96 thoughts on “Value/health care dollar: U.S. vs. rest of world”

  1. With a correlation coefficient of 0.51, that’s not a terribly good fit. It might suggest a line of further investigation, but to be honest, I’d look more closely at the data for principle components.
    (It’s a long time since I had to do a proper ANOVA analysis though.)
    I suspect a cleaner result would be to compare pre-tax profit in the health-care industry with life expectancy. But that would fall foul of all sorts of inter-country comparison problems.

      1. It also looks like you could play with the shape of the curve a little to improve the fit.

    2. They should have used a log-log plot. Everything fits a straight line on a log-log plot.

  3. I don’t think the degree of correlation is the issue. The U.S. spends about twice per capita for health care compared to the rest of the world, but without concomitant benefit. Despite that, we hear from the Republicans that it is the best system in the world, and that Obamacare will ruin a perfectly functional system.

    2. Likely a contributing factor, but IIRC the same correlation shows up if you use the Gini index, indicating that it is the generic dysfunctionality of US society that is to blame. (But I have to check that.)

      2. Oops, sorry: rather the generic correlation is there. But US doesn’t look like an outlier, meaning (I think) it can’t be the only contributing factor.

    3. It IS the best health care system in the world – if you are a millionaire. That’s why the GOP is so opposed to the ACS, it would clog doctors’ waiting rooms with a bunch of hoi polloi and make the millionaires late for their tee times.

    3. It is curious, though, that the two massive nuclear-armed superpowers (or, at least, their decaying remnants) are the only ones substantially below the curve.

      Personally, I’d be interested in seeing a similar plot of per-capita consumption of refined sweeteners, and another one of alcohol. The former may well account for a significant portion (though almost certainly not all) of the anomaly of the US deviation, and the latter for almost all of the Russian deviation.

      b&

      1. I think they have narrowed the decrease in lifetime expectancy down to “refined sugars”. It was all over the news here the last week or two.

        Scientists here wants to decrease the recommendations by a factor 1/2, already quite low. (Meaning that for instance bread better be unsweetened in general.) The authorities have yet to respond.

        Dunno if sweeteners in general have been found to have any effect. If they aren’t used as much, they wont show up in the statistics that was used in the research.

        1. I generally refer to, “sweeteners,” rather than, “sugars,” for two main reasons.

          First is that many people don’t think of honey or corn syrup or agave nectar or the like as sugars, even though not only is that exactly what they are but they’re also all effectively metabolically identical; all are roughly half fructose and half glucose (±~10%), with inconsequential trace elements thrown in for flavor. (Don’t get me worng; I love honey and have even thought about getting an hive for the garden, but I’d never eat more than a small spoonful a day at most.)

          Second is that most other sweeteners are aspartame and saccharine and the like, and those are almost certainly worse toxins than even sugar.

          If you have a sweet tooth, satisfy it with fruit — and then work on straightening out your metabolism so you don’t crave sweets any more. Once you’ve done that, all sorts of unsweetened foods actually taste sweet, such as raw carrots and boiled golden potatoes fresh cabbage; further, the spices on your rack will provide all the added sweetness you’ll want — fennel, cloves, cinnamon, and others are not only sweeteners but full of much more complex and interesting flavors, and even have some negligible nutritional and / or health benefits.

          Cheers,

          b&

          1. I wonder if you have any proof (I mean properly conducted studies) that e g aspartame is ‘an almost certainly worse toxin than even sugar’?

          2. Funny you should ask. I just got back from dinner with Mom and Dad. On the evening news they were reporting about a brand-new study that found significantly increased rates of cardiovascular disease amongst women who habitually drank diet sodas or otherwise consumed artificial sweeteners compared to those who never did. Those women also had higher rates of diabetes and obesity.

            That matches with anecdotal evidence I’ve heard from more than one person who works as a restaurant server. The unhealthiest customers are always the ones who drink lots of diet soda, followed by those who order regular soda. The lean and fit customers mostly just drink water.

            Cheers,

            b&

          4. There are good reasons to strongly suspect that artificial sweeteners are even worse than sugar, and it’s quite clear that sugar is what’s powering the epidemic of the metabolic condition. Just the fact that the sweeteners are metabolized in the liver should tell you all you need to know.

            You’re welcome to consume them if you like. I won’t, and I won’t recommend that anybody else does — but don’t let that stop you. Especially if you’d like to experience the metabolic condition for yourself….

            b&

          5. On the evening news they were reporting about a brand-new study that found significantly increased rates of cardiovascular disease amongst women who habitually drank diet sodas or otherwise consumed artificial sweeteners compared to those who never did. Those women also had higher rates of diabetes and obesity.

            Sounds like a case of reversed cause and effect: overweight people and diabetics choosing to consume diet sodas in an attempt to limit energy intake.

            That matches with anecdotal evidence I’ve heard from more than one person who works as a restaurant server.

            Now there’s some reliable evidence.

      2. One of the biggest problems Russia has is it’s got a population of 140 million, 1/2 of USA, but a GDP of only 2 trillion, about 1/7 of the USA.

        By comparison, Canada, with a population almost 1/5 of Russia, has a GDP of 1.7 Trillion, almost as much as Russia.

        Russia is a very poor country so it’s not surprising to see it do so poorly. The only thing that surprises me is that it was ever a superpower. The money that had to be sucked out of the economy to support the military infrastructure had to be truly massive.

        While it still has a massive number of tanks and weapons it doesn’t have the money to use them. Which is perhaps why Putin is helping himself to Crimea, and desperate to keep Ukraine (and other countries) in the Russian sphere of influence.

      3. Are you serious? Artificial sweeteners causing decreased life expectancy? There is no good evidence for this. Whereas sugar is linked to overweight, diabetes, and heart disease.

        Furthermore, even if a graph showed a relation between per capita artificial sweetener consumption and population-average life expectancy, it would be meaningless. Do I really need to state on a science bl…er…website that correlation does not imply causation? Aside from that, you can’t impute a relation at the population level to a relation at the individual level. That’s the ecologic fallacy.

        1. Even a superficial analysis of the uncontested facts is ample to conclude that artificial sweeteners are at best a fraud. You’ve just agreed that sugar causes the metabolic condition, and artificial sweeteners do nothing to alleviate the metabolic condition. If artificial sweeteners worked as advertised, people who consumed them exclusively in lieu of sugar would see improvements comparable to those who give up sugar without any substitutes. Instead, those who switch to artificial sweeteners do worse, if anything.

          That, and your accusation of the ecologic fallacy would work equally well to dismiss claims of the health hazards of cigarettes….

          Cheers,

          b&

          1. Even a superficial analysis of the uncontested facts is ample to conclude that artificial sweeteners are at best a fraud.

            It’s rare that supericial analysis gives the correct answer, and your analysis is not an exception.

            You’ve just agreed that sugar causes the metabolic condition, and artificial sweeteners do nothing to alleviate the metabolic condition.

            I have agreed to neither. Sugar does not “cause” metabolic syndrome, if that is what you’re talking about. Metabolic syndrome has a complex etiology involving genetic predisposition, diet, and energy balance. No one thing, including sugar, “causes” it.

            Artificial sweetners are obviously not the cure for metabolic syndrome, and they are not intended to be. However, I can assure you that if someone eliminates the sugar in their diet from sodas by replacing those sodas with diet sodas, and makes no other changes to their diet, their energy intake will be lower. And if they were in energy balance before the change, they will lose weight as a result of it.

            Instead, those who switch to artificial sweeteners do worse, if anything.

            Again, there is zero evidence that switching from sugar to artificial sweetners causes weight gain or associated metabolic disorders. You are still confusing cause and effect.

            [Y]our accusation of the ecologic fallacy would work equally well to dismiss claims of the health hazards of cigarettes.

            Ecologic correlations are generally worthless for establishing cause and effect; it doesn’t much matter what they’re applied to. You are correct: an ecologic correlation between population disease incidence and the prevalence of smoking would likely be meaningless. However, we have much stronger evidence than ecologic correlations that smoking plays a causal role in heart disease and various cancers.

            Your thinking on this subject is utterly unscientific.

          2. However, I can assure you that if someone eliminates the sugar in their diet from sodas by replacing those sodas with diet sodas, and makes no other changes to their diet, their energy intake will be lower. And if they were in energy balance before the change, they will lose weight as a result of it.

            There is no better way to demonstrate complete ignorance of metabolic physiology than with statements such as this.

            Yes, of course; physics places upper bounds on matter and energy intake, expenditure, absorption, and excretion rates.

            But metabolic systems are so far from the perfectly-efficient ideal machines necessary for those limits to be relevant that it’s not even funny. Worse, food label calories are determined using a bomb calorimeter, which is pretty close to a perfectly-efficient machine. The label says you could get your 2,000 daily kcal from 3/4 pounds of sugar or 27 pounds of celery. Need I further explain the uselessness of that type of simplistic calorie counting?

            Far more significant in real-world metabolism is the means by which various foods are metabolized. Glucose, for example, is (mostly) absorbed directly into the bloodstream and taken up by cells, where it’s directly used as an energy source. Fructose, on the other hand, is (almost entirely) metabolized by the liver, with a small proportion converted to glucose but with most of the rest converted to fat and low-density cholesterol.

            The naïve physics-based diet plans such as you’re proposing (“assuring” that changes in caloric intake are directly proportional to weight gain or loss) completely ignore these sorts of not-at-all-subtle “nuances” of the actual chemistry of real bodies. And, again, it’s trivially demonstrated false; if it really were true that a calorie is a calorie is a calorie, then any hydrocarbon fuel would work the same in the human body — yet just try substituting some methanol for ethanol and see (or not!) what happens.

            Since you’re so profoundly confused (even if unknowingly) about how food works, permit me to offer some very simple advice for health.

            Eat no fewer than three meals a day, and ideally five (or three meals and two snacks, etc.). With more meals, portion sizes will be smaller for the same daily totals. Don’t skip meals and don’t wait until hunger sets in before eating; if you do, you’re telling your body that food is in short supply and it should prepare for famine by hoarding as much as it can.

            With every meal (including breakfast!), eat bountiful amounts of fresh or lightly-cooked veggies. Don’t use commercial dressings or dips; instead, use oil and vinegar (and maybe some salt and pepper and herbs), or something like a yogurt-based bleu cheese dressing that you can make easily enough just by mixing bleu cheese into (plain, unsweetened) yogurt, along with maybe some herbs, lemon juice, vinegar, etc. Simplest and quickest is to just munch on carrots, radishes, celery, etc. unadorned just as they are.

            With every meal, eat a portion of protein about the size of the palm of your hand. Poultry and fish are very good, but unprocessed pork and beef are fine. Fresh sausage is as easy to make as mixing some spices in a spoonful of water (or wine, broth, etc.), and then mixing that into store-bought ground meat. Tofu is good, but not as an exclusive source. Eggs are excellent.

            With every meal, eat about as much carbohydrates as the protein. Prefer complex carbohydrates to simple ones, whole grains over fruits. Restrict refined sweeteners to ones composed of sucrose, glucose, and fructose; that would be table sugar, honey, maple syrup, and the like. And limit your average daily intake of such sugars to absolutely no more than a tablespoon, or 15 grams. No sugar is better than some sugar; try to get in the habit of simply not eating any sugar, except for rare treats. If you have a sweet tooth that just won’t let you rest, sate it with whole fresh raw fruit (not juices). And don’t forget that, not only is sugar in almost every processed food, it’s most of what’s in things like ketchup and salad dressing or other commercial sauces.

            And with every meal, garnish foods as culinarily appropriate with minimally-processed fats. That might mean olive oil with the salad, butter (not margarine) on brown rice, mayonnaise (homemade — takes under five minutes to make) on a sandwich, that sort of thing. Fats are essential components of much of the body’s cellular structure, and dietary fats are generally used for that purpose or burned for energy; it’s the dietary fructose that mostly gets turned into excess fat deposits.

            In addition to eating well, at least a few times a week, put in a solid half an hour or so of strength-building exercises. Aerobic exercise can be fun and are better than being sedentary, but they don’t do all that much, comparatively, for body composition and overall health. There’s no need for a gym or fancy equipment unless that helps with motivation; indeed, your own body is the ultimate gym. Pushups, squats, pullups, crunches, and innumerable variations thereon are far superior to any mechanized exercise equipment ever invented.

            Last, get ample sleep; at least eight hours a day in bed, possibly more if you’ve been chronically depriving yourself. Poor sleep habits do nasty things to the human body, including make it put on excess fat.

            Do all that and odds are superlative (though, of course, there’s no guarantee) that you’ll solve (or prevent) all your metabolic problems. It takes time to heal, of course; if you’ve been abusing your body for a couple decades it may well take a few years to fully recover, though it shouldn’t be more than a couple / few months before you’re not only secure in new habits but that it’s obvious that you’re living right.

            And one last bit of advice: ignore the number on the scale and on the tape measure. Many people with excess body fat are actually below their ideal body weight, for the simple reason that they have much too little lean body mass (muscle, bone, etc.). That is, the problem with most Americans isn’t too much weight, but rather too much fat; we’re mostly a bunch of lard-assed pencil-necked geeks. Fixing lifestyle habits will often result in weight gains, either temporary or permanent depending on initial body composition. But the body you wind up with will be lean and athletic, without any love handles or spare tire or the like — and it’s that excess fat that makes people unattractive, not the numbers on the scale. Indeed, you can actually go up a few waist sizes but look leaner, simply by swapping midsection fat for abdominal muscle. You can’t have both six-pack abs and a 27″ waist, after all.

            Cheers,

            b&

          3. Ben, I can’t compete with the pseudo-information you’ve bought into from the new-age non-science books you have read and websites you have perused but don’t have the background in science to see the silliness of. What strikes me as completely bizarre is that you are spewing this nonsense on Jerry’s website, which is dedicated to combating exactly that sort of pseudoscience. It would be nice if Jerry would speak up here, but I suspect that human nutrition is outside his area of expertise (especially considering some of the atrocious meals he routinely brags about consuming!).

          4. You have seriously got a metric fuckton of remedial physiology to catch up on if you think what I was doing was spewing pseudoscientific nonsense.

            Start here, with this lecture from the University of California at San Francisco:

            That should at least get across the basic idea that metabolism isn’t just about calorie counts — though I rather though the comparison between celery and sucrose I made would have made that painfully plain. But maybe hearing it from a UC professor who specializes in metabolism, complete with diagrams of the various metabolic pathways, will help you accept that human bodies aren’t the idealized perfect thermodynamic engines you like to pretend they are.

            One last analogy. Newton says that, if you give your car a push, it’ll keep going at that same speed forever. Except, of course, he doesn’t, really, and you actually have to factor in air resistance and rolling resistance from the tires and the mechanical inefficiencies of the Carnot cycle and all the rest to explain why you need to stop for gas somewhere on your drive from San Francisco to Los Angeles instead of simply getting your friend to give the car a good heave in SF and have another friend catch you in LA after coasting the whole way between. The calorie is a calorie is a calorie school of physiology that so many “diet plans” are based on is as silly and irrelevant in its gross and incompetent oversimplification of physiology as that treatment of automobiles as frictionless spheres in a perfect vacuum. Yes, it can have limited didactic usefulness in certain academic settings, but only to establish the outer limits of the energy budgets; anything beyond that and you’re into Saturday morning cartoon physics.

            Cheers,

            b&

          5. Is it truly your position that there would be no epidemiological effects for substituting, calorie-for-calorie, celery for sugar (or vice-versa)?

            No. I never said anything that would even remotely imply that.

            If not, how do you reconcile such a position with your earlier statements about caloric equivalences and substitution?

            Obviously food choices affect health. But energy balance is energy balance. If your energy intake exceeds your energy expenditures you will gain weight regardless of what foods you eat. If your energy expenditures exceed your energy intake, you will lose weight regardless of what foods you eat. I have no idea why you think that celery being less energy dense than sugar refutes .

          6. If your energy intake exceeds your energy expenditures you will gain weight regardless of what foods you eat. If your energy expenditures exceed your energy intake, you will lose weight regardless of what foods you eat.

            Ergo, if you currently eat 2000 kcal daily of whatever food you eat today, and you change your diet to one of exclusively 3/4 pounds of sugar per day, you will neither gain nor lose weight (assuming your daily activities remain the same). Same thing if you instead eat nothing but several pounds of celery per day. In all three scenarios, you’re still eating 2000 kcal daily; according to your harebrained theory, a person on all three diets would maintain a constant weight.

            That may well be the case in Play-Pretend Physics Place, where all organisms are frictionless spheres powered by 100% efficient internal combustion engines, but it’s so patently obviously not the case in the real world that I’m not even sure why I’m dignifying it with a response.

            I get it. You have a philosophical attachment to the childish toy model of metabolism you were taught in grade school because it’s as self-evidently obvious as Aristotle’s need for a Prime Mover. It’s just that your philosophy is so far out of touch with even the easiest of observations to make that it’s worse than useless.

            Just like we actually know a bit more about how the planets move than Aristotle did, we know a bit more about the biochemistry of mammalian metabolism than he did, and the reality is that it’s much more complex than naïve assumptions of idealized perfection would suggest. Again, the exact same caloric intake of glucose as opposed to fructose, two chemically very similar compounds, will result in radically different physiological effects; that sort of complexity isn’t even hinted at by your “a calorie is a calorie is a calorie” fantasy.

            Cheers,

            b&

          7. @ Jay @ March 31, 2014 at 10:40

            Jay, I’m with you on your arguments here but please know that being critical of our host and/or host’s tastes is a banning offence on WEIT!

          8. @Diane G:

            Send the guy a picture of yourself with a cat on your head: you get a free book. Try and keep the guy from getting a heart attack: you get banned. What can I say?

          9. Start here, with this lecture from the University of California at San Francisco:

            Lustig, of course. The crank who started the whole hysteria about high-fructose corn syrup (HFCS) by noting — guess what — an ecolgoic correlation between intake of HFCS and prevalence of obesity.

            But maybe hearing it from a UC professor who specializes in metabolism, complete with diagrams of the various metabolic pathways, will help you accept that human bodies aren’t the idealized perfect thermodynamic engines you like to pretend they are.

            All those diagrams of metabolic pathways in a Youtube video seem quite compicated. And the message, delivered by a UC professor, sure sounds impressive when you don’t have the science background to critique it.

            Ben, this has been an interesting case study on what happens when misinformation on the Internet meets a smart person lacking in a rigorous science education.

            Oh, wait, it’s April 1. D’oh! You got me, Ben. Good one!

          10. <sigh />

            So, in response to my repeated examples of cold, hard, indisputable facts (such as the comparison of the caloric content of sugar and celery) and references to, e.g. an endocrinologist presenting an introductory-level lecture on the metabolism of different forms of sugar…

            …your response is to not even pretend to address a single fact, but to dismiss it all as crank nonsense with a liberal sprinkling of ad hom. for flavor.

            If you’d like to continue this discussion, you could start with explaining how your caloric equivalence theory is consistent with the expected consequences of obtaining all one’s daily calories exclusively from sugar or celery. Let’s either get past that much or just let this discussion drop, okay?

            Is it truly your position that there would be no epidemiological effects for substituting, calorie-for-calorie, celery for sugar (or vice-versa)? If so, why should anybody take you seriously? If not, how do you reconcile such a position with your earlier statements about caloric equivalences and substitution?

            Cheers,

            b&

          11. Oh, looky here! Brand-new research by the University College London, published in the Journal of Epidemiology and Community Health, that says to eat several portions a day of fresh veggies:

            http://www.washingtonpost.com/news/to-your-health/wp/2014/04/01/mom-was-right-eat-lots-of-veggies-theyre-even-better-for-you-than-fruit/?tid=pm_national_pop

            I wonder where, earlier in this thread, one might find somebody recommending the consumption of fresh veggies with every meal and of ideally eating five meals a day and to eat some but not a lot of fruit — exactly the same as the study suggests?

            Or is this just more crank pseudoscience, and the evil Herr Doktor Lustig has infiltrated his agents into that cesspool of pinko Commie Limeys?

            Cheers,

            b&

          14. Sorry, Ben, you don’t get to answer a question with a question (especially when it is the wrong question, but that’s another story). But I’ll give you a pass on answering my original question, bedause as soon as I posted it I realized I should have asked you a simpler, more-focused question. Here it is:

            Suppose you eat 2000 kcal of food per day and you burn 2000 kcal of food per day, please explain how you could gain weight: specifically, where would the calories for this added body mass come from, since you have burned an amount of energy equal to the amount you have consumed. And, how could you lose weight since you only burned as many calories as you consumed?

          15. <sigh />

            Suppose you eat 2000 kcal of food per day and you burn 2000 kcal of food per day, please explain how you could gain weight: specifically, where would the calories for this added body mass come from, since you have burned an amount of energy equal to the amount you have consumed. And, how could you lose weight since you only burned as many calories as you consumed?

            Because, as you’ve already admitted, calories and food are not interchangeable entities!

            Like, duh!

            Eat several pounds of celery a day for your 2,000 kcal, and the very first day you’ll have gained several pounds of mass.

            And, because you’ve got damned less control over how many calories you burn than you’re pretending you do.

            You’re pretending that the only calories you burn come from physical activity — that, if you total the number of steps you take over the course of the day and add to that the total number of pounds you lift to such-and-such an height, that’ll magically total your caloric expenditure.

            What bullshit!

            Even a most vigorous workout is only going to burn at most about as many calories are as in a single piece of fruit. If it was only brute physical activity of motion that accounted for caloric expenditure, we’d do just fine on no more than a few hundred calories per day.

            Instead, a very significant portion of your dietary calories go to making your brain do its thing, and most of the rest go to basic metabolic housekeeping tasks, such as regulating body temperature, growing new cells and replacing and repairing old ones, transporting nutrients to and wastes from cells, and so on.

            This then goes to why I asked the questions that you’re too stubborn and / or ignorant to address. Since you can’t, I will.

            Sugars come in many forms. One, glucose, is the energy source for all living cells on the planet. Glucose is (mostly) absorbed directly into the bloodstream and thence to the cells; from there, it’s either immediately used for fuel or stored as glycogen. Other sugars first need to be metabolized by the liver. Fructose, in particular, gets converted into glucose in the liver…but very inefficiently, in a process that leaves behind lipids (fats) and low-density cholesterol as major byproducts. That cholesterol is what tends to clog arteries, and the particular fats tend to get stored in fat cells.

            Other common carbohydrates include starches and fiber. Starches get mostly converted to glucose in the digestive system. Fiber for the most part isn’t directly metabolized; instead, it introduces healthy inefficiencies into the system. In addition to being used for energy, glucose in the bloodstream triggers the release of the hormone insulin — and insulin is a regulatory hormone that both triggers the uptake of glucose and lipids by cells and has further cascading effects on other hormones, including those that control feelings of hunger and satiation. Different kinds of fiber either slow down the absorption of glucose (and other nutrients), causing a “timed release” effect and thus reducing blood glucose levels and the resulting insulin levels (important because chronically high insulin levels lead to insulin resistance, aka Type II diabetes); or they provide bulk that helps provide physical feelings of fullness as well as prevent solids from forming hard clumps in the digestive system.

            Proteins are broken down by digestive enzymes into their component amino acids which get absorbed into the bloodstream; those amino acids are then used to build and repair protein-based cellular structures, especially in muscles.

            Fats come in many different forms, some of which can only be metabolized by the liver, again with deleterious health benefits — but that’s mostly fats that have been damaged by heat or modern industrial preservation processes. Minimally-processed fats, such as vegetable (including nut) oils from cold pressing, are mostly used to build lipid cell membranes and other cellular structures, with much of the remainder broken down to (once again) glucose and burned for energy. The fats that the liver has to deal with again mostly wind up as low density cholesterol and adipose tissue.

            Now that we’ve got that basic lesson on metabolism out of the way, it should be obvious why you can’t just substitute one calorie for another. So many calories of extra virgin olive oil will (mostly) be used to build cellular structures and for metabolic energy; the same number of calories of trans fats will mostly get stuck in the liver and in fat cells or clog arteries. And the same number of calories of protein will mostly be used to build new muscle or repair broken down muscle.

            That last bit there is actually the reason why exercise is so important. Again, since even an intensive workout session is only going to burn a few hundred calories or so, it’s most emphatically not the “energy expenditure” of whatever movement you do that is associated with increased metabolic activity. Rather, it’s the fact that the body has to spend enormous amounts of metabolic energy in building and maintaining the muscle tissue worked in the exercise session.

            That brings us to the final point. Your “a calorie is a calorie is a calorie” theory would, again, naively predict that two people the same height and weight, one a flabby pencil-necked geek and the other an elite athlete, sitting idle on a couch, are expending the same number of calories in that sedentary “activity.” They’re not; the athlete is burning significantly more calories just sitting there. Why? Because the athlete’s body is doing that much more to build and maintain all that muscle, whereas the bum’s fat hardly has any metabolic load at all.

            And that really should bring this thread to a close. If you really want to continue this further, you’re really going to have to step up to the plate and demonstrate that you actually know your shit and that you’re not just talking shit. I’ve already slaughtered far more electrons than I really should have…but what the hell.

            Cheers,

            b&

          16. Ben. You have absolutely no idea what I’m talking about. The words you’ve put in mouth, and the things you mistakenly believe I have either said or implied, fill a book at this point. Furthermore, you lack an elemtary understanding of energy balance, and consequently you have come to too many erroneous conclusions to list. For a brief example, so what if a dietary sugar molecule is immediately burned but a dietary amino acid is incorporated into muscle? How much net muscle do you, as an adult, accrue on average in a week, a month, or year? Unless you are bodybuilding, the answer is 0. This implies that for every dietary a.a. you incorporate into muslce, you breakdown one a.a. from muscle. That is, you are in protein balance. The point, which I doubt you will get, is that the ultimate fate of dietary protein, fat, and carbohydrate is to be burned. Therefore, except for their contribution to thermogenesis, it doesn’t matter what the body uses a particluar fat, carb, or protein molecule for. It’s gonna’ get burned eventually, and if it isn’t burned immediately, some other molecule of body protein, carb, or fat is going to get burned. This must be the case, because non-lactating, non-pregnant, non-currently menstruating, non-bodybuilding, non-healing-from-a-recent-serious-injury-or-disease, fully grown adult is in protein and carbohydrate balance, and if their weigh is stable, fat balance. This in turn implies that their energy intake equals their energy expenditures (I have no idea why you think I mean just energy expended in exercise).

            Furthermore, notice that what I just said made no mention of the macronutrient profile of ther diet. It is idetically true for any diet that is nutritionally adequate, which is to say just about any realistic, energy-efficient diet. (If you want to go on talking about hypothetical all-sugar or all-celery diets, that’s your silly business.) Bottom line is we’re done here. You don’t have the scientific background to understand what I’m talking about, or to realize that half of what you’re saying is nonsense and the other half is irrelevant to anything I’ve been talking about.

            Finally, you have twice evaded a key question I have asked you, that had you answered it accurately, would have shown that your dietary ideas are incompatible with the first law of thermodynamics, and hence flat-out wrong. Understanding energy and macronutrient balance is hard. A lot harder than reading fad diet books written by journalists and watching Youtube videos made by notorious crank scientists. A standard text in nutritional biochemistry would set you straight; unfortunately, it would probably require a serious investment in time studying basic sciences before you could understand the material. The investment would be worthwhile, IMO. Lots of MOOCs out there these days.

          17. For a brief example, so what if a dietary sugar molecule is immediately burned but a dietary amino acid is incorporated into muscle?

            Again, you demonstrate complete ignorance of metabolism by using the “calorie” metric to establish equivalence between them.

            A dietary molecule of sucrose has twice as many calories as a dietary molecule of either glucose or fructose. A dietary molecule of glucose is (typically) burned as energy; a dietary molecule of fructose is (typically) incorporated into adipose tissue or LDL cholesterol. Individual amino acid molecules have yet another different dietary caloric value per whatever matter-measuring unit you want to use. They’re typically incorporated into muscle — a process that, of thermodynamic necessity, consumes more energy than the caloric value of the amino acid; however, if the body is forced by stress, especially including starvation and overexercise, into catabolism, it will consume its own muscle tissue for energy.

            And you want to use the same “calorie” unit to describe all those different metabolic pathways!

            How much net muscle do you, as an adult, accrue on average in a week, a month, or year? Unless you are bodybuilding, the answer is 0.

            Yet more complete and total fantastic nonsense about basic metabolism — right up there with the stork theory of reproduction.

            The body is constantly repairing and replacing muscle tissue, even if the average total amount remains constant. It’s obvious when you feel muscle soreness (though, of course, the soreness itself is mainly due to lactic acid buildup), but the process is lifelong even in depressingly sedentary individuals, just at a reduced rate. Yet your “the answer is 0” hypersimplification very strongly implies that this Red Queen style running in place can consume no dietary calories. What nonsense!

            Further, as we age, the tendency is for the body to become less efficient at repairing and replacing muscle mass, which is why people tend to get weaker as they get older. Yet those same people typically gain weight as they age — but that weight is fat, not lean body mass. Nobody is in some form of metabolic homeostasis — save, of course, the dead. And yet you use that as your fundamental assumption!

            And that points to perhaps your most dangerous misunderstanding of all — that the goal should be weight reduction. This again assumes yet another false equivalency; this time, of adipose and muscle tissues. This same fallacy is reflected in the body mass index, one that would label a 5’8″ male (the American average) as “overweight” at 180 pounds, even if he had single-digit percentages of body fat and the physique of a Greek statue. According to the BMI, every single special operations soldier is obese — and yet they’re practically the textbook definition of peak physical condition and ideal body composition.

            The goal is not “weight loss.” The goal is health, and healthy individuals have lots of muscle and little fat. An unhealthy individual could have the exact same weight but dangerously little muscle and gross amounts of fat. Do you really think that “eat fewer calories” is going to restore that person to health? At absolute best, starvation is going to cause that person to waste away, to lose even more muscle that he can’t afford to lose at the same time as he’s losing fat.

            On top of that, you’d probably recommend aerobic exercise for that person “because it burns more calories.” On a starvation diet, that could well wind up killing the person. It’s what we see in famine-struck regions: people are forced to reduce caloric intake, forced to go on long marches, and die even faster. Aerobic exercise builds very little muscle and generally leads to accelerated loss of the unused muscles, as the body strives for efficiency; look at all the long-distance runners with lean legs and no upper body strength, compared with other athletes with more total and more evenly proportioned muscles. And if the body is being starved, all that aerobic exercise is going to do is slow down the loss of the muscles used and accelerate the loss of unused muscles — it’s certainly not going to do anything to build new muscle.

            Instead, this hypothetical pencil-necked lardass needs to become at least an amateur bodybuilder. He’s going to need to do resistive exercises with all major muscle groups in order to stimulate new muscle growth; he’s going to need to eat lots of protein to provide the raw materials for the muscles; and he’s going to need enough non-fructose carbohydrates to provide energy to perform the exercise and power the metabolic activity of muscle growth. (In addition, of course, to lots of veggies and modest amounts of healthy fats.) And he shouldn’t be thinking about any “caloric deficits” to spur “fat burning,” at least not until he’s got an healthy amount of muscle; otherwise, he puts himself at significant risk of mental depression and destructive catabolism. That means this lardass actually needs to gain wait, at least initially. Eventually, after he’s fat and strong instead of fat and weak, if he didn’t manage to reduce his adipose tissue during his initial muscle building, he can then focus on (carefully) reducing carbohydrate (not “calorie”) intake to create the (slight!) deficit necessary to convince the body to replenish its adipose tissues slower than it uses them.

            Finally, you have twice evaded a key question I have asked you, that had you answered it accurately, would have shown that your dietary ideas are incompatible with the first law of thermodynamics, and hence flat-out wrong.

            I’ve addressed that question with practically every post.

            Your profoundly ignorant fantasy has humans as perfect thermodynamic engines, with every calorie that passes your lips either being burned for energy or stored as fat, with no other options. Your theory ignores the diversity of metabolic energy uses, the gross inefficiencies of metabolism (you’ve yet to mention dietary fiber!), the biochemical products of metabolism, the regulatory mechanisms of the body, and the fact that two food items can have identical calorie contents yet radically different masses and metabolic functions.

            It’s exactly as if you were arguing that the only factor that determines which car wins a particular race is the octane rating of the fuel the driving team uses.

            A standard text in nutritional biochemistry would set you straight

            “Physician,” heal thyself. You’ve yet to even hint at the slightest understanding of metabolic biochemistry; all you keep doing is parroting your “a calorie is a calorie is a calorie” bullshit, all whilst using “calorie” in such laughably inappropriate ways that demonstrate that you really don’t understand what the unit actually measures.

            You know, there’s a reason why people who follow your idealized physics-based diet so often wind up resembling the spherical cows physicists like to jokingly refer to in their physics models….

            Cheers,

            b&

          18. Yikes, typos galore in my last response to Ben. Most eggregiously, I wrote “energy-efficient” when I meant “energy-sufficient.”

          19. Ben, as predicted, you have once again completely misunderstood everything I have said and drawn the wrong conclusions from it. You’ve pulled the most complete Kruger–Dunning act in the history of the internet. Let’s talk after you’ve had a formal introduction to physics, biochemistry, and nutrition.

            See ya’

          21. Ergo, if you currently eat 2000 kcal daily of whatever food you eat today, and you change your diet to one of exclusively 3/4 pounds of sugar per day, you will neither gain nor lose weight (assuming your daily activities remain the same). Same thing if you instead eat nothing but several pounds of celery per day.

            Well you can’t live on sugar. For one thing, it contains no protein. For another thing, you can’t eat 2000 kcal of celery in a day. But on any realistic 2000 kcal diet that is nutritionally adequate, if you burn 2000 kcal you will not gain or lose weight.

            In all three scenarios, you’re still eating 2000 kcal daily; according to your harebrained theory, a person on all three diets would maintain a constant weight.

            Yes. And I wish I could take credit for those crazy “harebrained” laws of thermodynamics, but they were deduced by greater minds than mine.

            [B]ut it’s so patently obviously not the case in the real world that I’m not even sure why I’m dignifying it with a response.

            Actually, you haven’t responded to it with any cogent explanation. Since you think it so patently obvious, then please explain in your own words the following. If I eat 2000 kcal of Diet A and switch to 2000 kcal of Diet B, and in both cases burn exactly 2000 kcal, how I can gain or lose weight on either diet. Assume both diets are nutritionally adequate, and keep in mind that we’re talking about physiologic calories. These are the calories that are used in nutrition tables and food labels, and are defined as the total calories in the food minus calories lost due to partial absorption and incomplete oxidation.

          22. Well you can’t live on sugar. For one thing, it contains no protein.

            And yet you’re still insisting on measuring the metabolic value of both of them based on caloric content alone.

            Assume both diets are nutritionally adequate

            But that’s just it. You’ve been defining “nutritionally adequate” as caloric content, and now you’ve just conceded that that definition is useless — even as you continue to try to cling to it.

            So before we get into that quagmire, how ’bout you do a bit of the heavy lifting for the moment — you are the self-proclaimed expert, after all.

            Explain for the peanut gallery why it is that, despite your repeated insistence to the contrary, a kilocalorie of dietary sugar does not have the same metabolic function as a kilocalorie of dietary protein. What happens to the sugar after you ingest it, and what happens to the protein after you ingest it? And, for bonus points, you could do the same for fat and fiber. To be really thorough, you should at least hint at what happens to different types of sugars and fats and fibers, but a bit of glossing is probably just fine.

            And if you can do so in a way that doesn’t bust wide open your fantasy about kilocalorie equivalence, I’ll eat my hat.

            Cheers,

            b&

  5. With the diminished returns with increased spending who is getting the best bang for the buck? KOR, ISR, ITA?

    Are there are any statistics on the quality of health for those lifetimes?

    We keep hearing how unhealthy the American lifestyle is. I wonder how much more of a healthier lifestyle America would need to fit on that line commensurate with its spending?

    1. I was thinking that too. There are likely a combination of factors which includes our eating habits, beginning with how parents program their children by giving them soda and artificial juice in the baby stroller. There are other factors too, including ‘food deserts’ in urban areas, unnecessary testing, and the high cost of hospital administrator salaries.

  6. We idolize greed too much and way back in the ’60s we allowed the insurers to buy out and operate the hospitals. On top of that, unlike the EU we don’t fine the pharmaceutical companies billions of dollars for running a cartel, instead we make up lame excuses and support their insane profits. Insurance for the medical profession is also utterly ridiculous thanks to a culture of litigation and practically unbounded payouts from successful lawsuits. Health care should be run by the government to minimize costs to the community while providing the highest quality service. If the sooper-rich want their own hospitals, they can pay for ’em (and they do).

    1. I must say I was quite shocked when I learned how the US compares with other advanced countries in many important areas such as life expectancy, child mortality or school dropout rates. Please have a look at these stats from Gar Alperovitz’s book What Then Must We Do?:

      “Moreover, this wealthiest of all wealthy nations has been steadily falling behind many other nations of the world. Consider just a few wake-up-call facts from a long and dreary list: The United States now ranks lowest or close to lowest among advanced “affluent” nations in connection with inequality (21st our of 21), poverty (21st out of 21), life expectancy (21st out of 21), infant mortality (21st out of 21), mental health (18th out of 20), obesity (18th out of 18), public spending on social programs as a percentage of GDP (19th out of 21), maternity leave (21st out of 21), paid annual leave (20th out of 20), the “material well-being of children” (19th out of 21), and overall environmental performance (21st out of 21).

      Add in low scores for student performance in math (17th out of 21), one of the highest school dropout rates (14th out of 16), the second-highest per capita carbon dioxide emissions (2nd out of 21), and the third-highest ecological footprint (3rd out of 20).

      Also for the record: we have the worst score on the UN’s gender inequality index (21st out of 21), one the highest rates of failing to ratify international agreements, the highest military spending as a portion of GDP (1st out of 21), and among the lowest spending on international development and humanitarian assistance as a percentage of GDP.”

  8. My guess: a combination of a) the law of diminishing returns applied to a subset of people (the wealthy). e.g. 1/2 of Americans spending 3 times as much as, say, the British, with the rest getting much less, and b) inefficiencies of healthcare run through private insurance policies

  9. Two arguments are worth mentioning.

    1. The US has historically qualified as the most significant contributor to advanced medical technologies and medicines. This costs money and hence the discrepancy.

    2. Living a healthy long life has less to do with money and more to do with just knowing how to live a healthy long life. The majority of the US has politically, socially, and culturally not figured this out. Maybe they think medicine should hand them the answer. It is not. America is getting lazier and larger and that costs money too.

    1. Yes, this seems to be the standard “defense” of our spending. Through R&D, the U.S. leads the world in developing/originating quality treatment(s) (which other countries can then make use of for much less money). At least, that’s what people say in political discussions. I wonder how much this is actually true, though.

      1. Don’t know about the current situation (I figure it is not true anymore, mostly due to the Harper gubbnint) — but a former Toronto resident VERY close friend of mine & person personally and extensively acquainted with health care of Ontario told me that rather than investing in state of the art equipment (e.g. NMR machinery back in the day) and the infrastructure to support it, in many cases it was cheaper simply to pay for transport and diagnostics at Johns Hopkins. My feeling is that this kind of work-around has dried up of late, but it does illustrate one facet of the picture. It also shows how the “big players” in the medical picture negotiate for and receive bigger breaks — in this case, the Canadian govt’s health care service itself.

        1. True, or at least the practice of Canadian hospitals sending Canadians to the US for particular problems.

          It makes sense, especially in smaller communities. Rather then spending money on equipment that will see little use, it’s much cheaper to send the patient either to a larger Canadian city, or the the US if the Canadian system is experiencing heavy usage.

          This is, or was even more so when the US system had higher excess capacity. Lately the Catholic hospital systems (and others) have been buying up hospitals and closing them, consolidating their market share.

          I’ve seen this used as an argument for why the Canadian system is so horrible, but I see it as an intelligent use of limited resources.

          If you have five people in your town who need dialysis every week and your ten minutes from a city that has excess dialysis machines sitting around, with people getting paid to do nothing, you send the patients there instead of setting up a dialysis unit that will be closed 95% of the time.
          It’s just rational resource planning.

          Certainly one of the issues the Canadian system has is Canada’s very large land mass versus it’s very small population. And while much of it’s population is in urban centers it still has a significant rural population.

          Canada’s three western provinces, British Columbia, Alberta and Saskatchewan have the about the same population of Washington state, roughly 9 million people. Washington state fits in the lower third part of British Columbia.

          So there is the very real problem of not having a large enough population to support enough specialists, most especially in the rural areas. Sometimes it just happens that more of these cases happen requiring certain specialized knowledge or tools, so the excess is piped to the USA. Should the US lose most of it’s excess capacity, which it very well might since costs have been rising above almost all other costs, Canada will have to invest more resources.

          I’d also point out that the usual Republican talking point of Canadian doctors abandoning Canada does not hold up to the facts. Canada has a net increase in doctors coming in.

          1. Thanks for that — coupled with the estimate that 75% of the Canadian population is 100mi from the US border adds greatly to this calculus, I’m sure. Seems to me we should be working towards a “North American” health care system… but unfortunately, we’d have to dismantle our idiotic private insurance model first. Ain’t gonna happen, I’m afraid (unless there is complete worldwide upheaval a la WW I coupled with another 1918-esque influenza pandemic, followed by a complete reorganization and recovery). I’d better be careful what I wish for.

          2. I’ve heard that stat, “75% within a hundred miles of the border”, but the majority of Canada’s population is in Ontario and Quebec, so while the saying might be true(ish), it doesn’t really tell the whole tale.

            The Canadian system isn’t perfect, not by a long shot, but I much prefer it over the US version.

            It’s a shame that Republicans constantly lie and exaggerate about other countries healthcare systems, and even more so that so many believe them.

    2. …and yet the US pharmaceutical industry now spends more on marketing than it does on research. Furthermore, this kind of argument doesn’t explaqin why Americans citizens pay more for the products of research than do people in other countries.

      1. The trappings of marketing-fed-research. Maybe it is the only way they have found to hang on to their resources: employees, labs, manufacturing facilities. So they push insanely invasive ad strategies that get people to buy stuff (some of which is unneeded) so that future research can continue.

        In my lifetime I have seen zero drug adds to such a plethora of ads I can not even tell if they are selling something that will make your heartburn go away, give you a hardon, or relieve heart-ache from a lost love affair.

    3. One factor that goes into the ignorance, but as a generic ignorance since the medical profession has been blind to it too, is the population disparity that doesn’t show up as much in smaller nations with more indigenous population.

      Similarly to how women are mistreated in most walks of life by having the systems set up for men (from increased damage risks in cars to decreased efficiency of medicines), groups like afro-americans and latinos need tailored treatments. E.g. foods and medicines will interact differently and as a result these groups have heightened circulatory respectively diabetic problems.

      AFAIK that is now recognized as a part, albeit perhaps a minor part, of the problem.

      1. In the Southwest (AZ,NM,TX,etc.) diabetes is like some cruel hoax to people not but a few generations from the indigenous Native Americans who were hardly designed for the diet of modern America. Thankfully, awareness is growing in this area, but slowly.

    4. Ad 1: but many results of this research are commercially exploited, as far as they haven’t been sponsored by the corporate world in the first place. Both things the USA also excels in.

    5. So if I understand you correctly you are trying to explain excessive health care costs by a high research budget? What makes you think that the latter factors into the former? I at least would be very surprised if it did, so the argument does not appear to make a lot of sense.

      Apart from that, the belief that other developed countries do not sink a lot of money into medical research is just another facet of American exceptionalism.

    6. 1)
      I’ve heard this said many times, but I’ve never seen anything that corroborates the assertion. On the other hand I’ve read many statements saying other countries don’t produce advances in medical science or procedures, which simply is not the truth.

      But even if the first part is true, much research is paid for by Americans via taxes for research grants, yet the American taxpayers get neither a break on the cost of the medicine or procedures they help produce, nor a return on their investment. The poor don’t even get the benefit these new procedures or medicine, esp. with the trend of copyrighting surgical procedures and the high cost of new medicines, so they lose out on every score.

      It hardly seems fair that large portion of the population who helped pay for developing these new medicines or procedures can’t afford them?

      2)
      It’s all very well and good to say you should live a healthy life but that falls apart when your child gets cancer, your wife gets rheumatoid arthritis, lupus, or any one of a thousand diseases that have nothing to do with how you live your life.

      There are millions of Americans who don’t take medicine or go to the doctor or deal with chronic healthcare problems because they can’t afford it. This isn’t just their problem, the problem effects their children, parents and every other citizen through increased government services and reduced ability to be functioning contributing members of society. Which doesn’t even address moral and ethical questions of allowing children to suffer because they are poor.

      Most everyone on this website would probably agree allowing children to suffer or die by refusing them healthcare because of religious reasons is not just wrong but criminal and repugnant. I think the same is true for children who’s parents are poor.

      But this is the reality for many children in the USA. There are many situations in which the current system does not work. Hospitals only have to provide care if the patient is in immediate danger of losing life or limb.

  10. US healthcare costs are complex but here are a few factors that contribute:
    1-Lifestyles – obesity, smoking and poor exercise.

    2- Acute care focus – Americans prefer a quick fix to long-term health and wellness. Emergent care is extremely expensive and patient expectations are unreasonable.

    3-End of life decisions not linked to reasoned outcomes. Americans are interested in all that can be done, not what should be done.

    4-Emphasis on procedural care. Reimbursements are much higher for procedures than for assessment services. Training programs follow the money just like the rest of the world.

    5-Obsession with payment structure rather than care delivery. Optimizing the delivery system in an environment of science-based care, will ultimately provide the best value.

    6-Regulatory environment-Hardly a day goes by without the addition of some new federal requirement. Often these decisions are created in an environment quite separate from the actual workflow of practicing clinicians. Rare is the addition that accounts for workflow disruption. Most additions are piecemeal attempts to address some real or perceived issue that is not incorporated into some comprehensive assessment or plan. The result is often the creation of new problems.

    Just scratching the surface obviously.

  11. The underlying function seems to peak at around 2500 ppp and then slowly goes down. Probably the point where accidents and infectious stop being an issue.

  13. Surprised it’s only about a factor of 2. I wonder how much that would change if suddenly MD’s weren’t worried about malpractice suits for not having ordered some test to rule out something with less than 1% chance of being the cause of the problem.

  14. One thing that I am curious about, is the risk for litigations by patients in the U.S., does it happen? How frequent is it? And if it is a relevant factor, the true cost of litigations, which for many other developed countries truly is a “non” issue.

    And when I think about cost in this aspect, I think about both the direct costs related to insurance against, as well as the cost of litigations when it does happen.

    But perhaps also indirect costs, such as routinely performing more tests for low probability events, then are perhaps strictly medically or clinically justified, just to counter the risk to miss something that could bear a “risk” from patients action further down the line.

    1. Most experts I have read think that medical malpractice litigation is at best a very small part of what is driving up health costs in America.

      A stronger driver for unnecessary screenings is that they are a profit center for many hospitals and clinics.

      1. I am curious, because I think there exist both a) ripple effects, and b) synergistic effects at play here, and it is not certain that they would show up in clearcut, easily identified categories.

        McKinsey in a 2007 report estimated that the U.S. spent $477 billion more on health care then peer countries, and,

        Finally, insurance against malpractice adds to higher operational costs. Doctors in the United States pay an estimated average of $27,500 a year for coverage. With some 700,000 doctors in practice, this amounts to approximately $20 billion in insurance costs that are not fully incurred in other countries.

        That direct operational cost would represent up to ~5% of the total difference.

        But what interests me more is rather the indirect costs, because I have a hunch, that there exist a number of ripple effects, along several dimensions.

        Because these “fears” are transported over to the clinical diagnostic labs, who take “extra” precautions, and they in turn, set up requirements for the manufacturers of diagnostic tests/instruments, sometimes requiring the manufacturing companies to develop “special” tests for the U.S. market alone, costs which of course are ultimately reimbursed by the insurance companies and patients in the U.S., and so on…

        And if this is true,

        “A stronger driver for unnecessary screenings is that they are a profit center for many hospitals and clinics.”

        Purely “defensive” medical decisions would only just reinforce the same pattern…

  16. The problem with the American medical system is that the powers-that-be insist on treating the medical market as if it is a normal free market in respect to the relationship between demand and pricing.

    It is isn’t. Demand is highly price-insensitive–you don’t quibble over the cost of something that will save your life or your health. Moreover, in the crazy system we now have, it is difficult to determine the cost of medical service before you receive it. You want to be a cost-conscious consumer and go to a low-cost provider of colonoscopies to get your discretionary screening colonoscopy? Good luck on that bit of comparison shopping. In most cases, you’ll know what it cost only after you receive the bill.

    This creates the perfect environment for price gouging. And that is EXACTLY what is going on in America today.

    If you want to read what is driving up the cost of health care in America, you might want to read the series of articles that the New Times did last summer. Here’s one on the cost of a bag of saline water to get you started:

    http://www.nytimes.com/2013/08/27/health/exploring-salines-secret-costs.html?_r=0

  17. My question is any GOP Congresscritter capable of understanding the graph? All they’ll see is America is in front.

  18. People concerned with unnecessary tests and procedures being a major source of medical costs should beware of weakening the medical malpractice system. The same oligopoly that owns the US media, has its way in US legislatures, and would dearly love to strip down the US regulatory system is held in check by citizens being able to sue manufacturers of medicines, medical equipment, and incompetent physicians.

    It almost certainly isn’t the best way to protect consumers from preventable bad health care outcomes, but to the great extent to which the US is overwhelmingly controlled by business interests, I for one don’t want the fear of lawsuits to disappear.

  19. The US should really be plotted as two data points, one for the wealthy and one for everyone else. One of the points would lie much closer to the curve.

  20. But there is worse. Sub-standard roadside care.

    I was driving down I-10 with a doctor-friend when we came across smoking cattle from a burned truck. A motor-cyclist had run into them and was writhing on the road. My doctor-friend told me to keep quiet about his job as we went over to take a look. And then he called me back to our jeep, suggesting that the young man was ‘probably a gonna’, but that he dare not help out for fear of a lawsuit. And so the First Responder to the dying young man was two Mexican fruit-truck drivers, bless-’em.

    1. Good Samaritan laws would have covered him, as long as he didn’t try to crack the guy’s chest on the side of the road. What is his specialty? Despite public expectations, no doctor is jack of all trades. An oncologist in that situation might have been no more capable than the fruit-truck drivers.

  21. These graphs are great because they illustrate the difficulty in interpreting biostatistics. All of the factors mentioned above are probably at work: misallocation of resources, environmental discrepancies, social inequalities, diverse populations, marketing the unmarketable, diminishing returns. The real question driving most of these factors is in the title of the post – value. What is value in healthcare? Is it what makes these statistics look better? If so, which ones? Is it what brings the most QALY – quality adjusted life years (?!) – for the individual? For the population? Is it really cost vs. life expectancy? Nobody has a good answer to these questions. Nobody is thinking about them systematically.

  22. My woo friends would have no trouble explaining the discrepancy: alternative medicine is widely used in many of those countries. It’s cheaper, less harmful, and it works. There’s your answer.

    No it’s not and no it doesn’t. Not really. But you better believe that a lot of people will slap out homeopathy and energy healing like trumps. The solution! The United State’s discrepancy in medical cost and lifespan would disappear if we all went to naturopaths.

    1. Someone close to me is afflicted with a condition that is in its 4th year of baffling every specialist her personal doc recommends after each failed diagnosis. She took her first foray (that I’m aware of) into homeopathy a few days ago.

      Often when I hear of terminal cancer patients who as a final resort access a high-dollar “treatment” in Mexico or somewhere, I wonder if there is anything useful I could say to them. In this actual real life moment of truth, I decided nothing I have to say will improve on silence regarding the decision made by the woman I know. She can’t afford this futile expense, either, unfortunately.

  24. The regression line in the figure is not a good fit to the data. The relation between spending and life expectancy is flat above $2000, suggesting no additional benefit for greater expenditures. Among countries spending above the threshold, life expectancy looks to be about 82 ± 2 years, except for the U.S., with the highest spending by a large margin, and a life expectancy of only 78 years, 4 years less than the average of the above-spending-threshold countries.

    2. I would agree the graph shows no additional improvement in life expectancy about $2000, but of course healthcare is about more than increasing life expectancy. It is about improving the quality of life and this graph does not show that.

  25. here is a better-fitting, segmented model, with an R^2 of .86. I fit this model after excluding USA from the analysis. The slope of the line segment for the higher-spending countries (excluding USA) is not significantly different from 0.

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