Blowing Yesterday’s Cigarette Smoke Into Today’s Healthcare Debate

In a June 15 address to the American Medical Association, President Obama made an argument that has become axiomatic in the national debate about healthcare reform. “Today we are spending over $2 trillion a year on health care,” he said. “And yet for all of this spending … citizens in some countries that spend substantially less than we do are actually living longer.”

That Americans trail other developed countries in life expectancy is beyond dispute. Average life expectancy for a U.S. baby born in 2006 was 78 years, a number that trails nearly every country in Europe. The Germans live almost two years longer than we do, the Canadians two-and-a-half, the Swiss three.

Yet according to Frederick J. Warren Professor of Demography Sam Preston, the U.S. healthcare system bears little blame for the longevity gap. In fact, he argues in a forthcoming paper with co-author Jessica Ho C’09, a graduate student in demography at Penn, our healthcare system actually performs better than most when it comes to diagnosing and treating major killers like cancer and cardiovascular disease, which in 2005 accounted for 61 percent of deaths among American adults age 45 and older. The problem, he contends, is not that we treat disease less effectively than other countries, but that we have more of it.

“The healthcare system could be performing exceptionally well in identifying and administering treatment for various diseases,” he writes, “but a country could still have poor measured health if personal healthcare practices were unusually deleterious.”
 
For the 50-year period ending in 1985, American personal health practices were in fact the worst in the world, at least as measured by per-capita cigarette consumption. During that time Americans smoked in excess of eight cigarettes a day, which at times was double the rate of the next closest country. While in recent years Americans have kicked the habit in record numbers (posting the largest reduction in cigarette consumption of any country between 1970 and 2000), Preston’s research shows that our decades of heavy smoking set the stage for substantial downstream health costs.

In 2004 the U.S. had twice the rate of lung cancer and heart disease found in Europe, and a substantially higher rate of people receiving medical treatment for high blood pressure. These disease burdens are almost certainly directly attributable to smoking—Preston estimates that 85 to 90 percent of lung cancer deaths in a high-smoking population are owing to cigarettes—and they weigh heavily on both our healthcare budgets and our international health rankings. 

“The Institute of Medicine has estimated that about 18,000 unnecessary deaths occur each year in the United States because of a lack of health insurance,” writes Preston. “To put this number in context, the Centers for Disease Control estimates that 435,000 excess deaths occur each year in the United States because of past and present cigarette smoking.”

With UC-Berkeley collaborators Dana Glei and John Wilmoth, Preston has found that once smoking deaths are controlled for, the U.S. moves from near the bottom of life expectancy among 20 Organization for Economic Cooperation and Development (OECD) countries to the top half. “In the United States,” he writes, “we estimate that male e50 [life expectancy at age 50] in 2003 would be 2.8 years higher if smoking-attributable deaths were eliminated, while female e50 would grow by 2.6 years. Removing smoking-attributable deaths for all countries would improve the e50 ranking of U.S. women from 17th (out of 20) to 7th; men’s ranking would improve from 14th to 9th.” 

According to Preston’s research, U.S. medical care, rather than being at fault for America’s lagging longevity, actually outperforms European peers in the treatment of major diseases. Preston reviewed medical research on the effectiveness of screening for breast and prostate cancer and found a simple formula at work: comprehensive screening leads to earlier diagnosis, which leads to lower mortality rates. The U.S., Preston writes, “identifies prostate cancer at an earlier stage, on average, than Sweden, Japan, or the United Kingdom,” and once it’s identified, American doctors treat cancer more aggressively. Screening rates for breast cancer are also higher in the U.S. than elsewhere. 

The different approaches to diagnosis and treatment are borne out in five-year survival rates for all major forms of cancer, which are higher in the U.S. than in a composite of European countries. In the most thorough international breast cancer study to date, Preston writes, “The five-year survival rate was higher in the U.S. than in Europe (89 percent vs. 79 percent), and survival for each stage-at-diagnosis category was also higher in the U.S.”

Preston acknowledges that five-year survival rates have the potential to mislead. “It’s not entirely convincing to stay with five-year survival rates, because as we say in the paper, if you’re just catching cancer earlier and you’re not affecting the clinical course of the disease, then so what?” 

Given the politically charged atmosphere surrounding healthcare reform, he expects his work to be scrutinized closely. “I’m ready to get blown out of the water tomorrow, but I don’t know by whom or on the basis of what information,” he says. “The five-year survival rates could be the thing.”

So Preston and Ho went beyond five-year survival rates to study population-level trends in mortality from prostate and breast cancer. They found that the U.S. has had significantly faster improvements in mortality from these diseases than European countries, indicating that the U.S. had been unusually successful in identifying and treating them. 

When Preston’s research surfaced in a September New York Times science column, it attracted a flurry of comments, many of them attacking his methods or motives or both. “First question I’d like to see answered: Who paid for Preston’s research?” wrote one angry reader, upset that in his view Preston’s study discounted the need for healthcare reform. (Preston’s research was funded by the National Institute of Aging and the Social Security Administration.)

For his part, Preston does not see his work as an endorsement of the status quo. He notes that the 45 million uninsured Americans tend to lack access to the cancer screening techniques that his analysis showed to be so beneficial. 

“There are people who favor healthcare reform and think the paper undercuts their case,” Preston says.  “I hope they’re wrong because I favor healthcare reform myself—but on different grounds than that our medical system is not working well.”

—Kevin Hartnett