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If US health Care's So Good, Why Do Other People Live Longer?

Carrie Peyton Dahlberg

Ask around for the healthiest country in the world, and the United
States won't come close to topping the list.

People live longer in just about every industrialized nation, from
Canada to our north, throughout much of Europe, and around the Pacific
in Japan, Australia and New Zealand.

mothers and their babies also face a rockier start here, with U.S.
infant and maternal death rates double some of our industrialized

debate swirls in Washington and at town halls nationwide over health
care reform, there is also a more fundamental question — what about

Could policymakers change our medical system in ways that would make America a healthier country?

everyone should help — but less than people might think, according to
doctors and public health experts who've studied the issue. Putting
more resources into primary care should also make a dent, they say.

Neither one, though, is likely to send America to the top ranks of its global peers.

you want to see dramatic changes in health, you're not going to get
there even by doubling the efficiency and effectiveness of the health
care system," said Dr. Richard Kravitz, a University of California,
Davis, professor of medicine whose research interests include quality
of care.

"When you need it, you really need it … but in general,
the benefits of medical care to populations are a little bit
overrated," he said.

When taken all together, the other factors
that play a bigger role include education, income, toxins in the
environment, crime, violence, family structure, stress, obesity,
nutritious food and exercise.

Across large populations, he said,
numerous studies suggest that medical care contributes only modestly to
overall health, perhaps somewhere between 10 percent and 25 percent.

care for all would provide a "very large" improvement for some deprived
populations, Kravitz said, but "a surtax on high fructose corn syrup
would probably be more effective … than anything we could do for the
health care system, just because of obesity."

Researchers who
have delved into the effects of medical care on the health of large
groups overall have made some surprising and sometimes conflicting

An experiment in the 1980s that extended different
levels of insurance to otherwise uninsured people found that more
coverage fostered more use of the medical system but not necessarily
healthier people, said Dr. Peter Muennig, a professor of health policy
and management at Columbia University's Mailman School of Public Health.

2006 study that compared white people in England with whites in the
United States, in an effort to keep different ethnicities from
complicating the findings, reached conclusions Muennig found startling.
Even the richest white Americans, who are pretty much universally
insured, had more diabetes, more high blood pressure, more heart
disease and more cancer than the richest white Britons. On most
measures they were a little less healthy than middle income Britons.

points to a vast range of things health care cannot do, from providing
mass transit that makes it likelier people will walk more, to providing
the kind of education that correlates strongly with better health.

is the fundamental ingredient for what you need to survive in any
ecological niche," Muennig said. People with less education are likely
to have jobs that are lower paying, higher stress and possibly more
dangerous. They're likelier to live in unsafe housing and eat cheap,
calorie-dense food. They're less likely to be offered job-related
health insurance. Except for the insurance, he said, health care
reforms cannot fix that.

Those who examine health across many nations puzzle over other oddities.

international health care measures, America's ranking improves when
life expectancy is measured for people age 65 and older. While still
not at the top of the health heap, Americans who make it to age 65 have
remaining life expectancies closer to 65-year-olds in other developed
countries, and men stack up a little better than women against their
peers worldwide.

That might mean that American medicine treats
older people more effectively. Or it could mean that Medicare,
universal coverage available at age 65, may be keeping older people
healthier. Or it could be something called the "survivor effect,"
suggesting those who have lived past earlier perils are more robust.

the factors that optimize health are complex, doctors say there are
things federal policymakers could do to make America a little healthier.

them are strengthening primary care, finding ways to encourage better
diet and exercise, and effectively reforming how health care is
financed, said Dr. James G. Kahn, a professor of health policy and
epidemiology at the University of California, San Francisco.

do better in nations that encourage them to have a regular primary care
provider, Kahn said, perhaps partly because regular, front-line care
helps bolster healthy habits.

"Even in the United States, in
locations with a higher concentration of primary care providers, people
have somewhat better outcomes and also lower costs," he said.

and encouraging primary care might also offset an American tendency to
do too much, driven by a system that pays for each procedure performed
by a doctor, hospital or testing lab, Kahn added.

"We do too many surgeries," he said. "Rates of cardiac surgery are lower in Canada, yet they have better outcomes."

is hope, too, for "accountable care" groups that would move away from
fee for service payments but be held accountable for keeping all their
patients as healthy as possible, said Stephen Shortell, dean of the
school of public health at UC Berkeley.

Shortell is also pleased
that the health legislation being discussed in Washington includes
billions for disease prevention and health promotion.

"You can't
ignore the health care system, but the big payoff is in lifestyle
factors and disease prevention," he said. "A dollar spent on those
activities saves $5 in health care costs."

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