Our outcomes are world-class but the costs are exorbitant

From The Myth of Americans' Poor Life Expectancy by Avik Roy.

Life expectancy is an appealingly simplistic, but deeply flawed, way to think about the quality of a country’s health-care system. After all, shouldn’t good health care make you live longer? Well, yes, but. The problem, of course, is that there are many factors that affect life expectancy.

[snip]

If you really want to measure health outcomes, the best way to do it is at the point of medical intervention. If you have a heart attack, how long do you live in the U.S. vs. another country? If you’re diagnosed with breast cancer? In 2008, a group of investigators conducted a worldwide study of cancer survival rates, called CONCORD. They looked at 5-year survival rates for breast cancer, colon and rectal cancer, and prostate cancer. I compiled their data for the U.S., Canada, Australia, Japan, and western Europe. Guess who came out number one?

[snip]

Another point worth making is that people die for other reasons than health. For example, people die because of car accidents and violent crime. A few years back, Robert Ohsfeldt of Texas A&M and John Schneider of the University of Iowa asked the obvious question: what happens if you remove deaths from fatal injuries from the life expectancy tables? Among the 29 members of the OECD, the U.S. vaults from 19th place to…you guessed it…first. Japan, on the same adjustment, drops from first to ninth.

I think Roy's points are well taken. I have repeatedly made the argument that when making comparisons, you have to ensure that you are comparing like-to-like (The Texas-Wisconsin Paradox and intergenerational income mobility and Every one of those common assumptions is simplistic, misguided, or downright wrong. My conclusion is that because the US is so large, so multicultural and so exceptional, it often is highly misleading to look at surface comparisons without understanding the degrees by which countries differ from one another.

For example, I think it is reasonably clear that, when making apples-to-apples comparisons on education, the US is inefficient (much more is spent per outcome) but also much more effective (generally the highest outcomes on a homogenous basis). See US Education: Expensive and ineffective? Not so fast and Americans living intensely.

What Roy is suggesting is something similar for health; that if we want to measure effectiveness, we have to look at health outcomes by intervention rather than overall averages of mortality. In other words, we have to compare apples-to-apples. Nothing particularly controversial about that except that the outcomes are so different from the message we are accustomed to hearing; that for a given health intervention, the US is at the top of the league for positive, effective and desirable outcomes.

What this suggests is that, when taking into account the multiculturalism of the US and comparing apples-to-apples, that in three crucial policy areas, education, health, and welfare (see Income Inequality, Positional Goods, Identity Multiplicity, and Functional Convergence), the US is producing highly effective outcomes that place it at the top of international performance tables when comparing like-to-like. The exceptional effectiveness is achieved, however, with dramatically poor efficiency: Our outcomes are world-class but the costs are exorbitant and perhaps unsustainable.

So we know we can achieve excellence, as we are doing, but what we need to learn is how to improve the efficiency of achievement. Effectiveness - Done; Efficiency - Work in Progress.

What the apples-to-apples comparisons are doing is forcing us into a very uncomfortable corner. IF, in a multicultural country such as the US, we acknowledge that different cultures (the average amalgam of Knowledge, Experience, Skills, Values and Behaviors for each self-identified group) yield different outcomes for a given system or a given exogenous shock, then the fastest way to achieve standard outcomes is to do one of two things.

We can either change the system so that we achieve comparable results for all groups by treating each group differently OR we can synthesize the culture of all groups around the best performing culture.

Under a pluralistic system founded on individual agency, accountability and freedoms, neither approach is feasible. But even if it were, is there actually a preferred choice between the two? I suspect not, both seem anathema.