U.S. versus U.K.

Last week, in his New York Times column , Paul Krugman wrote about a study from the Journal of the American Medical Association , and the study is fascinating enough that it’s worth a second look. It was conducted by a group of epidemiologists at University College London (my parent’s alma mater!). The point was to compare the health of the United States and the United Kingdom. It’s an interesting question for a number of reasons, but principally because the United States spends $5274 per person, per year, on health care and the United Kingdom spends $2164, or substantially less than half as much. The question is—what do we get, in terms of health, that for extra $3100 a year?

Comparisons between countries are pretty tricky. So the study takes a number of precautions. Obviously the United States has a much larger percentage of immigrants, particularly Latino, and a large and (relatively poor) black population. So the comparison is limited to non-Hispanic whites in both countries. Health also differs, dramatically, by socio-economic status, so that everyone in the study was broken up into one of three groups by income and education. It was also limited to men and women between the ages of 55-64, and the age distribution of the two countries was identical.

So what do they find?

The first conclusion is that Americans are really, really sick compared to the British. In every socio-economic group, for instance, the prevalence of diabetes is roughly double in the United States than it is in the United Kingdom. Rates of hypertension, heart disease, heart attacks, stroke, lung disease and cancer are also all higher in the United States. And not just a little big higher. Much higher. So, for example, 2.3 percent of the English have had a stroke, versus 3.8 percent of the Americans.

Is that because Americans have unhealthier lifestyles? Not really. Levels of smoking, in the two countries, are pretty similar. Americans are much more likely to be obese (31.3 versus 23 percent). But then 30 percent of the British were heavy drinkers, versus 14.4 percent of Americans. (One of the curious facts in the study:  in both the United States and the United Kingdom, the more money you make and the more education you have, the more you drink. There are roughly twice as many heavy drinkers in the best educated English cohort as there are in the least educated English cohort. So much for class assumptions about alcohol.) The study’s author did a statistical exercise, where they assumed that the British group had exactly the same lifestyle risk factors as their American counterparts. The result? Nothing much changes. Americans were still far sicker than the British. 

Krugman argues that this is evidence of how much more stressful living in America is than living in England. I think that's absolutely right. I would simply add that it is one more nail in the coffin of the notion that good health is something that can be purchased through fancy, high-tech drugs and doctors and hospitals,.I know the idea that health care is just another consumer good is pretty popular at the moment. But its very hard to read the JAMA study, see what our $5274 actually buys us--and still believe in that notion. Our health is in reality a function of the broader society in which we live--the pressures and conditions and environments in which we find ourselves. The next time we have a debate about, say, how much to tax the rich, or how to structure old age pensions, it would be nice if someone in Washington had the courage to make this point.

Comments

[Felix]

You've read the study? If you have a copy, or a link to it, do send it my way: [email protected]. I tried emailing the lead author to ask for it, but got no response... Before one jumps to conclusions about these things, I always think it's a good idea to read the actual research rather than newspaper articles about the research.

[Cynthia Closkey]

Having not read the study, my first response is to wonder whether Americans are just more diagnosed than the English. Americans might be more inclined to look for medical solutions, to visit doctors when feeling unwell or unhappy or whatever; or American doctors might be more willing to provide diagnoses and prescribe treatments.

It would be useful to know how the study controlled for societal attitudes toward sickness and healthcare.

[Danny]

Huge fan; recently saw you at the Connecticut Forum... Loved the Simon and Garfunkel comment. Anyway I know you are a sports fan and like talking about anomalies in the NBA. Your email conversation with the curious guy was very interesting. So how do you quanitify or make sense of the the first two games between the Nets and the Heat? Nets blow out the Heat in game one, and in game two tonight the opposite happens. Any thoughts or insights?

[Laura Bennett, Embrace Pet Insurance]

Malc (as the Brits might like to say), I love that I can comment on your blog.

I am surprised that you of all people would jump to the conclusion that stress is the "obvious" difference between the US and UK health. Can't you think of a number of other possible reasons off the top of your head?

Having lived in both places for a number of years, I think it is "obvious" that a difference in the quality of food we eat here in the US might be responsible for some of the difference. I am hazarding a guess that food in the US is more processed than in the UK and has more transfats (I don't know for sure but it feels right to me).

I am absolutely certain though that there is more sugar in the US diet compared to the UK (just check your bread labels and really taste a slice of regular supermarket bread next time you eat it - there is way too much sugar than there should be, even the supposed good-for-you bread).

Perhaps there's a restorative effect from drinking tea? And I'll bet that Brits drink more wine than in the US. I'm sure we could come out with a number of differences along these lines and these are just to do with food and drink.

And finally, perhaps Americans obsess more about their health and use all the fancy gadgets to diagnose the same illnesses as they have in the UK. Are Americans sicker or just spend more money on being sick?

I'm sure we could talk for hours on this.

Wonder what would happen if we compared the US to Sweden...?

[vamshi]

that was an interesting blog. as some of your other readers remarked, the reason the US seems sicker than the UK is multifactorial.

i think the difference in the rate of obesity you quoted (31 vs 23 percent) is very significant. in the coming years, i strongly believe obesity will be proven as a bigger risk factor for cardiovascular morbidy and mortality than other traditional risk factor (tobacco, hypertension,etc.)

it's not suprising the US spends twice as much as the UK per person on health care. perhaps there are sicker people in the US and that's why we spend more money. in our litiginious medical climate, doctors practice cya (cover your ass) medicine and order excessive diagnostic tests and treatments. also, in our medicalized (is that a word?) culture, patients seek expensive health care (specialist, the latest drugs, state of the art radiologic exams, etc.)

[Jim]

I read the actual study when it came out last week. My background is in engineering, so epidemiological-type studies aren't really my specialty, but I have at least some knowledge of statistics. I did discuss it with my brother, who works in this field.

First, apparently this was the first study to screen out so many of the variables that might confuse the results. In particular, previous studies had failed to account for the greater diversity in the U.S. So, this really is something new.

Second, the authors are careful not to read too much into the results. From their results, they make a very simple conclusion - the British are healthier than Americans at every level of socio-economic status.

Third, the authors attempted to account for problems with self-reporting by using a backup set of measure. (They called these the "biological" measures.) This part used physical (measurable) data collected from the people in the study, such as insulin level, as a way to support/test the results of self-reporting. Unfortunately, I don't remember what the other biological measures were. Anyway, the biological measures were consistent with the reported conditions, which tends to support the conclusions.

I, too, am trying not to read too much into the study. However, it does tend to suggest that we're not getting good value for our money, which should make one wonder whether we have the best possible system. (I'm pretty sure I know the answer to that.)

One reason for the additional cost is the cost of drugs, of course. Pretty much everyone else puts significant controls on the price of drugs, which means that we're subsidizing the rest of the world by paying full price.

[John Dilworth]

Were expenses for dental work included in those health costs?

[Phil]

Not having read the study, I would agree with one of the commenters above that we might explore more specific "lifestyle" variables to come up with an explanation. The poor quality of the US food supply is one place to look. Overreliance on the automobile is another. It would be interesting just to control for the amount of time spent driving per day.

Look on the bright side, though. If Americans are sicker, they should be spending more on health care!

[Lynn]

There are two big factors that differ between Britian & the US in terms of impact on health that I would add to the list. As an American in London for 10 months now I have noticed that people do a lot more walking here. And I don't believe it's restricted to urban environments like London. This is a big "let's take a walk" nation. And often the best/easiest way to get somewhere will involve walking as part of the journey. Good public transportation systems here (well, better than I'm used to) bring walking into every days journeys. Walking on a regular basis has been shown to be associated with better health and longer life I believe.
Factor two would be that the British (as well as most of Europe) receive significantly more holiday time than US workers. From my experience 5-6 weeks holiday a year is typical here and 2-3 weeks is typical in the US. Being able to take a break from work and the constant low level stress (or high level!) seems likely to play a role in health.

[Meg]

I'd love to see how Canadians would fare in comparison. I have a feeling we used to be far more like the UK, but now we're sliding hard towards the US. As is our medical system, for that matter.

[Darren]

I'm a computer programmer living in the UK, and spend a lot of time hanging out on predominantly US discussion groups on the internet. One of the things that continuously amazes me is the number of hours people work in the US compared to the UK. Stories of 70+ hour weeks are more common than not, with 2-3 weeks holidays the norm, and few public holidays.

In all the jobs I've had in the UK, 37.5 hour weeks are the norm, overtime is never expected (though it may be ASKED for), and holidays are about 5 weeks a year with many public holidays (2 in this month alone)

Working in the UK seems to me to be far less stressful, with few worries about lay offs and health insurance thanks to unemployment benefits and the National Health Service. While it's true that the US economy is probably far stronger as a result of these working practices, I have to wonder how much they contribute to the health problems of Americans.

[Sharon]

Does the research include recovery rates from serious illness? Here in the U.K, there is a tendency to let the old and the very sick die rather than given them expensive treatments on the NHS. If you have a bad headache, you get sent home with a packet of aspirin. In the U.S. you get sent to hospital for a scan. In 9 out of 10 cases, the scan may be a waste of money, but it might have saved my friend's life.

[Jeremy Ballenger]

Interesting that sample group age in the study was limited to 55-64.

Residing in the UK and working on occasion in the US, what strikes me is that based on utterly general observations, I think the findings might well be somewhat different, and nowhere near as widely spread if a differing age sample, say somewhere between 18 and 34 were used.

It is in this sample group that working hours and stresses on people in the UK are more analogous with the US. Further, I doubt the differences between quality of diet would be as distinct.

Acknowledging the higher number of holidays available to the UK working population (of which, somewhere in the vicinity of 40% are employed by the public service in some fashion) as Lynn has done can explain some of the difference in health levels, but not all of it.

[Ian Thomas]

Here's an idea. The study group would have been born during or just after the end of the second World War. Here in the UK, rationing was in force well into the 1950s, and some of the things that were hardest to get hold of were 'bad for you' foods - butter, cheese and so on. I don't believe that the US had these kinds of shortages during and immediately after the war.

So it's possible that the better health of this age group in the UK is linked to early exposure (or a lack of it) to saturated fats and the like. I know there's recent research that shows that fat cells laid down early in life are impossible to shift and can contribute to obestity later in life.

[Marsh]

Interesting thoughts, as always. Thanks MG. I love that you have a blog.

I'm curious to know how visit frequencies vary between both countries. Is one system more accessible?

The medical culture could be a factor--do doctors in the UK influence the daily choices of their patients more? Is one system more proactive?

Are expensive operations blowing out the US numbers (does the US lavish more on the toughest cases)? Does the study compare the group's medians?

It's also difficult to account for lifestyle factors such as amount of time spent watching tv on the couch (as shown to lead to worse diets) or amount of time spent driving (not walking).

Finally, perhaps Americans lean on their expensive medical care system like a crutch. Taking resposibility for one's own health probably trumps any other care.

[jamesl]

The JAMA article is available here
http://jama.ama-assn.org/cgi/content/full/295/17/2037
The paper's conclusion that "Americans are much sicker than the English" was proven only for non-hispanic whites aged 55 to 64 years while the quoted per person health care cost is for the whole population. Americans may spend more on infant or "end of life" care boosting total cost while having no impact on the studied population.
It is an interesting and thought provoking paper but as usual, further study is warranted.

[jamesl]

The JAMA study is a shapshot -- a single point in time. If the US population is sicker but getting better that is very different than if it is unchanging or getting worse. There is a lot of data showing that deaths from coronary heart disease peaked in the 1960s and has been declining since -- 482/100,000 (age adjusted) in 1968 vs 187 in 2000.
http://www.nhlbi.nih.gov/about/04factpdfa4.pdf#fig4-13
So the data hints that things are getting better.
If you and Krugman are going to argue that the difference is caused by stress, you'll need some numbers to back it up. The only conclusion I can draw from the study is that the best way to improve health is to cut spending on healthcare.
It is a very interesting and complex problem.

[newyorkette]

Was there any study of how often Americans were prescribed medicines that the English were NOT prescribed? For example, would the English be less likely than Americans to take a certain non-vital but nonetheless offered medication. Such as painkillers, sleeping pills, antibiotics, etc.

For example, I have often refused medications (antibiotics, and the like), and therefore consider myself a rather cheap date for an insurance company (and am in perfectly good health, nonetheless) which is why I ask.

[Ann Michael]

I just went to a Professional and Scholarly Publishing (PSP) presentation yesterday that discussed how to integrate medical information into the workflow. One of the slides showed that the us spends the most on healthcare and gets almost the worst result - I'm going to try and get the slide and reference from the speaker. It's interesting to think about why - one theory is on this blog - the PSP forum (with a significant number of docs in the room) had another theory and attributed it to our inability to reduce medical errors, inflated costs as a result of no competition in medicine, etc.

[stephen]

I remember reading a study that found there was an inverse correlation between a population's health and the number of hospitals in an area.

So the basic assumption most people make is that healthcare is good for you. This is probably true if you are very sick of injured. But to the extent that basically healthy people get all sorts of treatments from surgery to drugs, it is probably not true for them.

[Elizabeth]

I wonder about the socioeconomic data, and how it was determined. Having lived in Scotland for a couple of months, my impression was that people had a lot less stuff and simpler lifestyles than their US counterparts in similar positions. And of course, the vastly greater amount of standard vacation that most workers get could be a factor.

[James]

This is an interesting post to read this morning. Last night I heard parts of Alternative Radio, in which ER physician Stephen Bezruchka analyzes why American health care is so lacking compared to other countries that spend less per person, such as Cuba. (The show's available at http://alternativeradio.org/programs/BEZS003.shtml) He ends up arguing that we need to focus more on primary care, and that the inequality between rich and poor in the country is inherently detrimental to the quality of our overall health care, even for the rich half of the equation.

I'm inherently skeptical, but I found Bezruchka's points interesting and would like to find out more. Studies like this one, which came out after Bezruchka gave his presentation, sound like even more evidence that something is not quite right in American health care.

[Tuwanda]

I keep reading that your stress level affects your health, so my comment is based on this theory being true. A lot of stress for Americans is derived from financial issues that affect people from all walks of life. For an example, the increase in gas prices is a concern for the very poor to the middle class. The politicians would probably say that their efforts to offer tax breaks such as - Earned Income Credit, Capital Gains, gas refunds - is a way to lighten the financial burdens and thereby improving the quality of life. Some of the stress could also be the result of trying to keep up with the “Joneses”. There is nothing that the US politicians can do about that. Maybe the British ignore the “Joneses”?

[James]

Immediately after college I moved to London where I commenced exploring the nether regions of British culture. I drank way too much (including at -- shock horror -- lunch), ate fish and chips and English breakfasts, &c, &c. After several years I moved back to New York and put on 10 pounds almost instantly. I really believe the cause of this health disparity, and my 10 pounds, is due to the amount of synthetic and processed foods we Americans ingest.

Have a look at Dr. Mahmet Oz's new book for what I think is a great explanation.

[Douglas]

I think I would have less stress and be healthier if I didn't have to worry about my retirement, my vacation time was doubled and not dependent on my tenure with my employer, if I had healthcare no matter how I was employed, and if I didn't have to own a stupid money sucking life sucking car . .