On the Low Life Expectancy of the U.S. Compared to Healthcare Expenditure

What can we actually control, and how can we control it?

This particular argument is getting dredged up again because of the purported murderer of Brian Johnson, who had been the CEO of UnitedHealthcare’s health insurance arm having written a sad excuse of a “manifesto” that mentioned this in passing:

Exclusive: Luigi's Manifesto

A reminder: the US has the #1 most expensive healthcare system in the world, yet we rank roughly #42 in life expectancy.

So that was one of the many items in the block of text.

Cremieux has already addressed most of what I want to say, but I think I can present some of the items differently, as I’ve looked at this for a long time:

Grading the World's Shortest Manifesto

How Much Does Healthcare Relate to Life Expectancy Difference?

Let me pull from Cremieux’s piece:

America lags behind its peer countries largely due to obesity and its comorbidities, violence, drug and alcohol abuse, and needless risk-taking. But notice: it generally leads in screenable and treatable cancers.

….

Others have noted that Americans lag for the same sets of reasons: obesity, eating too much, being too lazy, being violent, driving fast cars and, more unfortunately, being near people who drive fast cars, and so on. It should also be noted that much of the obesity-related death delta against the U.S. doesn’t seem unique to the U.S. It appears more like a disease of affluence.

The 2024 John’s Hopkins Life Expectancy Report reiterated these facts. It reported that 57% of the life expectancy gap between the U.S. and the U.K. was down to cardiovascular disease, another 32% was down to drug overdoses, 20% was down to firearm-related homicides and suicides, and 17% was due to motor vehicle accidents. But, as the above treatable/screenable cancer note suggested, the report also concluded that, if anything, America is ahead when it comes to mortality from conditions the healthcare system can actually affect—namely, COVID and cancer.

The source on the life expectancy gap comparison comes from this paper:

[emphasis added]

Causes of America’s Lagging Life Expectancy: An International Comparative Perspective, Jessica Y Ho, PhD

The Journals of Gerontology: Series B, Volume 77, Issue Supplement_2, May 2022, Pages S117–S126, https://doi.org/10.1093/geronb/gbab129

….

Results

In 2018, life expectancy for American men and women was 5.18 and 5.82 years lower than the world leaders and 3.60 and 3.48 years lower than the average of the comparison countries. Americans aged 25–29 experience death rates nearly 3 times higher than their counterparts. Together, injuries (drug overdose, firearm-related deaths, motor vehicle accidents, homicide), circulatory diseases, and mental disorders/nervous system diseases (including Alzheimer’s disease) account for 86% and 67% of American men’s and women’s life expectancy shortfall, respectively.

If you look at the age 25-29 bucket, you know that in the U.S. they’re not dying of natural causes, for the most part.

I will do a quick query from CDC WONDER:

Top 15 Causes of Death, Age 25-29, 2018, Male

The top three are the nasties:

1. Accidents (and the top two sub-types here are motor vehicle accident deaths and drug overdoses)

2. Suicide

3. Homicide

These are far and away more numerous than the natural causes of death, but when you look at the “natural” causes, there are nasties in there, as well:

• HIV

• Chronic liver disease/cirrhosis

• Legal intervention (i.e., shot by cop)

To be sure, if these three causes were solved for this age group, this would barely affect the total death rate for this age group. The order of magnitude of the top three causes swamps everything else.

Ranking Tables for Cause of Death, Age 25-29, 2018, Female

Accidents are also the top cause for females in this age group, but homicides are at a fifth of the rate.

Indeed, let’s look at the difference between male and female death rates for this year — there was nothing special about 2018, other than a bad seasonal flu.

Gender Ratio in Deaths, Age 25-29, 2018, U.S.

Something to know: at old ages, when almost all of the causes of death are natural causes, the male-female ratio of death rates is about 1.1 — that is, males have a 10% higher chance of death for ages 85+ compared to females in the U.S. (in 2018.)

For age 25-29, the ratio is 2.4.

Males have a 140% higher chance of death.

It was worse during the pandemic.

Where Are the Differences?

A graph from the research paper:

In the graph above, the dotted lines are from 2008. The solid lines are from 2018.

You will notice something got much worse for ages 20-39 between 2008 and 2018.

In the 2018 ranking I showed above, you might guess that the “accidents” category is the driver.

Guys, it’s drug overdoses. I’ve talked with actuaries elsewhere, and they were shocked at how bad the U.S. drug OD death problem is.

And 2018 was before the pandemic jump-up in overdose deaths.

It is horrendous. Rather than go through all the aspects of this trend again, you can peruse the posts below at your leisure.

Drug Overdoses

Sept 2024: Drug OD Deaths Down... It's Okay News, I Guess

July 2023: Mortality Quick Take: Drug Overdoses At Their Worst in 2022

Nov 2022: Movember 2022: Men and Drug Overdoses (and Giving Tuesday!)

Mar 2022: Drug Overdoses, Part 1: High-Level Trends, 1999-2020

Mar 2022: Drug Overdose Deaths, Part 2: U.S. Age-Related Trends 1999-2020 with Provisional Results in 2021

Mar 2022: Drug Overdose Deaths, Part 3: Geographical Differences for 2019 and 2020

Jul 2021: Mortality with Meep: Huge Increase in Death by Drug Overdose in 2020

April 2017: Mortality Monday: Huge Heroin Death Increases

Observations on “Preventable” or “Treatable” Deaths

One can argue that suicides and drug ODs are failures in healthcare, in terms of mental and emotional treatment.

Heck, homicides could have been attempted homicide in some cases, if the victims got to the ER in time.

Motor vehicle accident deaths partly decreased due to improved medical care, but mostly due to improved highway and vehicle safety. Oh, and recessions and oil emergencies.

That said, there are problems in the long-term trends for various natural causes of death. However, is it due to inadequate healthcare… or our crappy lifestyles? (Or both?)

I’ve updated much of my standard presentation on U.S. mortality (see below for copy), so I need to do some videos to update last year’s videos. But here are some selections:

Concerning U.S. Mortality Trends: Heart Disease, Diabetes, Liver, Kidney, and More

Heart disease mortality improved for years — then sputtered in the mid-2010s. It got worse during the pandemic, but so did many other non-COVID causes of death. As COVID waned, so have excess heart disease deaths.

Similar to heart disease, stroke deaths stopped improving around 2012 and got worse during the pandemic.

Alzheimer’s disease has been doing odd things for a while.

Diabetes — the age-adjusted death rate went flat well before the pandemic. Where is the improvement?

I kept flu/pneumonia in here for comparison, so you could see what “steady” improvement looks like.

Liver and kidney disease-related deaths have been sideways forever. Where is the progress?

Yes, some of these have huge lifestyle connections — poor diet, drug use, little exercise, obesity — these all connect to many of these conditions leading to death by these causes.

But note: these are all long-term situations. The liver disease deaths above are from chronic disease, not acute liver disease (that’s a different ICD code.)

U.S. Has Stalled Out In Mortality Improvement for Natural Causes of Death

There is still a problem for the U.S. compared to other countries if you strip out all the external causes of death:

Data source: WHO Global Health Estimates, https://www.who.int/data/gho/data/indicators/indicator-details/GHO/gho-ghe-ncd-mortality-rate, Excludes communicable diseases like the flu and external causes of death such as homicide, car accidents, and drug overdoses.

I marked the U.S. in red, and all the other OECD countries are just grey lines, but I will tell you what they are (and you can go to the link above to see who is who.)

Most of the countries with death rates above the U.S., though OECD countries, are countries such as Hungary, Mexico, and Poland. They are countries not known for being as economically developed, and many are ex-Communist states. Most of them have shown great improvement in mortality in their post-Communist years.

The two countries at the bottom, with the lowest age-adjusted death rates, are Japan and South Korea.

The mass of the better-developed OECD countries (mainly European) have lower death rates than the U.S., and have continuing mortality improvement through 2019 (the end of this graph).

The U.S. stalled post-2012.

What is going on?

Yes, I know people will want to blame Obamacare, or something-something-Trump, or whatever their preferred hobby horse they want to ride.

But this is something slow-moving and long-term.

It is likely related to the increasing obesity of the U.S. population, as well as the concomitant diabetes and other metabolic problems. Americans were far less likely to die from screenable cancers than comparable countries, but much more likely to die from heart disease.

Perhaps the GLP-1 drugs will turn this around. Who knows?

I have been supporting the Insurance Collaboration to Save Lives with volunteer analysis, as we’re seeking the answers to some of these questions. There are some acute problems, such as drug overdoses and some causes of death spiked by the pandemic, and there are longer-term increases or stalling-out in improvement.

Some problems extend beyond the U.S., as we dig into data from other countries.

But if we want to talk about the effectiveness of healthcare, we need to focus on the problems healthcare can solve. Sorry, healthcare is not going to solve motor vehicle accident deaths (not at this point) nor homicides. More might be done with suicide, but most suicide deaths are not among young people, so there may be some difficulties. There are loads of assumptions and attitudes involved.

Mortality Trend Presentation

Mary Pat Campbell U

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