The Cheeseburger Problem

Paul Krugman writes about excuses people make for the poor performance of the American health care system. One excuse -- too many cheeseburgers:

Americans don’t have a bad health system, say the apologists, they just have bad habits. Overeating and teenage sex, not the huge overhead of America’s private health insurance companies — the United States spends almost six times as much on health care administration as other advanced countries — are the source of our problems.

There’s a grain of truth to this claim: Bad habits may partially explain America’s low life expectancy. But the big question isn’t why we have lower life expectancy than Britain, Canada or France, it’s why we spend far more on health care without getting better results. And lifestyle isn’t the explanation: the most definitive estimates, such as those of the McKinsey Global Institute, say that diseases that are associated with obesity and other lifestyle-related problems play, at most, a minor role in high U.S. health care costs.

One might also note that insofar as Americans have less healthy lifestyles than we should -- which we certainly seem to -- that this, too, is a policy problem worth addressing, not just a factoid to wave around. One wouldn't want to go too far in terms of restricting liberty in the name of public healthy, but we certainly ought to take a closer look at the public health implications of our farm subsidies and land use policies (here both in terms of car accidents and the lost moderate exercise that comes from walking).

On top of all of that, however, is the point that giving people sound lifestyle advice and getting them to follow it is part of a good medical professional's job and part of the job of a good health care system would be to create a situation where people are getting their health status checked up and getting good advice about what they should be doing.

Photo by Flick user Derusha used under a Creative Commons license

Comments

Man that burger looks good.

Posted by cheflovesbeer | November 9, 2007 2:24 PM

Anyone who has ever known someone who is extremely obese knows that Matt is right about this. Many such people never go to the doctor, because they don't want to be told they need to lose weight.

Indeed, this is one more knock against Health Savings Accounts. They are designed to make us consume less medical care, i.e., to make us less likely to call a doctor unless we absolutely need to, because we become price sensitive when spending our own money. But that's going to make it much harder, not easier, to ensure that people are getting advice on diet and exercise from medical professionals, whereas a single payer program would not only get people that advice, but likely pay for medically supervised weight loss for those who need it.

Posted by Dilan Esper | November 9, 2007 2:27 PM

My employer-based plan includes an HSA as well as free annual checkups. If all a plan included was an HSA, it could make people forego regular checkups. I don't know whether HSAs are typically implemented with or without other benefits like free checkups.

Obese people who avoid going to the doctor because they don't want to be told they're too fat aren't lacking sound lifestyle advice. They're lacking the will to face up to the unsound lifestyle choices they know they've already made. Unless a medical plan compels them to see a doctor, it's not clear how it would fix this problem.

Posted by henry evans | November 9, 2007 2:34 PM

the point that giving people sound lifestyle advice and getting them to follow it is part of a good medical professional's job and part of the job of a good health care system would be to create a situation where people are getting their health status checked up and getting good advice about what they should be doing.

Agree wholeheartedly, with the provise that the getting them to follow it part is on the hard & unsolved problems list.

Posted by Bill Gardner | November 9, 2007 2:42 PM

Considering that heart disease is the #1 cause of death in America, lifestyle as a "minor factor" of costs is a rather dubious claim. It is incredulous that our sedintary lifestyle and processed foods isn't costing billions, seeing as it kills more people in America than anything else.

Posted by freddiemac | November 9, 2007 2:54 PM

Matt,

As a physician, I heartily agree that it is my job to provide lifestyle advice. Indeed, I frame the question as each person in the therapeutic relationship as having a job: my job is to give you the right medicines and interventions and their job is to reduce salt/fatty food intake, stop smoking, and exercise. The value of these recommendations, though, should not be overstimated. When studied, modifications of longstanding behaviors are the exception not the rule. 75% of smokers want to stop, the vast majority don't -- even with physician exhortation. (see Law M, Tang JL. An analysis of the effectiveness of interventions intended to help people stop smoking. Arch Intern Med 1995; 155:1933-1941.)

Thanks,

JB

Posted by Josh B | November 9, 2007 2:55 PM

Um, the problem with the emphasis on "lifestyle" is that everyone gets sick and eventually gets sick enough to die. Being obese may hasten that end, but doesn't change the fact that everyone has to be taken care of at some point. The tut-tuting over those darn fat people is just a way to avoid the issue. Skinny folks need health care too.

Posted by Matthew Stevens | November 9, 2007 2:55 PM

Mr. Stevens,

Wouldn't you agree that there are more health problems associated with obesity than with a slim profile? Sure, we all die. But some ways are more expensive than others. Dying of heart disease can typically mean having a heart attack, surviving, and having a stint, angioplasty, open heart surgery, and then a second or third heart attack ultimately causing death. Add to that diabetes due to obesity. See the extra costs that fatness accrues?

Contrast that to my great grandfather, who died at 91 of organ failure. Cheap and quick.

Posted by freddiemac | November 9, 2007 3:04 PM

First let me say that I agree with the main thrust of the post.

On the other track, I think we need people who are paid less than doctors to tell us we're too fat. There are a thousand different things to do about obesity, provided you restrict yourself to the medically approved treatments. Rather than talking to a doctor about them, it should be a simple course of action to talk to someone who speciallizes in weight loss (and costs a lot less) who will suggest a good course of action that can be submitted to the patient's doctor for a quick yes or no.

This sort of thing would be cost effective if people weren't switching health care providers every few years. As it is, why should Blue cross invest now in preventing a future USHealth patient from having heart disease.

Posted by Njorl | November 9, 2007 3:06 PM

This is one of the reasons I'm for a single-payer system: that single payer (the government) would have a powerful financial incentive to give individuals better incentives to make healthier choices.

Like Matt says, our farm subsidies deserve a look. Ezra had a great diagram the other day of the Food Pyramid side by side with the Farm Subsidy Pyramid - the one showing which foods we ought to be eating, and the other showing which foods the government was paying for us to be eating.

All those people who'd like to lose weight - would they be more successful at it if they all had access to a dietitian? Under single-payer, we might find out. It's great to say, "you should eat healthier foods," but the trick is to find healthier foods that you're willing to largely restrict your diet to, year in and year out, that aren't too much work to prepare when you get home in the evening, tired from the workday and the commute.

I've often wondered if, under single-payer, the government would come out ahead in the long run by nationalizing the tobacco industry (paying the tobacco companies market price), then continuing to run it as it is, only ceasing all advertising and product promotion (which would be the purpose of the whole deal).

Etcetera.

Posted by low-tech cyclist | November 9, 2007 3:09 PM

Damn, that cheeseburger looks awesome.

Posted by nate | November 9, 2007 3:14 PM

freddiemac,

Your example is kind of ridiculous. Sure, some heavyset people have heart attacks and survive, and then get expensive procedures that cost money and then die anyway. And some fat people die on their first heart attack, which is a pretty cost-efficient way to die. And some skinny people have heart attacks too, and some of them survive and cost money, and some of them die the first time...

And some people (thin and fat) die of cancer, which costs a lot of money. And some people die instantly in car accidents (cheap!), while some people end up living for years in comas after car accidents (expensive!).

So, no, I don't see how anything you've said shows the extra costs that fatness accrues to the health care system. I do see how suggesting that one hypothetical plus an anecdote about your great grandfather is a pretty poor way to determine the cause and effects of health care costs, though.

Posted by LittleMac | November 9, 2007 3:17 PM

Off topic. Matt what is your favorite burger place in DC. I like Sign of the Wale on M street.

Posted by Dave | November 9, 2007 3:19 PM

Wouldn't you agree that there are more health problems associated with obesity than with a slim profile? Sure, we all die. But some ways are more expensive than others. Dying of heart disease can typically mean having a heart attack, surviving, and having a stint, angioplasty, open heart surgery, and then a second or third heart attack ultimately causing death.

Yes, but that healthy guy who lives to 91 will then die of a heart attack or something else. Yes, the obese guy may get sick faster (although that's by no means guaranteed; again, skinny people get sick too) but ultimately it happens to everyone.

Again, this is simply a way of changing the subject from what is best for society as a whole to what is the best lifestyle, what should invidual doctors be doing, etc.

If we're going to talk about relatives, my skinny grandfather ran 3 miles a day until he got alzheimers in his early 70s. He had to be housed in a nursing home ($80,000 a year) until he and his healthy body dropped dead. On the other hand, my chubby grandmother lived on Doritos until she suddenly dropped dead last week at age 91.

Posted by Matthew Stevens | November 9, 2007 3:19 PM

Well littlemac, let's examine the evidence that I did present:
Obesity has lead to a rise in obesity, which costs billions
http://care.diabetesjournals.org/cgi/content/full/26/3/917
obesity leads to expensive medical procedures:
http://www.americanheart.org/presenter.jhtml?identifier=3024569
Obesity is easily preventable by a change in lifestyle.
Obesity is on the rise.
http://www.cdc.gov/nccdphp/dnpa/obesity/trend/maps/
So, are you really going to argue that fat people don't accrue more in health care than skinny people, on average? Or are you being deliberately obtuse because you like argue?

Posted by freddiemac | November 9, 2007 3:26 PM

Let's talk about that burger. What is that potato looking thing? Is it a hashbrown or one big french fry or what? Crabcake? Man it looks good. I would put some mayo on it. The burger itself could be a little thicker but otherwise that looks pretty good.

Posted by FSMDP | November 9, 2007 3:29 PM

Matt, you said "Again, this is simply a way of changing the subject from what is best for society as a whole to what is the best lifestyle, what should invidual doctors be doing, etc."

No, you're wrong. Lifestyle choice is about what is best for society as a whole. Fatty Yglesias was close to the mark when he started about farm subsidies. Ultimately, what the government decides has an effect on the lifestyle people choose. If federal, state, and local governments decide to build sprawly housing far from businesses and shopping, cut transit options to cars or cars, and make processed foods really cheap, individuals are going to chose a sedintary lifestyle full of processed foods that lead to obesity and heart disease. Why is this so hard for people to understand?

Posted by freddiemac | November 9, 2007 3:33 PM

Let's talk about that burger. What is that potato looking thing?

I was thinking it was the cheese, breaded and fried. After all it's a post about unhealthy lifestyles, and what's more deliciously unhealthy than fried cheese?

The burger itself, however, looks overdone.

Posted by lemuel pitkin | November 9, 2007 3:37 PM

Good post by Matthew - not by Paul.

Some private health insurance companies give non-smokers and people with normal BMI a rate discount after a health check.

My insurance firm gives a 5% discount for non-smokers and a 10-15% discount for low BMI.

How does public health insurance give incentives for prevention and not treatment?

The British government has recently urged citizens to be more lean and to eat less meat and animal fats in order to avoid cancer.

The connection between heart disease and diet is also as strongly established by know that it is not even worth mentioning.

So how can we move from treatment to prevention? How do we discourage the bad and encourage the good? In both cases the true costs must be reflected directly to the citizen. In the supermarket and not on some health bulletin.

It is prices. Indeed - we should stop subsidizing unhealthy foods and should stop making healthy products artificially expensive. We should stop punishing those who try to prevent and take incentives away from those who rather wait until it is too late? Or at least - if we know we do more bad than good - we should try not to intervene with statism at all?

What is Paul Krugman good for, as a socially conscious economist, if cannot even point that out? The Rich can afford healthy foods and are generally leaner and better off due to the status quoe. They practice prevention. It is the poor that Paul claims to be concerned about and whose government offers them a burger for less than $1 and an apple for more...

Paul sounds as if he only wants to control more tax billions but it is not all clear how he would use it or why he would make a better job?

But the big question isn’t why we have lower life expectancy than Britain, Canada or France, it’s why we spend far more on health care without getting better results. And lifestyle isn’t the explanation: the most definitive estimates, such as those of the McKinsey Global Institute, say that diseases that are associated with obesity and other lifestyle-related problems play, at most, a minor role in high U.S. health care costs.

With all due respect - where is this McKinsey study? Paul Krugman does not link to the study. McKinsey is a very good strategic business consulting firm - but I am not certain about their health and medical expertise? Instead - a random Google search yields the following:

Reuters: Obesity may push U.S. health costs above Europe: study; Oct 2, 2007

An old Washington Post article, Obesity Gets Part of Blame for Care Costs, states:

"A spokeswoman for the Centers for Disease Control and Prevention said its budget for nutrition, physical activity and obesity for fiscal year 2004 is $45 million, up from $34 million the previous year."

Wow. This is how much prevention is worth to us? Over a few short years we have given meat and sugar industries over $ 250 billion in tax money. All this while we invest a few pathetic millions for some pathetic prevention initiatives - leaflets about how Americans should eat less animal fat, sugar and eat more fruits and veggies. And then we wonder about health care (which is only sick care) spending?

Does Mr Krugman also doubt the value of prevention? That would explain a lot about his recent openings on policy issues?

It does not matter if you look at this issue from the left or from the right - we all lose given current consumption incentives by the government. And especially the poor citizens and the environment, aka our children. I have no clue from what angle Mr Krugman is looking at it.

Posted by Hugo Pottisch | November 9, 2007 3:39 PM

Matt also said "Yes, but that healthy guy who lives to 91 will then die of a heart attack or something else. Yes, the obese guy may get sick faster (although that's by no means guaranteed; again, skinny people get sick too) but ultimately it happens to everyone."

You are missing the point here also. Everyone dies. But dying of something related to obesity, like heart disease, has more externalities than other causes of death. The fact that children are now being diagnosed with type 2 diabetes for the first time in history and will incur health care costs related to that for the rest of their lives (most likely) should probably tell you something right there.
http://www.childrenwithdiabetes.com/d_0n_d00.htm
(for the google deficient)

Posted by freddiemac | November 9, 2007 3:39 PM

...the point that giving people sound lifestyle advice and getting them to follow it is part of a good medical professional's job and part of the job of a good health care system...

C'mon, Matt, you'd have to be living the life of a sequestered juror not to know that eating every other meal at Burger King's not good for you.

Still, one way to sum up the situation is: if we're going to have a crappy healthcare system, why can't it be a cheap crappy healthcare system like Britain's?

Posted by Jasper | November 9, 2007 3:41 PM

Yes, freddie, diabetes is bad. So is obesity. Who said otherwise? But you're not seriously grappling with Krugman's point: American lifestyles have little impact on the expensiveness of the US healthcare system. Tut-tutting at fat Americans is just a way to change the subject, and you're being a useful idiot and taking the bait. Your stats on obesity would be relevant if diabetes was the only health care expense. It isn't.

Posted by Matthew Stevens | November 9, 2007 3:44 PM

You're all missing the most damning part of the post.

"...but we certainly ought to take a closer look at the public health implications of our farm subsidies and land use policies (here both in terms of car accidents and the lost moderate exercise that comes from walking)."

In other words, MY wants to use automobile accident statistics and peoples' walking habits as an excuse to dictate what kinds of houses they build.

Why are so many 'left' wingers actually benevolent dictators at heart?

Sk

Posted by Sk | November 9, 2007 3:47 PM

I'm thinking that big fried wedge on top of the burger is just a really thick onion ring. Man, that looks tasty!

Posted by Citizen (World) | November 9, 2007 3:51 PM

You are missing the point here also. Everyone dies. But dying of something related to obesity, like heart disease, has more externalities than other causes of death.

I daresay you are missing the point, or at least not making a strong case. On the AHA site, the first contributing factor listed for heart disease is age. Look on page 11, and notice that 92%(!) of women over 80 have CVS. Now, maybe it is more expensive to be treat an overweight person with heart disease than an old one, but you have to explain why.

http://www.americanheart.org/downloadable/heart/1166711577754HS_StatsInsideText.pdf

Posted by Brad L | November 9, 2007 3:54 PM

American lifestyles have little impact on the expensiveness of the US healthcare system.

Not true. This is the point I have been arguing, though I see that Hugo has done so much more eloquently that I. American lifestyles have a large impact on health care costs, and I challenge any so called "difinitive" study that says so, because a 30 second google search will find credible sources stating otherwise.

"Tut-tutting at fat Americans is just a way to change the subject"
I think it is you who is being the idiot here, or deliberately obtuse. The subject isn't being changed at all. We are arguing obesity and health care costs. I disagree with Yglesias' position that obesity isn't driving up health care costs. And as far as "if diabetes was the only health care expense. It isn't." I never said it was, as my previous post with the much ballyhooed anecdote relates (stints, open heart surgery, etc). Heck, obesity even lowers fuel economy by increase the loads that cars carry and create a dead weight loss for fuel costs. Again you are either a moron or an argumentative ass. Which is it?

Posted by freddiemac | November 9, 2007 3:56 PM

I don't understand why people get so motivated to improve other people's lives, in those areas where their problems are due to their choices.

Yes, I think we should restrict school children's food options somewhat to guide them toward more healthy eating. For adults, we should try to ensure that low income people have healthy food options readily available. Banning transfats is fine because the effect on food taste is minimal.

But beyond that, I don't care if the government takes extra measures to convince people to be healthy. At a certain point, you just have to let people make the choice for themselves: is it more important to live long, or is it more important to eat something really tasty right now?

Posted by Jim W | November 9, 2007 3:58 PM

Freddiemac:

You make several good points, but "Obesity is easily preventable by a change in lifestyle." I guess, except unfortunately the data show that this change in lifestyle is very hard.

Posted by Bill Gardner | November 9, 2007 3:58 PM

Is anyone else reminded of the argument that went "our current Social Security system is racist because black Americans die sooner than white Americans and thus receive lower average lifetime benefits?"

Posted by Julian Elson | November 9, 2007 4:01 PM

I'm sure the 60 year old in-shape British guy who has to wait three months to see an oncologist when he gets prostate cancer (giving the cancer a chance to spread elsewhere and become less treatable) is consoled by the knowledge that Brits don't eat as badly as Americans. Socialized medicine = rationing and sick people being denied care. It's that simple. You want to give some of my tax money to help low-income Americans afford health insurance, I have no problem with that. But why ditch the best cancer care, the best heart disease care in the world, etc. because a small percentage of people here are uninsured?

When you subtract the illegal aliens who shouldn't be here, and the people who can afford health insurance but chose not to get it (e.g., those who spend hundreds of dollars per month on new car payments instead of buying a used car and getting health insurance), and those who are eligible for Medicaid but haven't signed up, that leaves probably 5-10% or less of Americans who can't afford health insurance. I think we can all agree on subsidizing insurance for this group. So let's do it and move on. Why destroy a system that serves the vast majority of us better than a socialized system would?

Posted by Steve O. | November 9, 2007 4:06 PM

"In other words, MY wants to use automobile accident statistics and peoples' walking habits as an excuse to dictate what kinds of houses they build.

Why are so many 'left' wingers actually benevolent dictators at heart?

Sk"

No. He wants (probably) government to stop subsidizing unhealthy policies. He might even be so tyrannically inclined as to wish that government would instead subsidize healthier policies.

Just because the government doesn't clear and pave a road out to your exurban McMansion or give you a big bag-o-tax deductions for building it doesn't mean the government will prevent you from building it.

Posted by Njorl | November 9, 2007 4:12 PM

Mr Gardner said "I guess, except unfortunately the data show that this change in lifestyle is very hard."

Sadly true, but also sadly because of poor government policies that affect consumer choices. Cutting subsidies for processed foods like high fructose corn syrup and vegetable oils would be a good start. Cutting federal highway money and increase commuter transit money is another. A gas tax is another. Some are more difficult than other, politically. I like to say that we can kill two birds with one stone by driving less; reduced greenhouses gases and dependence on foreign oil and decreases in obesity and health care costs. Based on the bike post yesterday, it seems unlikely.

Posted by freddiemac | November 9, 2007 4:13 PM

Freddie, your use of insults just makes it clear you understand how to make an argument. You haven't given me any more than a lot of assertions, and some links to an (irrelevant) study saying how bad diabetes is. And you bring up more irrelevant crap about fuel-economy standards (fat people are responsible for the energy crisis)! Did I say fatness was a good thing? No. Did I say it wasn't a health issue? No.

Yes, I've seen studies on the costs of obesity. There is no consensus by any means, largely because the obesity-is-responsible-for-health-care-cost crowd doesn't take increased mortality rates into account. (In any event, that google search comes up with a single study covered about 20 times.) I don't expect you to understand that, though, because that would require actual thought rather than just a series of assertions on how awful fat people are.

Posted by Matthew Stevens | November 9, 2007 4:26 PM

Hey, Freddie, I agree that there are many government policies that might help with the obesity problem. Based on yesterday's bike post, however, these policies will likely fail unless the cycling fashion police (benevolent dictators at heart, if I ever saw them!) let me wear my 2XU jersey...

BTW, please call me Bill, or if you want to be formal, Herr Professor Doktor would do just fine.

Posted by Bill Gardner | November 9, 2007 4:42 PM

Mr Stevens,

You began with the insults, by calling me a "useful idiot", long before I called you an idiot, which you certainly are. It also demonstrates your lack of argumentative skills. Furthermore, on top of your initiation of ad hominems you created strawman arguments numerous times. You state "fat people are responsible for the energy crisis", as if it is an argument I made. I certainly never claimed that as such. In fact, you have repeated misconstrued my arguments with strawmen. I posted many links, and you bring up one involving diabetes and dismiss it as somehow irrelevant (which it isn't if you bothered to read it) and ignore the crux of my argument - once again.

The worst is really your lack of reading comprehension. Your most offensive strawman is claiming I made "a series of assertions on how awful fat people are". Nowhere did I ever place moral values on obesity or make any claims against the character of fat people. I simply stated facts, that the study Yglesias cites is demonstratably false. Fat people are not good or bad. They are people who are driving up health care costs through rational decision making.

Posted by freddiemac | November 9, 2007 4:50 PM

I can has cheeseburger?

Posted by LOLCat | November 9, 2007 5:02 PM

"I can has cheeseburger?"

Get away from that, BAD KITTY!

"Let's talk about that burger. What is that potato looking thing? Is it a hashbrown or one big french fry or what? Crabcake? Man it looks good."

I believe your first instinct (hash-brown) is the correct one.

"...I would put some mayo on it...

So much for your instincts. MAYO????!!!! Are you a raving lunatic! You must be either a sheltered, "live with my mom" wingnut or a sheltered, "live with my girlfriend's parents" moonbat to make such an utterly abhorrent condiment suggestion. Good god, hamburgers must be smothered in catsup/ketchup (with perhaps a smidge of mustard) or else the terrorists win. All good and true Americans know this…

Posted by Rihilism | November 9, 2007 5:24 PM

Brad

On the AHA site, the first contributing factor listed for heart disease is age. Look on page 11, and notice that 92%(!) of women over 80 have CVS. Now, maybe it is more expensive to be treat an overweight person with heart disease than an old one, but you have to explain why.

Brad - you are absolutely right to point to even more of Paul Krugman's fuzziness. Why mention only obesity by name when diet and other consumption clearly also affect heart and cancer disease? To be fair, Paul does mention the term other life-style diseases..

Diet and bad health are clearly related beyond obesity and heart disease? There is a heavy overlap if you will (ie saturated fats and sugar)?

Some quotes from the American Heart Association statistics that Brad has linked to:

• According to the NCHS, if all forms of major CVD were eliminated, life expectancy would rise by almost seven years. If all forms of cancer were eliminated, the gain would be three years.

• According to the same study, the probability at birth of eventually dying from major CVD (I00-I78) is 47 percent and the chance of dying from cancer is 22 percent. Additional probabilities are 3 percent for accidents, 2 percent for diabetes and 0.7 percent for HIV.

• ....CVD claims more lives each year than cancer, chronic lower respiratory diseases, accidents and diabetes mellitus combined.

• Over 147,000 Americans killed by CVD in 2004
were under age 65.

• ...32 percent of deaths from CVD occurred prematurely (i.e., before age 75, which is close to the average life expectancy).

• ...eating a Mediterranean-style diet and greater physical activity are associated with 65–73 percent lower rates of all-cause mortality, as well as mortality due to CHD, CVD and cancer. (JAMA. 2004;292:1433-1439.)

• The NHANES II Mortality Follow-UP Study indicates that the risk for fatal CHD was 51 percent lower for men and 71 percent lower for women with none of three major risk factors (hypertension, current smoking and elevated total cholesterol ≥240 mg/dL) compared to those with one or more risk factors.

• The estimated direct and indirect cost of CVD in the United States for 2007 is $431.8 billion.

So the question is - why do we subsidize those things that lead to elevated cholesterol and hypertension? Apart from smoking - the causes of heart disease and obesity are more or less the same (sugar, saturated and trans fats, etc. - which we have subsidized with $ 250 billion over the last few years while fruits and vegetables get virtually nothing)?

We have managed to cut smoking drastically in only 2-3 decades. We can achieve the same when it comes to obesity and heart disease. It is not like you have to give up smoking - you just smoke less or different stuff and can still enjoy your body into old age rather than becoming a vegetable because of never eating one.

And again - we invest more than 1000 times less in prevention and free markets than in treatment and symptom fixes? Why? A few hundred billion in tax money here (sick care and not health care).... a few hundred billion there (meat and sugar subsidies and school lunches)... but you bad libertarians - stay away from our tax budget - we know how to spend it wisely and in the best interest of the poor?

This is just like the strongly religious Christians supporting torture and the death penalty while fighting the pro-life war? Stop!

Posted by Hugo Pottisch | November 9, 2007 6:24 PM

America's lifestyle choices are really the world's lifestyle choices, at least that portion of the world rich enough to afford them. There's a silly superstition current on the Left that Europe is some sort of Shangri-la where everything and everyone is above average-- but it isn't. Obwsity is a worldwide plague. Ditto for smoking, excess drinking, risky sex, and bad driving habits. Throughout the First World large numbers of people spend their working day sedentary at a desk. If European health outcomes are better than our own I would suggest that universal healthcare really does have something to do with it, because middle class Europeans at least really aren't living any better than we are.

Posted by Jonf | November 9, 2007 6:28 PM

The British have a healthier lifestyle than us? You gota be kidding. And don't get me started on the Scots.

Posted by J | November 9, 2007 6:47 PM

think of it this way: is it easier, given purely financial (dis)incentives, to influence real people or those quasi-people we call corporations?

people have psychologies, which lead them to want what isn't good for them.

corporations, not being actually human, do not have desires which conflict with the bottom line.

therefore, re. public health, I'm with freddie. influence corporations, individual health will follow.

Posted by metaleptic | November 9, 2007 6:49 PM

I can has cheeseburger?

if u has cheeseburger, u inkreese risk of adult onset diabetis, hart diseeze, and other helth problums. y do u want cheeseburger? I never meant 2 cause u any illness. (Although u being a cat, I don't want 2 see u bathing in the purple rain either, since that would probably cause u pain.)

America's lifestyle choices are really the world's lifestyle choices, at least that portion of the world rich enough to afford them. There's a silly superstition current on the Left that Europe is some sort of Shangri-la where everything and everyone is above average-- but it isn't. Obwsity is a worldwide plague. Ditto for smoking, excess drinking, risky sex, and bad driving habits. Throughout the First World large numbers of people spend their working day sedentary at a desk. If European health outcomes are better than our own I would suggest that universal healthcare really does have something to do with it, because middle class Europeans at least really aren't living any better than we are.

It's true that these problems exist all around the world, but the U.S. does have the highest obesity rate in the OECD and I think in the world too, and it's not really an issue of all of the rich countries being near enough to each other in this statistic that the differences don't matter much. Americans are almost ten times as likely to be obese as Japanese.

http://www.nationmaster.com/graph/hea_obe-health-obesity

Posted by Julian Elson | November 9, 2007 7:11 PM

You don't have an illustration for the cause of high rates of teen pregnancy ;-) This is, of course, the relative lack of availability and promotion of contraception in the USA. Greg Mankiw (the target of Krugman's column although he is too polite to name names) would have us believe that the high US teenage pregnancy rate is based on uh hard to modify behavior. This is false. Teenage sexual activity is very similar in all rich countries (starts around age 16). The big difference is in use of contraception which has a whole lot to do with health care systems.

Also, teen pregnancy does not, by itself, have a large impact on health outcomes. The babies of teenage mothers are much more likely to die soon after birth (risk up about 40%) but most of this (all but 10 %) apparent effect went away when Arlene Geronimus included race income and a crude indicator of access to health care in the regression. Roughly, the infants of teenagers are more likely to die, because their mothers are more likely to be poor Black and with poor access to health care. The identification of teen pregnancy as a major root cause is a gross confusion of correlation and causation.

see

Arlene Geronimus. 1987. On teenage childbearing and neonatal mortality in the United States. Population & Development Review 13(2):323-334.

Basically, the factor stressed by Mankiw turns out to be less important than the ones he claims are not critical when they go head to head in a regression.

Posted by Robert Waldmann | November 10, 2007 1:05 AM

Re: Why destroy a system that serves the vast majority of us better than a socialized system would?

Have you bothered to read the proposals of the major Democratic contenders? Each of them allows you the choice of keeping your current insurance or switching to a public program. So where is the "destroying" part?

Re: it's not really an issue of all of the rich countries being near enough to each other in this statistic that the differences don't matter much.

Um, yes it is. You cite the Japanese but they are an outlier: for some reason (genetic metabolic factors?) Japanese people have to try really, really hard to get fat. Hence the special diet and regimen of sumo wrestlers. Europeans on the other hand pork out just like Americans do. (By the way, why are you making the points for the right on this (unless that's what you want to do)? They're the ones claiming American healthcare isn't at all inferior because we Americans are fatter, smoke more, drink more etc. I'm trying correct that piece of disinformation.)

Re: This is, of course, the relative lack of availability and promotion of contraception in the USA.

I disagree that there's any lack of availability of contraception: you can buy condoms in Walmart and some bars even give them away for free. It's kind of like seat belts in cars: they're there if you want to use them, but it's very hard to force people to do so. It might be worthwhile to consider the cultural factors that impede contracpetive use in the US. Availability is not an issue.

Posted by Jonf | November 10, 2007 1:30 AM

'Why destroy a system that serves the vast majority of us better than a socialized system would?'

LOL, spoken like someone who has absolutely no experience with anything beyond our system. Really, this is so laughably dishonest that I just have to assume you're a lying hack.

Posted by Soullite | November 10, 2007 7:15 AM

Where can I get that cheeseburger? I need one now!!!

Posted by thehova | November 10, 2007 12:22 PM

Greg Mankiw on waistlines and health care costs:

The Carpe Diem blog has an interesting table, reproduced above, that corrects life expectancy data for differences in the rates of premature death from non-health-related injury, such as homicide and car accidents. The resulting number reflects health-related mortality. Notice that the United States has the longest standardized life expectancy.

I have not studied the details behind the construction of these numbers, but they are asking a sensible question. If our goal is to evaluate health systems, we should correct for international differences in outcomes that arise from other causes.

Homicide and accidents are only the beginning of the story, however. For example, I would also correct for differences in obesity, which are largely a function of lifestyle and can have significant health effects. Here, from OECD data presented in the O'Neil study, are the percentages of the male population with a body-mass index of 30 or more (female obesity rates are similar):

Japan 2.8

France 9.8

Germany 14.4

Canada 17.0

U.K. 22.7

U.S. 31.1

Given how overweight we Americans are compared with citizens of other countries, it is amazing that we live as long as we do. If we further standardized life expectancy by body-mass index, the U.S. lead in health outcomes would likely grow even larger.

Posted by Hugo Pottisch | November 11, 2007 1:42 PM