[rcdmd]

A few things off the cuff as a physician-- the US has dangerously unequal access to care. I suspect most of the "drag" on life expectancy is from patients without access (this is conjecture but based on personal experience). Even patients eligible for medicaid don't necessarily go through the steps to get it. Often we see patients show up to the hospital who haven't seen docs in a many years until they've developed terrible sequelae like gangrene requiring an amputation. At that point, during admission, the hospital generally helps get them on medicaid. Also, obesity is becoming the new normal in US with all of its associated co-morbidities (a common morbidity/mortality sequence is obesity -> diabetes, hypertension -> coronary artery disease, end stage renal disease, general vascular disease -> death. More healthcare spending is required to treat patients, but the root cause for a growing part of the population's illnesses can't be cured by medicine yet. Also, economically speaking-- the US spends a lot more per capita on mostly everything-- its GDP per capita is higher than these other countries. But, mostly, I suspect the US's health mortality problem is access related. We're spending a lot of money on things that don't help people with poor access to care until their original diseases have done irreversible damage.

[3pt14159]

I agree with most of what you said, though I want to highlight something as a matter of looking at it from a different angle.

That the US has a higher GDP (and therefore spends more on most things that can't be imported) isn't divorced from the health policy of the US. It is the prioritization of GDP in the public policy sphere in the US that has, partially, led to the GDP being higher. For example, drug companies in the US make more from patients partially because there is no national collective bargaining program there. This gives them enough profit to meet the testing requirements to get into other countries around the world. There are many similar examples of this.

I'd also argue that more effective people in America are discouraged from working for the state due to cultural prestige differences with other western countries.

The French are healthier. Not as wealthy, but healthier. Healthcare spending is just one part of it. The other part is a culture that emphasizes other parts of life over raw income or cost. Nobody is tallying up the healthcare benefit of eating fresh veggies instead of a pizza pocket, but it is there, even if it is invisible in the numbers.

[quizotic]

Do you have any insight into the reason for the unequal access? Is it that poorer or uninsured patients cannot afford non-emergency healthcare? Is it that they are too far away? Is it education/knowledge/social - belief that they shouldn't go to a doctor for "nothing". Are they "too busy".

Also, are there any studies to show that populations in other countries use their medical systems more frequently across the board, or that they use more frequent preventative visits?

You mention the problem with obesity and its co-morbidities. Are there any studies or plots that show health outcomes (lifespan, infant mortality, maternal mortality) as a function of % of population who are obese? I wonder if poor health is linearly correlated with obesity, without regard to healthcare spending...

[bluedino]

It's common for baby boomers (at least the males) to refuse to the go to the doctore.

Refusing to go for checkups, screenings, even after mild heart attacks, refusal to take prescribed medications for blood pressure or diabetes...

[brianjoseff]

> Do you have any insight into the reason for the unequal access? Is it that poorer or uninsured patients cannot afford non-emergency healthcare? Is it that they are too far away? Is it education/knowledge/social - belief that they shouldn't go to a doctor for "nothing". Are they "too busy".

I am not a Doctor observing patient populations, but I have lived and worked in East Palo Alto, CA for the last few years, which from my perspective, is a stark case study in all sorts of inequalities (For non-SV residents, East Palo Alto is a small historically socio-economically depressed city wedged between Palo Alto, Facebook, and Google. Zuck's house is a stone throw away from crack houses)

Anecdotally, what I have seen regarding poorer/uninsured people not utilizing health services involves all the things you have mentioned.

Non-emergency healthcare without insurance is pretty much out of the question. Even with insurance, co-pays can be prohibitively expensive. There are people I know living paycheck to paycheck with zero savings and like 50%+ of income going to housing expenses. Even a $50 unplanned-for copay is a painful blow.

Distance is also an issue for a population that may not have consistent access to a car--and the bus system takes too much time. If you are working a few jobs, it's nigh-impossible to take a random 1hr+ bus ride to a medical facility.

Education/knowledge is, unfortunately, also a huge issue. I have observed some astonishingly unhealthy habits that stem primarily from ignorance. Additionally, even navigating our health system requires some level of education, literacy, and time that often seems prohibitive for many in the population I have interacted with. And, with regards to distrust of the medical system, I have observed that as well. I have also seen this coupled with exploitative homeopathic "care" providers...which is doubly sad. These are more complex issues that I don't feel well-equipped to begin to speculate the underlying reasons for. Perhaps some of it is cultural. I am not sure if that is the primary story though.

Generalized ambient anxiety and depression is also, I believe, the more ultimate, albeit distal, cause here, rather these more proximate poverty mechanics. The emotional toll of living in poverty, primarily extreme _relative_ poverty (remember Zuck across the freeway and the swarms of Tesla commuting through your city on their way to high-paying tech jobs that are inaccessible to you) results in all sorts of extremely unhealthy compensatory behaviors. Heavy alcohol and drug use--even if just Marijuana, binge eating fast-food, violent communication styles that contribute to always-on fight or flight reactions, dangerous activities like racing cars or weaving bikes through traffic--perhaps done as some way to "feel something" or perhaps find identity in the only way available--acting out anti-social power displays as a way to reify self-worth contra a system that clearly treats them like shit on nearly all levels. And more.

Frankly, unequal access is both a moral failure and also, I believe, soon to be an instrumental failure for the strength of the United States. Having a large population of enfeebled, diseased people does not bode well for nice things we care about like innovation, improved quality of life, stability of our governance systems, or even things like the strength of our fighting force.

However you want to cut it, the issue of unequal health access is a shame.

[jackcosgrove]

I'd be curious to get your take on the Oregon Medicaid study, where a randomized subset of Medicaid-eligible patients were given access, and no significant effect on health outcomes between those who enrolled and those who did not was observed.

[petschge]

If the US has higher GDP per capita and pays more for everything per capita, then maybe the reason is not that the US is so exceptional, but that the US dollar is artificially stronger than it should be. And a reason for that might be the willingness of the US to wage war (economic war if not outright bombing and invasion) against anybody who tries to trade oil in anything but US dollars.