Does Life Expectancy Matter?

U.S. life expectancy declined in 2015 for the first time in more than two decades, according to a National Center for Health Statistics study released last week. The decline of 0.1 percent was ever so slight ― life expectancy at birth was 78.8 years in 2015, compared with 78.9 years in 2014.  However, this reversal of a long-time upward trend makes these results significant.

While many researchers are scratching their dumbfounded heads in utter astonishment, I hypothesize the decline in life expectancy is partly due to the decrease in the primary care physician supply.  Studies have shown the ratio of primary care physicians per 10,000 people inversely correlates with overall mortality rate.  It is a well-known and reproducible statistical relationship that holds true throughout the world.  In the U.S., increasing by one primary care physician per 10,000 population, decreases mortality by 5.3%, ultimately avoiding 127,617 deaths per year.

Headlines last week highlighted how much these unexpected results left the researchers baffled.   Jiaquan Xu, a lead author of the study told The Washington Post, “This is unusual, and we don’t know what happened…so many leading causes of death increased.”   Age-adjusted death rates went up by 1.2 percent, from 724.6 deaths per 100,000 people in 2014 to 733.1 in 2015.  Death rates increased for eight of the ten leading causes of death, including heart disease, chronic respiratory illness, unintentional injuries, stroke, Alzheimer’s disease, diabetes, renal disease and suicide.  Differences in mortality were most prevalent in poorer communities, where smoking, obesity, unhealthy diets, and lack of exercise are ubiquitous. 

For fear of sounding like a broken record, I reference a post published on this site about investing more in primary care if the healthcare system wants more people alive and healthy.  Funding a system with a primary care focus is not an innovative concept; it is a well- accepted winning strategy on which to build the health of a nation.  In 2007, the Director-General of the World Health Organization, Margaret Chan, said “A primary health care approach is the most efficient and cost-effective way to organize a health system.  International evidence overwhelmingly demonstrates that health systems oriented towards primary care produce better outcomes, at lower costs, and with higher user satisfaction.”  A thorough meta-analysis by Macinko, Starfield, and Shi (2007) addressed the question of whether increasing the number of primary care physicians could improve health outcomes in the U.S.   In every health outcome analyzed, the PCP/10,000 rate was associated with improved results.  You cannot find a more definitive conclusion than that. 

Health policy experts, IT executives, and politicians jumped on the ACA, HITECH, and MACRA bandwagon while clinging tightly to their misguided belief that more electronic records, ACO’s, care coordinators, administrators, pay for performance schemes, and other fads or gimmicks would improve health outcomes; it turns out one of the most fundamental measures of healthcare quality, our life expectancy, is no better than before. 

Unfortunately, thanks to predatory insurers, lobbyists, and self-serving CMS directors plundering the private health care practitioner, now there is another obstacle looming on the horizon which will prove to be a larger hurdle than originally anticipated.  The primary care physicians we so desperately need are running from clinical medicine like their hair is on fire resulting in a supply that cannot meet demand.   

Based on statistics in 2000, increasing by one PCP/10,000 required 28,726 more primary care physicians.  The situation has worsened as the plight of the primary care physician has become more unpredictable and calamitous.  Considerable gains in population health could be realized if CMS focused their efforts on more adequately reimbursing physicians rather than penalizing them.  Coaxing more physicians to enter primary care or strategizing ways to entice those “retiring” physicians to rejoin the workforce would be worthwhile endeavors indeed.   It would be far better than waiting to crank out a new generation from medical school.  After all, only 7% of graduates choose primary care as a career for reasons that should be clear by now. 

Fifty years ago, just over half of the physicians in the U.S. practiced primary care; today that ratio sits at 30/70.  The U.S. has a lower life expectancy and higher infant mortality rate than many other highly developed countries where the primary care to specialist ratio far exceeds ours.  Evidence from studies of those countries indicates a primary care centric system results in better health outcomes, fewer medical mistakes, cost-containment, and higher patient satisfaction.  If I have said it 1000 times, I will say it again:  expanding insurance coverage makes no difference if there are not enough primary care physicians in the workforce to care for patients in need.  Paying primary care doctors adequately enough to retain them is the only way out of this mess.    

Neither researcher, health policy expert, politician, nor economist, I am just a primary care physician on the front lines seeing sick patients who are getting sicker.  A decline in life expectancy was not unforeseen by many of us.  What if life expectancy continues to decline in 2016?  What if my hypothesis is correct as to the reason life expectancy is heading in the wrong direction?  Will the political machine and predatory insurance industry wake up and pay attention?   My hope is researchers, economists, and politicians holding the fate of our healthcare system in their hands take my words to heart.  Decreasing life expectancy may be just the tip of the iceberg.    The dwindling primary care physician supply will matter more as the predicted physician shortage materializes.  Before primary care physicians go the way of the dinosaurs, make sure to establish a relationship with one of us.  In the future, there is no doubt your life expectancy will depend on it.    

Niran al-Agba, MD is a pediatrician practicing in Washington State

Categories: Uncategorized

88 replies »

  1. To Niran Peter says: “Like your Tricare benefits are the taking my tax dollars and “giving” it to someone else?”

    That is a military benefit similar to any benefits provided by our bureaucracy. I don’t think her husband was paid very well in the military and there is a good chance he had to risk his life protecting yours. However, I think Niran and others would be open to discussing all the benefits given to those working for the federal government. If anything we could reduce the total salary and benefits provided to the bureaucrats and increase it to those that risked their lives.

    “ I guess it’s all “highway robbery.”

    When government creates winners and losers without regard to the Constitution it is all “highway robbery”

    “ narrow networks and in-network is wide spread across all insurance plans except those”

    Narrow networks are a relatively recent phenomenon.

    “And by the way Allan, I could not find any reference to ACA rules where the “secretary” has created what Niran is complaining about. ”

    You have to read the text where it say “the secretary shall” or something similar. That means the rules are open to the decision of the secretary making all these decisions part of the law. In the case of “the secretary shall” there are 920 of the entries. I suggest you learn to read before you type.

    I guess telling another that they are wrong when the proof is on their side is another Peterism.

  2. “They are “giving” at someone else’s expense.”

    Like your Tricare benefits are the taking my tax dollars and “giving” it to someone else? Or Medicare is taking tax money and “giving” it to someone else? Or employer subsidies are “giving” it to employees so that people who buy their products are “giving’ it to someone else.

    I guess it’s all “highway robbery.”

    And by the way Niran, narrow networks and in-network is wide spread across all insurance plans except those “Cadillac plans” and very expensive plans. You yourself said the ACA Gold plan puts you “in-network”.

    And by the way Allan, I could not find any reference to ACA rules where the “secretary” has created what Niran is complaining about. So I guess you are wrong – again.

  3. Exactly Allan! They are “giving” at someone else’s expense. Only ACA plans were allowed to do this. Its highway robbery.

  4. It’s correct. The number of times decision making was left to the secretary was high.

    When premiums aren’t paid I think the physician should be allowed to know. This type of grace period is typical of leftist generosity. The leadership gets praised for giving, but that giving is someone elses expense. It makes the entire group of patients suspect and probably diminishes their level of care.

    Narrowing networks are a phony way of making believe prices aren’t as high as they are. They can be quite dangerous for the sick.

  5. Assuming that’s correct (I doubt but will search), I guess you favor insurance companies paying for medical care when premiums are not paid and the elimination of narrow networks/out-of-nerwork contracts since this is what Niran is complaining about.

  6. ” but still fail to see how these insurance rules are written in the ACA act.”

    It is simple. go to the act and do a search for “the secretary shall decide” or a variable of the phrase and one sees that the ACA is something of a skeleton where many of the most important things are left open for the secretary to approve or deny. If the secretary didn’t want that type of clause she would have denied it. The government determines which insurance plan is compliant.

    The ACA is almost totally to blame as are every single legislator that voted for it.

  7. I see the problems Niran, but still fail to see how these insurance rules are written in the ACA act. Insurance networks have been around for a long time and it’s frustrating for anyone with any insurance. I don’t agree with networks and I also don’t agree that insurance can establish separate risk groups – but the ACA did not create this and repealing it will not relieve the insurance problem in this country.

    Maybe if the ACA is repealed all those then uninsured could be brought under Tricare – a government program you seem happy with.

  8. Peter- You may find it hard to believe, but that is the way it works. I was actually “out of network” only on exchange plans for Premera, not regular Premera plans. After Children’s won the case, we were all back on but it took a while. Doesn’t matter if they are the same companies, they “named” themselves a little differently. ie Lifewise created “Bridgespan”, same company; completely different rules, networks, coverage etc.

    The reason verification is different at the front desk is exchange plans would “confirm” eligibility for 90 days, then suddenly “un-confirm” it and take the money back. This has NEVER been done on a regular insurance plan for my office. It is called bait and switch and really is fraud, but was allowed for ACA plans with a 90 day window.

    I can only speak for my patients but they were much happier on the plans before the ACA. Those now on state plans were mostly on plans with high deductibles before, and with lower premiums. They paid in cash for visits and were fine with it. These are working poor families and they HATE their ACA subsidized plans because they liked their plans before with less “comprehensive” coverage. On the state ACA plans, not one single eye drop or ear drop is covered by insurance. No one will let them pay cash for medicine if they know about state coverage so now patients have less choice than before.

    I was in network for all ACA plans that were gold, most that were silver, and was not on 3/5 bronze plans. That is how I am so familiar with them. Premera’s plan for example, I was “in network” on the gold plan as was care provided at Children’s Hospital, however their bronze plan did not cover any specialty care at a pediatric facility and did not have many of us “in network.”

    I am an office based practice so we do not have as much trouble getting paid by insurance companies in general, but the exchange plans, both subsidized and unsubsidized, created a host of new problems. They were a real pain to deal with for physicians, patients, and just about anyone else I can think of.

  9. I am with John on this one. That is, of course, why I write for the health care blog.

  10. Only as space allows. In other words he has to wait on line if there is time.

    How does the doctor differentiate himself? The professor that has a tremendous success rate is paid the same as a first year graduate.

  11. TOTALLY AGREE on subsidies for fresh fruits and veggies….though not sure how that would work….and taxes on sugar-laden products etc. Already happening in some parts of the country, and is widespread in EU. Very hard politically in US….but works with tobacco. We have to start seeing these food products as almost as bad.

  12. Take note Peter you still haven’t answered a very important question asked in several of the paragraphs above.

    How does one decide which patient gets to see the fantastic surgeon if we are all in the same boat?

  13. I don’t know if what you say is even true. But, assuming it is, governments have ways of preventing private businesses from functioning. You accuse others of being misinformed when you don’t even know the basic regulations affecting physicians here and in Canada. My corrections of your errors are in black and white on the multiple threads.

    I will bet for many Canadians it is less expensive to obtain certain studies and treatments in the US than in Canada if paid for privately. I’ve treated enough Canadians to know a good deal of their problems. They can choose whatever system they want. The reverse is true that for certain studies and treatments Canada is less expensive for Americans.

    …And of course you forget all about those Canadians that jump the que.

  14. “It makes no difference.”

    It makes a lot of difference. Why are you so secretive?

    You are so misinformed on the Canadian system. The case in Quebec involved only PQ. It gave the right of people in that province to buy private insurance. After the decision no one purchased private insurance – I wonder why.

  15. It makes no difference. The incentives exist. I have Canadian friends that are doctors. Special people are moved ahead in their lines all the time while others choose to pay for care that is being delayed. They cross the border and have what they need in the US. There are actually companies that assist Canadians in doing so. If you look at what happened in Quebec a number of years ago a case was decided (In the Quebec Supreme Court) in favor of the patient, not the government, calling the wait time for certain treatement inhumane and against the Constitution of Quebec.

  16. “It’s a powerful incentive for doctors to exercise restraint”

    It’s a powerful way to delay needed medical care while the patient waits in line. What do you think the more affluent patient does?

    My wife is not American and lived under a socialized system. When one needed care they went to the doctors office and needed no money. The office would be filled and when the day was over the office was closed and the remaining people had to return the next day and the next day etc.

    In order to get care an envelope with money was dropped off at the doctor’s office and the next day she was promptly seen.

  17. Yes, Peter. I want to take away people’s healthcare. I want to make sure that as few people as possible have it. Ideally, I’d like as many people as possible to die. If that’s not possible, I’d like to make sure we have the worst possible outcomes we can afford.

    That’s why I run a health care blog.

  18. “I love this idea borrowed from the German system.”

    In for a penny, in for a pound:

    “Nearly all hospital-based doctors are salaried, and those salaries are part of hospital budgets that are negotiated each year between hospitals and “sickness funds” — the 240 nonprofit insurance companies that cover nearly nine out of 10 Germans through their jobs. (About 10 percent, who are generally higher income, opt out of the main system to buy insurance from for-profit companies. A small fraction get tax-subsidized care.)

    Office-based doctors in Germany operate much like U.S. physicians do. They’re private entrepreneurs who get a fee from insurers for every visit and every procedure they perform. The big difference is that groups of office-based physicians in every region negotiate with insurers to arrive at collective annual budgets.

    Those doctor budgets get divided into quarterly amounts — a limited pot of money for each region. Once doctors collectively use up that money, that’s it — there’s no more until the next quarter.

    It’s a powerful incentive for doctors to exercise restraint”

  19. “My husband is retired military and our family has Tricare”

    So you’re getting government subsidized heath care but you want to repeal the ACA’s government subsidized health care.

  20. Niran, I find it hard to believe that the same insurance companies who provide coverage outside the exchanges are any different (and more difficult to deal with) inside the exchanges. They’re the same companies.

    Why is verifying coverage at the front desk different for exchange insurance over non-exchange coverage – even if you could tell?

    As to affordability, where did patients with exchange policies, who complain about rising premiums (which is happening everywhere), get their (subsidized) coverage before the ACA? Were they happier then?

    And if you’re not on the list of docs who’s patients with exchange coverage can use, how are you getting so many problems with exchange covered patients?

    This article (May 2015) seems to refute your claim about patient dissatisfaction.


    I don’t doubt complaints and problems with the ACA exchanges (as with other insurance), but unless people have good employer subsidized coverage we’re all complaining about access affordability. As well many docs in hospitals are not “in-network” but the patient does not find out until they get the bills, some into the thousands.

    A fellow at my fitness club has a successful business which advocates for patients having problems getting (non ACA) insurance to cover their claims. He charges people to get the claim paid, when in the end, turns out to be something the insurance company should have paid in the first place.

    My experience with BCBS was about the same – non-payment of legitimate claims dragged out over months to frustrate premium payers. It’s a business strategy.

  21. Yes, it is the result of the ACA! These things are ONLY occurring on the exchange plans. That was your original question to me. Every point I have made were in regard to the terrible plans offered on the exchange.
    We do not see these issues with regular insurance. Other insurances have you pay by the month if you are self-employed… therefore if you don’t pay your premium, it is pretty clear quickly and the physician can collect the one or two office visits from the patient directly.
    On the exchange plans, it is near impossible to chase a family for 7 or 8 visits over a three month time period and have them pay cash. They transfer to a new office, never to be seen again and run the bill up at the next place.
    No commercial or state insurance plan has made children’s hospital and all courtesy staff “out of network.” It is ridiculous because eventually someone is going to get sick and need pediatric care at a pediatric hospital. They do not ration care like the ACA is allowed to do.
    Honestly, the system we had before allowed better flexibility for physicians to meet the needs of the community. I have not seen improvement in health status since the ACA in my community. The waits are longer and care far more fragmented than before. Actually, many of the complaints are from my frustrated patients who cannot afford their plans anymore.
    I am sure you must have figured out I have no idealogical axe to grind except I like what I do and would like to continue doing it free of EHR, ACO, MACRA, and just about anything else they can throw at me.

  22. You did leave off the beginning of that quote… “it might be that” I do not carry my own insurance through the business as I cannot afford it. My husband is retired military and our family has Tricare, though I had private insurance before I married a decade ago. If you ask the Surgery Center of OK, which has been in business 20 years, a knee is 15k and a hip is 25k. You might be in trouble on the whole kidney transplant thing without insurance however.
    So over the last 16 years, I have cared for many without insurance who drive up to 2 hours to see us. I find them samples and have a variety of ways to provide resources. Not every chronic condition has to be so expensive to treat especially when you give physicians the freedom to practice their craft.
    I have absolutely done it for free and I have done it at reduced rates.
    Every few months, I end up doing some Good Samaritan thing or the other because this is a small town and I can’t seem to go anywhere without something happening. The last time was volunteering at my children’s school last month. The teachers pulled me out of the reading group and I managed an urgent situation until the mom arrived.
    And of course, health care helps if you can afford it. We need to think about innovative models for those who cannot and apply them. We don’t KNOW beyond a shadow of a doubt that paying PCP’s to stay in practice will lower morbidity, but even you have to admit, it is a possible common sense solution to a big problem. It is certainly an equal or better strategy to the asinine ideas the government has like ACO’s and pay for value keep forcing on us.

  23. Peter, you quote your left wing think tank and I’ll quote Fraser. At least Fraser’s numbers are real and not contrived like those metrics so dear to your heart and that of the left.

    Yes, Americans will travel to other countries especially those with inadequate insurance.. But, Canadians? They have universal health care already paid for them. Why would they want to leave? Why do our uninsured have as many mammograms and pap smears as the universally insured Canadian? These are questions that are begging for answer.

    But the biggest question left unanswered is the question near the bottom of this thread. It remains unanswered by you.

    “You wrote: “The boat I meant was the access to health care and it’s cost.”

    But under Medicare for all both doctors would be forced to charge the same price.

    Therefore, I repeat my question.

    How does one decide which patient gets to see the fantastic surgeon if we are all in the same boat?”

  24. The population of Canada is 35 million. I said few. Now tell me the incomes of those 52K. Not sure how many were vacationing with travel insurance or how many had the Canadian health care system pay for the treatment. Not sure where they get the numbers? What is non-emergency, does that mean an MRI?

    The Frazer Institute is Canada’s right wing “think tank” (an oxymoron). And actually the article you quote says,” Traveled Abroad” , not exclusively to the U.S.

    I’ve seen published statements about 1.4 million Americans traveling outside the U.S. through medical tourism for care. I went to India for a hip.

  25. “The boat I meant was the access to health care and it’s cost.”

    But under Medicare for all both doctors would be forced to charge the same price.

    Therefore, I repeat my question.

    How does one decide which patient gets to see the fantastic surgeon if we are all in the same boat?

  26. “How does one decide which patient gets to see the fantastic surgeon if we are all in the same boat?”

    The boat I meant was the access to health care and it’s cost.

    How would patients know which surgeon was better? How do we know now? In fact with high deductible plans they attempt to say that a procedure is a procedure – so pick the cheapest.

    What you seem to want is a way for richer people to get the best care and poorer ones to get the worst.

    I don’t mind paying for skill, but as been asked here on THCB many times, where do we get the transparency to judge.

  27. “few Canadians would choose the U.S. system and it’s costs given a choice.”

    52,513 Canadians received non-emergency medical treatment in the U.S. and elsewhere in 2014 which was a 25% increase from the prior year. (Fraser Institute). If Canada were the size of the US that would mean over 450,000 crossed their borders for healthcare. Check my numbers for I was a bit shocked as well by such a large number.

  28. Median household income ppp for US=$43,585 Germany = $33,333.

    I guess we have more money to spend in the first place. Take note how Germany manufactures different products for US consumption than for German consumption. Things they export to the US are bigger and more expensive. I wonder why. There are differences.

    But you say “we should all be in the same boat on health care.”. Let us say there are two surgeons doing a lifesaving procedure and many people need their services to survive. One is fantastic and the other is average with a higher mortality rate. How does one decide which patient gets to see the fantastic surgeon if we are all in the same boat?

  29. Nothing you have said Niran is a result of the ACA, it is a result of insurance running our health car system. Tell me of an insurance company that pays for treatment when the insured does not pay their premium – because I’d like that.

    “I want the ACA repealed and replaced with a system that is organized, humane, effective, and fair.”

    Did we have that system before the ACA? Did the people who were helped by the ACA have that system before they were given subsidies to buy insurance?

    Do you think Republicans, taking away subsidies so people can afford insurance and health care will give you what you want?

    Most of the complaints about the ACA are from doctors and from people with subsidized insurance of one form or the other – outside the ACA and with an ideological axe to grind.

    Problems with the ACA are the off the cliff income qualifier for subsidy and having to buy insurance through your spouse’s employer when those plans can be very expensive, and a weak mandate which keeps the young healthies on the side lines.

  30. I love this idea borrowed from the German system. That would catch so many hard working people who fall through the cracks. This is the meaningful type of dialogue I have been talking about.

  31. “access to insurance has no affect on your fate regardless”

    Do you carry insurance? How about if someone needs a new hip or knee or kidney – would insurance determine your fate? What about a chronic condition and you have little resources and no insurance – could that affect your fate – unless Niran you will do it for free, or even a reduced rate.

    Health care helps if you can afford it, you know that. But what we don’t know is if paying PCPs more will improve our health and lower our morbidity.

  32. I am going to try one more time to answer and then I may just give up… I was not out of network because I was expensive. I was “out of network” because I had courtesy privileges at Children’s Hospital. The hospital sued Premera for discrimination and won. The only place a child can get specialty care is at Children’s so Premera was in essence, rationing care and refusing to pay if a child got lymphoma. What kind of “care” is that?

    #2, you can keep trying to insult me with words like Duh, however this does not contribute to meaning dialogue between two presumably, human individuals. A patient has 90 days to pay said premium, however coverage beings day #1, so as a good doctor I took care of said patients starting on day #1. I was paid up until day #90, none the wiser they had not paid premiums. Every eligibility check said they had the insurance. Then on day #91-three years later, the insurance takes back everything after the fact. This is not a “duh”, this is fraud. Period.

    Finally, please do not put words in my mouth. It is inconsiderate to me and I do not like it. I want the ACA repealed and replaced with a system that is organized, humane, effective, and fair. The system I am interested in is one that allows me to be more doctor than administrative clerk.

    My livelihood is an art and science, I am not a protocol driven machine. Nor do I want to be. I went to school for 11 years post high school for the privilege of helping the sick get well. I have been a physician for almost half my life at 42 years of age. My first job at 9 was manning the front desk, pulling charts, and checking in patients for my father on Saturdays for $2 per hour in 1983. I have been doing this a long, long time. Let me do the work for which I was trained. I am good at it and my patients like it. We have dozens of second and third generation families. Our quality care is on display everywhere you look.

    Allowing me and others, like Dr. Nelson, Dr. Palmer, Allan, to practice the way we know how, is a system that works. It has worked for the nation for decades. The government has added layers but they are layers of fluff with no tangible, scientifically proven benefit.

    Medicare is probably fine for the elderly, but expanding it makes no sense as Barry said below. Now if you are going to respond, please do so in a way that encourages meaningful dialogue. Aren’t we all trying to make the system better?

  33. I doubt that is John’s conclusion Peter. The conclusion might be that having access to insurance has no affect on your fate regardless. It is healthcare that can help. An insurance card may mean less than you think it does.

  34. I am hoping that is not the case Peter. Rather, someone needs to start change somewhere.

  35. While I am surprised we agree on something… we finally do. There are many things at play and each of these individually moving targets likely affects the overall mortality rate. It is never easy to tease these details apart. It is difficult to know as well whether one’s risk for obesity, drug addiction and misuse, malaise etc. is altered considerably by access to primary care or if there are other unforeseen factors involved. Interested to see next years expectancy numbers for a trend.

  36. Interesting information Dr. Nelson. No surprise that there is a correlation between maternal mortality and longevity past age 65. There is an element to all of these statistics that the better the overall health status of the population (likely care is a contributor to this) the more longevity increases.

  37. Our nation’s maternal mortality ratio (MMR) is small in total numbers, as in 17 deaths per 100,000 live births. In 2013, there was just slightly less than 4 million births and about 600 maternal deaths. What’s important about this is not how much it contributes to the over-all longevity (very small) but what it says about our nation’s health care. Remember, the MMR has increased by about 2% a year for more than 20 years, AND among the developed nation’s of the world, we would need to reduce our MMR by 75% to rank among the 10 lowest/best developed nations of the world. There is a known – 0.95 Pearson correlation of longevity past age 65 years between a state’s maternal mortality ratio and the state’s average longevity past age 65. It likely means that the better a State’s healthcare prevents death with a pregnancy, the better it keeps people living. The MMWR reports excluded the folks living in institutional settings. So, the longevity measured the people who are caring for themselves. The basis for Maternal health starts with availability and accessibility, just like everything else.

  38. The preference of Canadians for their system over the U.S, system tells us nothing about Americans’ willingness to accept the Canadian system.

    Regarding the German system, one thing they do that I think is good and would like to see us replicate is that their unemployment insurance fund pays the health insurance premium for people who lose their job as part of their unemployment benefit.

    If we had a guaranteed issue provision for those who maintain continuous coverage with no more than a 63 day coverage gap, unemployment and loss of income could cause people to stop paying their premium and result in no longer being eligible to renew their coverage without passing underwriting again.

  39. No, I said “also”. But if you are trying to box me in a corner about “tiered” somehow trying to trap me to make a point, I’ll respond by saying no system is perfect or will ever be, they all require constant management and change.

    I do not like tiered systems as we should all be in the same boat on health care. I would certainly take the German system (11% tiered) over our own, which is about as tiered as you can get, as they spend about 10% GDP on health care, about half of what we spend.

  40. Stevan, I think much more spending on public health in those “at risk” communities where poor habits (not always a chose) contribute to poor health. I also think that the subsidy on corn should be replaced by subsidies on fresh fruits and vegetables. I am also in favor of a tax on sugar/calories where the tax would be used to offset the health care cost of bad habits – much like a cigarette and alcohol tax. People need to see a direct result of poor choices. Changing culture is long and arduous.

    But it seems we’ll never get there and just continue to do the same thing with the same results.

  41. Peter, I am not comparing the two systems for if I did I would include a lot of things like outcomes in the US are better than the outcomes in Germany. Mine was merely a question. You said you would take the German’s healthcare system so one might assume that is your favorite plan in the world.

    Thus the question becomes “Peter does that mean that you like tiered systems where the rich and the bureaucrats are treated better than everyone else?” I am not asking for you to tell me how to fix their system rather if that type of tiered care is acceptable to you? It either is or isn’t. If it isn’t then the German system is just another system you tout, but don’t agree with.

  42. “89% of the (German) population is covered by a comprehensive health insurance plan”

    Not bad eh Allan, but if you want to make the 11% rich and bureaucrats use the same plan then I’d support you.

  43. Terrific dialogue on this surprising and sobering demographic development, which adds to other findings earlier this year out of Princeton about rising death rates among non-hispanic white people aged 25 to 55. Also great example of the role THCB can play in examining and probing issues like this.

    Entirely feasible that poor access to primary care is a factor, though there are obviously many factors at play. The CDC director in the coverage of this news prominently mentioned obesity, drug addiction and misuse, and deep malaise and ill-health among low-income white men of working age who have dropped out of the work force — The Hillbilly Elegy argument.

    References to the ACA/Obamacare having caused any of this are, imho, without any merit. But I would say the new administration and Congress may want to consider ways to address this development as they advance ACA repeal and their own health agenda.

  44. “I’d take the German system”

    Peter does that mean that you like tiered systems where the rich and the bureaucrats are treated better than everyone else?

  45. But Peter, I have said that many times. I’ll take it as a compliment that is rare because almost everything seems to go over your head.

    But, since we are in agreement with regard to SES don’t you think we shouldn’t be wasting money on healthcare programs that have little to do with the treatment of disease when that money could be applied to SES?

  46. Actually Barry, I’d take the German system also. However you are uninformed of the facts about the Canadian system – where few Canadians would choose the U.S. system and it’s costs given a choice.

  47. The first intelligent thing you’ve said in a long time – and something we can agree on.

  48. I think we are talking across one another. I was. probably inadequately, trying to demonstrate that numerous non healthcare problems and deaths can lead to a lower reported lifespan. Some of them are neo natal deaths due to drugs and the death or shortened lifespan of older drug users, those killed in auto accidents and other accidents, military deaths, etc. One that dies immediately upon being born removes about 80 years from the lifespan pool from which we calculate lifespan.

    I am trying to make it clear that socio-economic problems have a tremendous impact on life-span, not on our healthcare system.

  49. Peter writes: “Well duh. How is this different than any other insurance? You’re dealing with insurance companies, not the government. How long do you expect insurance to pay for care that is not paid for?”

    Duh is the only right word Peter should be using when discussing this issue. Why? Because it is obvious, Peter, that you don’t know what the law says yet you babble on almost incomprehensibly to anyone that understands the law. I’ll let you figure out what the specific law actually says and why the specific law is such an abomination. In the meantime I will simply listen to you constantly repeating ‘duh, duh duh…’ for that seems to be the best you can do.

    You like Medicare for all. I can understand your logic in that desire. If there are so many people committed to Medicare for all why don’t they first fix Medicare and then attempt to integrate Medicare for all into the system. Their problem is they have no solutions for the Medicare problems now and in the future and that means that all one is doing is adding another failed program. I think Barry mentioned a few things wrong with the Medicare for all idea so I won’t bother to provide my concerns.

  50. Peter writes: “Well Niran, no access to insurance is no access to care.”

    The problem is clear. Peter believes an insurance contract is a guarantee of good medical care. This is so ridiculous one has to question Peter’s ability to separate his intellect from his ideology.

    Over the years countless numbers of patients have been treated for cash. In fact that was the way one obtained medical treatment before the days of insurance contracts. At least in my personal experience many patients even without adequate funds have been treated and even hospitalized without such a contract. Today there are even laws to mandate emergency patients be seen and treated in the hospital even if it is known beforehand that no one will be paid.

    Peter thinks that if a man has a heart attack he can be admitted to a bed with his insurance contract placed on his belly and suddenly he will be cured. This is an unusual view, but then again it’s Peter’s view.

    Peter, the insurance contract is nothing more than a guarantee of a place in line.

  51. Ah, the Canadian system which, of course, includes lots of rationing for non life threatening conditions like hip and knee replacements, screening colonoscopies and non-emergency imaging. Also, doesn’t the Canadian Medicare system fail to cover prescription drugs?

    Canadian doctors also have to use billing codes to get paid just like American doctors do. However, as one Canadian primary care doctor told me, patients often think nothing of cancelling appointments at the last minute or just not showing up because they are not obligated to pay any cash at the point of service. This can leave doctors with open time for which they aren’t paid and poorly serves other patients who couldn’t get an appointment on as timely as basis as they would have liked.

    As I’ve said many times, I think a single payer Medicare for all system would create more problems than it solves. Even liberal expert Ezekiel Emanuel opposes it. Americans like choice even if it costs more. It’s part of our culture and our DNA. If people in other countries like their healthcare system, it doesn’t mean Americans will react the same way if we tried to replicate it here.

  52. “Sure the ACA insured a lot of people, but that doesn’t tell us what happened to them after they entered the system.”

    I guess John having access to insurance and medical care actually kills you.

    Is that your conclusion?

  53. Bobby,

    The linked post refutes a news report and is evidence of very little.

    You may or may not be right about the ACA, but there must be better evidence.

    Niran has an interesting point about the potential link to the primary care shortage. I wouldn’t be so quick to write her off. Sure the ACA insured a lot of people, but that doesn’t tell us what happened to them after they entered the system. Could the life expectancy numbers reflect a system struggling to do things it wasn’t designed to do? I think that’s Niran’s point.

    If we attribute the EHR debacle and Meaningful Use to the ACA, the calculation becomes a bit trickier ..

    / j

  54. Thanks Niran. I’m learning plenty from you. Keep the essays and interactive comments coming.

  55. Well Niran, no access to insurance is no access to care.

    “The exchanges deemed my care too expensive”

    The “exchanges” are insurance companies and you are not “in network”, just like any other policy. It’s done to maintain costs – like everyone Republican wants.

    “Second problem with the exchange plans is they only pay the physician if the patient has paid their premiums.”

    Well duh. How is this different than any other insurance? You’re dealing with insurance companies, not the government. How long do you expect insurance to pay for care that is not paid for?

    “so premiums and deductibles are outrageous.”

    Yes they are, as also with all other insurance. Republicans support high deductible insurance.

    So you want the ACA to be repealed and replaced with a system that pays docs even when the patient has not paid their premiums, has no networks and pays whatever the doc wants to charge, and has no co-pays or deductibles? Where is that system Niran?

    My preference is Medicare for all with no networks, no deductibles and the cost deducted from taxes. We’re all covered, we all pay, and all the care is paid for.

    So I guess after your list of problems you must favor Medicare for all as the solution.

  56. Possible. There are a lot of people out there hoping you are right. But what if its more than just small deviations up or down, here and there?

  57. Thank you for reading and commenting Richard. I do think this is a significant contributor to the declining life expectancy. It IS likely the tip of the iceberg. As with all things, likely there will be no immediate attention paid to the need for primary care docs to be paid what they are worth. It is so simple it is likely going to take years to get action. I absolutely agree consumers will have to drive this change when they see the system flaws . It might take a few more years but it is coming. I will see it in my lifetime.

  58. Given the current lifestyles of US citizens we possibly could be seeing the age of mortality already maximized. In which case such small deviations will become the norm going forward.

  59. Ah, Peter you just stumbled on my issue with the ACA. Access to insurance is not access to care. While I do not think it caused life expectancy to decline, it probably did not help matters. Some people still believe access to insurance makes them able to see a doctor, however where I am it only lets you get on a wait list.

    Yes, I do treat people on the exchanges, however it is really quite a mess. Three major plans offered would not cover any physician who is good enough to be on staff at Children’s Hospital. Since I know you read my stuff, you likely know I am on staff AND teach Advanced Life support at the local Children’s Hospital. The exchanges deemed my care too expensive because I also have an academic appointment at the state’s medical school. Shame on me. I called the local newspaper about this stupidity and they wrote an article after the plans confirmed this was the criteria used to keep my name (and many others) off the approved list.

    Second problem with the exchange plans is they only pay the physician if the patient has paid their premiums. If the patient does not, the insurance does a “take-back” for whatever they paid over the previous three months for care. United almost bankrupted my practice over this. They can actually go back for as long as 3 years and take back from me. If I do not file a claim within 4 months, I will never be paid by the insurance. Who comes up with these unbalanced, stupid rules?

    Next problem with the exchange plans now is that they “underestimated” how sick people were going to be, so premiums and deductibles are outrageous. Quite a few local self-employed adults have contacted me about seeing them as needed on a cash basis so they can buy a “junk” insurance plan and then not have to use it. They are young and healthy, so financially this option makes the most sense.

    How on earth did we get here?

  60. You two always go back and forth…which makes me afraid to jump in but here goes… many of the insurance plans actually do not cover immunization charges such as administration etc… This business that everything preventative is covered without a copay is not what is happening in reality. There are loopholes and the insurance (especially GEHA) and others are taking advantage.

  61. If the drug deaths are ruled as suicides then yes, they added to the tally. However, homicide is not in the top 10 and while it may have added to the overall total, likely was not the cause being that 8/10 top causes of death increased.

  62. Barry, I look forward to your points as they always make me think. Overall, you made some excellent points and could be correct on some of your assumptions regarding increased deaths of young or old seeking hospice earlier.

    However, not so fast on the accidents and suicide business. The majority of teenagers who commit suicide have seen their PCP within 3 months prior. Meaning, we have an opportunity to talk some of those off the ledge. We discuss proper weapon storage and access issues. I make my suicidal teens think through their potential funeral and how it will feel to them, me, their parents, and other loved ones. I remind them how final a decision this is. I tell them how much I will miss them if they make this decision. There are a lot of things a PCP can do to affect lives, likely more than many realize.

    As far as accidents go, discussions about drinking and not driving, proper car seat installation and other primary prevention interventions (public health side of me) are important educational moments that can make a difference. Do not make the mistake of painting the scope of primary care into a corner.

    Wholeheartedly agree with you on the autonomy at the end of life. I do think we often prolong things when they are futile. If your hypothesis is correct, then next year should recover regarding life expectancy numbers.

    As far as differences in SES, you are correct the poorer tend to be less healthy in general. Again, this is where we do our best work! I call the school and ensure children are receiving free school lunch, backpacks over the weekend with good nutrition, the school counselors and I strategize ways to get children what they need to learn better. Education is the cornerstone of what a PCP does every day. Immunizations keep them well to attend school and get good grades. Talking to parents about ways to help their child be more successful can turn things around. One poorer family I take care of has two brilliant children. After getting them into a local private preschool on scholarship, we got them accepted into a local STEM school and of course, they are both blossoming far beyond anyone’s expectations (except mine, I knew they were brilliant! 🙂 There are so many stories like this, I could go on and on. I do realize these are anecdotal and intangible measures,but I suspect they add more value than people realize.

    Finally, infant mortality is increased with lower SES. However, early intervention and good prenatal care provided by PCP’s makes a difference in infant mortality irrespective of SES. This is a very important point. 10 years ago, the family docs and OB’s saw pregnant women earlier than 12 weeks gestation, Now they are so overwhelmed, they do not have their first appointment until 12 weeks. So much is missed! Literally even a prenatal vitamin administered once the pregnancy test turns positive makes an impact. These are important details not to be overlooked. Yet this is exactly what is happening.

    I hope this helps explain my thoughts more. Thank you as always for keeping me on my toes!

  63. In reality, the PCP is not going to change lifestyle habits of patients. It is the longer term consequences of untreated morbidity from those lifestyle changes where a PCP can make a difference.
    For example, (remember I am a pediatrician so this is a stretch for me) an obese person with high blood pressure over a 30 year time period is at a significantly increased risk of suffering a stroke. Treatment for that hypertension over a 30 year time period has been shown to significantly reduce risk irrespective of being obese. Now, of course if the patient lost weight, he or she would do better on many fronts. However, treatment and education regarding medication compliance alone actually has long term reductions in mortality.
    The differences did not include death by violent crime as “homicide” as a cause of death fell out of the top 15 in 2012. To my knowledge, it remains out of the big leagues still. I hope that helps.

  64. “In fact, while I do not think Obamacare helped things, it is not responsible for the decline in life expectancy imo.”

    “Allan, it did cross my mind while writing this post the ACA maybe partially to blame.”

    Obamacare made ALL types of care more accessible, including primary. Niran, you have not answered my question: Do you see patients with exchanges coverage?

  65. Bobby, I hope you understand this is not what this post is about. In fact, while I do not think Obamacare helped things, it is not responsible for the decline in life expectancy imo. We are not certain if this is statistical error, true reflection of current state of healthcare, and my post is hypothesizing some of the decline is due to reduced access to primary care physicians. I think we will know more when numbers come out next year….

  66. Dr. Palmer – life expectancy has trended in the right direction since 1993. The fact that we did not stay relatively constant over the years 2014-2015 when care was “better” is significant. You absolutely could be correct that this small change is a statistical anomaly, but what will you say next year if there is a small drop again? The big picture of what is happening to primary care is what concerns me the most. We are sorely needed… and will be missed once we are gone. Thank you for reading as always.

  67. “Motivated reasoning.” Partisan ideological wishful thinking. The ACA haters want SO badly to find one adverse thing after another to pin on ObamaCare. The notion that in a span of just a few years a piece of insurance reform legislation can quickly CAUSE a significant decrease in national “longevity” is simply fatuous. Gotta love it.

  68. When you have only small changes like this for one hundred thousand people–724 deaths going to 733 deaths–you have to wonder about noise and artifacts: death certificates written for folks who are insured might be more accurate than for people who are uninsured. Does every person even get a death certificate? Maybe in 2014, there were more deaths without certificates for some reason? I mean we are only talking about an increase of nine people! …in a hundred thousand. Better to chalk it up to ststistical error.

  69. I can’t help it if you have trouble reading the English language. My comments, Peter, contradict what you are saying above. “***Without*** providing opinion one way or another” “Life expectancy as a whole is a terrible metric to judge a healthcare system.”

    What you should learn from this discussion is that stupid comments that favor your position can later be used to dismiss it.

    “The ACA provided subsidies so people could afford coverage and get those tests”

    Your premise above may or may not be true, but your rhetoric is empty of data. It doesn’t sound like you have a strong background in science where understanding what constitutes proof is a necessity. I provided you with a bit of knowledge. 1) as premiums rise more people decline insurance. This testing you are talking about raises premiums and can leave more people without insurance. You claim that insurance saves lives. That means that these tests elevating the premiums lead towards death in some people. 2)I provided you with a comparison between Canada and the United States. It was shown that our uninsured had as many mammograms and pap smears as the insured Candian. That means our uninsured are availing themselves of these tests without increasing the premiums and thus without additional folk declining insurance and therefore according to your logic more likely to die.

    I wouldn’t make much about any of this data except the fact that lifespan is a lousy metric to determine how well a healthcare system functions.

  70. “By making them free the insurer has burdened itself with the cost of the mammogram plus the cost of administration. That increases the premium and we know for every increase in premium a certain percentage of people drop insurance.”

    So how does that relate to your claim the ACA is causing the increase in mortality? The ACA provided subsidies so people could afford coverage and get those tests – valid or not. Not having those tests covered also prevents people from having them.

    As usual you change the subject and argue in circles.

  71. “Well early diagnosis can “prevent” mortality”

    That is true. However, both pap smears and mammograms are relatively inexpensive and affordable. By making them free the insurer has burdened itself with the cost of the mammogram plus the cost of administration. That increases the premium and we know for every increase in premium a certain percentage of people drop insurance.

    A number of years back a comparison between the US and Canada was performed to see how much of this preventative care (really early diagnosis) was performed in each country. The surprising thing was that though a large segment of our population was not insured for these tests, the US demonstrated a much higher use of them. What was really surprising was that the US uninsured had an equal number of these tests as the insured in Cananda. That makes one who is not an ideologue think a little deeper.

    “To attempt to blame the ACA for increased mortality is just plain stupid.”

    If you read both of my comments a bit more carefully you will find that that with just this information on lifespan I drew no conclusions. There are reasons to blame the ACA for increased mortality and reduced mortality, but I don’t think conclusions can easily be drawn just based upon the metric under discussion. Lifespan data contains a whole slew of variables perhaps more applicable to defining the social system than the health care system.

    The above is important because funding is limited and if money is spent on healthcare it may not be available for changes that could be made in society that would demonstrate a much greater benefit.

  72. Your point about primary care is a very good one. Life expectancy as a whole is a terrible metric to judge a healthcare system.. If the ACA is to blame for problems I wouldn’t use that metric as a type of proof though I would want to investigate why life expectancy decreased.

    A major problem for life expectancy is socio economic. We have had an increase in drug deaths and killings. If there are more drug deaths then one might assume more use of drugs which would also lead to higher infant mortality. Among other things early death takes a toll on one’s life expectency averages.

  73. Bobby, apparently you didn’t get my point. I was raising the question, if ACA supporters pushed the ACA because it would increase this type of metric then they should similarly look at the ACA as a failure since those metrics decreased.

    I didn’t hold the former view nor do I presently hold the latter view. I am just pointing out one of the many false claims of ACA supporters. You can see a lot more of this type of false proof from Peter in his many comments.

  74. I am very familiar with Preventive services. What is your point?

    Additionally, just to help you out with your arguments preventative medicine is not the same as early diagnosis.

  75. “maybe we should be blaming the ACA for our recent lower life expectancy.”

    Ever look up the preventative services covered with no co-pay under ACA?

    I always look forward to your unbiased and informed opinion.

  76. I expected as much Bobby.

    So it seems Niran access to a doctor (because of access to insurance) makes you die faster.

    Niran, do you treat people on the exchanges?

  77. “Differences in mortality were most prevalent in poorer communities, where smoking, obesity, unhealthy diets, and lack of exercise are ubiquitous.”

    How is a PCP going to change those lifestyle habits? Did the “differences” not include death by violent crime?

  78. I remember reading that Leonard Schaeffer, in his 2007 Shattuck Lecture, told us that the health status is determined 40% by personal behavior such as diet, exercise, smoking, drinking, etc., 30% by genetics, 20% by socioeconomic status and environmental factors, and only 10% by the quality of healthcare one has access to.

    In the U.S. the ten most common causes of death include accidents and suicide neither of which is likely to be influenced by access to healthcare or health insurance. Trends in deaths caused by accidents, murder, suicide and inadvertent drug overdoses can move the needle on death rates and life expectancy, especially among younger people.

    Within the older age groups, we may be seeing more people choose hospice care sooner as they approach the end of life. If people are choosing less futile or marginally useful care that merely prolongs the dying process with poor quality of life, that’s a good thing in my view even if it drives life expectancy numbers down somewhat. I think our emphasis should be on trying to increase health span or years of reasonably healthy life as opposed to life span or the number of years we are technically alive irrespective of quality of life.

    If we slice the population by income, we are likely to find that higher income people live longer than lower income people and that gap is probably widening in recent years. Maybe lower income people would live longer and healthier lives if we tried to do more to reduce poverty and improve education especially in the inner cities. That all said, I have no doubt that more primary care doctors would be helpful, particularly in underserved areas.

    Finally, with respect to infant mortality rates, I note that Medicaid pays for roughly 40% of the four million births in America each year. That means that 40% of women who give birth in this country are poor. Many live in substandard housing and have poor diets and don’t take very good care of themselves even if they have access to decent medical prenatal care.

    It’s better for people to have health insurance than not have health insurance but there are a lot of moving parts here.

  79. Allan, it did cross my mind while writing this post the ACA maybe partially to blame. However, that would not encompass what I see as an even larger problem. If we do not entice primary care physicians to stay in practice, outcomes for all our nations citizens will get worse. Your point is a good one, I have no doubt the ACA added insult to injury.

  80. Without providing opinion one way or another, the ACA was passed in part because supporters of the bill claimed our life expectancy was lower than it should be and that the ACA would increase life expectancy. Before, life expectency was increasing every year. Now with the passage of the ACA life expectancy is falling. Based upon the arguments of the left pushing the ACA maybe we should be blaming the ACA for our recent lower life expectancy.

  81. Thanks Dr. Al-Agba- Thanks for shedding some light on a likely contributor to the recent report about declining life expectancy in the US. Yes- this is the tip of the iceberg indicative of the general decline of US healthcare. And it should command our immediate attention-“Paying primary care doctors adequately enough to retain them is the only way out of this mess”. I stand with you on this an important solution. But I am weary of this recommendation and others which have been painfully obvious for many years. I guess ultimately consumers will have to demand necessary change through the ballot box when they come to realize the inherent unfairness of our current greed driven healthcare system which quite literally robs them of years of life and decent relationships with caring doctors?.