“We spend far more on health care than other peer countries yet have worse outcomes. Why is U.S. health care so expensive?” I’m sure you’ve encountered similar statements, maybe even expressed it yourself. It occurs often, including by knowledgeable people and health-related institutions. However, it’s a fallacy because it confuses health care with population health.
Health care is a proper subset of population health. For example, longevity is determined by more than just health care. Using a specific recent estimate (Appendix Exhibit A6 – gated), an average 20-year old U.S. white male who did not graduate high school will live 10.5 fewer years than a similar man with a college degree. That’s over ten years of life related to educational attainment. Sure, there are many reasons for the difference, and health care or the lack of it is only one of them.
An example of the health-care-is-health fallacy is from an essay in the Health Affairs blog written by Arthur Kellermann, a health policy insider. He writes:
In 1950, health care accounted for 4.5 percent of GDP. Today, it claims nearly 18 percent….
Over the past 20 years, the life expectancy of U.S. women has dropped from 22nd in the world to 36th….If we can’t do better than this, why is American health care so expensive?
Kellermann cites an Institute of Medicine (IOM) report and goes on to argue for an improved health-care market place. An implication is health outcomes are all about health care.
Another example is from Tom Daschle who writes, also in Health Affairs,
Recently, the Institute of Medicine and the National Research Council reported that Americans die earlier and live in poorer health  than people in other industrialized countries. This is the latest evidence of the urgent need for health reform, as embodied in the Affordable Care Act
and continues on about health care issues.
Before going further, I do not mean to single out Arthur Kellermann, Tom Daschle, or Health Affairs except as up-to-date examples of knowledgeable people and institutions repeating what I suspect is meant as a shibboleth to convey their seriousness about health care outcomes and costs. Nor am I an apologist for the U.S. health care “system”. Rather, what agitates me is the fallacious ambiguous thinking and, through its health-care specificity, that it detracts from a more holistic long-term ideal of improving U.S. social determinants of health.
The Kellermann quotes actually represent two separate fallacies. The first quote, where health care costs in 1950 are compared with costs today without taking into account value, commits the “All things are equal” fallacy (number 5). Health care in 1950, even 30-40 years ago, was pretty basic compared to 2013. Circa late ’70′s, if you had a heart attack and managed to get to the ER, they’d give you morphine and watch you have your heart attack. The medical team might run a few tests but otherwise there really wasn’t much they could do. If you were lucky enough to survive, chances are you’d be a cripple for the rest of your life: no climbing stairs, no sex. On the other hand, today, assuming you make it to the ER, chances are that within a few months you’ll be back playing tennis. There are many other examples of contemporary health care’s greater value: laparoscopic surgery, joint replacements, insulin pumps. In terms of value, health care in 1950 was not the same as health care in 2013.
The second quote uses health (measured by longevity) and health care ambiguously, resulting in an error in reasoning: the fallacy of equivocation (number 10). The subject, health, is used for population-health outcomes which stem from socioeconomic, environmental and personal factors as well as health care, and then in the context of costs, switches meaning to just health care. This is an equivocation on different meanings of health.
Given the United States’ dominant ideologies of the primacy of the market and extreme individualism, plus attendant short-term thinking, I can see why as a nation we might be predisposed to emphasize individual health care over reference to a model of long-term integrated population health.
A September 2011 paper in the American Journal of Public Health, “US Opinions on Health Determinants and Social Policy as Health Policy” by Stephanie A. Robert and Bridget C. Booske (gated) supports the notion that the U.S. public sees a greater health role for medical care and personal habits. From their abstract:
Respondents said that health behaviors and access to health care have very strong effects on health; they were less likely to report a very strong role for other social and economic factors.
Their survey supports the idea that the U.S. public perceives health care (along with behaviors) as more important for health than social, economic and environmental factors.
The Kellermann and Daschle essays both cite the IOM report. Here is the lead paragraph of its foreword:
The United States spends much more money on health care than any other country. Yet Americans die sooner and experience more illness than residents in many other countries.
The difference is the IOM authors then use this apparent conundrum, instead of segueing into a pitch for more market-oriented health care, to introduce other determinants of health. It’s not all about health care:
But health care systems and the health services they deliver are not the only influences on population health. Life-styles and behaviors, social and economic circumstances, environmental influences, and public policies can also play key roles in shaping individual and community health. And a number of these factors may be critical to understanding why some high income countries experience significantly better health outcomes than the United States. (from p14 of the IOM report)
The bulk of this thoughtful 400-page report is in fact about the influence of social determinants of health.
To save you the trouble of searching—I’ve already done that—there are no generally useful estimates of what percentage health care contributes to population health. That makes sense given the many causes and extrinsic factors leading to health outcomes. Additionally, health care today is vastly improved from just a few years ago, so assessing the efficacy of health care is a moving target. Thus it is impracticable to derive a general point estimate about the percentage of health care’s contribution to health. Nevertheless, estimates I’ve seen of health care’s effect range from less than 20% to near 50%. But these are either based on older data or related to specific morbidities. Regardless, health care is clearly only part of total health.
It’s time to put a hold on fallacious shibboleths like “We spend far more on health care than other countries yet have worse outcomes. Why is U.S. health care so expensive?” As a nation, our health care expenditures are undeniably out of line. And there are many areas where our population health could be much better. In either case, the path to policy solutions will surely benefit from clear and unambiguous expression, which will in turn require clear thinking.
Frank de Libero is an independent statistical consultant oriented toward policy and strategy. This post originally appeared on his blog, Letting the Data Speak.