with cancer, compared with only 5.4 percent in a composite of 10 European countries. Avendano et al. (2009) reported similar figures for the age range 50-74, with England intermediate between the United States and Europe but closer to Europe. Some fraction of these very large differences in prevalence could, of course, be attributable to real differences in disease incidence or to reporting differences, which are discussed briefly below. Thanks to a large number of cancer registries that record new cancer di- agnoses and follow individuals forward from the point of diagnosis, 5-year survival rates for people initially diagnosed with cancer are widely available to provide evidence about the success of detection and treatment. Because of their relative comparability and pertinence to a major disease process, these data are among the best indicators of comparative health care system performance. In this summary, we use 5-year relative survival rates, which compare the survival of those diagnosed with cancer to that of an average person of the same age and sex as the person diagnosed. International comparisons of cancer survival rates show a distinct ad- vantage for the United States. Using cancer registry data, researchers from the Eurocare Working Group compare 5-year survival rates for cancers of 12 sites that were diagnosed between 1985 and 1989 (Gatta et al., 2000). The aggregate of 41 European registries, which were drawn from 17 countries, had lower survival rates than the United States from all cancer sites except the stomach, where differences were small and attributed to differences between the distributions of sites within the stomach. The U.S. data were drawn from the National Cancer Institute’s Surveillance, Epidemiology and

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 LOW LIFE EXPECTANCY IN THE UNITED STATES End Results (SEER) database, a population-based cancer registry covering approximately 14 percent of the U.S. population. For the major sites of lung, breast, prostate, colon, and rectum cancers, U.S. survival rates were the highest of any of the 18 countries investigated. Cancers first diagnosed on the death certificate (5 percent in Europe and 1 percent in the United States) were excluded from analysis; if they had been included, the U.S. survival advantage would have increased. The authors discount the possibility that the U.S. advantage was attributable to statistical or registration artifacts. An updated analysis reached similar conclusions. Based on period survival data for 2000-2002 from 47 European cancer registries, 5-year sur- vival rates were found to be higher in the United States than in a European composite for cancer at all major sites (Verdecchia et al., 2007). Table 9-1 presents the comparative data for all sites for which the U.S. 95 percent con- fidence interval was < 0.025. For men (all sites combined), 47.3 percent of Europeans survived 5 years, compared with 66.3 percent of Americans. For women, the contrast was 55.8 versus 62.9 percent. The male survival difference was much greater than the female primarily because of the very large difference in survival rates from prostate cancer. Scattered data for cancer of various sites indicate that tumors are typi- cally detected at an earlier stage in the United States (Ciccolallo et al., 2005; Gatta et al., 2000; Sant et al., 2004). Thus, the United States appears to screen more vigorously for cancer than Europe, and people in the United States who are diagnosed with cancer have higher 5-year survival prob- abilities. Of course, all of these phenomena could be the exclusive product of lead-time bias if early detection afforded no benefit for the clinical course TABLE 9-1 5-Year Relative Survival Rates for Cancer of Different Sites, U.S. and European Cancer Registriesa 5-Year Survival Rate (%) Site United States Europe Prostate 99.3 77.5 Skin melanoma 92.3 86.1 Breast 90.1 79.0 Corpus uteri 82.3 78.0 Colorectum 65.5 56.2 Non-Hodgkin lymphoma 62.0 54.6 Stomach 25.0 24.9 Lung 15.7 10.9 All malignancies (men) 66.3 47.3 All malignancies (women) 62.9 55.8 aBased on period survival data for 2000-2002. SOURCE: Adapted from Verdecchia et al. (2007).

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 INTERNATIONAL DIFFERENCES IN MORTALITY AT OLDER AGES of the disease. Below, we present evidence that innovations in diagnosis and treatment of prostate and breast cancer were associated with faster declines in mortality in the United States than in OECD countries. Such a pattern would not be observed if lead-time bias were the only factor at work, that is, if early detection conferred no advantage. INTERNATIONAL STUDIES OF CARDIOVASCULAR DISEASE In contrast to cancer, nations do not have registries for heart disease and stroke. So information about the comparative performance of medical systems with respect to cardiovascular disease is not as systematic and or- derly as it is for cancer. One useful source of comparative data is the Health and Retirement Survey (HRS) and its European counterpart, the Survey of Health, Ageing and Retirement in Europe (SHARE). Thorpe et al. (2007a) compared the United States with a composite of 10 European countries on the frequency with which people with a particular diagnosis reported using medication. Of people ages 50+ diagnosed with heart disease, 60.7 percent of Americans and 54.5 percent of Europeans reported being on medication. The proportions using medication after a stroke are comparable at 45.1 and 44.6 percent, respectively. Of those reporting high cholesterol levels, 88.1 percent of Americans report being medicated versus 62.4 percent of Europeans.2 Crimmins, Garcia, and Kim (Chapter 3, in this volume) show that a much higher fraction of Americans are using lipid-lowering drugs at a particular age than in Italy, Japan, or the Netherlands, even though the proportions with elevated cholesterol in these countries are similar to or higher than that in the United States. Among those reporting high blood pressure in HRS and SHARE, the proportions reporting taking medication for the condition are similar in the United States (88.0 percent) and Europe (88.9 percent) (Thorpe et al., 2007a). However, when actual measures of blood pressure are used rather than self-reports, the U.S. position improves. Wolf-Maier et al. (2004) em- ployed regional or national samples in the United States, Canada, and five European countries. Hypertension was defined as the population of persons who have systolic blood pressure of 160+ or diastolic blood pressure of 95+ or who are using antihypertensive medication. Of persons ages 35-64 with hypertension, 77.9 percent were being treated in the United States, com- pared with a range of 41.0 to 62.4 percent in the other six countries. Among those with hypertension, 65.5 percent were being successfully treated in the United States (i.e., their levels were reduced below the hypertension-defining threshold), compared with 24.8 to 49.1 percent in the other countries. 2The U.S. figure for cholesterol is drawn from the Medicare Expenditure Panel Survey be- cause HRS did not gather this information.

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 LOW LIFE EXPECTANCY IN THE UNITED STATES Survival data for cardiovascular disease start not from the point of di- agnosis but from an acute event of heart attack or stroke. An OECD study, following up on a study by the Technological Change in Health Care Re- search Network, computed 1-year case fatality rates for people hospitalized for acute myocardial infarction in Australia, Canada, Denmark, Finland, Sweden, Great Britain, and the United States. The samples were sometimes regionally rather than nationally representative. Among the seven countries in 1996, the United States had the third-lowest case fatality rate for men ages 40-64 and the second-lowest rate for men ages 85-89. For women at these ages, the United States ranked fourth and first (Moise, 2003). Part of the explanation for why the U.S. performs better may be related to its unusually aggressive treatment regime. Of the seven countries, the United States had the highest proportion of male and female patients in both age intervals undergoing revascularization operations (percutaneous translu- minal coronary angioplasty or coronary artery bypass graft) (Moise, 2003; see also Technological Change in Health Care (TECH) Research Network, 2001).3 One study has explicitly linked more aggressive surgical treatment in the United States to better outcomes. It compared Canadians and Americans who had just experienced an acute myocardial infarction and who enrolled in a drug trial (Kaul et al., 2004). Data are not nationally representative but rather reflect the patient base of hospitals participating in the trial. Ameri- cans had a small but statistically significant advantage in 5-year survival. Controlling many baseline characteristics, the hazard rate was 17 percent higher in Canada. When revascularization was added to the model, it was associated with a 28 percent reduction in the hazard rate and its addition reduced the international difference to an insignificant 7 percent. The authors conclude that “our findings are strongly suggestive of a survival advantage for the U.S. cohort based on more aggressive revascularization” (Kaul et al., 2004, p. 1758). The OECD (2003) has conducted a large international study of isch- emic stroke, which accounts for roughly 88 percent of stroke cases except in Japan, where it represents about 70 percent. They calculate in-hospital 7-day and 30-day survival rates for patients newly admitted with ischemic stroke. For both men and women ages 65-74, the U.S. ranking on 7-day survival rates was third out of nine; at ages 75+, it was second out of nine for both sexes. For 30-day hospital survival rates at ages 65-74, the United States was second for women and tied for second with two others among men. At ages 75+, the U.S. 30-day survival rate was first for men and second for women. Counting all deaths, not simply deaths in the hospital, and limit- ing comparison to six regions, including two in Canada, the U.S. survival 3Data on treatments at ages 85-89 were not available for Spain or the United Kingdom.

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 INTERNATIONAL DIFFERENCES IN MORTALITY AT OLDER AGES rate ranked first for men ages 65-74 and 75+ and second for women in these ages. However, the U.S. 1-year survival rate among this set of populations was considerably poorer, ranking fifth out of six for men ages 65-74 and fourth out of six for men ages 75+. For women at these two ages, the rank- ings were fourth and third. Consistently in these rankings, the U.S. position was better at ages 75+ than at ages 65-74. Carotid endarterectomy (surgical removal of plaque from inside the carotid artery) is used to prevent stroke or the recurrence of stroke. Such surgery is much more common in the United States than in any of 11 com- parison OECD countries (Organisation for Economic Co-operation and Development, 2003). We are unaware of any studies linking this surgery to international patterns of stroke mortality, but a randomized clinical trial reported a large survival advantage for persons undergoing the procedure (Halliday et al., 2004). In summary, persons with high blood pressure or high serum cholesterol are more likely to be treated for these conditions in the United States than in other countries. Survival rates following a heart attack are somewhat above average in the United States, whereas survival rates following a stroke are comparable to those of comparison countries. The evidentiary basis for international comparisons of the treatment of cardiovascular diseases is much weaker than in the case of cancer. CONTRARY EVIDENCE? “MORTALITY AMENABLE TO MEDICAL CARE” The Commonwealth Fund (2008) has recently issued a “scorecard” on U.S. health care system performance that consists of 37 indicators. A prominent indicator is “mortality amenable to medical care,” on which the United States currently ranks last among 19 countries. This index was de- veloped and applied in Nolte and McKee (2008), in which amenable deaths are described as “deaths from certain causes that should not occur in the presence of timely and effective health care” (p. 59). Only deaths below age 75 are included; these constitute 43.2 percent of deaths in the United States in 2005 (National Center for Health Statistics, 2008). For some causes of death, an earlier age cutoff is used. The distribution of major causes of death included among the “ame- nable causes” is provided for the United States, the United Kingdom, and France (Nolte and McKee, 2008). A majority of amenable deaths in all three countries is attributed to ischemic heart disease and other circulatory diseases, even though only half of ischemic heart disease deaths are included because some are believed not to be amenable to health care. That rule of thumb is clearly a poor substitute for an effort to attribute international variation in mortality from ischemic heart disease to its various compo-

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 LOW LIFE EXPECTANCY IN THE UNITED STATES nents, including health care systems and behavioral and social factors.4 The authors note that a similar rule of thumb could have been introduced for cerebrovascular diseases, which constitute at least a quarter of the “ame- nable” deaths in the United States and the United Kingdom. But it would have been no more satisfactory for that cause of death. In view of the studies that show that the United States does relatively well in treating cardiovascular disease, it seems inaccurate to attribute its high death rates from these causes to a poorly performing medical system. And these diseases contribute a majority of their set of amenable deaths, rendering the totality of amenable causes problematic. On one hand, a re- lated objection could be raised to the inclusion of diabetes deaths in the set. On the other hand, prostate cancer is excluded from the list of amenable causes despite the fact that the 5-year survival rate from prostate cancer in the United States is above 99 percent and the disease can be readily identi- fied (see below). According to Nolte and McKee (2008), males in the United States had a faster fall in mortality from nonamenable causes of death (an 8 percent decline) than from amenable ones (4 percent) between the latest two read- ings, 1997-1998 and 2002-2003. This anomaly suggests either flaws in the index or the unimportance of medical care relative to other factors that are operating. Causes of death whose inclusion in Nolte and McKee’s list of ame- nable causes at older ages is more defensible are influenza and pneumonia. Mortality from both causes is heavily influenced by smoking (Centers for Disease Control and Prevention, 2002), so the international distribution of mortality is a product of factors beyond the health care system. However, influenza is partially immunizable, and death from pneumonia can often be avoided through administration of vaccines or antibiotics or improvements in hospital sanitation. The United States ranks ninth out of 23 OECD countries in the propor- tion of the population above age 65 offered an annual influenza vaccina- tion (Organisation for Economic Co-operation and Development, 2007). Figure 9-1 demonstrates that the 2000-2004 age-standardized death rate from influenza at ages 50+ in the United States is among the lowest of the 16 countries investigated. The United States fares less well in mortality from pneumonia, having sixth highest rates among the 16 countries investigated (see Figure 9-2). However, the ranking is somewhat deceiving because its death rate is closer to all but one of the better ranked countries than to the five countries with higher rates. The U.S. death rate from pneumonia at 4The strategy adopted by Nolte and McKee is no different from saying that genetic factors play some role in cardiovascular mortality and, as a consequence, attributing half of interna- tional variation in cardiovascular mortality to genetic factors.

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 INTERNATIONAL DIFFERENCES IN MORTALITY AT OLDER AGES 3.0 2.5 Death Rate (per 10 0,0 00 ) 2.0 1.5 1.0 0.5 0.0 BR SA R S C E A LD AN EU P N T E N A AU AU H FR ES O SW R JP IT FI N U G C C D G N FIGURE 9-1 Age-standardized death rates at ages 50+ from influenza, 2000-2004. NOTE: AUS = Australia, AUT = Fig9-1.eps = Canada, CHE = Switzerland, Austria, CAN DEU = Germany, ESP = Spain, FIN = Finland, FRA = France, GBR = Great Britain, patterned fill GRC = Greece, ITA = Italy, JPN = Japan, NLD = the Netherlands, NOR = Norway, SWE = Sweden, USA = United States. 120 10 0 Death Rate (per 10 0,0 00 ) 80 60 40 20 0 R C E A LD AN EU P BR E T SA S N N A AU H FR ES O SW R AU IT JP FI N U D C C G G N FIGURE 9-2 Age-standardized death rates at ages 50+ from pneumonia, 2000-2004. NOTE: AUS = Australia, AUT = Fig9-2.eps = Canada, CHE = Switzerland, Austria, CAN DEU = Germany, ESP = Spain, FIN = Finland, fill = France, GBR = Great Britain, patterned FRA GRC = Greece, ITA = Italy, JPN = Japan, NLD = the Netherlands, NOR = Norway, SWE = Sweden, USA = United States.

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 LOW LIFE EXPECTANCY IN THE UNITED STATES ages 50+ is actually below the weighted or unweighted mean for the other 15 countries. DISEASE PREVENTION Medical procedures and survival rates are indicators of what happens to individuals whose health problems come to the attention of the health care system. But a health care system can also help prevent serious health problems from occurring in the first place. Of course, early identification of a disease is also preventive medicine in the sense that it may prevent death. But access to preventive medicine would appear to be an especially problematic area in the United States because 47 million people lack any form of health insurance (DeNavas-Walt, Proctor, and Smith, 2007).5 Such people are less likely to see a doctor and thus to receive routine testing that might detect the early stages of a disease and prevent its clinical manifesta- tions (Institute of Medicine, 2001). They are also less likely to receive advice about health maintenance and disease prevention (Institute of Medicine, 2001). While this chapter focuses on ages above 50, the mortality levels in this age range reflect the conditions to which individuals have been exposed throughout their lives. Preventive medicine may have a large role to play at younger ages as well as older ones. An additional factor that may inhibit disease prevention in the United States is the shortage of primary care physicians. The United States scores in the bottom group of 6 out of 18 OECD countries on a scale of the adequacy of primary care (Macinko, Starfield, and Shi, 2003). The scale is built from items relating to policy, finances, and personnel. In turn, the adequacy of primary care may be related to disease prevention (Macinko, Starfield, and Shi, 2003). The best indication of the success of prevention is disease incidence— but international data on disease incidence are nil. As noted earlier, disease prevalence is higher in the United States than in a European composite for cancer, heart disease, stroke, chronic lung disease, and diabetes (Thorpe et al., 2007a). Such a difference could result from higher incidence, better detection, or longer survival after detection in the United States. It could also result from reporting differences, for example, a greater inclination to report disease in the United States. But a careful study by Banks et al. (2006) using biomarkers suggests that morbidity differences between England and the United States at ages 55-64 are real and not a result of differences in reportage. A related study found that, faced with the same set of health- 5It has been claimed that this number includes 10 million people who are in fact covered by Medicaid insurance but who fail to report it (Ohsfeldt and Schneider, 2006).

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 INTERNATIONAL DIFFERENCES IN MORTALITY AT OLDER AGES Figure 9-4 shows the annual age-standardized death rate in the United States and the unweighted mean for our 15 OECD countries since 1980. Clearly, the United States has had a faster decline in breast cancer mortality than average among the comparison countries. Is the faster decline in the United States statistically significant? To answer this question, we repeat the approach used for prostate cancer, using WHO data files on deaths by cause and population by 5-year age groups. We employ negative binomial regression on data at ages 50+ (in 5-year-wide age groups until 85+). The dependent variable is the log of the number of deaths from breast cancer in a certain age group for a particular country and time period. Independent variables are a set of age group identifiers, a set of period identifiers, a dum- my variable for the United States, and a set of U.S./period interactions. We designate six 4-year-wide time periods, beginning with 1982-1985 and end- ing with 2002-2005, and choose 1982-1985 as the reference period. Because of the rapid increase in the proportion of women receiving mammograms from less than a third in 1987 to 74 percent in 1998, a reference period in the early 1980s appears appropriate. Significance tests recognize the cluster- ing of observations by country. Results are presented in Table 9-3. Using 1982-1985 as the reference period, we find that the U.S./2002- 2005 interaction term is significant at .01. With a coefficient of –.126, the coefficient implies that mortality in the United States has fallen 13 percent faster since 1982-1985 than in other countries. U.S. interactive coefficients United States Average for 15 countries 24.0 22.0 Death Rate (per 10 0,0 00 ) 20.0 18.0 16.0 14.0 12.0 10.0 00 04 02 0 6 0 4 6 8 8 94 92 2 8 8 8 8 8 9 9 9 20 20 20 19 19 19 19 19 19 19 19 19 19 Year FIGURE 9-4 Age-standardized death rates from breast cancer, 1980-2005. Fig9-4.eps

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 LOW LIFE EXPECTANCY IN THE UNITED STATES for 1994-1997 and 1998-2001 are also negative and significant at 5 percent. The interactive variable, U.S./2002-2005, is always significant at p < 0.01 regardless of which date is selected as the reference period (not shown). Thus, the United States has experienced a significantly faster decline in breast cancer mortality than comparison countries. SUMMARY We have demonstrated that mortality reductions from prostate cancer and breast cancer have been significantly more rapid in the United States than in a set of peer countries. We have argued that these unusually rapid declines are attributable to wider screening and more aggressive treatment of these diseases in the United States. It appears that the U.S. medical care system has worked effectively to reduce mortality from these important causes of death. This conclusion is consistent with other evidence that we have reviewed on the performance of the U.S. health care system in enhancing survival: screening for other cancers also appears unusually extensive; 5-year survival rates from all of the major cancers are very favorable; survival rates fol- lowing heart attack and stroke are also favorable (although 1-year survival rates following stroke are not above average); the proportion of people with elevated blood pressure or cholesterol levels who are receiving medication is well above European standards. These performance indicators pertain primarily to what happens af- ter a disease has developed. It is possible that the U.S. health care system performs poorly in preventing disease in the first place; however, there are no satisfactory international comparisons of disease incidence. Individuals report a higher prevalence of cancer and cardiovascular disease in the United States than in Europe, and biomarkers confirm the higher prevalence of many disease syndromes in the United States compared with England and Wales. Higher disease prevalence is prima facie evidence of higher disease incidence, although it could also be produced by better identification (e.g., through screening programs) or better survival. The history of exceptionally heavy smoking in the United States, and the more recent massive increase in obesity, suggest that a high disease incidence in the United States could not be laid entirely at the feet of the health care system, unless that system were held responsible for all health-related behaviors. Evidence that the major diseases are effectively diagnosed and treated in the United States does not mean that there may not be great inefficien- cies in the U.S. health care system. A list of prominent charges include frag- mentation, duplication, inaccessibility of records, the practice of defensive medicine, misalignment of physician and patient incentives, limitations of access for a large fraction of the population, and excessively fast adoption

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0 INTERNATIONAL DIFFERENCES IN MORTALITY AT OLDER AGES of unproven technologies (Garber and Skinner, 2008; Cebul et al., 2008; Commonwealth Fund, 2008). Some of these inefficiencies have been iden- tified by comparing performance across regions of the United States. Of course, the fact that certain regions do poorly relative to others does not imply that the United States does poorly relative to other countries. And many of the documented inefficiencies of the U.S. health care system add to its costs rather than harm patients. Just as we are not addressing issues of efficiency on the production side, we are not treating patient welfare as the main outcome. Practices that produce greater longevity do not necessarily enhance well-being. This potential disparity is central to the controversy involving PSA testing, which uncovers many cancers that would never kill patients but whose treatment often produces adverse side effects. The question that we have posed is much simpler: Does a poor per- formance by the U.S. health care system account for the low international ranking of longevity in the United States? Our answer is “No.” ACKNOWLEDGMENTS This research was supported by the U.S. Social Security Administra- tion (SSA) through grant no. 10-M-98363-1-01 to the National Bureau of Economic Research (NBER) as part of the SSA Retirement Research Consortium. The findings and conclusions expressed are solely those of the authors and do not represent the views of SSA, any agency of the federal government, or the NBER. We are grateful to Beth Soldo, Jason Schnittker, Eileen Crimmins, and anonymous reviewers for useful comments and sug- gestions. REFERENCES Ahern, C.H., and Shen, Y. (2009). Cost-effectiveness analysis of mammography and clinical breast examination strategies: A comparison with current guidelines. Cancer Epidemiol- ogy, Biomarkers & Preention, (3), 718-725. Andriole, G.L., Grubb, R.L., Buys, S.S., Chia, D., et al. (2009). Mortality results from a randomized prostate-cancer screening trial. New England Journal of Medicine, 0, 1310-1319. Antonarakis, E.S., Blackford, A.L., Garrett-Mayer, E., and Eisenberger, M.A. (2007). Survival in men with nonmetastatic prostate cancer treated with hormone therapy: A quantitative systematic review. Journal of Clinical Oncology, (31), 4998-5008. Aus, G., Bergdahl, S., Lodding, P., Lilja, H., et al. (2007). Prostate cancer screening decreases the absolute risk of being diagnosed with advanced prostate cancer—Results from a prospective, population-based randomized controlled trial. European Urology, , 659- 664. Australian Institute of Health and Welfare. (2008). BreastScreen Australia Monitoring Report 00-00. Cancer series no. 42, cat. no. CAN 37. Canberra: Author.

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