David Frum observes that there’s more to health outcomes than treating illness:
So if the U.S. health system does such a good job saving its middle-aged and elderly sick, why do Americans die comparatively young?
Answer: because Americans are much more likely to get sick in the first place.
And that likelihood owes very little to the health care system and a great deal to the bad choices American individuals make. If you eat too much, exercise too little, drink too much, smoke, take drugs, fail to wear a seat belt or ignore gun safety, there is only so much a doctor or hospital can do for you. And Americans do all those things, more than other people.
This is all more-or-less true, but I think the erection of a false dichotomy between “bad choices American individuals make” and “the health care system” obscures more than it reveals. Most Americans make choices in life that lead them to have jobs in which they get health insurance from their employers or else they’re retired and they receive health insurance on a socialist basis. Then they make choices to put this employer-provided or government-provided insurance to use by visiting doctors. Then they make choices to put those doctors visits to use by getting certains kinds of treatments. These are “choices”—for those old enough or prosperous enough to have them—but they’re also what the health care system consists of.
And the system does a good, though seemingly not cost-effective, job of treating serious medical problems once they develop. But the system does not do a very good job of persuading people to seriously consider the health implications of some of their actions. There’s evidence from the UK than when doctors are compensated in a way that rewards them for persuading patients to quit smoking, their effectiveness at getting people to quit smoking goes way up. Parents rely on doctors for advice about their kids in many ways. And pediatricians could, but generally don’t, say to the parents of school age children “I know many parents feel it’s safer to drive their kids to school than to have them walk with friends, but the evidence suggests that the risks of car accidents and physical inactivity are greater than the risk of crime.”
Last, the resources consumed by the health care system are one of the reasons people make the choices they do. You might walk a few blocks to the metro, then ride it most of the way to work, then walk a few blocks more to the office. But whether or not you make this choice has a lot to do with whether or not someone built a metro line. If we build more, people will make different choices. But that would be expensive. And Medicare is also expensive. Blueberries are healthy and easy to prepare. But they’re also a lot more expensive than, say, potatoes. Every dollar spent on insurance premiums or doctors visits is a dollar that could be spent on berries.
The point is that a well-functioning health care system should be conducive to public health. Ours isn’t. It’s true that our medical interventions are fairly effective, but that just tends to illustrate that our priorities are somewhat off base.