Wednesday, November 23, 2011

Life Expectancy and Health Care Expenditures: Fun with Statistics

Recent data from the University of California Santa Cruz show that although the United States spends far more on health per capita than any other nation, the average life expectancy of its citizens ranks only 28th in the world.

To support this, the website displays the following graph. It depicts life expectancy as bars and the purple line denotes health care expenditures per capita.
Can you see any problems with the data or the way the data are displayed?

I can. Let’s look at the countries ranked ahead of the US. Of the 27 countries ranking higher than the US, 16 have populations of under 11M with 6 of those having populations under 513K [Luxembourg 512K, Iceland 318K, Malta 418K, Andorra 85K, Monaco 35K, San Marino 32K]. At 312M, the US is by far the largest country in the top 30. Japan is second with 128M people.

The US has a much more heterogeneous population than any other country on the list. The per capita expenditures do not take social factors into account. For example, when anyone twists a knee in the US, an expensive MRI is likely to be ordered, not because it’s necessary, but because it’s expected by the patient. There are issues of non-compliance with medications and self-abuse with drugs, alcohol and tobacco. We also expend a lot of money on futile end-of-life interventions.

The bar graph itself is deceptive in that the scale range is from 74 to 82 years old. This makes the difference between the US and Japan seem much larger than the four years it actually is. This is a chart showing the actual difference on a scale of 1 to 85.

Now scroll down the page on the UCSC website and find this:

Although Cuba has limited resources and many economic problems, it has made health care a priority. It is not alone. Sri Lanka, China and the Indian State of Kerala are considered "low-income, high well-being" countries, which have adopted policies that not only reduce inequality but also increase overall health and well-being. The results of these policy priorities are significant, and can be measured in survival indicators, such as average life expectancy.

Now go back and look at the figure. You will not find Sri Lanka, China or the Indian State of Kerala in the list of the top 30 countries in life expectancy.

I am not saying we should not try to do better with our health care dollars. But I think the discussion should not be distorted by those with agendas. The behavior and expectations of our citizens will have to undergo a real sea change before anything meaningful will happen.


jac said...

Good post. Edward Tufte would be proud.

Skeptical Scalpel said...

Thanks. I've read all of his books.

Anonymous said...

Who wouldn't want to have a long life expectancy when you live in such places like Cuba, China, Sri Lanka and India? But of course, these data conclusively prove the superiority of Communist/Socialist state! As long as you're not a woman, when you're aborted before you're even born. Or a dissident. Or anyone but a member of the Party. But such collateral damage is to be expected in the upcoming global proletarian revolution. Viva la revolucion!

Skeptical Scalpel said...

Good points, comrade.

F.E.R. said...

Nice post!
Education and Eating Habits are also two factors that are not considered. It would be interesting to see that.
Also, I would expect the graph to behave differently if you separate it with data of different the USA's states.
Thanks for the info!

Skeptical Scalpel said...


Agree. Education and (over)eating are two more social problems that affect mortality rates and really aren't impacted by health care spending that much.

Joe S. said...

While I agree that population behavior will need to change to fix the US health care system, there is good evidence to indicate that our system is seriously lacking in quality compared to other industrialized nations. The link below has a thorough discussion of quality indicators.

Skeptical Scalpel said...


I read a few of the sections of the link you posted. Regarding physicians, the US is behind in implementing electronic medical records. So what. There is no proof that EMRs improve quality of care. MDs are dissatisfied. True but again, that doesn't mean the quality is bad.

The life expectancy data is the same numbers as displayed in my blog. Obviously, I have the same objections. Infant mortality also is subject to a lot of social issues similar to life expectancy.

Joe S. said...

While I haven't seen any research indicating that EMRs improve outcomes (I haven't looked into it), there is excellent evidence that more coordinated care does improve outcomes which is something that an EMR can facilitate. Additionally, if you look at what a system like Kaiser has been able to do with the data available from its EMR, it is clear that they can be a powerful tool for improving care.

While infant mortality is subject to social issues, this issue is addressed. The author points out that not only does the US have worse outcomes on quality metrics than other industrialized nations, these outcomes, for the most part, have improved at a slower rate than other countries. Moreover, it isn't just one metric that the US lags in. Across the board, the US is at the bottom of the pack.

Skeptical Scalpel said...


Thanks for the comments. There's a reason you haven't seen any research indicating that EMRs improve outcomes. It doesn't exist.

Joe S. said...

While your contention about EMRs may be true, that doesn't address the fact that the US lags behind in numerous quality metrics. Clearly there is a lot of room for improvement in the US health care system.

Kate S. said...

Kerala is not a country, it's a state in the south of India. #justsaying

Skeptical Scalpel said...

I know Kerala is not a country. I'm not the one who said it was. UCSC said it.

P. Pettit said...

but how do you address that we spend twice with everyone else does per capita with a very very minor effect.

Skeptical Scalpel said...

As I said in the blog, there are social issues that lead to markedly increased health care expenditures. Those issues have no bearing on life expectancy.

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