"Disease and Disadvantage in the US and in England"

By Hootsbuddy

The health and insurance reform debate includes any number of ignorant allusions to the excellence of American health care, ignoring (hence the word "ignorant") comparative reports and statistics comparing US outcomes with the rest of the world indicating otherwise.  Last night a commenter at Crawford Kilian's blog llinked yet another such report appearing in the Journal of the American Medical Association.

Results: The US population in late middle age is less healthy than the equivalent British
population for diabetes, hypertension, heart disease, myocardial infarction, stroke,
lung disease, and cancer. Within each country, there exists a pronounced negative socioeconomic
status (SES) gradient with self-reported disease so that health disparities
are largest at the bottom of the education or income variants of the SES hierarchy. This
conclusion is generally robust to control for a standard set of behavioral risk factors, including
smoking, overweight, obesity, and alcohol drinking, which explain very little of
these health differences. ...among those aged 55 to 64
years, diabetes prevalence is twice as high in the United States and only one fifth of this
difference can be explained by a common set of risk factors. Similarly, among middleaged
adults, mean levels of C-reactive protein are 20% higher in the United States compared
with England and mean high-density lipoprotein cholesterol levels are 14% lower.
These differences are not solely driven by the bottom of the SES distribution. In many
diseases, the top of the SES distribution is less healthy in the United States as well.

Conclusion: Based on self-reported illnesses and biological markers of disease, US
residents are much less healthy than their English counterparts and these differences
exist at all points of the SES distribution.

Science is so dry and natter of fact, isn't it? Reports such as this have been piling up by the ream for years, but they rarely headlines because they are so prosaic. Consequently a majority of the public, confronting a buffet of commercial messages and soundbites, selects news and information with the same bad judgment as their actual food selections, resulting in the intellectual equivalent of obesity.

Anyone engaged in conversation with an opponent of health and insurance reform may now cite another report underscoring how badly we need improvement. If the opponent would like to compare us with the Brits, these are the most recent statistical realities.

Table I lists...the fraction of individuals who self- report
that they have 7 specific diseases�
diabetes, hypertension, heart disease,
myocardial infarctions, strokes, diseases
of the lung, and cancer. To ensure
that patterns are not confounded
by age, comparisons are limited to those
aged 55 through 64 years old....Diabetes
prevalence is twice as high in
the United States (12.5%) compared
with England (6.1%). This between country
differential exists for both
sexes, but male prevalence rates are
higher in both countries. Similarly, all
forms of cardiovascular diseases have
self-reported prevalence considerably
higher in the United States than in England.
To illustrate, hypertension is
about 10 percentage points more common
and all heart disease 6 percentage
points higher in the United States.
And although heart-related conditions
are more common among men in
both countries a higher prevalence is
observed in the United States for each
sex. Finally, both lung disease and cancer
exhibit a similar cross-country differential�
higher prevalence rates for
both sexes in the United States but now
the disease is more common among
women in both countries,

Among the comments we find these interesting remarks...

The influence of inequality in economic
resources on health remains controversial. Income inequality is indeed
much higher in the United States
than in England, but the rapidly increasing
levels of inequality in the
United States do not appear to have had
a dramatic effect on the health of those
at the bottom.

Two simple but powerful conclusions
follow from our comparisons using
biological and self-reports of disease
in England and the United States.
First, Americans are much sicker than
the English. Self-reports of disease are
not deceiving us about the reality of the
situation on one side of the Atlantic vs
the other. Second, the SES-health gradient
is also not a reporting mirage; a
by-product of differential ability by
standard SES markers to recognize and
report disease in surveys, an ability that
has been thought might differ even
among the western industrialized countries.
Instead, the SES health gradient
appears with equal force in either self reports
or biological measures of health.

In other words, poor people in the US have had poor health long enough that the widening gap between rich and poor seems to have had no measurable differences in health outcomes from those at the bottom. This is very interesting, since in this country it is those near the top who seem satisfied with the status quo and those at the bottom of the socio-economic scale who are more panic-stricken about reform.

One would think that the reverse would be true, that the group more likely to benefit from reform would be most in favor but they are not. Ironically, although they are not the loudest voices (they leave that to others frightened into believing the birther/deather/rationing myths) it is Medicare beneficiaries, along with well-insured pundits, politicians and a handful of key professionals orchestrating and funding the opposition who are the groups most likely to benefit from changes.

And finally, self-reporting is not as unscientific as some might argue. In the dry language of the study,  the results are the same with "either self reports or biological measures of health." In other words, self-reporting is accurate. Whether you think you are sick or well, it's not your imagination. Enough people really know facts about themselves that hypochondriacs and Pollyannas don't skew the results. 

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I keep thinking about our teeth and dental health. That makes a good comparison with the greater picture of health care. Even under the worst of conditions, neglecting dental health may be cosmetically disagreeable and personally challenging, but neglected dental care rarely results in death. For some reason, dental insurance alone is rare. Typically it is a rider to broader health policies. Most people attend to dental health on an ad hoc basis. Many, blessed with a good set of teeth, go years with little or no attention. Others manage dental problems as they come along, in effect being self-insured. Consequently, dentists practice their profession in much the same way that physicians did prior to the advent of health insurance. Dental care, therefore, is a good model showing true market economics at work.

Losing all your teeth is to dental care what get-sick-and-die is to overall health. That's not the model of health care I want for me or my family because it's linked to what we can (or cannot) afford.