Stalled Healthcare Reform: It’s Worse Than You Think

In 2021, 1.1 million U.S. deaths would have been averted if the U.S.’s mortality rates matched those in other wealthy nations. Furthermore, Americans are dying increasingly younger than in those other countries

As a result of these excess younger deaths, Americans lost fully 25 million productive years of life, according to a brilliant but troubling new study by Boston University epidemiologist Jacob Bor. Bor shows that these trends predated the coronavirus pandemic, but have only accelerated since.

These findings fly in the face of this blog’s previous conclusion that, despite the U.S.’s exorbitant healthcare spending, at least the system produces comparable – or in some cases better – quality and outcomes.

No. The performance of our healthcare system – and of our wider society of which it is a part — is worse than you think.

Years-of-Life-Lost versus Crude Death Rates

In reaching this grim conclusion, Bor and colleagues used years-of-potential-life-lost (YPLL) methodology to compare the U.S. to Canada, Japan, and 14 Western European countries.  This technique was first introduced by the Centers for Disease Control in 1982 to evaluate the true impact of various causes of death. It takes into account the age of death – and thus potential years of life lost – not just the occurrence of death.

For example, heart disease ranks numerically first, by far, as cause of death in the U.S., with 647,000 deaths in 2017. But cancer accounts for 1.5 million YPLL and unintentional accidents 1.1 million YPLL, outranking heart disease with its 1.0 million YPLL, because cancer and accidents kill younger persons.

Previous comparisons of the U.S. healthcare system performance have focused only on specific diseases or on specific public health metrics. To our knowledge, Bor’s study is the first to use the YPLL methodology to compare peer countries globally, not just their health systems. And it uses new databases recently released by the Centers for Disease Control and by the Human Mortality Database.

What This Means

Bor terms these excess YPLLs, especially among younger citizens, as “missing Americans.” This means that American society is not keeping its citizens alive in the prime of their lives on par with other countries. So, drilling down, these are also the “missing workers,” whose absence slows productivity and drives up inflation.

And, tragically, it also means missed birthdays, graduations, and weddings – not to mention “years of disability, illness, and loss of human potential, creativity, and dignity” preceding those deaths.

Most fundamentally, this means that our system is falling short of fulfilling its ideals of “life, liberty, and pursuit of happiness.” And it is reneging on the Constitutional bargain to obtain for ourselves “general Welfare, and secure the Blessings of Liberty to ourselves and our Posterity” in exchange for participating in our “more perfect Union” with others.

Bor’s study confirms the disparities that disproportionately affect disadvantaged groups. But no group is unscathed, with White ethnicity numerically showing the greatest losses of YPLL. In particular,

Despite relatively higher mortality rates among Black and Native Americans, and larger mortality impacts of COVID-19 on Black, Native and Hispanic Americans, most “Missing Americans” were White, a consequence of the larger and much older population of White U.S. residents. In 2021, there were 749,752 excess deaths among White Americans … and 224,197 excess deaths among Black Americans.

It’s a fallacy for any American to think that “this won’t affect me,” both directly and indirectly.

Previous Blog Conclusions

This blog’s message has morphed several times. It first claimed that the healthcare system was providing a few excessively high-cost-low-benefit services. We reasoned that jettisoning low-value services would constrain spending, as was done in Oregon back in 1994.

Dr. Irene Papanicolas, writing in JAMA in 2018, challenged this notion with new evidence. She showed that high costs were embedded in the entire healthcare system across the board, not confined to just a few questionable low-value services. But this blog and Dr. Papanicolou still framed the healthcare problem as one of excessive spending, and, more specifically, pricing.

Economist Larry Summers pointed out that healthcare spending was not necessarily a bad thing in a post-industrial service economy, so long as the U.S. otherwise maintained fiscal discipline. This blog countered that excessive healthcare spending carried opportunity costs, wasted dollars that could have been better directed elsewhere.

Meanwhile, Journalist Steven Brill explained with his “moats” theory in 2018 that the Baby Boom generation, initially high-minded and innovative, had, little-by-little, built small advantages for themselves into the political and economic system. These advantages now had cumulated into a complex ugly tangle of interconnected “moats.” These moats were profiting them, but not serving the rest of us. His hope was that public-minded innovators, part of the same Baby Boom generation that had subverted the system, could now un-tinker the system back to serving the public good.

In particular this blog asserted health insurance as a public good, highlighting data that lacking healthcare insurance is lethal. This blog has gone on to recognize inequities, the promises embedded in the social contract that have been broken to varying degrees throughout our society, stemming from pervasive underlying social-psychological pathology and civic dysfunction.

Until now, this blog framed excess healthcare spending as unwise and foolish – the symptom of civic self-indulgence and self-defeating attitudes – but otherwise relatively harmless.

New Blog Conclusion – “Crisis of Early Death”

But Bor’s new study reveals the unnerving truth about early deaths. Lots of them — that weaken our economy, fray the social fabric, and deprive Americans of precious life.

Bor’s new data now shows that our nation – not just its healthcare system — is simply not working for its citizens. Not even keeping them alive. Journalist Ed Yong condemns this as a “crisis of early death.” Yong likens our complacency so far toward this crisis to that of unsuspecting frogs slowly boiling to their demise.

The greed and cronyism that drive excessive healthcare spending is bad enough, but now is recognized for its depravity and societal irresponsibility.

Of course, this blog has already glimpsed, through its healthcare lens, the larger societal problems that feed on each other and amplify each other. Public health officials, commenting on the Bor study for Yong in The Atlantic, cite factors that contribute to excess YPLL, which themselves are symptoms of our underlying dysfunction — tattered social safety net for parenting, job loss, or housing insecurity; public health underinvestment; non-universal healthcare; lagging minimum wage; deregulation of pollution, hazardous workplaces, guns and opioids.

Healthcare Reform Can Lead the Way

This blog has thus concluded that healthcare reform is an integral component of general societal reform. It has proposed that healthcare reform can lead the way. It maintains the conviction that if we understand the problem, we can fix the problem. This will require hard work  to change hearts and minds. In light of Bor’s study, reforming healthcare and society takes on new urgency.

Take Action

This blog advocates raising awareness and taking action.

Image Credit

Titles:  1. Excess deaths and years of life lost in the U.S. relative to other wealthy nations, 1933-2021.  2. Excess mortality by age group for select years: 1933 – 2021.

Source: Jacob Bor, Andrew C. Stokes, Julia Raifman, Atheendar Venkataramani, Mary T. Bassett, David Himmelstein, Steffie Woolhandler. Missing Americans: Early Death in the United States, 1933-2021. doi: https://doi.org/10.1101/2022.06.29.22277065 (This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.)

Blogger Disclaimer: I changed the labels in the Excess U.S. Deaths graph to read “Comparable Peer YLL” instead of published original “USA YLL (counterfactual)” and to read “Actual USA YLL” instead of published original “USA YLL (observed)”

URL: https://www.medrxiv.org/content/10.1101/2022.06.29.22277065v2.full.pdf Published online July 21, 2022.

License: The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-ND 4.0 International license.