Why Does the U.S Rank 29th in Longevity?

Yes, the U.S. healthcare system is full of inefficiencies which lead to bloated costs. But no, that’s not the reason that U.S. longevity ranks only 29th in the world.

That’s the gist of a working paper (abstract here; pdf here) by Samuel H. Preston, a health demographer at Penn, and Jessica Y. Ho, a health economist.

As summarized in the NBER Digest:

The authors demonstrate that mortality reductions from prostate and breast cancers have been exceptionally rapid in the United States relative to a set of peer countries. They argue that these unusually rapid declines are attributable to wider screening and more aggressive treatment of these diseases. Screening for other cancers also appears unusually extensive, and five-year survival rates from all of the major cancers are very favorable. Survival rates following heart attack and stroke are also favorable (although one-year survival rates following stroke are only average), and the proportion of people with elevated blood pressure or cholesterol levels who are receiving medication is well above European standards.

These performance indicators pertain primarily to what happens after a disease has developed, though. It is possible that the U.S. health care system performs poorly in preventing disease in the first place. Unfortunately, there are no satisfactory international comparisons of disease incidence. Some researchers report a higher prevalence of cancer and cardiovascular disease in the United States than in Europe, and biomarkers confirm that many disease syndromes are more prevalent in the United States than in England and Wales, for example. Higher disease prevalence is prima facie evidence of higher disease incidence, although those high incidence rates also could be produced by better identification (for example, through screening programs) or better survival. The history of exceptionally heavy smoking and the more recent increase in obesity in the United States suggest that a high disease incidence cannot be laid entirely at the feet of the health care system.

Evidence that the major diseases are effectively diagnosed and treated in the United States does not mean that there may not be great inefficiencies in the U.S. health care system, according to the authors. A list of prominent inefficiency charges levied against the system include: fragmentation, duplication, inaccessibility of records, the practice of defensive medicine, misalignment of physician and patient incentives, limitations of access for a large fraction of the population, and excessively fast adoption of unproven technologies. Some of these inefficiencies have been identified by comparing performance across regions of the United States, but the fact that certain regions do poorly relative to others does not imply that the United States on the whole does poorly relative to other countries. The authors also note that many of the documented inefficiencies of the U.S. health care system simply add to its costs rather than harming patients.

They conclude that the low longevity ranking of the United States is not likely a result of a poorly functioning health care system.

This doesn’t come as much of a surprise to anyone who’s dug a bit into the healthcare data (which is vast vast vast), but I don’t believe the public thinks of the issue this way. Many politicians also probably don’t — and their positions are further compromised by the fact that, politically, it can be very hard to blame bad health outcomes on their voters’ overeating, smoking, and other personal choices.

While we don’t have a dedicated healthcare chapter in SuperFreakonomics, healthcare is probably the single most prominent topic throughout the book. A lot of the stories we tell point to failures that could be easily corrected if the existing incentives were aligned less perversely than they are. There are huge gains to be made, for instance, in decreasing hospital-acquired infections and paying attention to the inefficacy of many types of chemotherapy. Also, it may be that less interaction with the healthcare system in general would be a very good thing.


The main factor is demographics not healthcare. Swedes in the US live plenty long. The problem is that there are also lots of non-swedes that don't live as long.


Still, we're paying much more for our 29th ranking in longevity. Even if much of the reason we're 29th is because we're fat, lazy and stupid, humans still need affordable health care.

Isn't this like paying 400,000 dollars year to attend the 29th ranked university? Why would anyone want to do that?

We are forced to overpay for health care by insurance companies.

What I don't really get is why the health industry is so against a socialized system. It seems to me that at the CEO/Hedge fund/Investor level, the business you run is really arbitrary. Meaning that this cabal of millionaires should just invest in a different industry, I don't understand why it makes a difference to them.


As published, such health comparisons just feed political agendas and help no one.
USA is a pluralistic, multi racial society, others are not. Any stats that make inter-country longevity comparisons should take that into account. For example, do American-Europeans (whites) have a shorter lifespand than, for example, German or French whites. By the same token, American-Blacks should be compared to other blacks, such as those in UK. There are studies which have shown, for another example, that controlling for environmental influences, Negroids have a slightly lower life expectancy than Caucasoids.
It would also make sense to control for social class, since the so called life style choices seem to related to class, i.e. junk food and sugar consumption, exercise, etc.


The 29th ranking is always a bit unfair. While I feel happy that the 16 people who live in Andorra live a long life, that's not a good comparison to a nation of 300 million.

To me, the keys to this are:

1) Genetics/culture -- Four of the top six nations in lifespan are from the pacific rim. it's likely that there is some difference, mostly diet, that contributes.

2) Obesity - among G7 nations, the US's obesity rate is first by a longshot. It is ten times that of Japan, three times that of France. You're simply not comparing equivalent populations.

3) Violence and substance abuse -- the US ranks top in our peer nations in these categories.

The only nation that comes anywhere close to us in culture, diet, obesity, violence and substance abuse is the UK. And they live about six months longer.


AC is correct. Look at the state with the highest life expectancy, Hawaii. It also has the greatest percentage of Asian Americans, who tend to live longer than other demographics.

North Dakota, which has the highest percentage of Norwegian Americans, has a life expectancy rate almost the same as Norway.


Don't we also rank badly in infant mortality (http://www.webmd.com/baby/news/20091103/preemies-raise-us-infant-mortality-rate)? When babies die, it has a huge impact on the life expectancy, based on averages. That has to play a part in our lower life expectancy. I'd be curious to see life expectancy comparisons based on how long a 5 year old might expect to live.

Obviously high infant mortality is horrible, but solving it would require a different set of solutions than thinking the problem lies with things like cancer treatment.


Jack Millman

The numbers are suspect. People insist on comparing the very diverse US to countries that are homogenous. By diverse I don't mean by race (whatever that means) etc. I mean geographic. For example indian reservations or ghettos in the big cities where hope, medical care, good food are in scant supply. It reminds me of the 1936 poll for president which only used the phone when most people didn't have one.


Two other things to add to AC's well-taken point:

1. Infant mortality rates are higher here, because we count every baby. Other countries may wait a day or two before officially counting a live birth, and/or not count extremely premature babies.

2. There's a much higher murder rate here. The effect is overall tiny, but perhaps not insignificant.



The 29th ranking and high costs are directly related. Because a disproportionate number of people suffer from problems associated with obesity, such as diabetes and cardiac issues, a high number of people are forced to seek treatment for those problems. Look at financial statements of these insurance companies - their profit margins are not unreasonable compared to other industries.

Health insurance is a social tool to spread risk. It works well when a low percentage of insured actual make claims. In the US, where fast food is cheaper than eating healthy, and harmful preservatives make unhealthy food more affordable than fresh food, many people become obese for economic reasons, not taking into account their future health care expenditures. This is a negative externality.

The best way to account for that is to tax unhealthy foods so that they are at least equal in price to healthy alternatives. Of course, that will never happen because of the number of huge corporations relying heavily on sales of unhealthy foods. It would be a political disaster, as jobs would be lost and the economy would suffer in the short-term. Even something as simple as removing the corn subsidy and sugar import tariff (which would allow for cheaper, healthier food) doesn't have a chance at becoming a reality because of economic incentives of US food producers.



"People insist on comparing the very diverse US to countries that are homogenous. "

OK compare it to Australia - roughly the same geographic extent. Huge mixed migrant population.

Ranks #2 for longevity.


In studies I have read of longevity, improving factors cited included such issues as social support and spiritual life. I believe both of these are lacking in the US.
As an Oncology Data Manager, I suspect that our Cancer incidence rates are probably higher in the US than in some other countries. It would be interesting to see if other countries add as much junk to their food chain as we do. A recently released SEER report shows that mortality rates have actually increased for certain cancers since 1950.
I personally feel that allowing patients to select their own care often results in a higher use of unproven therapies. Everyone seems to think that "The Latest Treatment" or being on a clinical trial is a good thing. When adverse events occur the patient always seems so surprised. The Commission on Cancer has demonstrated that certain known treatments can be considered the "Gold Standard" in Cancer Care and patients should be encouraged to trust their local physicians without this frenzy to run off to the nearest University Medical Center and get on a clinical trial. I believe the media shares some responsibility for the low compliance rate amongst US patients. The majority of US physicians are caring and trustworthy. Have some faith folks....



So many of the commentators argue that because vast swaths of America are entrenched in poverty, those areas should be ignored when calculating statistics? Kind of like the Soviet Union saying everything is wonderful, so long as you don't ask anyone who's not a high-ranking party member?

Cheryl M

Exceptionally heavy smoking? Has anyone been on a train in France? Or a pub in Ireland? We're pikers compared to other countries.

Matt Moore

Anyway to crunch longevity against population living in the suburbs? Growing up in car-centric (i.e., you don't walk) areas with plenty of fast food and frozen meals, and you stay inside a lot of the time, one develops bad habits and lays the ground work for an unhealthy, obese lifestyle.

Compare that to walking cultures of Europe with a more urban population and you might start to explain some differences.


How much skew is put in the data set by the astonishingly high homicide rate in the US? I guess that most of these homicide deaths are in the 16-25 age bracket which must have some effect on the averages.


There are two interesting points in this post; both of which are a result of a privately-delivered health care system.

The first is that though people receive excellent care when they get seriously ill, they still get seriously ill. Health insurance becomes treated like any other type of insurance (something goes wrong, you make a claim - you don't put the effort up front in preventing something from going wrong in the first place). Preventative medicine seems to be failing.

The second is that private companies have created a system where "fragmentation, duplication, inaccessibility of records, the practice of defensive medicine, misalignment of physician and patient incentives, limitations of access for a large fraction of the population, and excessively fast adoption of unproven technologies" occurs.

While this certainly benefits health care delivery in isolated cases (and helps socialized systems in the rest of the world that can take the best of the US system and apply it to their own), it results in an inefficient system in the United States.



On examination, quite a bit of the healthcare data also seems to be suspect - or at the very least, subject to the same unscientific bias as the climate issues we've seen. Check out http://junkfoodscience.blogspot.com/ for specific examples.


For Americans who reach the age of 65, mortality rates are comparable to the top tier of developed countries. This is because our socialized medicine (Medicare) works comparably well to theirs, but unfortunately, under-65s have to wait to enroll in it.


RE: "The authors demonstrate that mortality reductions from prostate and breast cancers have been exceptionally rapid in the United States relative to a set of peer countries."

Can anyone point me to the data behind this. I'm interested in seeing how cancer (any/all types) survival rates have trended over the last century.



Brenda: The part that often gets ignored about infant mortality is that the US has a different (and much looser) set of rules for what constitutes "born." A lot of nations don't count premature births as "births" unless the infant survives - and some European countries don't count a child as "born" unless there's a birth certificate (which isn't issued for at least three days after the birth - sometimes longer). So a child that is born and doesn't survive past the first hour counts as "infant mortality" in the US, but as "stillborn" in many places.

This has a noticeable influence on lifespan calculations, of course (having a person with an effective lifespan of zero has a much more powerful impact on average expected lifespan than losing ten people two years early).

The same thing turns up in other stats... look at suicide rates in the US versus other countries, and you find funny little things - like a "low" suicide rate that doesn't match the number of suicides (a lot of "accidental deaths" are blatantly obvious suicides, but are counted as accidental deaths to keep the claimed stats in line).