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!!)
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'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.
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.
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.
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).
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.
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.
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.
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.
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.
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?
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 really thought footnote 1 was just going to say "Fuck Yeah".
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'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.
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.
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.
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).
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.
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.
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.
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.
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.
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.
And please stop putting corn in my gasoline.
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?