It’s cliche/overly simple, but certainly America’s culture of individualism/liberty/“muh freedoms” or whatever you want to call it comes into play. Americans of both parties place high value on allowing other people to do what they want, or at least they themselves being free from the moralizing and micromanaging of people who think they know better. And the clear outcome at a societal level is, people die. Now I sound weird and authoritarian. But it’s pretty simple- most moral pressure in groups is rooted in the idea that if everyone did X, we’d see better group outcomes, even if individuals might feel a little stifled. It’s easy to see that on things you agree with- “if no one had guns, we’d have fewer deaths!” vs things that code as “the other guys”- “if no one had sex til they were married, we’d have fewer out-of-wedlock kids and they’d grow up in more stable homes!” (See also Nellie Bowles’ piece on liberals who fight for the right of people to choose to die on the streets of SF.) Anyway I could go on and on here. But your thesis is refreshingly straightforward- what can we do from a *policy* perspective? And I just caution that any policy that aims at expanding life expectancy runs the risk of being coded by the voters as “nanny state thinks they know better than me how to run my life!” which is political poison in our culture. That said I think it’s possible to thread the needle, and your ideas aren’t bad. But gas and sugar taxes won’t be popular. (Also I thought this piece was very interesting and well-done and I learned quite a bit!!)
I'm firmly in the category of American who finds Matt's analysis in this piece disquieting, not because it is wrong, or that there is nothing that can or should be done about any of these things, but because this sort of technocratic statistical approach does in fact disguise serious value judgements that are implicated. There are many policies that will raise life expectancy that are not the place of the state to act upon, and many of them that the pursuit of poses a true threat to the pluralist, liberal, egalitarian state ideal that free society should be working towards. Even the most benevolent version of the crushing police state required to truly smother violent crime is not a trade off worth making. The version of this logic where we are banning food on the basis that it's carb content imposes a burden of Medicare is not a trade off worth making. A version of America where the average American drives a number of miles more line with the average European is totally ludicrous pipe dream that the strong version of pursuing would absolutely implicate a state so totalitarian it would be difficult to comprehend. These are not trivial concerns and every individual case demands careful understanding of tradeoffs. Prohibition? Nightmare. Drug war? Nightmare. Policing? Maybe more money for better cops, but more of what we have now? Nightmare. The technocratic urge to "solve" these problems is an extremely dangerous one.
“ A version of America where the average American drives a number of miles more line with the average European is totally ludicrous pipe dream that the strong version of pursuing would absolutely implicate a state so totalitarian it would be difficult to comprehend. ”
Huh? Matt’s whole approach is to reduce regulation - zoning, parking minimums, etc. One of the main reasons we drive so much is heavy handed state intervention in the economy.
Sure, Matt's actual housing stuff is pretty well calibrated. I almost always agree with it. But the logic of "Americans die more because they drive too much." also gets cited by the #BanCars people. And as Matt noted yesterday, extremely dense urban living is a very minority preference in America.
Things like housing and a carbon tax are examples where Matt is really good on this stuff. When Matt is at his absolute worst is when he starts giving into his 90's era "tough on crime" and nanny state(porn, alcohol, etc.) impulses.
“ And as Matt noted yesterday, extremely dense urban living is a significant minority preference in America.”
At current prices, sure.
Big picture it’s a mistake to assume that the current situation is the natural state of the world. Absent heavy handed regulation, how we live would be quite different.
I'm 100% on team zoning is evil. I don't at all buy that anything like a majority of people will organically agglomerate in high density, carless, urban living situations even in the most accommodating regulatory environment
Your use of the term organically is also interesting. I was reading the other day that at one time the vast majority of America’s transportation infrastructure consisted of privately owned railroads, street cars, etc. And these businesses were the largest payer of property taxes in many areas. With the advent of the car the choice was made to not follow the railroad model of privately owned infrastructure but rather to make this new infrastructure publicly owned. This obviously put the property tax paying railroads at a huge disadvantage.
If we rerun history and let roads follow the existing railroad model the organic growth would be very different.
I notice you said carless. That sort of phrasing implies, at least to me, some kind of restriction. When the actual issue is that anyone can have a car if they want one and many people do. It’s just that you don’t have to have one to do the vast majority of daily activities.
Not specific to you but a lot of comments imply that not needing a car means you can’t have one. Which isn’t how it works.
I think Matt does a very good job of aiming for a libertarian-friendly version of this, where we don’t prohibit but just tax and nudge a bit, and don’t try to eliminate causes of death, but just try to find the cost/benefit trade-off.
Matt does a great job identifying opportunities to advance economic redistributive goals in ways that leverage rather than disrupt market forces. That's Matt at his best. Matt at his worst is when he goes to throwback 90's, nanny state, technocratic paternalism and tough on crime stuff. This article is the thinking that bridges the two.
Well said. This is a case where I'm glad a ton of comments got in before I could get to reading today's article, because otherwise I would have likely commented more glibly along the lines of "If this is a leading reason why, then it doesn't particularly upset me.".
May also correlate with reduced smoking rates. Nicotine is an appetite suppressant and cessation causes weight gain. However, things are sorting a bit different now since being a non-smoker is largely bundled with other healthy habits and factors instead of representing a broader sample of society. Of course, this doesn't exclude other environmental or dietary factors.
Setting aside the veracity of the site referenced here, the idea that an entity or entities collectively added "something" to "the food supply" (by "someone") that caused the growth in obesity is absurd on its face.
This is where someone will mention high-fructose corn syrup, but the "HFCS made everyone fat" is an urban myth.
NATURE, 18 September 2012:
Citation 1: The use of HFCS grew rapidly from 1970–1999, principally as a replacement for sucrose. HFCS usage in the United States peaked in 1999 and it has been in decline since that time. At its peak, HFCS was still less consumed in the United States than was sucrose, although sucrose did have a significant decline in usage during the time that HFCS usage increased. Worldwide, sucrose is still the dominant sweetener with over nine times as much consumption as HFCS.
Citation 2: "The hypothesis that the replacement of sucrose with HFCS in beverages plays a causative role in obesity is not supported on the basis of its composition, biological actions or short-term effects on food intake. Had the hypothesis been phrased in the converse, namely that replacing HFCS with sucrose in beverages would be a solution to the obesity epidemic, its merit would have been seen more clearly. Put simply, a proposal that a return to sucrose containing beverages would be a credible solution to the obesity epidemic, would have been met with out right dismissal."
Obesity is caused by a calorie surfeit. Calorie surfeit means you are eating more than you are expending. Eat more, be more sedentary, you get fat. A variety of factors led to exactly that for many people.
One thing that changed around 1980 was the rapid increase in cable TV adoption, resulting in way more TV watching (since there were many more options, aimed more specifically at audience segments).
Another factor was the rise of home video games, the personal computer, and later the internet and related technologies. Plus encouraging or allowing kids to stay inside at home because of "stranger danger" or similar fears, instead of letting them/forcing them to play outside.
If food has changed, it is only that processed foods have gotten cheaper, more caloric, and less nutritious -- and there are more of them, and they are more aggressively marketed. Portion sizes have continued to grow (check out the evolution of sizes of things like popcorn and soda).
Changes in societal mores about cooking at home and "eating stuff you don't like" have also had an impact.
There's probably also something to be said about the whole fat shaming/acceptance thing, but that feels too recent to be a significant factor.
“ the idea that an entity or entities collectively added "something" to "the food supply" (by "someone") that caused the growth in obesity is absurd on its face.”
How is it absurd? They started giving livestock antibiotics because through processes we don’t understand they put on weight. The humans that ate those animals also started putting on weight. That doesn’t strike me as absurd on its face.
They did for the US. One bit of evidence is that if there was something new used in agriculture you’d expect to find higher rates of obesity in places where agricultural runoff tends to accumulate. And that’s what you find.
Car culture is a huge issue. I moved from a dense city to its suburbs in 2021 and I still try to ride my bike for most trips within a 4-5 mile radius. I feel like I'm the only one, or at least one of a very very small group of people. Can't even find a bike rack most places.
When you say “culture” I see “the built environment” and “the economy”, which are hugely shaped by explicit government policies, in addition to whatever component of culture is independent of structural forces.
Not sure what the stats are on this, but anecdatily I grew up in the 70s and 80s and, though I was not especially athletic, was extremely active. There were far fewer screen options, and before helicopter parenting was a thing, kids just went outside and ran around playing. We also had to take gym. I recall some chubby kids but very few, if any, obese ones (also few obese adults). And this was the meat-and-potatoes Midwest!
Portions were definitely smaller, though my mom hated cooking and did as little as possible. I ate a lot of garbage frozen food (Lean Cuisine, Stouffer's French Bread Pizza, ugh) but not huge amounts of it.
If anything the probably "worked out" less in the sense of doing some activity for the sole purpose of physical exercise. But they were probably generally more active. Fewer people worked "desk jobs", there were many less compelling sedentary activities to spend your leisure time doing and generally fewer labor saving devices (riding/self-propelled lawnmowers, dishwashers, etc)
Most kids were fairly fit but hardly “swole” or “ripped” as we would now say, and most adults, at least in sedentary jobs, were “skinny fat,” as we now call it, but not fat.
Liberty doesn't "just" do this. It *can* do this, and crime is certainly the best case to make. But that's not the sum of it. Positive liberty is important, but so is negative liberty. We need both in a healthy society, and the answer to swinging too far to one direction must not be swinging too far to the other. Individual rights are super important, but they are not the be all and end all, or rather they should be understood in a holistic and sophisticated manner, that realizes e.g. that "dying with your civil liberties intact" is - in many circumstances - absurd and paradoxical. I think the northern European model, combining strong welfare state protections, redistribution and high levels of social trust and solidarity with social openness and tolerance, free speech, political liberty etc. is a good example of how to have your cake and eat it too so to speak.
I certainly think there's things that can and should be done to alleviate more of the harms of crime that inescapably fall disproportionately on the vulnerable. What I think I fundamentally disagree with is the notion that the burdens of aggressive enforcement against social ills has, or could ever, distribute in some more equitable manner than the burden of individual responsibility. The overdose epidemic is incredibly bad, but it's vastly more equitable than the drug war is, and I think that's the core of my consideration. Some baseline level of burden of individual choices is unavoidable and always preferable to the heavy handed imposition of burdens from the state apparatus. Good solutions demand a balance that implicates real value judgements on these things not simply a commitment to reducing bad statistical events to zero.
"the overdose epidemic is incredibly bad, but it's vastly more equitable than the drug war is, and I think that's the core of my consideration. " Can you please elaborate and unpack this statement?
Clearly economic resources provide some capacity to ameliorate the challenges of addiction/recovery, so that burden does not fall on individuals in purely equitable fashion, but the overall distribution of badly prescribed pharmaceuticals, along with the whole deaths of despair thing, that drives the current dynamic of OD deaths largely does. The impacts here fall heavily all across socio-economic and racial lines.
The impact of the drug war by contrast, has been almost entirely on targeted urban minority communities where oppressive enforcement destroys lives, families, and perpetuates the ghettoization of the redlining and school segregation schemes of old. It's been incredibly, overtly racist and destructive, promoting violence, poverty, mass incarceration, and ceaseless violation of civil rights almost exclusively among poor, urban minority communities and is almost entirely responsible for the vast, horrifying shit show that policing has become in this country.
It's not even remotely defensible to argue that criminal drug enforcement has equitably benefited the populations that have been targeted by it. It's the primary, go to, tier one example in action of exactly how this line of "_______ is bad. We should do something to stop ________." goes horribly, horribly wrongly off the rails without careful consideration of how to pursue such goals.
It is important to distinguish policies that deal with externalities (masking, vaccinations, taxation of net CO2 emissions) from those that are paternalistic (seat belts, sugary drinks/tobacco taxes, drug commerce criminalization). Some of course are both.
But the common externality of them all is “societal health and human flourishing.” It’s easy to extrapolate the externalities of things you care about and diminish those of ones you don’t.
I mean, I’m being somewhat obtuse, but the American culture/attitude that suggests I shouldn’t impose any kind of moral weight on others’ choices that don’t personally affect me is the whole point I’m trying to make about why our life expectancy might be lower. Other cultures have no qualms pressuring people to do things like lose weight or avoid drugs because it’s good for the other person, and society at large. I think Americans are unique in having a sort of taboo against this kind of moral policing. And, like, maybe that’s the cost of freedom, lower life expectancies! But they seem linked.
I don't necessarily disagree with this thesis in terms of needing more nanny-state like interventions and the collective spirit that goes along with them to improve health outcomes. That said, what explains the fact that the life expectancy situation has gotten FAR worse in the US since ~2010? as shown on the graph? It is common for the left to talk about everything getting worse with Reagan, but there's a clear inflection in the curve in this article since 2012.
There's been a bit of a push on the Left for what I would kind of call a left-social conservativism... saying sort of that the decline in religiosity is a problem, etc. But European religiosity is really low, Norway has like an 18% church attendance rate. There is also the "deaths of despair" theory from Case and Deaton that economic hollowing out of certain areas has resulted in social breakdown and more overdoses and suicides.
But really the only "despair" metrics that check out are the ones that relate to health and death. Huge chunks of the developed world for example have negative fertility rates and substantial outmigration.
I listened to Ezra Klein's podcast yesterday and he sort of said that people are moving further away from their hometowns and having smaller families, and this means weaker support networks and worse health (this was more as pertains to mental health but I've also seen it posited for all forms of health). But people are not moving further away from their families and families in the US are a lot bigger than in Italy or Japan which are averaging like 1.3 children per woman.
So IDK. The "individual cultural" explanations probably have something to do with this but I'm not sure how...
Well, in the spirit of Matt’s “now more than ever!” segue, I’m inclined to say the correlated cause that happens to be my pet topic is the increased polarization accelerated by social media since 2012. More and more, Americans map any position onto a two-party framework and interpret it as “good” or “bad.” But now even things that are objectively “good” for you are being filtered as “bad” bc it’s the other guy saying it. The obvious example on the right is Covid denialism, but also gun culture. On the left, it’s stigmatizing any discussion of the downsides of obesity, drug use, gang violence, etc as bigoted. Seems like opioid use is the only topic that both sides feel is uniformly bad and those affected as sympathetic characters, though I think many on the super-left have grown more numb, “you only care bc it affects white people, where was your concern during the crack epidemic?”
I do tend to think certain mental health issues may be partially attributable to widespread smartphone use but this makes the international comparison confusing.
Assuming that the decline in social pressure and rise in obesity are correlated, it's not actually obvious to me which way the causality runs. Did social pressure to maintain a healthy weight decrease causing people to get fatter, or do people get fatter making the social pressure to maintain a healthy weight untenable?
The Scandinavian countries are usually higher than the United States on various freedom indices (like that of the Heritage Foundation: https://www.heritage.org/index/ ) than the United States is. They are better described as “neoliberal” than “socialist”.
Also I’d like to see a more rigorous definition of this other kind of “individualism” that’s supposedly common to all those places but not to “Asian countries” or at least a good example.
But the question is what’s the relevant definition for the purposes of the disco at hand. I’d say the differences here are super pertinent for life expectancy.
I've found that the CDC's life expectancy numbers are not always as trustworthy as we might assume, and the gap between Asian and non-Asian American life expectancy may be smaller than the numbers show due to data problems.
As I've written many times here, I'm a European living in the US who is very cranky about American healthcare but thinks that the US is doing much better on most other metrics (which is why I'm here and not in Europe in the first place).
So, when I saw the part "A common left-wing knee-jerk reaction is [...] really is worth a pound of cure." I wanted to complain that a good healthcare system is all about being able to go at least once a year to a family doctor just to discuss what's going on in your life, get prescribed some routine tests, and get back to discuss the results with the doctor. That's probably the same doctor that has been seeing your parents since forever, so there is a lot of trust involved here, and that doctor does have credibility to tell you "Hey, you need to cut down on this and that.".
But I see that our host covered that part later in the post ("A big open question in the research, [...] the healthcare system is plausibly a factor."), so I don't know why he dismissed it previously.
I don't think I know any American below 30 who goes to the doctor for a couple of conversations like the ones I described at least once per year. I spend few weeks per year back home, and I still make sure to make time for these conversations. I would be surprised if that part of the American healthcare system, where you essentially get penalized financially for being proactive about your health, doesn't have an effect on things like obesity.
edit: And I should add here that Matt had a nice post about how the more entrepreneurial and profit-driven American system basically unleashed the opioid epidemic. Shouldn't at least some of these deaths be classified as healthcare system related?
I'm curious to hear from Europeans about their experience with health care.
I'm in Israel, and I just had a surgery and a two-night hospital stay. And I didn't have to pay anything (beyond my normal health insurance premiums). So I see the appeal of publicly-funded systems compared to the US! The fact that everyone has access to baseline health coverage is essential!
But! There's also the user experience. To get this appointment, I had to deal with a bureaucracy that was unlike anything I experienced in the US. In the US, you could call an doctor's office, and someone would pick up the phone. You wouldn't be put on hold for an hour, and then transferred endlessly until the line disconnects. In the US, you asked what appointments were available, they'd tell you the options and you'd schedule it. My experience in Israel was that you'd send in your referral for an appointment, and they would get back to you within 10 business days, and if you didn't pick up the phone exactly when they called, you were screwed. They'd assign you an appointment without asking your schedule. And sometimes the referrals weren't processed until you called, waited on hold for an hour, were lucky enough to get someone who answered, and pestered them to process your paperwork. Often they'd give you a date several months out (that you didn't choose), and you'd have to call back and wait another four business days to see if anything sooner opened up.
Then when you'd see a doctor, it was a this short, rushed, in-out visit, without the opportunity to ask as many questions or talk in as much detail about my health with the doctor. In the US, generally, the nurse (after taking your blood pressure and other vitals), asks you a lot of detailed questions before you see the doctor, who looks over your file and the report from the nurse before they see you. In Israel, you immediately go to the doctor, who hasn't looked over your file at all, and you have a few minutes to talk to them.
I'm wondering to what extent these experiences are common in other public-systems.
So, I am all for universal access to health care. But there are aspects to the US medical experience that are superior. Being able to call a doctor, schedule an appointment, without spending hours on the phone. And when you're at the doctor, not being rushed out after a couple minutes.
You're very much cherry-picking the good side of the US system.
The bad side is the unending discussions between hospital, patient, and insurer over pre-authorizations and out of pocket expenses for necessary procedures, the weeks spent on hold sorting out basic billing errors because your insurer's procedure codes are just that little bit different from the other four which have agreed on a standard schedule in your state, or the outright false denial of claims that result in you receiving a $30k bill and a heart attack even though something is actually fully covered.
I honestly think if the insurers were forced to compensate their policyholders at minimum wage for time spent resolving insurer and practitioner errors in billing most of the smokescreen/bullshit would mysteriously disappear.
Yes, I have also experienced that in the US! Arguing over a surprise bill from an ER visit between my insurance company (who processed the payment incorrectly three time), the hospital, the third-party provider that contracted with the hosptial, their former billing team that was responsible at the time I had my care, and their current billing team,. Yes it was a nightmare. But it all occurred AFTER I had my care, and didn't prevent me from getting the care I need. (It did have the potential of forcing me to forfeit the $770 they wanted to over-charge me!)
...you're right, sometimes you had to deal with pre-approval...
And 100% You don't have to convince me that the US needs health care reform! I also had bad experiences in the US. Once my insurance just flat out stopped processing payments to a provider for no reason, and the provider refused to see me unless I paid several thousand dollars (which they weren't legally allowed to bill me because I was in-network). It's bad, and it shouldn't work like this!
I am just saying that I lived 29 years in the US and 3 years in Israel. And the user experience of making an appointment and going to a doctor was generally better in the US that it has been in Israel. Yet Israel has a much saner system by all merits.
And a fortiori considering your Israeli equivalent in terms of education level and income probably has a better (perhaps significantly better) experience.
Not to mention not even knowing how much something is actually *supposed* to cost you before doing it. And the beauty of those who actually have to choose their health insurance and good luck figuring out which one would screw you over less.
Important caveat: There isn't an EU healthcare system. Each member state has its own approach, so your mileage may vary. (Incidentally, this is why I don't think Medicare for All is a good idea. I would prefer that Congress somehow forces each state to take care of its residents, but allow each state to choose its own approach to the problem.)
Thankfully, only one person in my close family needed surgery relatively recently (in the past decade or so). We took her to a private hospital and paid almost everything out of pocket (we got some small reimbursement roughly equal to what a similar operation would cost within the universal system). "Wait a minute! How is this a good example of universal healthcare?" you might say. Well, you have a much much much better bargaining position when discussing price, if the private hospital knows that the public system exists, so paying almost everything out of pocket isn't as terrible as it would have been in the US. My understanding is that private hospitals back home have much shorter waiting times than private hospitals in the US, as well, because they don't have to provide healthcare to everyone.
Crucially, I know of no system in the EU that is a communist utopia where everyone gets the same terrific treatment regardless of ability to pay, and that's okay. I'm just happy that everything (including private out of network healthcare) is much more affordable than it is here in the US. (Well, not that happy, because I currently live in the US, but you get the point.)
Right of course...in Europe there's not a single health care system, and systems vary from country to country from fully public to fully private, yet regulated.
But this aspect that you're talking about, about the interplay between the private and the public system that you discussed is really missed in the American dialogue! And the reason for it is that we always compare to Canada, which does not have a private system!
I agree! Having some (fortunately not much!) experience both with a European system where the government directly owns hospitals and employs doctors, and with one where everyone has mandatory private insurance, I would say that my personal preference is a publicly owned system alongside a private system regulated only for safety. All these regulations that the US has for "affordability" (like forcing private hospitals to provide services to people who can't pay for them) increase the cost for everyone. I don't have specific data to back this opinion though, so take it with a grain of salt.
I think you have to take into account that your comparison isn’t apples to apples. In the us you were part of the in group and in Israel the out group , as I understand ? Presumably not speaking the language and not raised in the culture ? This doesn’t change things like the need for refrrals but may well have more subtle consequences on how smoothly the process goes. Also many public healthcare systems , including Israel’s incidentally, are mixed and allow certain shortcuts for people willing and able to pay and who know what they’re doing. This of course advantages the relatively privileged (educated, middle class or above, native born) at the expense of the less so (poorer, immigrant or foreigner etc).* But of course us has these problems on steroids.
*the justification is that it helps keep the middle and upper class buy in to the public system and keep good doctors in it.
So it's true I have insurance for foreigners and not the full HMO insurance that citizens get. But from talking to enough Israelis, it seems like my experience is pretty common if you're dealing with the public system (it's not really one public system here, but 4 publicly funded HMOs, of which people belong to one...Also not to disparage the system here too much, it is still one of the best in the world in terms of health outcomes). I guess I'm curious if it's like this in Europe in countries with a public system...
Many of my friends here just told me to do it privately to not deal with these hassle of the public system. (Citizens here would have the opportunity to buy supplemental insurance that may cover some private services). And yes, many people here complain that the expansion of the private system has made the experience of the public HMOs worse.
The thing is, it’s not actually a dichotomy. The “private” system supplements the public baseline. Thus, it’s drastically cheaper than in the us. It’s also affordable to the middle class, at least in its basic forms that would allow to cut much red tape eg in waiting times for operation, allowing you to choose your doctor etc. also it’s the same doctors in many cases. This is important from a policy standpoint. It’s possible that the private stuff makes the experience of the public system somewhat worse but it may also allow it to keep functioning. It’s not like it’s a genuinely separate and competing domain like private vs public schools.
Edit: I suppose it’s more akin to perks you pay for at the airport to cut time in security or get more leg room than a private jet (which would be the us model).
But (at least in my recent experience), the user experience is also worse. (And my understanding is that the experience for the doctor is also worse). And for the patient, I'm not talking just about wait times for an operation or ability to choose your doctor. But I'm also talking about administrative burdens to get an appointment and your experience in the doctor's office. Now it could be that a positive user experience just isn't that important for good health outcomes. But I don't think that Americans will put up with a system with the administrative burdens that I've just experienced in, admittedly, one of the "best healthcare systems in the world".
What I'm saying is that to some extent, paying a bit extra may be worth it. (Though not to the extent that the US pays extra...)
I think if you're quite wealthy (mid or perhaps high 6 figure salary) the us system is better for you. It's probably worse for everyone else. All things considered. In other words, it's worse for 99% of the population.
your point is well-founded. Some of the healthcare companies (such as Blue Cross here in Georgia) have services which incentivize you (via partial rebates for your insurance payments) to get a physical, get a biometric screening, talk to a wellness advisor several times, on an annual basis. Maybe that will help with wellness visits in general
My insurance company has an incentive where if you don’t do a “wellness visit” each year, your insurance premium goes up by $30 a month for the next year. However, this “wellness visit” can’t be a visit that is scheduled for some other reason, since it has to be coded as a “wellness visit” on the insurance form, and it has to happen by a particular month.
I’m usually a huge fan of these paternalist nudges, but seeing the implementation of this has made me much more skeptical.
For what it's worth, I'm under 30 and I do see my doctor (ok, technically nurse practitioner but I really like her) once a year for a physical exam. And my insurance company doesn't even require a copay for the physical!
If the progressives want to expand universal healthcare, a good place to start would be for yearly doctor checkups and other forms of low-level preventative care.
That's important, but the other important thing is to fix the problem here where your insurer can unilaterally change which doctors you can see, or your employer can change insurer, which also unilaterally changes which doctors you can see.
I mean… as with basically every other federal regulation of the economy… “interstate commerce”. Hard to find hospitals with no occasional out-of-state patients or who do business with out of state insurers for employer-sponsored plans.
And in instances where that doesn’t hold up, “knuckle under or no public money ever flows through your doors”.
And there is damn-all stopping a state government from doing this.
Sure, the current Supreme Court will bend over backwards to knock down any federal initiative, but that’s out of an ideological commitment to elite rent-seeking, nothing else.
The judiciary is not going to allow just anything because the executive yells 'interstate commerce!', like Michael Scott yelling 'I declare bankruptcy!' The SC has struck down several uh creative interstate commerce stretches over the decades, including in US v Lopez, US v Morrison, etc. The 'no public money' is obvious extortion, the judiciary isn't dumb man- they're going to strike that down in a hot minute too. There are no states where the government can just do an uncompensated taking of 20% of the economy, they all have state constitutions with basic 1st world property rights in them, etc.
These kinds of schemes are why like Honduras, Zimbabwe, the Philippines etc. are 3rd world countries- just the government randomly deciding one day to set price controls on one-fifth of GDP. Let this one go dude
Unified rate-setting doesn’t mean “gubmint sets the price” it means “you negotiate a single price with Medicare and private insurers at the same time”.
If you wanna armchair lawyer your way to unconstitutionality, ok, but there are plenty of contexts in which price discrimination is disallowed and the Constitution doesn’t bat an eye.
That’s my impression too. And in addition to the lack of personal connection, it’s even becoming more rare to see a fully trained doctor (I.e. MD) when you do eventually need to see one. Increasingly you have to make do with a nurse practitioner (also referred to as “doctor” - unless you inquire nobody will even tell you you’re not actually seeing an MD !). I have nothing against the the NPs, but why couldn’t they just open more places in med schools to allow ambitious nurses (or others) to get the full training and solve the shortage problem?
From what I understand from my med student friends (more-informed commenters welcome to jump in here) the limit on minting new MDs actually *isn't* so much controlled by the inability to open new medical schools as it is by the fact that government somewhat mysteriously controls the training of new doctors by subsidizing residency slots such that "the number of residencies" (i.e. the number of subsidized residencies, unsubsidized residences seem to be almost nonexistent) is effectively capped at like 20,000 per year instead of being market-set.
From the outside view this system makes no sense: as I understand it, residents are extremely profitable for the hospitals that employ them--not least because they're paid peanuts, (like 50kish a year in NYC spending your time in some cases caring for gunshot victims in the ER on a near-nightly basis[1]) -- but somehow the federal government's subsidization is a load-bearing part of the system even though it seems like it should work under a pure private market model.
This is even weirder when you compare it to law (specifically Biglaw): first year attorneys need a lot of supervision (just like residents need attendings) but they're paid quite a bit because they become profitable for their firms later on. I guess it's more common to switch hospitals after a residency but it's not like attorneys never change firms. The model is entirely market-based, requiring no explicit subsidy (beyond federal student loans, but medicine is the same way) and as a result there's no (corporate, big-firm) lawyer shortage.
TL;DR: I'm pretty confident it's not a "not enough med schools" problem, it's least in part a "not enough residencies" problem, and as to why residencies are so limited and the federal government is involved in subsidizing them and the market can't or won't work around it: ¯\_(ツ)_/¯
[1] Not an exaggeration, I knew someone who did this
Incorrect = residents are profitable to hospitals/systems. They can be on net, usually near the end of their training or in fellowship, but not generally. More correct: residents are prestigious, residents can allow other profitable work to occur elsewhere (research grants). There are many many more costs beyond salary to accout for: benefits, direct educational costs, program adminins, GME departments, supervision by attending physicians (lower productivity), general lower productivity, etc.
also, 50K in NYC was probably in 2002. https://surgery.weill.cornell.edu/benefits-and-salary -- different programs are very similar within institutions, and salaries are comprable between institutions, though in NY housing stipends (essentially always included) may be part of salary or separate which can make salary numbers appear very different.
Incorrect: federal govt subsidizes the cost of residency. More correct: part of the cost, of older existing programs, but institution are (generally) free to add more and self-fund. Begs question about profitability (why not add more everywhere?)
Edit/add: difference between medicine residents/early law associates: law associates can bill, residents cannot. E.g., they do not generate direct revenue the way young lawyers do (and thus get paid for).
First off, thanks very much for the clarification and input!
It's important to note that first-year attorneys' work is often (I think generally) actually revenue-negative for their firms, so it's one more reason to be perplexed at the medicine/law disparity. Most in-house counsel (i..e the ones looking at and paying the bills) were themselves junior attorneys (often in Biglaw) at one time or another and won't pay for first-years' work on the belief that it isn't worth paying for, so the firms just eat it as an investment. (IME juniors can be pretty good at legal research because they have a lot of experience in law school and a lot of the paperwork that needs to get done can be done by juniors as well such that they add value to clients, but the attitude that they don't justify their billing rates is perhaps not entirely without foundation).
Does work done by residents really not end up anyone's bill? That seems inconsistent with them being profitable later on their residency.
I think the specific salary I had in mind was probably closer to 58k than 50k (a very significant percentage bump, but that extra 8k doesn't go all that far in NYC) but it was circa 2010 IIRC (at a hospital admittedly much less prestigious than Weill Cornell).
I appreciate the clarification on the methodology of the federal impact on residencies although I think it's consistent with my characterization ("subsidizes" usually doesn't imply "pays for in full" and the allusion to the market "can't or won't work around it" was my attempt at why it was an open question why hospitals didn't just create more residency slots under the assumption that residents were usually profitable (albeit obviously with higher margins for subsidized ones)).
Sounds like hospitals for whatever reason just don't approach residency in the same way that Biglaw approaches junior attorney hiring, maybe because absent subsidy the upfront costs are higher and have a longer time horizon to recoup investment?
Work by residents does often end up in the bill, but not all work (especially the many jobs assigned to residents) is billiable, and it requires an attending physician to also see the patient and review and confirm the resident's work.
Eg, a resident sees a new patient in the ER and gets them admitted to the hospital. If the attending sees them as well (typically a couple hours later) and confirms everything, the attending can bill for the encounter. Most specialties do this. They can bill for one encounter daily, generally. However, weirdly often surgical specialties don't even do this billing because OR time'/revenue is so much more valuable to them vs seeing the patients on rounds (admissions and inpatient care instead supervised by a senior resident with 4-7 yrs training who knows what to do). OR time almost always involves full attending time/work.
Most universally common resident work: in-hospital coverage evenings/nights of inpatients in wards, ICUs, etc. Tons of work, generally non-billable (or complex to bill for, requires attending presence which is not usually the case at night, so never billed).
The question of adding residents, or residency programs is a little more complex than the pure ROI question. There are tons of regulatory hurdles to navigate and millions in up-front costs (GME and program managers and directors, most of whom are doctors with expensive time you need to buy), and you need to have a sufficient patient population to treat (regulatory), and you need doctors who want to particiapte in it (work culture, money), and hospitals who want to trade efficiency for presteige, etc. All of this = real world challenges to expanding programs and starting new ones.
EDIT: this applies to hospital care. Outpatient (clinic) care is a little different in that "primary care" encounters can be billed by the attending in clinic without seeing the patient directly ("Primary Care Exception") and only discussing the care with the resident.
Jibes with my experience as well. The academic centers I've worked at have actually looked at cutting residency slots. Minting physicians takes a tremendously long time and they're mostly pigeonholed into one specialty for their entire career. Non-physician providers are often faster to train and may be able to retreat to other roles if jobs get scarce. They're not the same as a physician but there is value to not planning staffing on a 10-year cycle.
@Jim3: I'm a bit more skeptical and believe residents are very profitable. First, I think the detail around freeing up attending time shouldn't be understated. If you look at other high services industries (such as law or consulting), you see tons of specialization (paralegals, secretaries, junior associates, senior associates, etc.) in part due to the value of time of the top billing personnel -> so freeing up attending time is very valuable to the institution. Second, residents can often moonlight starting in years 2 or 3 at the same rate of an attending (or ~80% of the attending rate, or ~3x their residency salary). I agree that the calculations here are going to be super complex, including taking into account a lot of first year training which might be "at-loss", but would think that the moonlight market is revealing more of the true value.
It's not generally the case that first year associates are not profitable for BigLaw firms. An associate with a $200k salary billing 1900 hours at a realized hourly rate of $350 -- which is not pushing the limit for AmLaw100 -- brings in $665k in revenue. Even if you loaded the entire cost of a firm's summer associate and on-campus recruiting program onto the revenue from the first year class, which wouldn't really be fair accounting, there's a lot of revenue there to cover it.
Very interesting! I have zero good knowledge on the subject but my sense has always been that the number of mds in us is artificially kept down to keep their wages insanely high. People in us aren’t aware that in most of the world “doctor” is a respected profession but not synonymous with rich. This seems to back my priors, and point to the federal government as the culprit - but I imagine the doctors have lobbies to keep it that way.
Until maybe 1960, most every mid-sized town of a few thousand people had the town doctor, lawyer, and civil engineer, and each of them earned a living similar to what folks expect of a mid-level engineer in a big firm today.
Then the former two managed to engage in rampant regulatory capture and pad their pockets to hell and gone.
I don't fully disagree with the regulatory capture argument, but it was my understanding that the relative (to US society) income of physicians has decreased since the 60s.
edit: I will try to find some data for this, I have heard it discussed a number of times. Both for primary care and specialists.
Yes and no. There are a ton of unmet legal needs (largely in family, immigration, and business law), but it's more of an allocation problem. Well-trained lawyers often opt to work in lucrative commercial litigation where their goal is just to run down the other side's resources. The ones who hang a shingle and provide basic services are usually (not always) grads from low-ranking law schools without the credentials for a better job. Many communities don't have any lawyers at all or have incompetent ones.
There’s some layers to this onion but what you are proposing (‘they open more med school slots’) is for the government (us) to spend money forcing potential NPs to instead undertake additional training before they are allowed to prescribe and practice in a certain way. There could be some benefits, some of them would apply for even more ‘study’ (at this point medical study means taking a pseudo apprenticeship for less than market wage) and end up increasing the supply of some specialists. I would say, better to create some dedicated programs for college grads to learn to perform certain MD specialist roles in radiology or anesthesia etc and not become accredited general practitioners as well. Even if the NPs perform worse than GP MDs it’s unlikely caused by lack of training and far more likely down to adverse selection.
I caution, though, I really wouldn’t expect any of this to move the needle on life expectancy much.
Here’s a question : to begin with r the system was designed with mds only, specializations coming afterwards, with gp as one. Unless I’m mistaken np came about to address a shortage. It does not exist in many comparable developed countries, perhaps it’s even unique to us. This leads me to the a priori assumption that nps as a compromise to deal with a suboptimal situation l, and what you’re proposing a further compromise and reduction of standards. How much damage it will cause is an open question , but it sounds like reform aimed at making the most of a worsening situation rather than an attempt to genuinely improve a system to be objectively better. Am I wrong ?
You aren’t wrong but you’re not right either. Evolution of medical training and standards is much messier and more local than your big picture view. Legal codification of roles went hand in hand with state takeover in many places; in others it was more of a political scramble between interested groups. Our government certainly does NOT take for granted that a successful German general practitioner and MD could perform those roles within the US. We do not formally consider them to be equivalent despite a mountain of evidence and the tacit agreement of every single person within our medical establishment. In New York State Osteopaths were granted much more ability to operate as GPs on the same level as MDs because of a few personal political connections. The basis for their form of practice is currently considered to be essentially bunk but their training is largely about being competent GPs and they do indeed perform as such.
I would also say increasing the supply of people who can prescribe antibiotics and oversee check ups is not about a worsening situation but about stretching to give people more healthcare than they had before. It is an awkward compromise but more between rent seeking entities, popular political pressures, and the genuine wasted effort involved in overhauling historic systems across 50 states.
Thanks. This is good to know. I still think it’s bonkers town though that we can’t have German trained mds as gps in us but do have people as gps who are literally not even trained to be gps.
DO training is essentially identical to MD training these days (last 20 years). There is some remining manipulative medicine training in osteopathic schhols, likely grossly diminished from before, however in practice **I have never seen a DO reference, or use, or even really talk about this aspect of their med school training**. They are just funtionally the same as MDs and do the same things in residency, and practice.
It's important to know that what you learn in med school is not what you use as a practicing physician--it's only fancy building blocks for later, like math and reading are. **What you actually do day-to-day is 100% from your residency and fellowship training, and ongoing education.**
Yes this is my point, their training, standards, accreditation etc have all simply adapted where it was allowed to adapt. In other places a choice was made to shut down certain programs or practices and to instead potentially accredit more MDs, with no discernible benefit.
Yup. And allopathic boards are finally tearing down some of the barriers between DO and MD physicians. Indeed, last time I even heard even a whisper of osteopathic technique was when I asked a DO student about it as an intern almost 20 years ago.
As for resident selection, we've had DO chief residents, though candidates from DO schools are seen as lower quality candidates (though there are some schools that have good enough track records to overcome that bias).
“…but why couldn’t they just open more places in med schools…”
My understanding is the number of seats in medical school is directly tied to the number of hospital residency positions available. Residency programs are where MDs are actually trained to be doctors.
Plus there’s more significant regulatory issues involved in expanding medical school slots. (As opposed to a university expanding its master’s in film studies in order to make more money — even though there are few actual jobs.)
It's actually really expensive and difficult to do.
Number of MD enrollees does increase every year. pg 10 (doesn't include DO programs, couldnt find the same data quickly in easy format, but they are increasing way faster--more new programs and enlarging classes, total about 25% of MD students)
Yes, I would think it's really difficult for a hospital to expand the number of residents. There's regulatory issues, expense (even though residents aren't paid that much) and also residents have to be supervised by a senior physician.
Exactly, it's not impossible but it's very difficult. Which implies to me strongly that it's not tremendously, or even at all, revenue positive. See my other comments in this thread.
That's a hopeful hypothesis but I don't know of any data that supports it & I say that as a primary care physician who values sitting down and chatting with patients to understand what is going on in their lives over poking and prodding and running tests.
Fear of death and debility are closely tied to religion and much of the trappings of religion have been adopted by medicine. This occurs to the least (but some) effect in the sense of church as community, but it is community and social coherence that show the greatest correlation with unexplained variance in life expectancy. The current plateau in life expectancy in the U.S. has the greatest similarity to the decline witnessed as the Soviet Union broke up. It's no coincidence that the fall-off both in the USSR and the US was sharpest among those whose social status has increased the most in uncertainty.
I'd like to see "Life Expectancy at 40 by Country." Given that most people dying from medical conditions are old any way, you need to really improve your health care to make up for a few 20 year olds shooting eachother or getting into stupid car accidents.
Just checking Canada, it does seem to beat the US by a couple years for men at age 40 and 50.
Couldn't find a full life expectancy table for the UK, but at 65 they beat the US with 18.8 vs 18.09 additional years for men and 21.1 vs 21.07 years for women, although I think this is comparing pre-COVID vs. post-COVID data.
Depends on what you mean by "low hanging fruit." Banning fire arms will likely increase life expectancy more than a new treatment that cures Alzheimer's disease, but the latter is more politically feasible than the former, and there are ways I could see it even being more beneficial. (How do you weigh a quick death at 20 vs. a slow death at 80 where the person loses their self to memory loss?)
I would say so. Especially car accidents. The specific details on how to drive down car deaths really are available from Western Europe. Lots of tiny road engineering and car regulation changes, they can be applied much more incrementally than the gun stuff and there's no 2nd Amendment giving people the right to kill people with cars. No originalist will *ever* be able to show that the Founders wanted to protect their descendants' right to kill people with 2 tonne murder machines on state-funded roads.
Gun deaths require that you overcome the Second Amendment. Car deaths require that you overcome a century of path dependency. Not sure that the latter is actually easier than the former.
I would argue that it's easier for a number of reasons
1. The US has in the past managed to drive down car deaths with the same mixture of road re-engineering and car regulation (e.g. seat belts) so the path dependency is not as bad as you think
2. Legally you have far more room to work in
3. You really can work at this one interchange at a time, one trivial little regulation on car design at a time.
4. You can get results without having to cram down the numbers of miles driven, which is what most people want and need.
It's true the US will not reach UK of fatalities with American levels of miles driven, but it could save thousands of young lives every year
What happens to life expectancy when you break the data out by population density or some more direct measure of how much driving versus walking/biking people do?
I moved (back) to the US a year ago and have been slowly gaining weight despite eating nearly the same diet (we cook every meal at home) and maintaining the same exercise regime. Same with my wife. And our kids are getting noticeably fatter (they're still growing so they're always gaining weight).
One notable difference is that, instead of biking to work and school, we now drive and ride the school bus. And instead of walking to run errands and carrying our groceries, we drive and stuff everything in the back of the car. I think this is one of the frog-in-the-boiling-water things; it is absolutely jarring how little physical activity is baked into my new suburban American life as compared to my urban European life, but growing up it seemed totally normal to drive to a bunch of stores to run errands or sit in the school bus for 45 minutes twice a day.
All of the science on weight loss is very very clear that it's about diet and not really exercise. You'd have to almost kill yourself on a treadmill to burn even 400 calories, which is as much as a small sandwich.
If we're sharing anecdotes, I used to exercise constantly (I was on a competition BJJ team and also did powerlifting) and also ate quasi-unhealthy. Now I exercise much less but also eat very very cleanly- I weigh 25-30 lbs. less. There's not a ton of very clearly proven things in exercise science, but 'nutrition over exercise' is like the 1st Law of Thermodynamics
There was an article just the other day about how you need some baseline level of physical activity to see the health benefits of a healthy diet; one without the other is not sufficient. There are some quotes in there from people who exercise constantly and are surprised to find that they had a heart attack because of poor diet. That seems in-line with your anecdote.
But...if they eat the same diet that in Europe allowed them to maintain their weight but now causes them to gain weight, then the dearth of exercise is the most likely culprit. Even an extra 100 calories/day will add up to a pound a month. So I don't discount that in magnitude, dietary changes can *ahem* outweigh exercise, it doesn't mean the latter is useless, especially aggregated over a lifetime.
I'd agree with this as well. My diet isn't fantastic and I don't do a lot of deliberate exercise, but I do bike to work and walk to get groceries as well as using public transit for most other trips, which often requires a few minutes of walking in both directions. Because of that, I'm in far better shape than I think I have any right to be, and it's because my day-to-day naturally includes a consistent amount of physical activity
I think the mass consumption of heavily processed foods and sugars is potentially a big factor. I recently went on a ketogenic diet and it’s amazing how much better I feel. In my travels to Europe it was always noticeable how much less it seemed folks consumed the sorts of processed foods we do and with less frequency when they do. Sugar really is in damn near everything in the US.
Aren't nutrition and diet heavily researched? I would think we'd have some idea about the differing compositions of the diets in different countries, and not just observations and anecdotes (not saying your own observations aren't valid, mind you; I'd say the same thing about the way people eat here in China. I've yet to see my first Hot Pocket!).
From what I've read of it, most diet research is really, really bad. It relies way to much on self reporting and its very hard to untangle the observer effect. In fact, much of the dieting advice out there make use of the observer effect in that if you just start recording what you eat/calories, most people will naturally adjust their diet.
Interesting. I honestly have zero idea what to expect in this area. I wouldn't be surprised to learn a typical (say) Western European's diet is healthier than a typical American's. I also wouldn't be surprised to learn there's not all that much difference, health-wise.
Oh of course, sometimes I’ll throw out something on Slow Boring and someone will comment “Hey dingus, look at these 10 studies->see links!” and while I don’t like being called a dingus, it’s a small price to pay to have a smug but maybe more intelligent person with some free time give me the info I need to form a more educated opinion. It’s the real magic of Slow Boring! Long Live the Commenteriat!
I am in the apparently small minority of Americans who has decent health coverage and is not satisfied with American healthcare, despite being in good health. My complaints:
1. The administrative burden. If I am lucky, the provider bills the insurance company, the insurance company accepts the claim, and the provider accepts the allowed amount. If anything goes wrong, though, starting with the provider not accepting my insurance and me having to submit an out-of-network claim, it's a months-long process of threeway paperwork.
2. The record keeping. None of my providers know anything about the care I'm receiving from the others unless I personally request records from each and ferry them around.
3. The doctor shortage. My understanding is that AMA and Congress are to blame for the residency cap. I prefer to see nurses for primary care, because a nurse has more than 2 minutes to listen to you, whereas the doctor is seeing 15 patients per hour.
4. The uncertainty of it all. I'm an educated person and can explain the terms "deductible", "co-insurance", "lifetime maximum benefit", and "out-of-pocket limit". Even so, I have no idea what would actually happen, in terms of my finances, if I got seriously ill.
First world problems? Maybe! But my understanding is that other first-world countries have solved most of the above problems, with #3 being the most intractable (though for different reasons, obviously).
I also live in the US and have good healthcare coverage and visit doctors regularly for checkups and minor problems. Total time spent on all the paperwork per year is maybe 30 minutes for me. How much is it in your case and how many doctors do you visit per year?
1. One thing about the US is that the administrative burden is mostly on the side of billing and not on the side of interface with clinics or hospitals.
2. The record keeping issue in the US is the dumbest problem and one the face of it seems to me one of the easiest to solve. There was an episode of the Impact on medical records a few years ago. But what I remember is that although medical records are required to be electronic these days, the companies that make the electronic medical records software have incentives to make them the least compatible with the other companies' software as possible. https://www.vox.com/2017/10/30/16387306/american-medicine-healthcare-fax-machine
3. The doctor shortage is infuriating in the US (see above discussion on residency slots).
4. This is something that I don't really understand. What's uncertain? If you have a bad year with a lot of health care expenses, your out of pocket expenses will reach your OOPM (generally up to $8700/individual or $17400/family). Now if you can't afford this amount of money, then you're potentially in an unstable place. But unless you seek out-of-network care, your expenses for the year should stay within 8700 for an individual or 17400 for a family. (Now if you get a surprise out-of-network bill that's another story, but theoretically, we have the No Surprises Act Now to protect you for surprise out-of-network bills except for ambulances).
So far as drunk driving goes, one salient difference with a country like the UK is that they don't have any drunk driving. Instead, they have "drink driving", which makes them sound like jerks, except they don't have any jerks, so it makes them sound like poncy wankers.
I don't know how this bears on life expectancy, other than there's worse things than dying.
The density does make a difference though! Going to uni in Edinburgh I've never once had to worry about driving drunk because there's 500 pubs within walking distance of my flat, whereas whenever I'm home in Seattle it's super not obvious how I would meet a friend for a drink without one of us having to drive drunk or take the bus home at 1 am which i don't want to do
The fight against Drink/drunk driving in the UK was driven by a huge wave of public health campaigns in my youth, which seemed to have been really successful. Certainly by the time I was 20 it really was a big bad deal to be caught drunk at the wheel - social ostracism and vicious penalties (license gone for at least a year, fines, jail time - the works. For middle class crimes fear o punishment can be handy).
The fact that the US authorities are more relaxed about this is most evident in the fact that in some jurisdictions bars are *legally mandated* to have lots of parking spaces....WTF? What behaviour are they expecting, exactly?
One of the myriad cultural differences I've noticed between the US and China is: in the US, drinking and driving is basically considered ok. It's condoned. And in China it's much more strongly discouraged. What I specifically mean is: in America the taboo is against *drunk* driving. Not consuming alcohol and driving as such. It's perfectly normal in America for people to dine out, have a couple of drinks with food, and then get behind the wheel. Because, you know, they're not drunk. They've just had a couple of drinks. (Pretty plainly, dangerously large percentages of humans aren't good judges of whether they're impaired or not, especially if they've been drinking; also, even very modest amounts of alcohol reduce brain function, I think).
In China I haven't seen any mixing of drinking and driving. Indeed, if you drive to a restaurant and then decide to consume alcohol, you can text a service that will show up, and drive you home in your own vehicle. Very practical.
No doubt PRC legal sanctions play a role in the greater caution on the part of Chinese drivers. But it's a safer approach.
Sorry, that's right I should have clarified, part of the success of the campaign was recalibrating 'drunk' for the purposes of driving to more than a pint/glass, in line with scientific evidence that more than this is very dangerous. Somehow they managed to get through to my generation of beginning drivers that even one glass was a bad idea, given ou inexperience. I'm pretty sure a young alcohol-impaired driver gets and even longer driving ban. (In fact I think you have to retake your test as well, nowadays, to get it back).
Probably the Chinese system is similar? perhaps calibrated for Chinese people (in my limited experience) getting hit harder, on average, by smaller amounts of alcohol than Westerners
I certainly hope he didn't use -- gasp -- HYPERBOLE!
I learned the other week on this site that using hyperbole is an absolutely unforgivable sin that vitiates and undermines everything else the speaker says, and allows you to dismiss and discredit their authority on all other issues.
I love reasonable hyperbole, and wouldn't have mentioned this had I detected it. In this case (foolishly, in retrospect, I guess) I thought the "500 pub" claim was literal! And hell, maybe it is: I've never been to Edinburgh. The greatest concentration of bars I've personally seen in a small area was in Ho Chi Minh City. There's a nightlife district there (names escapes me) that reminds me a lot of George Bailey's nightmare vision of what Bedford Falls looked like in the absence of his existence. It was incredibly garish and beautiful at the same time. But at most I'd say say there were, like, 200-300 bars. (Though every single one of them featured unbelievably powerful neon signage to entice you inside).
Anyway, the point of the original comment was simply to laud Seattle, which, per my several month stay, seemed like a pretty walkable town with a lot of good nightlife options. I enjoyed it.
Seattle's good! And I'm intrigued to hear about Ho Chi Minh City, which I have never visited.
I also did not mean to single out you vis a vis hyperbole, since I don't remember whether you were one of the many commenters shrieking, fainting, and having the fantods when Phoebe M-B committed the sin of hyperbolizing. Read through the thread, if you have the stomach -- it's almost comical how often people say variations on, "I don't usually become hysterical when I read something written by a woman, but *she* used HYPERBOLE!!".
The weakest part of the article is the part on alcohol taxes. The reason I say this is that Americans drink less than Europeans on average and have a more restrictive alcohol culture (in large parts of the country, you can't buy alcohol at a grocery store, or in some parts only at a government liquor store, etc). In the US, water bottles are cheaper than beer bottles (unlike in parts of Europe...) Maybe changes in alcohol deaths in the US can explain some of the growing gap in life expectancy but I'd be surprised if it contributes to the absolute difference.
To the extent it's a factor I suspect it's more about walking versus driving. When I studied in Germany I drank beer every day and lost weight because I went everywhere by a combination of foot and train.
I mentioned the walking thing in another comment. I'm curious to what extent the fact that the US built environment discourages walking for day-to-day activities contributes to differences in life expectancy.
Not to sound snobbish, but I think it shows MY’s lack of experience of living abroad. These are the kind of differences that really strike you when you live in a place for a bit.
Now if I compare to Tel Aviv, where I live now, Americans drink way more. Alcohol here has a high tax ( and is quite expensive). At least from my experience, social life surrounds alcohol much less here in Israel than back home in the US. But if we are comparing health outcomes to European countries, who are known for plentiful and cheap booze as well as heavy drinking habits, then it's hard to point to alcohol policy being a significant contributor to the difference in life expectancy between Europe and the US.
Europe has alocohol culture but it’s different from American alcohol culture. E.g. much less drinking alone I believe. Israel has less alcohol culture , but also interestingly more permissive laws than us (well almost all non Islamic countries have more permissive alcohol laws than us!). I do wonder if alcohol laws in us aren’t a double edged sword. E.g. are European uni students - who can drink legally and who probably drank openly with their families in Social settings from childhood- as likely to be stupid in their drinking as American college students?
There isn't a single European alcohol culture. The Med countries have tourist destinations that are essentially identical to the stereotype about drunk spring breaks in Florida. Sweden has Systembolaget, a government-owned chain that is the only place where you can legally buy alcoholic drinks that contain more alcohol than a (low) threshold.
you're right, and you're wrong. I think Europe *does* have an alcohol culture in the macro, i.e. when compared to the ME or in some respects to the US (e.g. drinking age, and, I think, attitudes towards minors drinking in public, with family etc. though I may be wrong on the latter).
Now that I think about it, you may very well be correct!
I don't see some cultural differences between Americans from different parts of the US that actual Americans seem to be able to pick up. So in the same way I may be good at finding differences between Swedes and Spaniards that an American would never observe. I guess it's easier to see differences within a group if you are a member of the group.
Like if you ask me, having people learn to drink as minors with their family, so that they don't have to drink to excess in college/uni seems like a better plan than pretending that kids don't drink until 21, but having them drink behind closed doors or in secret till they pass out. But I don't know how much any of this contributes to life expectancy.
I'm not sure why, beyond a certain level of developed-ness, it would be counterintuitive that wealth as measured by more affordable gas and better washing machines isn't necessarily predictive of better health.
I don't understand this comment. Wealth—*any* reasonable way you describe it—is indeed predictive of better health. Isn't it? Rich countries tend to feature better health. Which is why the state of health in the United States is so frustrating.
Americans have undeniably responded to greater income by eating more red meat and driving further and faster in larger vehicles. None of that is good for your health.
The question is if other consumption is pro-longevity in a way that outstrips those vices of affluence. It's not automatically so at all income levels even if it very obviously is in the $1-$100/day range.
Vices of affluence? Everything I've seen suggests Americans are eating less red meat, not more. Ditto cigarettes. I think alcohol consumption has been declining, too.
Always is too strong of a word. It seems the optimal conditions for generally longer, healthier lives involve a mix of wealth and "good government". No place has everything - Norway is too cold, and Switzerland doesn't have the same levels of social trust the Scandinavians do (I'm pretty sure Swedes and Danes rate even higher in happiness than Switzerland despite being less rich than Norway or Switzerland). For whatever reasons, though, Swiss elites are presumably more out of touch (in such a diverse country, where even the German/French divide poses some challenges) than Scandinavian elites, but they do seem either more able or more willing (due to more effective institutional setups, maybe, or a legacy of old money noblesse oblige, or some combination) to maintain things in a way that just works better than American elites do. France is a more interesting comparison. They don't seem to have things as together as the Swiss elites and institutions do, and they aren't as rich, but they have some quality of life, stress-reducing factors going for them that make the country competitive with the US on life expectancy.
We (US) do things, including a cover-your-ass approach to healthcare, even (perhaps especially) at the VIP level, that are unbelievably stupid and inefficient, if you zoom out a little bit. Concerns about fraud accusations, being blamed, investigated or sued, and looking good and like you're "doing something (anything)" with your funds - as opposed to focusing on less visible long term investments in effective systems - lead people doing good work to have to choose between trying to *be* effective and trying to look busy and blameless.
Beyond a certain point of diminishing returns, I think on the margin it depends on the means by which you manage to achieve in higher levels of wealth as defined by GDP-adjacent or net worth-adjacent calculations. Even more nuanced estimates of true productivity gains don't automatically incorporate the value of, say, more people having close friends they can turn to for the sort of incidental life tips and informal help that's much more inefficiently and ineffectively delivered if you have to rely on paid professionals and the boundaries of formality that come with that, even for those who can afford it.
This is quite thorough and good. However it strikes me as odd that MY does not consider at all the role of the regulatory state. US is much worse than EU at regulating food. A lot of stuff that’s literally illegal to put in food there is common in us. A more important point perhaps is culture. Esp. American vs European diet and drinking culture. I think this latter point may well explain Italy’s exceptional life expectancy, for example. This, btw, is not merely about what you choose to eat, but what the stuff you buy even contains. American bread is almost a different product than European bread, for instance, and much less healthy (this is only in part a matter of underregulation). I’d also be really interested in exploring more Latvia and Mexico that seem from the tables to be underperforming relative to their wealth in ways similar to the us.
Maybe, but Europe makes a bunch of stuff "illegal" to put in food there that seems downright wrong to me and unrelated to health outcomes (GMO?)
I'd like specifics of what we think are the problem.
And sometimes it's not even additives. Soda is awfully full of sugar(well, High Fructose Corn Syrup) and "empty" calories - but.... so is regular fruit juice. It's got a few advantage over soda but it's still extremely sugary, without adding anything.
I don't even know who wants America's weird desserty sweet bread. I have never met a person who likes it more than a nice robust bread with a more natural flavor (and I live in the South!)
Fair!! And if I’m looking for bread to have on the side of a delicious pasta marinara dish, it ain’t Kings Hawaiian. They are practically donuts. (But I have had a grilled cheese sandwich made with a literal donut too, sooo…)
It's not doubt that the standard American diet is not good for us. I'm a bit skeptical that the food additives that the US allows but Europe does not play a huge role though in differences in life expectancy.
But overall food environment and food culture can play a large role. Eating more fruits, vegetables, fermented foods, whole grains, legumes. Having higher fiber intake. Eating more fish and omega-3 fats. Now I don't know to what extent Europeans are better than Americans in this (I was just in the Netherlands for a week, and I would hardly call its cuisine "healthfood"!). But generally, I would agree that the food environment in the US is not conducive to making healthful food choices on a daily basis.
Mexico's under performance is presumably related to the low intensity conflict related to the war on drugs that's been ongoing there for like 20 years?
Latvia is presumably related to having the highest alcohol consumption in the OECD.
I’m not sure life expectancy is the right metric. Every one of my grandparents (and step grandparents) lived too long. One had alzheimer’s for twenty years, one was blind for three years and acutely miserable her last several months, one told me “I’m no use any more but don’t have the balls for suicide.” None of them were happy their last year.
Murders, fatal auto accidents and obese 55 year olds having heart attacks are bad. I’m more interested in the proportion of the population that lives to 75 or 80 than anything else.
You make a great point, and I'm sorry about your grandparents.
There's a book called "The Blue Zones" by Dan Buettner that talks about how to increase healthspan (the number of years you are fit and healthy), not just lifespan. Highly recommended!
It would be interesting to compare rates of loneliness between US and Europe, especially as people become older, since social isolation is strongly linked to a variety of poor health outcomes (up to and including suicide).
And certainly our land use is a big input into this, as sparse car-centric development combined with high housing costs generates a max-alienation scenario of stymied communal interaction and families that have been forced to move far away from each other.
The early cancer screening stats seem to me like the exception that proves the rule. Maybe cutting edge research has changed, I’m a little out of date on this, but my impression is you see very little benefit longitudinally from prostate and breast cancer early screening. It improves the five year survival rate because you detect and remove cancers that never threatened the patient within in a five year time horizon. So you are just booking a lot of wins that other systems book for free.
Very curious about footnote #3: “The other interesting thing here is the very large gains in Black life expectancy over the past generation. A lot of this is the decline in crime and improved treatment for HIV/AIDS, but that doesn’t fully explain it — some other stuff is getting better.”
What’s the other stuff? Just one more sentence, please?
Pre-pandemic Black Americans hit their lowest poverty rate ever so I'm sure that has something to do with it. Also I wouldn't be surprised if this is a weird consequence of the housing crisis. A lot of poorer, traditionally black neighborhoods now have a not insignificant number of wealthy white residents who can support stores selling actual food and not just processed pre packaged meals etc.
I wrote a long reply elsewhere in today's comments on how Asian and Hispanic life expectancy numbers are probably pushed higher by immigration. Something like 1 in 10 Black Americans are now immigrants, so I wonder if some part of that improvement is simply the rise of Black immigration. If it is, some of that improvement may be due to the immigrants having better health than the native-born, but some of it may be just data collection problems as I elaborated on in my other reply.
It’s cliche/overly simple, but certainly America’s culture of individualism/liberty/“muh freedoms” or whatever you want to call it comes into play. Americans of both parties place high value on allowing other people to do what they want, or at least they themselves being free from the moralizing and micromanaging of people who think they know better. And the clear outcome at a societal level is, people die. Now I sound weird and authoritarian. But it’s pretty simple- most moral pressure in groups is rooted in the idea that if everyone did X, we’d see better group outcomes, even if individuals might feel a little stifled. It’s easy to see that on things you agree with- “if no one had guns, we’d have fewer deaths!” vs things that code as “the other guys”- “if no one had sex til they were married, we’d have fewer out-of-wedlock kids and they’d grow up in more stable homes!” (See also Nellie Bowles’ piece on liberals who fight for the right of people to choose to die on the streets of SF.) Anyway I could go on and on here. But your thesis is refreshingly straightforward- what can we do from a *policy* perspective? And I just caution that any policy that aims at expanding life expectancy runs the risk of being coded by the voters as “nanny state thinks they know better than me how to run my life!” which is political poison in our culture. That said I think it’s possible to thread the needle, and your ideas aren’t bad. But gas and sugar taxes won’t be popular. (Also I thought this piece was very interesting and well-done and I learned quite a bit!!)
I'm firmly in the category of American who finds Matt's analysis in this piece disquieting, not because it is wrong, or that there is nothing that can or should be done about any of these things, but because this sort of technocratic statistical approach does in fact disguise serious value judgements that are implicated. There are many policies that will raise life expectancy that are not the place of the state to act upon, and many of them that the pursuit of poses a true threat to the pluralist, liberal, egalitarian state ideal that free society should be working towards. Even the most benevolent version of the crushing police state required to truly smother violent crime is not a trade off worth making. The version of this logic where we are banning food on the basis that it's carb content imposes a burden of Medicare is not a trade off worth making. A version of America where the average American drives a number of miles more line with the average European is totally ludicrous pipe dream that the strong version of pursuing would absolutely implicate a state so totalitarian it would be difficult to comprehend. These are not trivial concerns and every individual case demands careful understanding of tradeoffs. Prohibition? Nightmare. Drug war? Nightmare. Policing? Maybe more money for better cops, but more of what we have now? Nightmare. The technocratic urge to "solve" these problems is an extremely dangerous one.
“ A version of America where the average American drives a number of miles more line with the average European is totally ludicrous pipe dream that the strong version of pursuing would absolutely implicate a state so totalitarian it would be difficult to comprehend. ”
Huh? Matt’s whole approach is to reduce regulation - zoning, parking minimums, etc. One of the main reasons we drive so much is heavy handed state intervention in the economy.
Sure, Matt's actual housing stuff is pretty well calibrated. I almost always agree with it. But the logic of "Americans die more because they drive too much." also gets cited by the #BanCars people. And as Matt noted yesterday, extremely dense urban living is a very minority preference in America.
Things like housing and a carbon tax are examples where Matt is really good on this stuff. When Matt is at his absolute worst is when he starts giving into his 90's era "tough on crime" and nanny state(porn, alcohol, etc.) impulses.
“ And as Matt noted yesterday, extremely dense urban living is a significant minority preference in America.”
At current prices, sure.
Big picture it’s a mistake to assume that the current situation is the natural state of the world. Absent heavy handed regulation, how we live would be quite different.
I'm 100% on team zoning is evil. I don't at all buy that anything like a majority of people will organically agglomerate in high density, carless, urban living situations even in the most accommodating regulatory environment
Your use of the term organically is also interesting. I was reading the other day that at one time the vast majority of America’s transportation infrastructure consisted of privately owned railroads, street cars, etc. And these businesses were the largest payer of property taxes in many areas. With the advent of the car the choice was made to not follow the railroad model of privately owned infrastructure but rather to make this new infrastructure publicly owned. This obviously put the property tax paying railroads at a huge disadvantage.
If we rerun history and let roads follow the existing railroad model the organic growth would be very different.
I notice you said carless. That sort of phrasing implies, at least to me, some kind of restriction. When the actual issue is that anyone can have a car if they want one and many people do. It’s just that you don’t have to have one to do the vast majority of daily activities.
Not specific to you but a lot of comments imply that not needing a car means you can’t have one. Which isn’t how it works.
I think Matt does a very good job of aiming for a libertarian-friendly version of this, where we don’t prohibit but just tax and nudge a bit, and don’t try to eliminate causes of death, but just try to find the cost/benefit trade-off.
Matt does a great job identifying opportunities to advance economic redistributive goals in ways that leverage rather than disrupt market forces. That's Matt at his best. Matt at his worst is when he goes to throwback 90's, nanny state, technocratic paternalism and tough on crime stuff. This article is the thinking that bridges the two.
Well said. This is a case where I'm glad a ton of comments got in before I could get to reading today's article, because otherwise I would have likely commented more glibly along the lines of "If this is a leading reason why, then it doesn't particularly upset me.".
I agree. Maybe your problem is his word "priority"
Each of these areas raise policy issues with costs and benefits to different regulations and or more or less expenditures.
“ Is food so much worse?”
Yes.
There is a very compelling case to be made that something was added to the food supply c. 1980 that caused the explosive growth in obesity.
https://slimemoldtimemold.com/2021/07/07/a-chemical-hunger-part-i-mysteries/
May also correlate with reduced smoking rates. Nicotine is an appetite suppressant and cessation causes weight gain. However, things are sorting a bit different now since being a non-smoker is largely bundled with other healthy habits and factors instead of representing a broader sample of society. Of course, this doesn't exclude other environmental or dietary factors.
https://www.statnews.com/2016/02/05/are-fewer-smokers-obesity-rate-linked/
No.
Setting aside the veracity of the site referenced here, the idea that an entity or entities collectively added "something" to "the food supply" (by "someone") that caused the growth in obesity is absurd on its face.
This is where someone will mention high-fructose corn syrup, but the "HFCS made everyone fat" is an urban myth.
NATURE, 18 September 2012:
Citation 1: The use of HFCS grew rapidly from 1970–1999, principally as a replacement for sucrose. HFCS usage in the United States peaked in 1999 and it has been in decline since that time. At its peak, HFCS was still less consumed in the United States than was sucrose, although sucrose did have a significant decline in usage during the time that HFCS usage increased. Worldwide, sucrose is still the dominant sweetener with over nine times as much consumption as HFCS.
Citation 2: "The hypothesis that the replacement of sucrose with HFCS in beverages plays a causative role in obesity is not supported on the basis of its composition, biological actions or short-term effects on food intake. Had the hypothesis been phrased in the converse, namely that replacing HFCS with sucrose in beverages would be a solution to the obesity epidemic, its merit would have been seen more clearly. Put simply, a proposal that a return to sucrose containing beverages would be a credible solution to the obesity epidemic, would have been met with out right dismissal."
Obesity is caused by a calorie surfeit. Calorie surfeit means you are eating more than you are expending. Eat more, be more sedentary, you get fat. A variety of factors led to exactly that for many people.
One thing that changed around 1980 was the rapid increase in cable TV adoption, resulting in way more TV watching (since there were many more options, aimed more specifically at audience segments).
Another factor was the rise of home video games, the personal computer, and later the internet and related technologies. Plus encouraging or allowing kids to stay inside at home because of "stranger danger" or similar fears, instead of letting them/forcing them to play outside.
If food has changed, it is only that processed foods have gotten cheaper, more caloric, and less nutritious -- and there are more of them, and they are more aggressively marketed. Portion sizes have continued to grow (check out the evolution of sizes of things like popcorn and soda).
Changes in societal mores about cooking at home and "eating stuff you don't like" have also had an impact.
There's probably also something to be said about the whole fat shaming/acceptance thing, but that feels too recent to be a significant factor.
“ the idea that an entity or entities collectively added "something" to "the food supply" (by "someone") that caused the growth in obesity is absurd on its face.”
How is it absurd? They started giving livestock antibiotics because through processes we don’t understand they put on weight. The humans that ate those animals also started putting on weight. That doesn’t strike me as absurd on its face.
People didn’t used to overeat. People could have gorged in the 50 up through the 70s, they just didn’t.
They did for the US. One bit of evidence is that if there was something new used in agriculture you’d expect to find higher rates of obesity in places where agricultural runoff tends to accumulate. And that’s what you find.
Car culture is a huge issue. I moved from a dense city to its suburbs in 2021 and I still try to ride my bike for most trips within a 4-5 mile radius. I feel like I'm the only one, or at least one of a very very small group of people. Can't even find a bike rack most places.
They’re living in villages where they can walk to a few shops. Rural Americans aren’t.
When you say “culture” I see “the built environment” and “the economy”, which are hugely shaped by explicit government policies, in addition to whatever component of culture is independent of structural forces.
Is it true that people before the 1980s worked out more?
There was far less activity that was explicitly “exercise” but probably a lot more activity built into daily life.
Not sure what the stats are on this, but anecdatily I grew up in the 70s and 80s and, though I was not especially athletic, was extremely active. There were far fewer screen options, and before helicopter parenting was a thing, kids just went outside and ran around playing. We also had to take gym. I recall some chubby kids but very few, if any, obese ones (also few obese adults). And this was the meat-and-potatoes Midwest!
Portions were definitely smaller, though my mom hated cooking and did as little as possible. I ate a lot of garbage frozen food (Lean Cuisine, Stouffer's French Bread Pizza, ugh) but not huge amounts of it.
If anything the probably "worked out" less in the sense of doing some activity for the sole purpose of physical exercise. But they were probably generally more active. Fewer people worked "desk jobs", there were many less compelling sedentary activities to spend your leisure time doing and generally fewer labor saving devices (riding/self-propelled lawnmowers, dishwashers, etc)
Most kids were fairly fit but hardly “swole” or “ripped” as we would now say, and most adults, at least in sedentary jobs, were “skinny fat,” as we now call it, but not fat.
We are now pressed to be either “paunchy” or “ripped” and no middle ground.
This is consistent with my "lived experience!"
Liberty doesn't "just" do this. It *can* do this, and crime is certainly the best case to make. But that's not the sum of it. Positive liberty is important, but so is negative liberty. We need both in a healthy society, and the answer to swinging too far to one direction must not be swinging too far to the other. Individual rights are super important, but they are not the be all and end all, or rather they should be understood in a holistic and sophisticated manner, that realizes e.g. that "dying with your civil liberties intact" is - in many circumstances - absurd and paradoxical. I think the northern European model, combining strong welfare state protections, redistribution and high levels of social trust and solidarity with social openness and tolerance, free speech, political liberty etc. is a good example of how to have your cake and eat it too so to speak.
I certainly think there's things that can and should be done to alleviate more of the harms of crime that inescapably fall disproportionately on the vulnerable. What I think I fundamentally disagree with is the notion that the burdens of aggressive enforcement against social ills has, or could ever, distribute in some more equitable manner than the burden of individual responsibility. The overdose epidemic is incredibly bad, but it's vastly more equitable than the drug war is, and I think that's the core of my consideration. Some baseline level of burden of individual choices is unavoidable and always preferable to the heavy handed imposition of burdens from the state apparatus. Good solutions demand a balance that implicates real value judgements on these things not simply a commitment to reducing bad statistical events to zero.
"the overdose epidemic is incredibly bad, but it's vastly more equitable than the drug war is, and I think that's the core of my consideration. " Can you please elaborate and unpack this statement?
Clearly economic resources provide some capacity to ameliorate the challenges of addiction/recovery, so that burden does not fall on individuals in purely equitable fashion, but the overall distribution of badly prescribed pharmaceuticals, along with the whole deaths of despair thing, that drives the current dynamic of OD deaths largely does. The impacts here fall heavily all across socio-economic and racial lines.
The impact of the drug war by contrast, has been almost entirely on targeted urban minority communities where oppressive enforcement destroys lives, families, and perpetuates the ghettoization of the redlining and school segregation schemes of old. It's been incredibly, overtly racist and destructive, promoting violence, poverty, mass incarceration, and ceaseless violation of civil rights almost exclusively among poor, urban minority communities and is almost entirely responsible for the vast, horrifying shit show that policing has become in this country.
It's not even remotely defensible to argue that criminal drug enforcement has equitably benefited the populations that have been targeted by it. It's the primary, go to, tier one example in action of exactly how this line of "_______ is bad. We should do something to stop ________." goes horribly, horribly wrongly off the rails without careful consideration of how to pursue such goals.
It is important to distinguish policies that deal with externalities (masking, vaccinations, taxation of net CO2 emissions) from those that are paternalistic (seat belts, sugary drinks/tobacco taxes, drug commerce criminalization). Some of course are both.
But the common externality of them all is “societal health and human flourishing.” It’s easy to extrapolate the externalities of things you care about and diminish those of ones you don’t.
I mean by "externality" something than more obviously harms another person, like my CO2 emission flooding the fiends of a Bangladeshi farmer
I mean, I’m being somewhat obtuse, but the American culture/attitude that suggests I shouldn’t impose any kind of moral weight on others’ choices that don’t personally affect me is the whole point I’m trying to make about why our life expectancy might be lower. Other cultures have no qualms pressuring people to do things like lose weight or avoid drugs because it’s good for the other person, and society at large. I think Americans are unique in having a sort of taboo against this kind of moral policing. And, like, maybe that’s the cost of freedom, lower life expectancies! But they seem linked.
I don't necessarily disagree with this thesis in terms of needing more nanny-state like interventions and the collective spirit that goes along with them to improve health outcomes. That said, what explains the fact that the life expectancy situation has gotten FAR worse in the US since ~2010? as shown on the graph? It is common for the left to talk about everything getting worse with Reagan, but there's a clear inflection in the curve in this article since 2012.
There's been a bit of a push on the Left for what I would kind of call a left-social conservativism... saying sort of that the decline in religiosity is a problem, etc. But European religiosity is really low, Norway has like an 18% church attendance rate. There is also the "deaths of despair" theory from Case and Deaton that economic hollowing out of certain areas has resulted in social breakdown and more overdoses and suicides.
But really the only "despair" metrics that check out are the ones that relate to health and death. Huge chunks of the developed world for example have negative fertility rates and substantial outmigration.
I listened to Ezra Klein's podcast yesterday and he sort of said that people are moving further away from their hometowns and having smaller families, and this means weaker support networks and worse health (this was more as pertains to mental health but I've also seen it posited for all forms of health). But people are not moving further away from their families and families in the US are a lot bigger than in Italy or Japan which are averaging like 1.3 children per woman.
So IDK. The "individual cultural" explanations probably have something to do with this but I'm not sure how...
Well, in the spirit of Matt’s “now more than ever!” segue, I’m inclined to say the correlated cause that happens to be my pet topic is the increased polarization accelerated by social media since 2012. More and more, Americans map any position onto a two-party framework and interpret it as “good” or “bad.” But now even things that are objectively “good” for you are being filtered as “bad” bc it’s the other guy saying it. The obvious example on the right is Covid denialism, but also gun culture. On the left, it’s stigmatizing any discussion of the downsides of obesity, drug use, gang violence, etc as bigoted. Seems like opioid use is the only topic that both sides feel is uniformly bad and those affected as sympathetic characters, though I think many on the super-left have grown more numb, “you only care bc it affects white people, where was your concern during the crack epidemic?”
I do tend to think certain mental health issues may be partially attributable to widespread smartphone use but this makes the international comparison confusing.
I'm a little unclear on how this differentiates us from Europe... the politics around Brexit are probably crazier than any issue in the US.
Assuming that the decline in social pressure and rise in obesity are correlated, it's not actually obvious to me which way the causality runs. Did social pressure to maintain a healthy weight decrease causing people to get fatter, or do people get fatter making the social pressure to maintain a healthy weight untenable?
What ? The socialist Scandinavian countries and the COVID-hawkish Australia New Zealand etc are “similar in Individualism to America “??
The Scandinavian countries are usually higher than the United States on various freedom indices (like that of the Heritage Foundation: https://www.heritage.org/index/ ) than the United States is. They are better described as “neoliberal” than “socialist”.
It depends on how you define individualism, I think.
I -suspect- that a lot of the social scientist types like to define it form a cultural-issues rather than economic perspective.
More on 'openness', rather than support or disapproval for a more intrusive govt.
Also I’d like to see a more rigorous definition of this other kind of “individualism” that’s supposedly common to all those places but not to “Asian countries” or at least a good example.
But the question is what’s the relevant definition for the purposes of the disco at hand. I’d say the differences here are super pertinent for life expectancy.
I personally doubt that the Scandis are more 'individualist' from an economic/state perspective.
And that's probably what is relevant.
Cultural openness probably isn't.
I don't think that 'survival vs self-expression values' translates very well to 'collectivist vs individualist'...
But it is interesting that the US is kind of an outlier.
I wonder if it is simply due to immigration from a lot of those cultures that are more leftward on the map?
I've found that the CDC's life expectancy numbers are not always as trustworthy as we might assume, and the gap between Asian and non-Asian American life expectancy may be smaller than the numbers show due to data problems.
I really thought footnote 1 was just going to say "Fuck Yeah".
missed opportunity for sure
get out of my head
As I've written many times here, I'm a European living in the US who is very cranky about American healthcare but thinks that the US is doing much better on most other metrics (which is why I'm here and not in Europe in the first place).
So, when I saw the part "A common left-wing knee-jerk reaction is [...] really is worth a pound of cure." I wanted to complain that a good healthcare system is all about being able to go at least once a year to a family doctor just to discuss what's going on in your life, get prescribed some routine tests, and get back to discuss the results with the doctor. That's probably the same doctor that has been seeing your parents since forever, so there is a lot of trust involved here, and that doctor does have credibility to tell you "Hey, you need to cut down on this and that.".
But I see that our host covered that part later in the post ("A big open question in the research, [...] the healthcare system is plausibly a factor."), so I don't know why he dismissed it previously.
I don't think I know any American below 30 who goes to the doctor for a couple of conversations like the ones I described at least once per year. I spend few weeks per year back home, and I still make sure to make time for these conversations. I would be surprised if that part of the American healthcare system, where you essentially get penalized financially for being proactive about your health, doesn't have an effect on things like obesity.
edit: And I should add here that Matt had a nice post about how the more entrepreneurial and profit-driven American system basically unleashed the opioid epidemic. Shouldn't at least some of these deaths be classified as healthcare system related?
I'm curious to hear from Europeans about their experience with health care.
I'm in Israel, and I just had a surgery and a two-night hospital stay. And I didn't have to pay anything (beyond my normal health insurance premiums). So I see the appeal of publicly-funded systems compared to the US! The fact that everyone has access to baseline health coverage is essential!
But! There's also the user experience. To get this appointment, I had to deal with a bureaucracy that was unlike anything I experienced in the US. In the US, you could call an doctor's office, and someone would pick up the phone. You wouldn't be put on hold for an hour, and then transferred endlessly until the line disconnects. In the US, you asked what appointments were available, they'd tell you the options and you'd schedule it. My experience in Israel was that you'd send in your referral for an appointment, and they would get back to you within 10 business days, and if you didn't pick up the phone exactly when they called, you were screwed. They'd assign you an appointment without asking your schedule. And sometimes the referrals weren't processed until you called, waited on hold for an hour, were lucky enough to get someone who answered, and pestered them to process your paperwork. Often they'd give you a date several months out (that you didn't choose), and you'd have to call back and wait another four business days to see if anything sooner opened up.
Then when you'd see a doctor, it was a this short, rushed, in-out visit, without the opportunity to ask as many questions or talk in as much detail about my health with the doctor. In the US, generally, the nurse (after taking your blood pressure and other vitals), asks you a lot of detailed questions before you see the doctor, who looks over your file and the report from the nurse before they see you. In Israel, you immediately go to the doctor, who hasn't looked over your file at all, and you have a few minutes to talk to them.
I'm wondering to what extent these experiences are common in other public-systems.
So, I am all for universal access to health care. But there are aspects to the US medical experience that are superior. Being able to call a doctor, schedule an appointment, without spending hours on the phone. And when you're at the doctor, not being rushed out after a couple minutes.
You're very much cherry-picking the good side of the US system.
The bad side is the unending discussions between hospital, patient, and insurer over pre-authorizations and out of pocket expenses for necessary procedures, the weeks spent on hold sorting out basic billing errors because your insurer's procedure codes are just that little bit different from the other four which have agreed on a standard schedule in your state, or the outright false denial of claims that result in you receiving a $30k bill and a heart attack even though something is actually fully covered.
I honestly think if the insurers were forced to compensate their policyholders at minimum wage for time spent resolving insurer and practitioner errors in billing most of the smokescreen/bullshit would mysteriously disappear.
Yes, I have also experienced that in the US! Arguing over a surprise bill from an ER visit between my insurance company (who processed the payment incorrectly three time), the hospital, the third-party provider that contracted with the hosptial, their former billing team that was responsible at the time I had my care, and their current billing team,. Yes it was a nightmare. But it all occurred AFTER I had my care, and didn't prevent me from getting the care I need. (It did have the potential of forcing me to forfeit the $770 they wanted to over-charge me!)
but it *would* make you think twice about getting the care in the first place if you were a bit poorer, perhaps?
You've never dealt with pre-authorization requirements, then,
And also, what THPacis says below.
...you're right, sometimes you had to deal with pre-approval...
And 100% You don't have to convince me that the US needs health care reform! I also had bad experiences in the US. Once my insurance just flat out stopped processing payments to a provider for no reason, and the provider refused to see me unless I paid several thousand dollars (which they weren't legally allowed to bill me because I was in-network). It's bad, and it shouldn't work like this!
I am just saying that I lived 29 years in the US and 3 years in Israel. And the user experience of making an appointment and going to a doctor was generally better in the US that it has been in Israel. Yet Israel has a much saner system by all merits.
And a fortiori considering your Israeli equivalent in terms of education level and income probably has a better (perhaps significantly better) experience.
Also, for ER specifically I would imagine pre-care admin issues wouldn't be that different between the systems anyway.
Not to mention not even knowing how much something is actually *supposed* to cost you before doing it. And the beauty of those who actually have to choose their health insurance and good luck figuring out which one would screw you over less.
Important caveat: There isn't an EU healthcare system. Each member state has its own approach, so your mileage may vary. (Incidentally, this is why I don't think Medicare for All is a good idea. I would prefer that Congress somehow forces each state to take care of its residents, but allow each state to choose its own approach to the problem.)
Thankfully, only one person in my close family needed surgery relatively recently (in the past decade or so). We took her to a private hospital and paid almost everything out of pocket (we got some small reimbursement roughly equal to what a similar operation would cost within the universal system). "Wait a minute! How is this a good example of universal healthcare?" you might say. Well, you have a much much much better bargaining position when discussing price, if the private hospital knows that the public system exists, so paying almost everything out of pocket isn't as terrible as it would have been in the US. My understanding is that private hospitals back home have much shorter waiting times than private hospitals in the US, as well, because they don't have to provide healthcare to everyone.
Crucially, I know of no system in the EU that is a communist utopia where everyone gets the same terrific treatment regardless of ability to pay, and that's okay. I'm just happy that everything (including private out of network healthcare) is much more affordable than it is here in the US. (Well, not that happy, because I currently live in the US, but you get the point.)
Right of course...in Europe there's not a single health care system, and systems vary from country to country from fully public to fully private, yet regulated.
But this aspect that you're talking about, about the interplay between the private and the public system that you discussed is really missed in the American dialogue! And the reason for it is that we always compare to Canada, which does not have a private system!
I agree! Having some (fortunately not much!) experience both with a European system where the government directly owns hospitals and employs doctors, and with one where everyone has mandatory private insurance, I would say that my personal preference is a publicly owned system alongside a private system regulated only for safety. All these regulations that the US has for "affordability" (like forcing private hospitals to provide services to people who can't pay for them) increase the cost for everyone. I don't have specific data to back this opinion though, so take it with a grain of salt.
This is also what I was alluding to in my comments. Note that similarly the prices of drugs *before* insurance are drastically cheaper than in us.
I think you have to take into account that your comparison isn’t apples to apples. In the us you were part of the in group and in Israel the out group , as I understand ? Presumably not speaking the language and not raised in the culture ? This doesn’t change things like the need for refrrals but may well have more subtle consequences on how smoothly the process goes. Also many public healthcare systems , including Israel’s incidentally, are mixed and allow certain shortcuts for people willing and able to pay and who know what they’re doing. This of course advantages the relatively privileged (educated, middle class or above, native born) at the expense of the less so (poorer, immigrant or foreigner etc).* But of course us has these problems on steroids.
*the justification is that it helps keep the middle and upper class buy in to the public system and keep good doctors in it.
So it's true I have insurance for foreigners and not the full HMO insurance that citizens get. But from talking to enough Israelis, it seems like my experience is pretty common if you're dealing with the public system (it's not really one public system here, but 4 publicly funded HMOs, of which people belong to one...Also not to disparage the system here too much, it is still one of the best in the world in terms of health outcomes). I guess I'm curious if it's like this in Europe in countries with a public system...
Many of my friends here just told me to do it privately to not deal with these hassle of the public system. (Citizens here would have the opportunity to buy supplemental insurance that may cover some private services). And yes, many people here complain that the expansion of the private system has made the experience of the public HMOs worse.
The thing is, it’s not actually a dichotomy. The “private” system supplements the public baseline. Thus, it’s drastically cheaper than in the us. It’s also affordable to the middle class, at least in its basic forms that would allow to cut much red tape eg in waiting times for operation, allowing you to choose your doctor etc. also it’s the same doctors in many cases. This is important from a policy standpoint. It’s possible that the private stuff makes the experience of the public system somewhat worse but it may also allow it to keep functioning. It’s not like it’s a genuinely separate and competing domain like private vs public schools.
Edit: I suppose it’s more akin to perks you pay for at the airport to cut time in security or get more leg room than a private jet (which would be the us model).
Cost, yes, the system is more affordable.
But (at least in my recent experience), the user experience is also worse. (And my understanding is that the experience for the doctor is also worse). And for the patient, I'm not talking just about wait times for an operation or ability to choose your doctor. But I'm also talking about administrative burdens to get an appointment and your experience in the doctor's office. Now it could be that a positive user experience just isn't that important for good health outcomes. But I don't think that Americans will put up with a system with the administrative burdens that I've just experienced in, admittedly, one of the "best healthcare systems in the world".
What I'm saying is that to some extent, paying a bit extra may be worth it. (Though not to the extent that the US pays extra...)
I think if you're quite wealthy (mid or perhaps high 6 figure salary) the us system is better for you. It's probably worse for everyone else. All things considered. In other words, it's worse for 99% of the population.
your point is well-founded. Some of the healthcare companies (such as Blue Cross here in Georgia) have services which incentivize you (via partial rebates for your insurance payments) to get a physical, get a biometric screening, talk to a wellness advisor several times, on an annual basis. Maybe that will help with wellness visits in general
My insurance company has an incentive where if you don’t do a “wellness visit” each year, your insurance premium goes up by $30 a month for the next year. However, this “wellness visit” can’t be a visit that is scheduled for some other reason, since it has to be coded as a “wellness visit” on the insurance form, and it has to happen by a particular month.
I’m usually a huge fan of these paternalist nudges, but seeing the implementation of this has made me much more skeptical.
I have a typical corporate health-care plan and everything preventive, including an annual "wellness visit," is 100% free to me.
For what it's worth, I'm under 30 and I do see my doctor (ok, technically nurse practitioner but I really like her) once a year for a physical exam. And my insurance company doesn't even require a copay for the physical!
If the progressives want to expand universal healthcare, a good place to start would be for yearly doctor checkups and other forms of low-level preventative care.
That's important, but the other important thing is to fix the problem here where your insurer can unilaterally change which doctors you can see, or your employer can change insurer, which also unilaterally changes which doctors you can see.
Mandated Unitary Rate-Setting.
What you charge to Medicare is what you charge to Blue Cross is what you charge in cash, and all of it is public.
Sure, Medicare costs will go up, but I suspect everything else will fall a lot more, and so much of the rent-seeking will get squeezed out.
Utterly unconstitutional. Would be literally laughed out of court. An unserious proposition
I mean… as with basically every other federal regulation of the economy… “interstate commerce”. Hard to find hospitals with no occasional out-of-state patients or who do business with out of state insurers for employer-sponsored plans.
And in instances where that doesn’t hold up, “knuckle under or no public money ever flows through your doors”.
And there is damn-all stopping a state government from doing this.
Sure, the current Supreme Court will bend over backwards to knock down any federal initiative, but that’s out of an ideological commitment to elite rent-seeking, nothing else.
The judiciary is not going to allow just anything because the executive yells 'interstate commerce!', like Michael Scott yelling 'I declare bankruptcy!' The SC has struck down several uh creative interstate commerce stretches over the decades, including in US v Lopez, US v Morrison, etc. The 'no public money' is obvious extortion, the judiciary isn't dumb man- they're going to strike that down in a hot minute too. There are no states where the government can just do an uncompensated taking of 20% of the economy, they all have state constitutions with basic 1st world property rights in them, etc.
These kinds of schemes are why like Honduras, Zimbabwe, the Philippines etc. are 3rd world countries- just the government randomly deciding one day to set price controls on one-fifth of GDP. Let this one go dude
Lol, “price controls”.
Unified rate-setting doesn’t mean “gubmint sets the price” it means “you negotiate a single price with Medicare and private insurers at the same time”.
If you wanna armchair lawyer your way to unconstitutionality, ok, but there are plenty of contexts in which price discrimination is disallowed and the Constitution doesn’t bat an eye.
I’m out, bye.
I thought the thinking now is that an annual physical is not that beneficial?
To elaborate, the prompt 'I havent been feeling quite right, doc...' visits are probably more important for general (and minimal) annual screening.
And those are the ones that cost money under the current system, as opposed to the annual check-up.
Right. I should have explicitly called them out instead of lumping them in under 'preventative care' in my original post.
This seems to be a case of “it’s not the plan, it’s the planning!”
I would think that more is included under preventative care than just that.
That’s my impression too. And in addition to the lack of personal connection, it’s even becoming more rare to see a fully trained doctor (I.e. MD) when you do eventually need to see one. Increasingly you have to make do with a nurse practitioner (also referred to as “doctor” - unless you inquire nobody will even tell you you’re not actually seeing an MD !). I have nothing against the the NPs, but why couldn’t they just open more places in med schools to allow ambitious nurses (or others) to get the full training and solve the shortage problem?
From what I understand from my med student friends (more-informed commenters welcome to jump in here) the limit on minting new MDs actually *isn't* so much controlled by the inability to open new medical schools as it is by the fact that government somewhat mysteriously controls the training of new doctors by subsidizing residency slots such that "the number of residencies" (i.e. the number of subsidized residencies, unsubsidized residences seem to be almost nonexistent) is effectively capped at like 20,000 per year instead of being market-set.
From the outside view this system makes no sense: as I understand it, residents are extremely profitable for the hospitals that employ them--not least because they're paid peanuts, (like 50kish a year in NYC spending your time in some cases caring for gunshot victims in the ER on a near-nightly basis[1]) -- but somehow the federal government's subsidization is a load-bearing part of the system even though it seems like it should work under a pure private market model.
This is even weirder when you compare it to law (specifically Biglaw): first year attorneys need a lot of supervision (just like residents need attendings) but they're paid quite a bit because they become profitable for their firms later on. I guess it's more common to switch hospitals after a residency but it's not like attorneys never change firms. The model is entirely market-based, requiring no explicit subsidy (beyond federal student loans, but medicine is the same way) and as a result there's no (corporate, big-firm) lawyer shortage.
TL;DR: I'm pretty confident it's not a "not enough med schools" problem, it's least in part a "not enough residencies" problem, and as to why residencies are so limited and the federal government is involved in subsidizing them and the market can't or won't work around it: ¯\_(ツ)_/¯
[1] Not an exaggeration, I knew someone who did this
Correct = cap is residency spots, total US # was 39,205 this year (https://www.nrmp.org/match-data-analytics/residency-data-reports/)
Incorrect = residents are profitable to hospitals/systems. They can be on net, usually near the end of their training or in fellowship, but not generally. More correct: residents are prestigious, residents can allow other profitable work to occur elsewhere (research grants). There are many many more costs beyond salary to accout for: benefits, direct educational costs, program adminins, GME departments, supervision by attending physicians (lower productivity), general lower productivity, etc.
also, 50K in NYC was probably in 2002. https://surgery.weill.cornell.edu/benefits-and-salary -- different programs are very similar within institutions, and salaries are comprable between institutions, though in NY housing stipends (essentially always included) may be part of salary or separate which can make salary numbers appear very different.
Incorrect: federal govt subsidizes the cost of residency. More correct: part of the cost, of older existing programs, but institution are (generally) free to add more and self-fund. Begs question about profitability (why not add more everywhere?)
Edit/add: difference between medicine residents/early law associates: law associates can bill, residents cannot. E.g., they do not generate direct revenue the way young lawyers do (and thus get paid for).
First off, thanks very much for the clarification and input!
It's important to note that first-year attorneys' work is often (I think generally) actually revenue-negative for their firms, so it's one more reason to be perplexed at the medicine/law disparity. Most in-house counsel (i..e the ones looking at and paying the bills) were themselves junior attorneys (often in Biglaw) at one time or another and won't pay for first-years' work on the belief that it isn't worth paying for, so the firms just eat it as an investment. (IME juniors can be pretty good at legal research because they have a lot of experience in law school and a lot of the paperwork that needs to get done can be done by juniors as well such that they add value to clients, but the attitude that they don't justify their billing rates is perhaps not entirely without foundation).
Does work done by residents really not end up anyone's bill? That seems inconsistent with them being profitable later on their residency.
I think the specific salary I had in mind was probably closer to 58k than 50k (a very significant percentage bump, but that extra 8k doesn't go all that far in NYC) but it was circa 2010 IIRC (at a hospital admittedly much less prestigious than Weill Cornell).
I appreciate the clarification on the methodology of the federal impact on residencies although I think it's consistent with my characterization ("subsidizes" usually doesn't imply "pays for in full" and the allusion to the market "can't or won't work around it" was my attempt at why it was an open question why hospitals didn't just create more residency slots under the assumption that residents were usually profitable (albeit obviously with higher margins for subsidized ones)).
Sounds like hospitals for whatever reason just don't approach residency in the same way that Biglaw approaches junior attorney hiring, maybe because absent subsidy the upfront costs are higher and have a longer time horizon to recoup investment?
Dunno about residents, but you're 100% correct about new lawyers. It takes a few years for them to become competent. Huge time and money pit.
Work by residents does often end up in the bill, but not all work (especially the many jobs assigned to residents) is billiable, and it requires an attending physician to also see the patient and review and confirm the resident's work.
Eg, a resident sees a new patient in the ER and gets them admitted to the hospital. If the attending sees them as well (typically a couple hours later) and confirms everything, the attending can bill for the encounter. Most specialties do this. They can bill for one encounter daily, generally. However, weirdly often surgical specialties don't even do this billing because OR time'/revenue is so much more valuable to them vs seeing the patients on rounds (admissions and inpatient care instead supervised by a senior resident with 4-7 yrs training who knows what to do). OR time almost always involves full attending time/work.
Most universally common resident work: in-hospital coverage evenings/nights of inpatients in wards, ICUs, etc. Tons of work, generally non-billable (or complex to bill for, requires attending presence which is not usually the case at night, so never billed).
The question of adding residents, or residency programs is a little more complex than the pure ROI question. There are tons of regulatory hurdles to navigate and millions in up-front costs (GME and program managers and directors, most of whom are doctors with expensive time you need to buy), and you need to have a sufficient patient population to treat (regulatory), and you need doctors who want to particiapte in it (work culture, money), and hospitals who want to trade efficiency for presteige, etc. All of this = real world challenges to expanding programs and starting new ones.
EDIT: this applies to hospital care. Outpatient (clinic) care is a little different in that "primary care" encounters can be billed by the attending in clinic without seeing the patient directly ("Primary Care Exception") and only discussing the care with the resident.
Jibes with my experience as well. The academic centers I've worked at have actually looked at cutting residency slots. Minting physicians takes a tremendously long time and they're mostly pigeonholed into one specialty for their entire career. Non-physician providers are often faster to train and may be able to retreat to other roles if jobs get scarce. They're not the same as a physician but there is value to not planning staffing on a 10-year cycle.
@Jim3: I'm a bit more skeptical and believe residents are very profitable. First, I think the detail around freeing up attending time shouldn't be understated. If you look at other high services industries (such as law or consulting), you see tons of specialization (paralegals, secretaries, junior associates, senior associates, etc.) in part due to the value of time of the top billing personnel -> so freeing up attending time is very valuable to the institution. Second, residents can often moonlight starting in years 2 or 3 at the same rate of an attending (or ~80% of the attending rate, or ~3x their residency salary). I agree that the calculations here are going to be super complex, including taking into account a lot of first year training which might be "at-loss", but would think that the moonlight market is revealing more of the true value.
It's not generally the case that first year associates are not profitable for BigLaw firms. An associate with a $200k salary billing 1900 hours at a realized hourly rate of $350 -- which is not pushing the limit for AmLaw100 -- brings in $665k in revenue. Even if you loaded the entire cost of a firm's summer associate and on-campus recruiting program onto the revenue from the first year class, which wouldn't really be fair accounting, there's a lot of revenue there to cover it.
Very interesting! I have zero good knowledge on the subject but my sense has always been that the number of mds in us is artificially kept down to keep their wages insanely high. People in us aren’t aware that in most of the world “doctor” is a respected profession but not synonymous with rich. This seems to back my priors, and point to the federal government as the culprit - but I imagine the doctors have lobbies to keep it that way.
It's similar to lawyers, frankly.
Until maybe 1960, most every mid-sized town of a few thousand people had the town doctor, lawyer, and civil engineer, and each of them earned a living similar to what folks expect of a mid-level engineer in a big firm today.
Then the former two managed to engage in rampant regulatory capture and pad their pockets to hell and gone.
The engineers didn't.
That's interesting.
I don't fully disagree with the regulatory capture argument, but it was my understanding that the relative (to US society) income of physicians has decreased since the 60s.
edit: I will try to find some data for this, I have heard it discussed a number of times. Both for primary care and specialists.
That sounds shocking to me.
but is there a shortage of lawyers??
Yes and no. There are a ton of unmet legal needs (largely in family, immigration, and business law), but it's more of an allocation problem. Well-trained lawyers often opt to work in lucrative commercial litigation where their goal is just to run down the other side's resources. The ones who hang a shingle and provide basic services are usually (not always) grads from low-ranking law schools without the credentials for a better job. Many communities don't have any lawyers at all or have incompetent ones.
There’s some layers to this onion but what you are proposing (‘they open more med school slots’) is for the government (us) to spend money forcing potential NPs to instead undertake additional training before they are allowed to prescribe and practice in a certain way. There could be some benefits, some of them would apply for even more ‘study’ (at this point medical study means taking a pseudo apprenticeship for less than market wage) and end up increasing the supply of some specialists. I would say, better to create some dedicated programs for college grads to learn to perform certain MD specialist roles in radiology or anesthesia etc and not become accredited general practitioners as well. Even if the NPs perform worse than GP MDs it’s unlikely caused by lack of training and far more likely down to adverse selection.
I caution, though, I really wouldn’t expect any of this to move the needle on life expectancy much.
Here’s a question : to begin with r the system was designed with mds only, specializations coming afterwards, with gp as one. Unless I’m mistaken np came about to address a shortage. It does not exist in many comparable developed countries, perhaps it’s even unique to us. This leads me to the a priori assumption that nps as a compromise to deal with a suboptimal situation l, and what you’re proposing a further compromise and reduction of standards. How much damage it will cause is an open question , but it sounds like reform aimed at making the most of a worsening situation rather than an attempt to genuinely improve a system to be objectively better. Am I wrong ?
You aren’t wrong but you’re not right either. Evolution of medical training and standards is much messier and more local than your big picture view. Legal codification of roles went hand in hand with state takeover in many places; in others it was more of a political scramble between interested groups. Our government certainly does NOT take for granted that a successful German general practitioner and MD could perform those roles within the US. We do not formally consider them to be equivalent despite a mountain of evidence and the tacit agreement of every single person within our medical establishment. In New York State Osteopaths were granted much more ability to operate as GPs on the same level as MDs because of a few personal political connections. The basis for their form of practice is currently considered to be essentially bunk but their training is largely about being competent GPs and they do indeed perform as such.
I would also say increasing the supply of people who can prescribe antibiotics and oversee check ups is not about a worsening situation but about stretching to give people more healthcare than they had before. It is an awkward compromise but more between rent seeking entities, popular political pressures, and the genuine wasted effort involved in overhauling historic systems across 50 states.
Thanks. This is good to know. I still think it’s bonkers town though that we can’t have German trained mds as gps in us but do have people as gps who are literally not even trained to be gps.
DO training is essentially identical to MD training these days (last 20 years). There is some remining manipulative medicine training in osteopathic schhols, likely grossly diminished from before, however in practice **I have never seen a DO reference, or use, or even really talk about this aspect of their med school training**. They are just funtionally the same as MDs and do the same things in residency, and practice.
It's important to know that what you learn in med school is not what you use as a practicing physician--it's only fancy building blocks for later, like math and reading are. **What you actually do day-to-day is 100% from your residency and fellowship training, and ongoing education.**
Yes this is my point, their training, standards, accreditation etc have all simply adapted where it was allowed to adapt. In other places a choice was made to shut down certain programs or practices and to instead potentially accredit more MDs, with no discernible benefit.
Yup. And allopathic boards are finally tearing down some of the barriers between DO and MD physicians. Indeed, last time I even heard even a whisper of osteopathic technique was when I asked a DO student about it as an intern almost 20 years ago.
As for resident selection, we've had DO chief residents, though candidates from DO schools are seen as lower quality candidates (though there are some schools that have good enough track records to overcome that bias).
“…but why couldn’t they just open more places in med schools…”
My understanding is the number of seats in medical school is directly tied to the number of hospital residency positions available. Residency programs are where MDs are actually trained to be doctors.
Plus there’s more significant regulatory issues involved in expanding medical school slots. (As opposed to a university expanding its master’s in film studies in order to make more money — even though there are few actual jobs.)
And why don’t we have more of those ?
It's actually really expensive and difficult to do.
Number of MD enrollees does increase every year. pg 10 (doesn't include DO programs, couldnt find the same data quickly in easy format, but they are increasing way faster--more new programs and enlarging classes, total about 25% of MD students)
https://www.aamc.org/media/57761/download?attachment
Yes, I would think it's really difficult for a hospital to expand the number of residents. There's regulatory issues, expense (even though residents aren't paid that much) and also residents have to be supervised by a senior physician.
Exactly, it's not impossible but it's very difficult. Which implies to me strongly that it's not tremendously, or even at all, revenue positive. See my other comments in this thread.
That's a hopeful hypothesis but I don't know of any data that supports it & I say that as a primary care physician who values sitting down and chatting with patients to understand what is going on in their lives over poking and prodding and running tests.
Fear of death and debility are closely tied to religion and much of the trappings of religion have been adopted by medicine. This occurs to the least (but some) effect in the sense of church as community, but it is community and social coherence that show the greatest correlation with unexplained variance in life expectancy. The current plateau in life expectancy in the U.S. has the greatest similarity to the decline witnessed as the Soviet Union broke up. It's no coincidence that the fall-off both in the USSR and the US was sharpest among those whose social status has increased the most in uncertainty.
I'd like to see "Life Expectancy at 40 by Country." Given that most people dying from medical conditions are old any way, you need to really improve your health care to make up for a few 20 year olds shooting eachother or getting into stupid car accidents.
Just checking Canada, it does seem to beat the US by a couple years for men at age 40 and 50.
Couldn't find a full life expectancy table for the UK, but at 65 they beat the US with 18.8 vs 18.09 additional years for men and 21.1 vs 21.07 years for women, although I think this is comparing pre-COVID vs. post-COVID data.
If the US lag is substantially caused by car accidents and shootings, wouldn't the low-hanging fruit be found in improving highway and gun safety?
Depends on what you mean by "low hanging fruit." Banning fire arms will likely increase life expectancy more than a new treatment that cures Alzheimer's disease, but the latter is more politically feasible than the former, and there are ways I could see it even being more beneficial. (How do you weigh a quick death at 20 vs. a slow death at 80 where the person loses their self to memory loss?)
I would say so. Especially car accidents. The specific details on how to drive down car deaths really are available from Western Europe. Lots of tiny road engineering and car regulation changes, they can be applied much more incrementally than the gun stuff and there's no 2nd Amendment giving people the right to kill people with cars. No originalist will *ever* be able to show that the Founders wanted to protect their descendants' right to kill people with 2 tonne murder machines on state-funded roads.
Gun deaths require that you overcome the Second Amendment. Car deaths require that you overcome a century of path dependency. Not sure that the latter is actually easier than the former.
I would argue that it's easier for a number of reasons
1. The US has in the past managed to drive down car deaths with the same mixture of road re-engineering and car regulation (e.g. seat belts) so the path dependency is not as bad as you think
2. Legally you have far more room to work in
3. You really can work at this one interchange at a time, one trivial little regulation on car design at a time.
4. You can get results without having to cram down the numbers of miles driven, which is what most people want and need.
It's true the US will not reach UK of fatalities with American levels of miles driven, but it could save thousands of young lives every year
What happens to life expectancy when you break the data out by population density or some more direct measure of how much driving versus walking/biking people do?
I moved (back) to the US a year ago and have been slowly gaining weight despite eating nearly the same diet (we cook every meal at home) and maintaining the same exercise regime. Same with my wife. And our kids are getting noticeably fatter (they're still growing so they're always gaining weight).
One notable difference is that, instead of biking to work and school, we now drive and ride the school bus. And instead of walking to run errands and carrying our groceries, we drive and stuff everything in the back of the car. I think this is one of the frog-in-the-boiling-water things; it is absolutely jarring how little physical activity is baked into my new suburban American life as compared to my urban European life, but growing up it seemed totally normal to drive to a bunch of stores to run errands or sit in the school bus for 45 minutes twice a day.
All of the science on weight loss is very very clear that it's about diet and not really exercise. You'd have to almost kill yourself on a treadmill to burn even 400 calories, which is as much as a small sandwich.
If we're sharing anecdotes, I used to exercise constantly (I was on a competition BJJ team and also did powerlifting) and also ate quasi-unhealthy. Now I exercise much less but also eat very very cleanly- I weigh 25-30 lbs. less. There's not a ton of very clearly proven things in exercise science, but 'nutrition over exercise' is like the 1st Law of Thermodynamics
There was an article just the other day about how you need some baseline level of physical activity to see the health benefits of a healthy diet; one without the other is not sufficient. There are some quotes in there from people who exercise constantly and are surprised to find that they had a heart attack because of poor diet. That seems in-line with your anecdote.
https://www.nytimes.com/2022/07/13/well/move/exercise-diet-disease.html
But...if they eat the same diet that in Europe allowed them to maintain their weight but now causes them to gain weight, then the dearth of exercise is the most likely culprit. Even an extra 100 calories/day will add up to a pound a month. So I don't discount that in magnitude, dietary changes can *ahem* outweigh exercise, it doesn't mean the latter is useless, especially aggregated over a lifetime.
Disagree – I think it’s a portion size and contaminant issue, exactly what Slime Mold Time Mold has posited.
"it is absolutely jarring how little physical activity is baked into my new suburban American life as compared to my urban European life"
This, x1000!
Signed, a naturalized U.S. citizen who used to live in Poland
I'd agree with this as well. My diet isn't fantastic and I don't do a lot of deliberate exercise, but I do bike to work and walk to get groceries as well as using public transit for most other trips, which often requires a few minutes of walking in both directions. Because of that, I'm in far better shape than I think I have any right to be, and it's because my day-to-day naturally includes a consistent amount of physical activity
I think the mass consumption of heavily processed foods and sugars is potentially a big factor. I recently went on a ketogenic diet and it’s amazing how much better I feel. In my travels to Europe it was always noticeable how much less it seemed folks consumed the sorts of processed foods we do and with less frequency when they do. Sugar really is in damn near everything in the US.
Aren't nutrition and diet heavily researched? I would think we'd have some idea about the differing compositions of the diets in different countries, and not just observations and anecdotes (not saying your own observations aren't valid, mind you; I'd say the same thing about the way people eat here in China. I've yet to see my first Hot Pocket!).
Heavily research - yes. Researched well - no.
From what I've read of it, most diet research is really, really bad. It relies way to much on self reporting and its very hard to untangle the observer effect. In fact, much of the dieting advice out there make use of the observer effect in that if you just start recording what you eat/calories, most people will naturally adjust their diet.
Interesting. I honestly have zero idea what to expect in this area. I wouldn't be surprised to learn a typical (say) Western European's diet is healthier than a typical American's. I also wouldn't be surprised to learn there's not all that much difference, health-wise.
Oh of course, sometimes I’ll throw out something on Slow Boring and someone will comment “Hey dingus, look at these 10 studies->see links!” and while I don’t like being called a dingus, it’s a small price to pay to have a smug but maybe more intelligent person with some free time give me the info I need to form a more educated opinion. It’s the real magic of Slow Boring! Long Live the Commenteriat!
I am in the apparently small minority of Americans who has decent health coverage and is not satisfied with American healthcare, despite being in good health. My complaints:
1. The administrative burden. If I am lucky, the provider bills the insurance company, the insurance company accepts the claim, and the provider accepts the allowed amount. If anything goes wrong, though, starting with the provider not accepting my insurance and me having to submit an out-of-network claim, it's a months-long process of threeway paperwork.
2. The record keeping. None of my providers know anything about the care I'm receiving from the others unless I personally request records from each and ferry them around.
3. The doctor shortage. My understanding is that AMA and Congress are to blame for the residency cap. I prefer to see nurses for primary care, because a nurse has more than 2 minutes to listen to you, whereas the doctor is seeing 15 patients per hour.
4. The uncertainty of it all. I'm an educated person and can explain the terms "deductible", "co-insurance", "lifetime maximum benefit", and "out-of-pocket limit". Even so, I have no idea what would actually happen, in terms of my finances, if I got seriously ill.
First world problems? Maybe! But my understanding is that other first-world countries have solved most of the above problems, with #3 being the most intractable (though for different reasons, obviously).
“ "lifetime maximum benefit"
That was made illegal several years ago.
Yeah that was gotten rid of with Obamacare
I also live in the US and have good healthcare coverage and visit doctors regularly for checkups and minor problems. Total time spent on all the paperwork per year is maybe 30 minutes for me. How much is it in your case and how many doctors do you visit per year?
1. One thing about the US is that the administrative burden is mostly on the side of billing and not on the side of interface with clinics or hospitals.
2. The record keeping issue in the US is the dumbest problem and one the face of it seems to me one of the easiest to solve. There was an episode of the Impact on medical records a few years ago. But what I remember is that although medical records are required to be electronic these days, the companies that make the electronic medical records software have incentives to make them the least compatible with the other companies' software as possible. https://www.vox.com/2017/10/30/16387306/american-medicine-healthcare-fax-machine
3. The doctor shortage is infuriating in the US (see above discussion on residency slots).
4. This is something that I don't really understand. What's uncertain? If you have a bad year with a lot of health care expenses, your out of pocket expenses will reach your OOPM (generally up to $8700/individual or $17400/family). Now if you can't afford this amount of money, then you're potentially in an unstable place. But unless you seek out-of-network care, your expenses for the year should stay within 8700 for an individual or 17400 for a family. (Now if you get a surprise out-of-network bill that's another story, but theoretically, we have the No Surprises Act Now to protect you for surprise out-of-network bills except for ambulances).
So far as drunk driving goes, one salient difference with a country like the UK is that they don't have any drunk driving. Instead, they have "drink driving", which makes them sound like jerks, except they don't have any jerks, so it makes them sound like poncy wankers.
I don't know how this bears on life expectancy, other than there's worse things than dying.
The density does make a difference though! Going to uni in Edinburgh I've never once had to worry about driving drunk because there's 500 pubs within walking distance of my flat, whereas whenever I'm home in Seattle it's super not obvious how I would meet a friend for a drink without one of us having to drive drunk or take the bus home at 1 am which i don't want to do
Congratulations, you turned drunk driving into a NIMBY-urbanism issue. You should consider subscribing to Matt Yglesias' Substack.
nimbys be like "fiery car wrecks are part of the neighborhood character" lol
Keep the sidewalks clean - Let them puke in their cars.
What, like you couldn't get on the roller-coaster because you weren't taller than the bunny's ears, so you hit the bar instead?
But in the us at least you can find parking at the bar thanks to mandatory parking minimums!
The fight against Drink/drunk driving in the UK was driven by a huge wave of public health campaigns in my youth, which seemed to have been really successful. Certainly by the time I was 20 it really was a big bad deal to be caught drunk at the wheel - social ostracism and vicious penalties (license gone for at least a year, fines, jail time - the works. For middle class crimes fear o punishment can be handy).
The fact that the US authorities are more relaxed about this is most evident in the fact that in some jurisdictions bars are *legally mandated* to have lots of parking spaces....WTF? What behaviour are they expecting, exactly?
One of the myriad cultural differences I've noticed between the US and China is: in the US, drinking and driving is basically considered ok. It's condoned. And in China it's much more strongly discouraged. What I specifically mean is: in America the taboo is against *drunk* driving. Not consuming alcohol and driving as such. It's perfectly normal in America for people to dine out, have a couple of drinks with food, and then get behind the wheel. Because, you know, they're not drunk. They've just had a couple of drinks. (Pretty plainly, dangerously large percentages of humans aren't good judges of whether they're impaired or not, especially if they've been drinking; also, even very modest amounts of alcohol reduce brain function, I think).
In China I haven't seen any mixing of drinking and driving. Indeed, if you drive to a restaurant and then decide to consume alcohol, you can text a service that will show up, and drive you home in your own vehicle. Very practical.
No doubt PRC legal sanctions play a role in the greater caution on the part of Chinese drivers. But it's a safer approach.
Sorry, that's right I should have clarified, part of the success of the campaign was recalibrating 'drunk' for the purposes of driving to more than a pint/glass, in line with scientific evidence that more than this is very dangerous. Somehow they managed to get through to my generation of beginning drivers that even one glass was a bad idea, given ou inexperience. I'm pretty sure a young alcohol-impaired driver gets and even longer driving ban. (In fact I think you have to retake your test as well, nowadays, to get it back).
Probably the Chinese system is similar? perhaps calibrated for Chinese people (in my limited experience) getting hit harder, on average, by smaller amounts of alcohol than Westerners
I'm going to guess that an economy that supports 500 pubs within walking distance of your flat may have other health issues than drunk driving.
Seattle has pub dense neighborhoods! Have you tried Ballard? UDistrict? Capitol Hill? Lower Queen Anne/Belltown.
(Probably not 500, though. You sure that number's not an exaggeration WRT Edinburgh?)
Also, Uber. I know people love to bash it, but I think it's a game-changer.
"You sure that number's not an exaggeration...?"
I certainly hope he didn't use -- gasp -- HYPERBOLE!
I learned the other week on this site that using hyperbole is an absolutely unforgivable sin that vitiates and undermines everything else the speaker says, and allows you to dismiss and discredit their authority on all other issues.
Or does that rule apply only to women?
I love reasonable hyperbole, and wouldn't have mentioned this had I detected it. In this case (foolishly, in retrospect, I guess) I thought the "500 pub" claim was literal! And hell, maybe it is: I've never been to Edinburgh. The greatest concentration of bars I've personally seen in a small area was in Ho Chi Minh City. There's a nightlife district there (names escapes me) that reminds me a lot of George Bailey's nightmare vision of what Bedford Falls looked like in the absence of his existence. It was incredibly garish and beautiful at the same time. But at most I'd say say there were, like, 200-300 bars. (Though every single one of them featured unbelievably powerful neon signage to entice you inside).
Anyway, the point of the original comment was simply to laud Seattle, which, per my several month stay, seemed like a pretty walkable town with a lot of good nightlife options. I enjoyed it.
Seattle's good! And I'm intrigued to hear about Ho Chi Minh City, which I have never visited.
I also did not mean to single out you vis a vis hyperbole, since I don't remember whether you were one of the many commenters shrieking, fainting, and having the fantods when Phoebe M-B committed the sin of hyperbolizing. Read through the thread, if you have the stomach -- it's almost comical how often people say variations on, "I don't usually become hysterical when I read something written by a woman, but *she* used HYPERBOLE!!".
You know what they say about British English: if you can't handle it at its "spag bol", you don't deserve it at its "wankers".
The weakest part of the article is the part on alcohol taxes. The reason I say this is that Americans drink less than Europeans on average and have a more restrictive alcohol culture (in large parts of the country, you can't buy alcohol at a grocery store, or in some parts only at a government liquor store, etc). In the US, water bottles are cheaper than beer bottles (unlike in parts of Europe...) Maybe changes in alcohol deaths in the US can explain some of the growing gap in life expectancy but I'd be surprised if it contributes to the absolute difference.
To the extent it's a factor I suspect it's more about walking versus driving. When I studied in Germany I drank beer every day and lost weight because I went everywhere by a combination of foot and train.
I mentioned the walking thing in another comment. I'm curious to what extent the fact that the US built environment discourages walking for day-to-day activities contributes to differences in life expectancy.
My completely uneducated and speculative opinion is a hell of a lot.
Not just europe.
South Korea has one of the highest per capita consumption rates in the world.
Japanese drinking culture is very much “bottoms up” binge drinking (like in China) and not “1 evening glass” like Italy
Just a few numbers:
Pure alcohol consumption per capita (L) (2016)
US: 9.8
Germany: 13.4
UK: 11.4
France: 12.6
Italy: 7.5
Canada: 8.9
Israel: 3.8
South Korea: 10.2
Japan: 8.0
China: 7.2
Not to sound snobbish, but I think it shows MY’s lack of experience of living abroad. These are the kind of differences that really strike you when you live in a place for a bit.
Now if I compare to Tel Aviv, where I live now, Americans drink way more. Alcohol here has a high tax ( and is quite expensive). At least from my experience, social life surrounds alcohol much less here in Israel than back home in the US. But if we are comparing health outcomes to European countries, who are known for plentiful and cheap booze as well as heavy drinking habits, then it's hard to point to alcohol policy being a significant contributor to the difference in life expectancy between Europe and the US.
Europe has alocohol culture but it’s different from American alcohol culture. E.g. much less drinking alone I believe. Israel has less alcohol culture , but also interestingly more permissive laws than us (well almost all non Islamic countries have more permissive alcohol laws than us!). I do wonder if alcohol laws in us aren’t a double edged sword. E.g. are European uni students - who can drink legally and who probably drank openly with their families in Social settings from childhood- as likely to be stupid in their drinking as American college students?
There isn't a single European alcohol culture. The Med countries have tourist destinations that are essentially identical to the stereotype about drunk spring breaks in Florida. Sweden has Systembolaget, a government-owned chain that is the only place where you can legally buy alcoholic drinks that contain more alcohol than a (low) threshold.
you're right, and you're wrong. I think Europe *does* have an alcohol culture in the macro, i.e. when compared to the ME or in some respects to the US (e.g. drinking age, and, I think, attitudes towards minors drinking in public, with family etc. though I may be wrong on the latter).
Now that I think about it, you may very well be correct!
I don't see some cultural differences between Americans from different parts of the US that actual Americans seem to be able to pick up. So in the same way I may be good at finding differences between Swedes and Spaniards that an American would never observe. I guess it's easier to see differences within a group if you are a member of the group.
Like if you ask me, having people learn to drink as minors with their family, so that they don't have to drink to excess in college/uni seems like a better plan than pretending that kids don't drink until 21, but having them drink behind closed doors or in secret till they pass out. But I don't know how much any of this contributes to life expectancy.
I'm not sure why, beyond a certain level of developed-ness, it would be counterintuitive that wealth as measured by more affordable gas and better washing machines isn't necessarily predictive of better health.
I don't understand this comment. Wealth—*any* reasonable way you describe it—is indeed predictive of better health. Isn't it? Rich countries tend to feature better health. Which is why the state of health in the United States is so frustrating.
Americans have undeniably responded to greater income by eating more red meat and driving further and faster in larger vehicles. None of that is good for your health.
The question is if other consumption is pro-longevity in a way that outstrips those vices of affluence. It's not automatically so at all income levels even if it very obviously is in the $1-$100/day range.
Vices of affluence? Everything I've seen suggests Americans are eating less red meat, not more. Ditto cigarettes. I think alcohol consumption has been declining, too.
Is there any reason to believe that Americans are uniquely different on these factors than other people?
"...more affordable gas and better washing machines..."
Or MY's other anti-European peeve, ice cubes. Ice cubes can delay decomposition, but only after you have already died.
Always is too strong of a word. It seems the optimal conditions for generally longer, healthier lives involve a mix of wealth and "good government". No place has everything - Norway is too cold, and Switzerland doesn't have the same levels of social trust the Scandinavians do (I'm pretty sure Swedes and Danes rate even higher in happiness than Switzerland despite being less rich than Norway or Switzerland). For whatever reasons, though, Swiss elites are presumably more out of touch (in such a diverse country, where even the German/French divide poses some challenges) than Scandinavian elites, but they do seem either more able or more willing (due to more effective institutional setups, maybe, or a legacy of old money noblesse oblige, or some combination) to maintain things in a way that just works better than American elites do. France is a more interesting comparison. They don't seem to have things as together as the Swiss elites and institutions do, and they aren't as rich, but they have some quality of life, stress-reducing factors going for them that make the country competitive with the US on life expectancy.
We (US) do things, including a cover-your-ass approach to healthcare, even (perhaps especially) at the VIP level, that are unbelievably stupid and inefficient, if you zoom out a little bit. Concerns about fraud accusations, being blamed, investigated or sued, and looking good and like you're "doing something (anything)" with your funds - as opposed to focusing on less visible long term investments in effective systems - lead people doing good work to have to choose between trying to *be* effective and trying to look busy and blameless.
Beyond a certain point of diminishing returns, I think on the margin it depends on the means by which you manage to achieve in higher levels of wealth as defined by GDP-adjacent or net worth-adjacent calculations. Even more nuanced estimates of true productivity gains don't automatically incorporate the value of, say, more people having close friends they can turn to for the sort of incidental life tips and informal help that's much more inefficiently and ineffectively delivered if you have to rely on paid professionals and the boundaries of formality that come with that, even for those who can afford it.
This is quite thorough and good. However it strikes me as odd that MY does not consider at all the role of the regulatory state. US is much worse than EU at regulating food. A lot of stuff that’s literally illegal to put in food there is common in us. A more important point perhaps is culture. Esp. American vs European diet and drinking culture. I think this latter point may well explain Italy’s exceptional life expectancy, for example. This, btw, is not merely about what you choose to eat, but what the stuff you buy even contains. American bread is almost a different product than European bread, for instance, and much less healthy (this is only in part a matter of underregulation). I’d also be really interested in exploring more Latvia and Mexico that seem from the tables to be underperforming relative to their wealth in ways similar to the us.
Maybe, but Europe makes a bunch of stuff "illegal" to put in food there that seems downright wrong to me and unrelated to health outcomes (GMO?)
I'd like specifics of what we think are the problem.
And sometimes it's not even additives. Soda is awfully full of sugar(well, High Fructose Corn Syrup) and "empty" calories - but.... so is regular fruit juice. It's got a few advantage over soda but it's still extremely sugary, without adding anything.
I don't even know who wants America's weird desserty sweet bread. I have never met a person who likes it more than a nice robust bread with a more natural flavor (and I live in the South!)
Come on, Kings Hawaiian rolls are delicious (and practically dessert, yes)
Please don't tell me that the policy solution for closing the life expectancy gap is getting rid of Kings Hawaiian rolls!!
Kings Hawaiian rolls are fine. It's that every loaf of bread in the supermarket is insanely sweet compared to any bread I ate before moving here.
Ok I'm being a bit unfair. They are a great sweet item! But they are replacements for a pastry etc rather than real bread IMO
Fair!! And if I’m looking for bread to have on the side of a delicious pasta marinara dish, it ain’t Kings Hawaiian. They are practically donuts. (But I have had a grilled cheese sandwich made with a literal donut too, sooo…)
It's not doubt that the standard American diet is not good for us. I'm a bit skeptical that the food additives that the US allows but Europe does not play a huge role though in differences in life expectancy.
But overall food environment and food culture can play a large role. Eating more fruits, vegetables, fermented foods, whole grains, legumes. Having higher fiber intake. Eating more fish and omega-3 fats. Now I don't know to what extent Europeans are better than Americans in this (I was just in the Netherlands for a week, and I would hardly call its cuisine "healthfood"!). But generally, I would agree that the food environment in the US is not conducive to making healthful food choices on a daily basis.
Mexico's under performance is presumably related to the low intensity conflict related to the war on drugs that's been ongoing there for like 20 years?
Latvia is presumably related to having the highest alcohol consumption in the OECD.
Mexico is also more obese than the United States, presumably not from the war on drugs.
I’m not sure life expectancy is the right metric. Every one of my grandparents (and step grandparents) lived too long. One had alzheimer’s for twenty years, one was blind for three years and acutely miserable her last several months, one told me “I’m no use any more but don’t have the balls for suicide.” None of them were happy their last year.
Murders, fatal auto accidents and obese 55 year olds having heart attacks are bad. I’m more interested in the proportion of the population that lives to 75 or 80 than anything else.
The real measure we should be optimizing for is “years of life without any care givers”. Once you’re in a retirement home it’s game over anyway.
Retirement homes are fine. Assisted living facilities, not so much.
You make a great point, and I'm sorry about your grandparents.
There's a book called "The Blue Zones" by Dan Buettner that talks about how to increase healthspan (the number of years you are fit and healthy), not just lifespan. Highly recommended!
It would be interesting to compare rates of loneliness between US and Europe, especially as people become older, since social isolation is strongly linked to a variety of poor health outcomes (up to and including suicide).
And certainly our land use is a big input into this, as sparse car-centric development combined with high housing costs generates a max-alienation scenario of stymied communal interaction and families that have been forced to move far away from each other.
Curious now about level of density vs suicide rates.
And please stop putting corn in my gasoline.
I’ve seen some gas stations proudly touting their ethanol-free blends and wonder what consumer is ranting about that?
I just got back from france and their default non-diesel gasoline is 10% ethanol as well. I assume it’s not corn ethanol but not sure what it is.
The early cancer screening stats seem to me like the exception that proves the rule. Maybe cutting edge research has changed, I’m a little out of date on this, but my impression is you see very little benefit longitudinally from prostate and breast cancer early screening. It improves the five year survival rate because you detect and remove cancers that never threatened the patient within in a five year time horizon. So you are just booking a lot of wins that other systems book for free.
Very curious about footnote #3: “The other interesting thing here is the very large gains in Black life expectancy over the past generation. A lot of this is the decline in crime and improved treatment for HIV/AIDS, but that doesn’t fully explain it — some other stuff is getting better.”
What’s the other stuff? Just one more sentence, please?
Pre-pandemic Black Americans hit their lowest poverty rate ever so I'm sure that has something to do with it. Also I wouldn't be surprised if this is a weird consequence of the housing crisis. A lot of poorer, traditionally black neighborhoods now have a not insignificant number of wealthy white residents who can support stores selling actual food and not just processed pre packaged meals etc.
I wrote a long reply elsewhere in today's comments on how Asian and Hispanic life expectancy numbers are probably pushed higher by immigration. Something like 1 in 10 Black Americans are now immigrants, so I wonder if some part of that improvement is simply the rise of Black immigration. If it is, some of that improvement may be due to the immigrants having better health than the native-born, but some of it may be just data collection problems as I elaborated on in my other reply.