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OT - Longevity in the US and abroad

None of what follows is meant as a comment on the politics of healthcare...

Some "fun" observations to wonder about.

1. There's a surprisingly strong body of evidence that healthcare, spending on healthcare, etc., don't affect average lifespan very much. I've never been able to reconcile this with my own life (saved at least twice in hospitals so far) but it comes up in several different places.

2. Averages are VERY misleading, especially for very large diffuse populations. Note about popluations in chart (quick wikipedia check)
France 65M, Japan 126M, Australia 24M, Canada 36M, Chile 18M, UK 65M add up to => 334M
US => 324M
There are a number of statistically weird things that happen with sample sizes.
But worse, the numbers of the US vary by state, and by race. Unless you happen to be some kind of ethnically average person, living in some average of the states, the national numbers don't mean much. (Which is probably true of relatively large places like France or the UK as well.)
And so there's something like a 10 or 12 year life expectency spread between asian males and black males (with hispanic, white, etc in between) in the US. The numbers vary state by state.

Averages also hugely gloss over lifestyle issues. Smoke? Exercise? Any semblance of sensible diet?

Averages will also be pulled down by plagues and scourages that may not affect you. The US is currently beset by an epidemic of deaths caused by opioid overdoses and deaths due to effects of alcoholism. Among middle aged white women. This is very bad. But is really more a social issue than a healthcare issue. And while it pulls down the average, by itself it doesn't pull down the actual life expectency for the people who are not afflicted with these things.

Yes, it means ON AVERAGE things are getting worse in the US - that is true. But it doesn't actually mean things are getting worse for any particular person.
 
None of what follows is meant as a comment on the politics of healthcare....

Agree with all your points. Would note, though, that France is a racially and ethnically diverse nation -- probably as much so as the US -- but with far better longevity.

What mostly amazes me is that we spend several trillion a year on health care; but have yet to had a well informed national discussion on just what it would take to have a healthier and more productive citizenry. As you say, lots more to it than just medical care and the 2x per capita more we spend out of our pockets, while still not insuring all our citizens.
 
if someone eats too much and is over weight they have problems when older.
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many cities where few people have cars but instead walk (to subway)there are fewer hugh overweight people. many cities everybody after dinner goes for a walk and you often seen thousands taking their evening after dinner walk,
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and in car, small cities where everything is 10 miles away people who park within 100 feet to save walking. those cities often have a lot of hugh people. just saying in new york city people on subway normally are not hugh over weight where other cities in new york state you see a lot of hugh people who only walking they do is often between drive way at home to house as the get food by delivery or drive through window
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to me it is more a car culture and a culture without cars and people walk more. even in USA it is different. i always hate driving in big city paying for local parking. often easier and cheaper to walk and take subway, if city setup that way where most things are a short walk away
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thats why in Florida price of gas went up in 2008 and people living 30 to 50 miles from work could not afford gas to go to work and pay house mortgage so mortgages were not paid and had housing collapse. literally being poor in the suburbs and no money for gas to go to work or buy food was often article in newspapers. talk about a car culture
 
No. Our Oncology may be, but then, we've given ourselves too much cause to need it, so..

BTW .. there is another source around that said that life expectancy in the US had actually dropped for the first time in ages, just last year. Or at least that the rate of improvement had taken a downturn.

Bill

You maybe thinking about the death rate of middle age white men rising an alarming amount.

https://www.nytimes.com/2015/11/03/...-middle-aged-white-americans-study-finds.html

We'll still get the good news propaganda similar to employment figures (like adding burger flippers to the head count of industrial output).

Good grief,
Matt
 
I will post some links to things I’ve written elsewhere. My views on a lot of this range from skeptical to cynical. Noone should take these as comments on what “should be”, rather they are sad observations on what I think “actually is”:

We are actually talking about three different things (all legit):

1. Why does the US not actually cover 'everybody' the way, say, the NHS does? Short answer - the vast majority of citizens don't want to, or don't want to if they have to pay anything at all.

The numerical majority in the US gets a very good deal. Changing that deal in a way that the numerical majority would have to pay more or get less (which due to scale would have to be) is very hard indeed.
See: EconoMonitor : Ed Dolan's Econ Blog >> CNN’s Sanders-Cruz Healthcare Debate: A Scorecard
And in particular the comments I wrote at the end (Bryan Willman)

Keep in mind that Medicaid covers 70million people, more than the total populations of France or Germany or the UK. It's not considered a great success.
Medicare covers another 50million if memory serves.
Which means the two largest programs cover about as many people as the population of Japan. Also keep in mind that because of how the tax system works, ALMOST everybody is eligible for medicare, but most assuredly NOT actually everybody. Medicare is as close to “universal” as the US has ever come.

This should give great pause to anyone arguing "the US 'can' and 'should' do what X does" – we might actually be socially or politically incapable of doing it. "The US is too stupid to do it right" might actually be true.


2. OK, but does it really have to cost so much? A system that doesn't cover some (smallish) parts of the population ought to be cheap, right?
There are lots of arguments about this, but as of this month I now think it comes to these two:

A. The US spends vast sums on lots of things, because we can. In fields where it's not clear how much is enough, and the stakes are very high, people will spend as much as they can "just to be sure." Healthcare and Education are the prime targets in the US. In fact, for someone living "the good life" in the US (which is *very good*) you could argue the rational thing to do is to spend 100% of their excess income on healthcare, in an attempt to extend the length of that goodness.

B. The US has a form of AxBxC cost disease, even worse than the say the UK. AxBxC is the case where A is consuming output from B which appears to be paid for by C. If you have health insurance from, say, MSFT (when I was there) all healthcare appeared to be free. No deductibles. No out of pocket. B (the healthcare industry) would be stupid not to take the money. C, employers, insurers, government, struggle to pay the bill. A (you and I) is actually paying the bill, but in opaque ways - you do not see it deducted from your paycheck, rather, you just get a lower paycheck. You don't see cost shifting, rather, you see higher bills from an inscruitable source.

Any 3rd party payer system, even one that runs its own providers (the NHS) will have pressures like this. (The US has such a system, called the VA. Go read about it at length before you decide that "VA for everybody" is the solution.)


C. Life expectency. The statistics for large groups can be very hard to interpret. Various reasonably credible sources claim that *my* life expectency (57yo white male) is at least 83. (We're talking about sources like the social security administration which have VAST statistical databases to work from - but which don't break down by race, etc.) Calculators adjusted for race, smoking history, etc. suggest the number is more like 90.

The chart PeteM started with is showing 78. Is it lying? Probably not. Probably a different datase, or from a different year, or not adjusted for date of birth.

(Life expectency for somebody BORN TODAY versus remaining life expectency for somebody at some particular age today are different.....)

Of course, this also means that the true life expectency of my mirror in France might really be 85, or 78, or 95. It’s hard to know.

Worse, for relatively small groups relatively confined scourages can make statistical life expectency look shorter than it is, by just a little bit. This appears to explain the drop in life expectency for non-rich middle aged white women. General health hasn't changed, but an alarming number of them are dying from alcohol and opioid scourages, and it changes the numbers.

Blogs I suggest its worth your time to look through and at least sometimes read.

Articles by Megan McArdle - Bloomberg View

EconoMonitor : Ed Dolan's Econ Blog >> CNN’s Sanders-Cruz Healthcare Debate: A Scorecard

Skip the woo-woo stuff for the analytic stuff, eye popping on:
Slate Star Codex

EDIT: this took so long to write I overlapped some posts above that raise similar points.
 
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Still a lot of unknowns although I remember in high school life expectancy was 69 for women and 65 for me. I have beat the odds at 69. Survivors of famine actually deposit a marker on their genes. If you starve prepubescent say around 10 to 13 years your grandchildren will live 20 % longer. Swedish demographer thought it was a fluke until he published and others did similar genealogical surveys and found similar results. Researchers then found the markers.
My father lived to 97 but for his last few years he considered it a curse.
 
Another way to think about this is to consider "health care" in three major categories:

1 - Daily habits (food, exercise, safe habits)

2 - Routine medical interventions (periodic exams, vaccinations, appropriate medicines, routine emegency and other care)

3 - High cost interventions (cancer treatments, heart bypass surgery, end of life treatment, etc.)

So, how does the US compare to the rest of the civilized world in these three areas?

1) Daliy habits? In the US there are lots of folks, tending to be both better educated and above average incomes, with fairly healthy daily habits. Good food, regular exercise, fit, alcohol in moderation, generally no tobacco or drugs, even wear helmets while motorcycling, etc.. These are our buddies still hiking, running a business, volunteering, etc. at 80 years of age. There are also folks who are chronically obese, eat poorly, don't exercise, and almost surely headed to diabetes. Some are are regularly drunk or high, and routinely engage in other risky behaviors. As a nation, we generally don't want to tell folks to eat their veggies (remember the reaction to that) much less incent healthy living habits. Personally, I think we ought to incent them; through such things as lower insurance rates for those with healthy habits and a re-do of assistance programs. There would still be people who would be ill or disabled through little fault of their own -- and I think they should not be denied access to low cost insurance.

Anyhow, I'd characterize big parts of our culture as fast-food eating, and exercise avoiding. We think it a violation of our rights to be economically or culturally incented to eat better, get exercise, and stop self-destructive behaviors but also apparently think we have a right to have someone else pick up the tab for the consequences of our behavior. Case in point: you can't tell me to wear a motorcycle helmet but you also have to pick up the tab for putting what brains I have back in my skull.

Layer on top of the food-exercise deal our high rates of addiction, reaching from the urban poor to Betty Ford, Rush Limbaugh, and any number of sports, business, and entertainment celebrities.

Add to that our perverse politics of sex, where big chunks of the citizenry think contraceptives should be hard and expensive to get, but babies left to be brought up mothers incapable of nurturing their babies. That is: addicted, immature, self-involved, mentally incompetent, maybe just too poor and poorly educated to put a roof over a kid's head. Our policies with respect to the poor and young create some of the budget-busting health care problems as these effectively abandoned kids go from toddlers to teens to middle age.

In 1900 the average white maie lived to be 45 years old. Since then life expectancy has risen 30 years. Here's the thing -- most of that increase came from technological advances more in the "daily habits" realm than the "health care" realm. It was things like clean water, sewers, refrigerated food, better agricultural practices, workplace and highway safety, infant care, etc. they caused most of that improvement. Things like vaccines and antibiotics also helped -- just not quite so much. If we're going to do a redo of health care, the notions of healthy daily practices, clean water and air, workplace safety, decent food, and incentives for fitness ought to be a part of it. It's more a parental/cultural thing than a Presidential, but when I was a kid Kennedy wanted us to hike 50 miles and today Trump wants us to tweet. Hard to know yet the pros and cons of a generation brought up by their phones and tablets.

2) Routine interventions? These are things that millions of us will need at any given time - vaccines, broken legs put in casts, treatments for scrapes and wounds, dealing with flu epidemics, etc. Due to their frequency, we ought to have both well-established best practices in dealing with them and treatments so far along the experience curve that they are very cheap. The US, it seems to me, has conspired against itself to make these things expensive and inconvenient. Guys tend not to seek medical treatment. Those with high deductibles tend not to seek treatment until they "can get their money's worth." A substantial number of us are anti-vaccine. Individual physicians and hospitals vary widely in treatments and costs. We have Bryan's point about patients not acting as consumers -- and indeed we've made it far harder to compare prices and quality of medical treatment than, say, microwave ovens. In addition, as many as 20% of us have no routine care -- a dumb idea for things like vaccines, communicable diseases, mental illness etc. where all of us are at risk from someone ill.

Bottom line is we have expensive routine care, some of it way below par, with medical lobbies doing all they can to eliminate competition (no bargaining on drug prices, nurse pracitioners more limited than garage mechanics in the complexity of routine things they can do, etc.). We also don't incent drug companies to produce inexpensive treatments -- the development of something as cheap and widely used as aspirin might be near impossible today.

Because of the lack of competition we have higher costs and lower usage of stuff that ought to be as cheap as any other large scale manufacturing or service business. To me, the sensible thing here is national insurance covering all our citizens for routine medical care -- along with much greater competition for any provider following known best practices. In a limited way we're moving towards this (think how easy and affordable it is to get some vaccinations now, say at a Costco or Walmart). This kind of national care wouldn't cost very much -- most folks don't have more than a couple hundred bucks of routine interventions in a year. We're now spending thousands of dollars for stuff that could and should probably be covered at a tenth the cost.

3) Major medical interventions.
This tends to be where both the frontiers of medicine and the big bucks are. Drug companies, for example, have retooled themselves towards cancer drugs -- enabled in part by our nationally funded decoding of the genome -- because that's where the money now is. List prices of $100,000 a year for drugs costing far less to develop and manufacture are now common. Here things get trickier. We don't have "best practices" -- we're still learning. We want to incent real research. But we also don't want companies gaming the system. Which they do in spades. Sometimes by treating a dying patient as an ATM machine -- spending hundreds of thousands of dollars in the last two weeks of life. Sometimes by gaming things like the orphan drug incentive or just buying up some sole-source pharmaceutical and jacking up the price 1000%. My own take on this is that this is were the budget-busting dollars for private, Medical, and Medicare insurance are being spent. Just as a thought experiment, suppose that Medicare were given to those 0 to 65 years old (generally young enough that they wouldn't use much of it, especially if a requirement for "free" Medicare were not smoking, getting some exercise, etc.. Then imagine that anyone who wanted to live to 100 were guaranteed they could buy insurance -- but they had to pay a big chunk of the costs. I'd imagine old folks would be more careful about what they bought, medical directives, and the like.

Anyhow, just some thoughts. My own take is that many of we Americans have a perverse attitude toward healthy living habits; have turned routine care into something way too expensive and inconvenient (even unavailable for some); and can rightly say we do great at major medical interventions -- but with far too many folks skimming money off the top.
 
. . . 1. Why does the US not actually cover 'everybody' the way, say, the NHS does? Short answer - the vast majority of citizens don't want to, or don't want to if they have to pay anything at all . . ..

Your first link expands on this; with those covered by company-paid insurance and Medicare not wanting to pay more. Point I'd add is that I think we could get "universal coverage" for the first and second of the three types of "health" investments noted above -- mainly because they'd be a good deal for the health-insured-incumbents as well.

Changing how we deal with "major medical interventions" is more problematic. We start hearing about "rationing" and "death panels" when the fact is that health care has and always will be rationed. In the past, insurance companies rationed care -- only the very-well-insured got the best and most care near the end of lives -- and even they didn't have infinite resources and infinite life. Any sensible system must have a point at which publicly paid health care costs stop (e.g. breast and penile implants for 90 year olds) and people are left to calculating their own 'druthers and resources. The trick, in my mind, is to do relatively affordable (make it affordable) and widely effective stuff for as many folks as possible. especially in the primes of their lives.
 
Our health care can be a lot better cheaper and smarter lets agree on that. Anything can be made better or a whole lot better. VA can be a lot better all of it can be it is up to us to see it done and tell both sides it will be done. Life expectancy, every 49 seconds a boomer dies. I understand it may make some happy but there it is.
Each great country is concerned that the birth rate is equal or greater. It translates into wealth, security, and manufactured goods. So we have undocumented workers to fill jobs.i have a personal opinion .


Where are all the Americans who would fill that void? My answer is that a greater number have been aborted yes actually murdered. As a great country we should protect the living unborn children. I agree with a few exceptions.

i would like to live long enough to see Roe vs Wade overturned even ms Row eventually came to believe the same.
 
Roe/Wade should NOT be overturned.
But rather should be seen as a last ditch option for extenuating circumstances...focus should be prevention and easy access to it.

Matter of fact prevention is pretty much the solution to all healthcare issues.
Most disease can be linked to dietary choices and our foods and current recommendations are garbage...make good foods available and educate people how to eat right and that right there would break the big pharma/healthcare/insurance industry at which point NHS becomes not only affordable but downright cheap.

Diabetes,heart disease would be almost unheard of...and the strain and cost of healthcare relieved.
 
I caution that schemes in which people are somehow educated to behave more wisely that the end result might not be what you expect.
In particular, lots of easily preventable illness and mortality could be avoided, which is a win.
But the net cost of the healthcare system might not go down.

If my speculation is correct - that people will spend as much as they can on healthcare and education, until diminishing returns are actually proven and accepted, then the fraction of GDP devoted to healthcare might be pretty much fixed by the relative costs of other things.

That is, the kinds of things that might really drive down healtcare spending as a fraction of GDP might be, oh, war, or gasoline rising to $10 per gallon, or the price of food tripling.

Because, some is good, and nobody can prove that more isn't better, so more it is....
 
if you travel a lot in general you see a lot higher percentage of fat overweight people in USA and some European countries where if you travel to Asia most are not as over weight. although people in general world wide tend to get heavier when older.
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just being in airports in different countries quite noticeable the number of fat people and in other countries often see nobody fat or vastly over weight beyond 10 or 20 lbs
 
We can all talk big about healthcare...until we need it. Its also easy (and asinine)to blame people for their illness'. Some of which are caused by lifestyle choices. The minute you start going down the lifestyle blame game road be prepared to find that something you enjoy may very well be on that list as well. It doesnt take much of a stretch to see where eventually having a job or hobby where you work with machinery all day becomes an increased risk, and therefore a higher premium.....you like boating and fishing?.....well....thats dangerous....100% of people who drown did so near water.
My views on these things have evolved as they often do based on life experiences. I have never had a surgery beyond a couple of teeth extracted....this spring I am going in to have a heart valve repaired or replaced. It has made me realize how fortunate I am to be living in the time and place that I do. I will be getting my surgery at Mayo Clinic in Rochester MN.....an hour and a half drive from home into Gods country and some of the best doctors in the world. The people who perform these surgeries are different from me ......I could spend the rest of my life trying to learn how to do what they do a dozens of times a month.....and never get it right.

Just my .02
 
Recall that I pointed out (a) there are statistical arguments that healtchare spending doesn't extend lifespan much but (b) this doesn't reconcile with own life.....

A problem is that there is some level of healthcare spending that is actually not at all controversial, and often relatively moderated cost. Appendectomy as a treatment for appendicitius. Antibiotics for clearly bacterial infections.

It seems to me that a great deal of the cost is hiding in things where it's not so obvious what is right or wrong. Or, as often, not so obvious which patients need what. For example there's some controversy over total knee replacement. What there is not controversy over is that for the right patient it can be a huge win (for example: me.)

Also - the "let's make everybody fix their lifestyle" gang misses a few things. Obesity is going up. Pretty much everywhere. Including among smart people who work hard to control or lose weight. Including people who exercise. Various basic schemes like "eat less and exercise more" have been tried several hundred million times and failed in all but a tiny handful of cases. Nobody actually knows why.

So it is on the ground proven that we do not really know what causes overweight and obesity and have only very poor ideas of how to effectively treat it. Preaching at people or attempting "nudges" misses the point.
 
Recall that I pointed out (a) there are statistical arguments that healtchare spending doesn't extend lifespan much but (b) this doesn't reconcile with own life.....

A problem is that there is some level of healthcare spending that is actually not at all controversial, and often relatively moderated cost. Appendectomy as a treatment for appendicitius. Antibiotics for clearly bacterial infections.

It seems to me that a great deal of the cost is hiding in things where it's not so obvious what is right or wrong. Or, as often, not so obvious which patients need what. For example there's some controversy over total knee replacement. What there is not controversy over is that for the right patient it can be a huge win (for example: me.)

Also - the "let's make everybody fix their lifestyle" gang misses a few things. Obesity is going up. Pretty much everywhere. Including among smart people who work hard to control or lose weight. Including people who exercise. Various basic schemes like "eat less and exercise more" have been tried several hundred million times and failed in all but a tiny handful of cases. Nobody actually knows why.

So it is on the ground proven that we do not really know what causes overweight and obesity and have only very poor ideas of how to effectively treat it. Preaching at people or attempting "nudges" misses the point.

Similar to taking your car in when it is running like crap....but not getting a code. Bad diagnostics = start throwing parts (and $ )at the problem. Maybe it will go away. Of course the human body is much more complicated.....
 
Most if not all industrialized countries have a national health care system using much less money per 1000 people than we do. Most use about 1/2 of what we spend. What is it with these clowns in Washington who can not copy one of the systems used by others and use all the money saved to make it even better. No Nation having a national healthcare system has ever gone back to a privately run for profit system. Yet, our clowns are pulling out all the stops to repeal something that is not very good with something that is even worse.
Their stories abound with people telling about someone they know in Canada and had to come over here to get treatment. Well, that person is now spending the rest of his life in poverty unless he walked out of the hospital and went back to Canada, or Mexico, or Honduras etc. without paying.
They - the Washington clowns - will most likely come up with about the same system they are trying to repeal and replace. After all, they are the ones who made sure the ACA was cut down until there was only a skeleton left from the original plan. That was the only way they had enough votes to pass something.
So guess what the result of all this bragging about replacing the ACA will be? At best something that looks the same as what we have now, or something that costs much more (again) and provides less service to the people.
Butt - they can not get their head out of the mud and finally adopt something that works well in other countries.
Where in the constitution does it say we have to have a healthcare system that guaranties big profit for the people who manage it?
Could be they count themselves as being a part of the healthcare money machine. Must be.
 
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Most if not all industrialized countries have a national health care system using much less money per 1000 people than we do. Most use about 1/2 of what we spend. What is it with these clowns in Washington who can not copy one of the systems used by others and use all the money saved to make it even better. No Nation having a national healthcare system has ever gone back to a privately run for profit system. Yet, our clowns are pulling out all the stops to repeal something that is not very good with something that is even worse.
Their stories abound with people telling about someone they know in Canada and had to come over here to get treatment. Well, that person is now spending the rest of his life in poverty unless he walked out of the hospital and went back to Canada, or Mexico, or Honduras etc. without paying.
They - the Washington clowns - will most likely come up with about the same system they are trying to repeal and replace. After all, they are the ones who made sure the ACA was cut down until there was only a skeleton left from the original plan. That was the only way they had enough votes to pass something.
So guess what the result of all this bragging about replacing the ACA will be? At best something that looks the same as what we have now, or something that costs much more (again) and provides less service to the people.
Butt - they can not get their head out of the mud and finally adopt something that works well in other countries.
Where in the constitution does it say we have to have a healthcare system that guaranties big profit for the people who manage it?
Could be they count themselves as being a part of the healthcare money machine. Must be.
Well said.

I have personal experience with the French and Swedish systems. Both -in my opinion - are markedly better than our own in a number of important ways.

We could enjoy a dramatically better system too were it not for the gross stupidity of the American people.

Gigantic insurers, big-pharma, hospitals, greedy physicians, over-specialisation with attendant high costs (greedy docs once again) have been raping American consumers for decades while providing a generally poor quality product.

So...what do the Ametican "sheeple" do? They go wild in support of the Tea Party, they put a whacked-out, greedy-assed billionaire in the White House whose personal interests (the only kind of interests he has) are in direct conflict with their own. Then they elect a pile of legislators who dance to the tune of their capitalist overlords while angrily denouncing incalculably better programs abroad as "socialism". This, as if it should be unquestionably accepted as a "bad" thing.

If you are one of those who continue to bring this kind of ruinous, inhumane crap upon us....Wake the fuck up! You are being had folks!

Ok, you don't want to adopt a sensible form of socialism like that found in Scandinavia, for example? Fine, why not look back to the New Deal, and fashion something sensible from that theoretical underpinning?

All we need do to dramatically improve our healthcare system in the short throw is to expand Medicare to serve everyone. Then, stop asking providers and pharmaceutical companies how much they will charge and instead tell them what the National healthcare programme will pay! You don't want to settle for the National coverage provided? No problem. Simply purchase a private policy for an enormous premium and get on down the road. Private insurance would be fine with me so long as the policies paid 100% of charges and you pay another 25% for being a selfish bastard and dropping-out of national coverage.

Time to stop sucking-up to the billionaires.

Squire
Another way to think about this is to consider "health care" in three major categories:

1 - Daily habits (food, exercise, safe habits)

2 - Routine medical interventions (periodic exams, vaccinations, appropriate medicines, routine emegency and other care)

3 - High cost interventions (cancer treatments, heart bypass surgery, end of life treatment, etc.)

So, how does the US compare to the rest of the civilized world in these three areas?

1) Daliy habits? In the US there are lots of folks, tending to be both better educated and above average incomes, with fairly healthy daily habits. Good food, regular exercise, fit, alcohol in moderation, generally no tobacco or drugs, even wear helmets while motorcycling, etc.. These are our buddies still hiking, running a business, volunteering, etc. at 80 years of age. There are also folks who are chronically obese, eat poorly, don't exercise, and almost surely headed to diabetes. Some are are regularly drunk or high, and routinely engage in other risky behaviors. As a nation, we generally don't want to tell folks to eat their veggies (remember the reaction to that) much less incent healthy living habits. Personally, I think we ought to incent them; through such things as lower insurance rates for those with healthy habits and a re-do of assistance programs. There would still be people who would be ill or disabled through little fault of their own -- and I think they should not be denied access to low cost insurance.

Anyhow, I'd characterize big parts of our culture as fast-food eating, and exercise avoiding. We think it a violation of our rights to be economically or culturally incented to eat better, get exercise, and stop self-destructive behaviors but also apparently think we have a right to have someone else pick up the tab for the consequences of our behavior. Case in point: you can't tell me to wear a motorcycle helmet but you also have to pick up the tab for putting what brains I have back in my skull.

Layer on top of the food-exercise deal our high rates of addiction, reaching from the urban poor to Betty Ford, Rush Limbaugh, and any number of sports, business, and entertainment celebrities.

Add to that our perverse politics of sex, where big chunks of the citizenry think contraceptives should be hard and expensive to get, but babies left to be brought up mothers incapable of nurturing their babies. That is: addicted, immature, self-involved, mentally incompetent, maybe just too poor and poorly educated to put a roof over a kid's head. Our policies with respect to the poor and young create some of the budget-busting health care problems as these effectively abandoned kids go from toddlers to teens to middle age.

In 1900 the average white maie lived to be 45 years old. Since then life expectancy has risen 30 years. Here's the thing -- most of that increase came from technological advances more in the "daily habits" realm than the "health care" realm. It was things like clean water, sewers, refrigerated food, better agricultural practices, workplace and highway safety, infant care, etc. they caused most of that improvement. Things like vaccines and antibiotics also helped -- just not quite so much. If we're going to do a redo of health care, the notions of healthy daily practices, clean water and air, workplace safety, decent food, and incentives for fitness ought to be a part of it. It's more a parental/cultural thing than a Presidential, but when I was a kid Kennedy wanted us to hike 50 miles and today Trump wants us to tweet. Hard to know yet the pros and cons of a generation brought up by their phones and tablets.

2) Routine interventions? These are things that millions of us will need at any given time - vaccines, broken legs put in casts, treatments for scrapes and wounds, dealing with flu epidemics, etc. Due to their frequency, we ought to have both well-established best practices in dealing with them and treatments so far along the experience curve that they are very cheap. The US, it seems to me, has conspired against itself to make these things expensive and inconvenient. Guys tend not to seek medical treatment. Those with high deductibles tend not to seek treatment until they "can get their money's worth." A substantial number of us are anti-vaccine. Individual physicians and hospitals vary widely in treatments and costs. We have Bryan's point about patients not acting as consumers -- and indeed we've made it far harder to compare prices and quality of medical treatment than, say, microwave ovens. In addition, as many as 20% of us have no routine care -- a dumb idea for things like vaccines, communicable diseases, mental illness etc. where all of us are at risk from someone ill.

Bottom line is we have expensive routine care, some of it way below par, with medical lobbies doing all they can to eliminate competition (no bargaining on drug prices, nurse pracitioners more limited than garage mechanics in the complexity of routine things they can do, etc.). We also don't incent drug companies to produce inexpensive treatments -- the development of something as cheap and widely used as aspirin might be near impossible today.

Because of the lack of competition we have higher costs and lower usage of stuff that ought to be as cheap as any other large scale manufacturing or service business. To me, the sensible thing here is national insurance covering all our citizens for routine medical care -- along with much greater competition for any provider following known best practices. In a limited way we're moving towards this (think how easy and affordable it is to get some vaccinations now, say at a Costco or Walmart). This kind of national care wouldn't cost very much -- most folks don't have more than a couple hundred bucks of routine interventions in a year. We're now spending thousands of dollars for stuff that could and should probably be covered at a tenth the cost.

3) Major medical interventions.
This tends to be where both the frontiers of medicine and the big bucks are. Drug companies, for example, have retooled themselves towards cancer drugs -- enabled in part by our nationally funded decoding of the genome -- because that's where the money now is. List prices of $100,000 a year for drugs costing far less to develop and manufacture are now common. Here things get trickier. We don't have "best practices" -- we're still learning. We want to incent real research. But we also don't want companies gaming the system. Which they do in spades. Sometimes by treating a dying patient as an ATM machine -- spending hundreds of thousands of dollars in the last two weeks of life. Sometimes by gaming things like the orphan drug incentive or just buying up some sole-source pharmaceutical and jacking up the price 1000%. My own take on this is that this is were the budget-busting dollars for private, Medical, and Medicare insurance are being spent. Just as a thought experiment, suppose that Medicare were given to those 0 to 65 years old (generally young enough that they wouldn't use much of it, especially if a requirement for "free" Medicare were not smoking, getting some exercise, etc.. Then imagine that anyone who wanted to live to 100 were guaranteed they could buy insurance -- but they had to pay a big chunk of the costs. I'd imagine old folks would be more careful about what they bought, medical directives, and the like.

Anyhow, just some thoughts. My own take is that many of we Americans have a perverse attitude toward healthy living habits; have turned routine care into something way too expensive and inconvenient (even unavailable for some); and can rightly say we do great at major medical interventions -- but with far too many folks skimming money off the top.

And they you ;)


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