Why Do Europeans Live Longer than Americans?

Ashish Jha: 00:00:07

Hey everybody. Ashish Jha here from Providence, Rhode Island. Welcome back to a moment in health, episode four, yes, a moment in health where we talk about one data point, then we talk about one study, and then we answer one question, usually with a guest. So let's go ahead and get started this week. Data Point. The data point, the number I want you to know, is 47.5% or about half. About half of all people enrolled in Medicaid or CHIP, which is a closely related program, are children. So when you hear about programs that are going to cut funding to Medicaid or reform Medicaid, think the main recipients of those reforms, the main people who are going to be affected by those changes, those cuts, are America's children. So about half the half the people, and about 80 million people are enrolled in Medicaid. About half of them are kids. In fact, about four in 10 children around the country are enrolled in Medicaid. Let me just take 10 seconds to talk about Medicaid versus CHIP. CHIP is a children's children's health insurance program. Medicaid, as people know, is a program generally targeting poor people and getting them health insurance. And then Congress, at some point, realized there were people who were whose families were making just a little too much money for Medicaid and how and their kids were uninsured, so they supplemented the Medicaid program with Chip about 7 million kids across the country. But the big picture point here is that when you hear about Medicaid reform, Medicaid or CHIP reform, what you're really hearing about is a program that is primarily covering kids across the United States. One more quick thing, just as a little bit of a of an add on that some of you might know about. 10 states have not expanded Medicaid in those states, most of the people, majority of the people who are on Medicaid are in fact, kids. Places like Texas. 76% of Medicaid chip enrollees are kids. States that have expanded Medicaid have added a lot more

Ashish Jha: 00:02:07

adults into the Medicaid program. There, the proportion is a little bit lower. It's down to about 43% but again, Medicaid is primarily a program that covers kids. That's what you need to know. You

Ashish Jha: 00:02:24

all right, let's talk about a study. It's a fantastic study from a colleague here at Brown University, Alyssa Bilinski and her colleagues. The paper is in JAMA Pediatrics, and it's called trends in maternal fetal and infant mortality in the US 2000 to 2023 now there's a lot in this study, and I'm going to highlight a few points. And if you're interested in the issue of maternal mortality and infant mortality in the United States, I would recommend that you go read this paper. So what's in it? The big picture of motivation behind this was we have seen this huge increase in maternal mortality in the United States, between 2020 23 and people have been wondering, what's going on? Why are women dying at the time of childbirth? Now, any death at the time of childbirth is completely tragic and horrible, if you think about it. These are young people. People should not women should not be dying during childbirth. There was a big concern in the policy world that we were undercounting maternal mortality. And so states between 2003 and 2017 started rolling out something called the pregnancy check check box, where on the death certificate you could check a box if you thought that the death was related to pregnancy. What that did, and this is what the Belinsky paper largely shows is that that has been largely responsible for the huge increase that we've seen. If you took that check box effect away, maternal mortality, while still pretty high in this country, has been pretty flat from certainly from 2000 through 2019 so we've not had some new epidemic, thankfully, of new maternal deaths. Couple more points I want to very quickly mention. Second is there was a huge, real increase in maternal mortality in the years 2020 and 2021 you all know what was going on in 20 and 21 that was obviously the two worst years of the pandemic. And what we saw in those years was healthcare was super disrupted, and that likely had a very large effect on women and

Ashish Jha: 00:04:21

their ability to get pregnancy related healthcare services. Last point from this really terrific study is what we have seen is a pretty consistent gap between African American women, Native American women, and white women. In terms of maternal mortality, much higher rates for African Americans and Native American women, and those gaps look like they got even wider during the pandemic. They have come down. The gap has come down, but it's still quite sizable. So the disparities that we have seen throughout the last 20 years that remains. So there's a lot more to dig in on this study, but it's a really fantastic study, and what it says is. It's really important to try to understand what's going on when you see phenomenon, when you see headlines like maternal mortality rates are spiking, it's important to understand, is there a new phenomena, something new that's going on, or are we just measuring things differently? And in this case, certainly, the increase from the year 2000 to 2019, is largely due to better measurement. You all right, that brings us to the final part of today's conversation, which is answering a question. To answer today's question I've asked my colleague and friend Irene Papanicolas. Professor Papanicolas is a director of the Center for Health System sustainability and Professor of Health Services here at the Brown University, School of Public Health, really one of the leading scholars on health systems, comparing different health systems and how they perform. She has a fantastic paper from a few weeks ago, published in the New England Journal of Medicine, finding that the wealthiest Americans have a survival rate that's similar to the poorest Northern and Western Europeans. That was a data point that I actually used in my first week. I believe it was week one of the of the podcast. So I have Irene here actually to talk not so much about that study that we can talk about that study too. But let me ask you the one question, why do

Ashish Jha: 00:06:18

Europeans live longer than Americans?

Irene Papanicolas: 00:06:22

Well, first, thanks for having me. That's a great question. That's a tough question, and I've been thinking about it a lot since we did the study. And so maybe we take a step back and then think about how wealth is related to health more broadly, and what that can tell us about what might be different between the US and Europe. So when I think about it, wealth can influence health through several different pathways. One is obviously through access to health care. Wealth can provide you better access to the best innovation, high quality care, diagnostics. But when we think of the wealthiest Americans, they're probably not people who are having trouble accessing services. So so what I think doesn't tell us the difference between the health of the wealthiest Americans and Europeans as access to health care. But there are other pathways. And the ones I'm more interested are, what are the pathways that could affect anybody in America that might not be present in Europe? And so there, I think of a couple. It's got to be something systemic, and things that I think of that affect everyone our environment. Do we have, you know, safe housing, clean air, nutritious food, secure neighborhoods? Could that be something that's different and affects even the wealthiest Americans? I think some of those things maybe, you know, we've we know the diet has gotten progressively worse. There's a lot of processed foods, but so maybe, maybe that's one factor that's contributing, possibly in certain parts of the country, maybe environmental effects. Something else that I've been thinking as a different determinant could be stress and psychological factors. Is there something about American society and the social fabric that makes even amongst the wealthiest Americans, makes them more exposed to chronic stress, which can be a risk factor for illness. And there, I think there might be some differences. The US has a welfare state that's much more

Irene Papanicolas: 00:08:11

tied to your work. And even if you're succeeding, there's a lot of pressure to be at the very top. Otherwise, not only do you not do well in your job, but you might risk losing your health care, the other benefits that you have, so that, I think could be one that that there's just more chronic stress because of the way the social welfare state is designed, and then, and I guess there's behaviors, just healthy lifestyles choices. There's some things Americans do better on, like Americans tend to smoke less than Europeans, but there's other things we talked about diet, but obesity is higher in the US. There's more of a sedentary lifestyle. So those might be other factors. Let's

Ashish Jha: 00:08:48

break this down a little bit. So your first point is, you don't think that the main difference is the differences in healthcare system that the Europeans have, health systems that are just way better than ours.

Irene Papanicolas: 00:09:01

Yeah, correct. I don't think that's it. I mean, I think when you look at the poorest Americans, that's definitely something to think, right, because of issues of access, but when you're looking at the wealthiest Americans, no, I think these are people who I would argue, have access to the best or some of the best health care in the world, even

Ashish Jha: 00:09:15

for the average American, right? I mean, think about the average American versus the average German or French person, yes, there are some cost barriers, but I think Americans in general are able to access healthcare at pretty good clips. Okay, what about the prevention argument that Europe does more prevention than America? Well, so it depends

Irene Papanicolas: 00:09:32

what you mean by prevention. If we're talking about screening and diagnosing illness, definitely not. I think in the US you have very high rates of screening, you have high rates of adult vaccination, you have actually high rates of diagnosis of hypertension and diabetes, and I would expect that that's even greater amongst the wealthiest in society. So in terms of that type of prevention, I don't think that's what's the difference in terms of public health. However, there, I do think there are differences the. US, for example, has more lax seatbelt safety regulations, more lax regulation on like what standards of food product has to be to be labeled organic. I think these things, in total, those are weaker in the US, and that could contribute to maybe more exposure to systemic factors that can affect

Ashish Jha: 00:10:19

health. Okay, so let's actually talk about food, because it's getting a lot of attention. RFK, Jr, our health secretary has been certainly talking about about this a lot. It is true that obesity rates are higher here. Obesity rates are pretty high in a lot of European countries, increasingly as well. I think fighting about obesity, overweight or obese rates about 74% of the US, by 67 68% in Finland. And yet Finnish life expectancy is dramatically better than ours, right? Like, that's not even a close call. So how much do you think obesity itself is? And then again, that's counter the counterfactual on the on smoking. I mean, smoking is absolutely awful for you, and Europeans smoke more than we do. So if you put all of that together, do you think that the differences between smoking and obesity, combine them into one set of risk factors, a little bit worse for America, a lot worse for America. How do you see that compared to Europe in terms of explaining the life expectancy gap?

Irene Papanicolas: 00:11:13

So you're right that in terms of smoking, your Europe is worse, and definitely in some of the countries that we have as as having the best survival, like France. But I do think obesity is one metric of how kind of food is affecting our health. That's obvious to an easy I guess, to report out, but I think it, you know, you can still have a nutritious diet and not be obese. And I do. And you know, if you look at other metrics of how bad the diet is in the US, there's much more, like ultra processed food and so. So I think, I think in terms of diet, I do think the US is probably considerably worse than Europe. If you factor in smoking, that makes it a little bit better, but, but I do think there is something to the diet.

Ashish Jha: 00:11:56

Okay, and then let's talk about the last couple of things. One of the things people often point two is violence, car accidents, gun violence. What's your best sense of my sense is those are worse here than they are in Europe. Yeah, how much do you think that contributes to lower mortality for the for Americans? So,

Irene Papanicolas: 00:12:13

you know, in another paper we had that came out last week, we looked at the number of avoidable deaths in the across US, States and European countries here, it's not divided by wealth, and we do see that one of the biggest differences that accounts for an increase in deaths in the US over the past 15 years is these deaths, suicides, homicides, and also drug overdoses. Yeah, now I would expect that that's probably less so in the wealthiest. But what's interesting is that Europe, those deaths are coming down. They're not going up. So that's definitely part of it, too. It's going to be less in the I imagine, in the wealthiest population. Again, we didn't look at that, so I wouldn't pull that off the table either. I do think there's something to that

Ashish Jha: 00:12:53

got it. And then environment and stress. You think maybe another contributor to Yes,

Irene Papanicolas: 00:12:57

I think this is so hard to measure, but I do think chronic stress is something that can influence so much of the risk factors for cardiovascular disease, which is one of the other big killers, and definitely in the sample that we were looking at, one of the leading causes of death amongst the older adults in our population. And I do think there's several things about the US that do make it potentially more stressful that there's more underlying chronic stress day to day than in in some countries that have kind of these just more robust welfare states that will protect you if you lose your job or in different situations. All

Ashish Jha: 00:13:32

right, so let's wrap up. Seems to me like what I'm hearing is there's no single, simple explanation. So for everybody who's like, ah, the Europeans live longer because they eat more fruits and vegetables or because they have better health systems. Your take is there's probably not one single thing. It's multifactorial fare, and it's probably a combination. For the poorest Americans, healthcare access may be a real problem, but once you get to middle class and certainly wealthier Americans, access to healthcare services and quality of healthcare services probably not a major determinant. I don't

Irene Papanicolas: 00:14:06

think access and quality of care, but affordability. I do think even for those middle quartile So, like for the middle class and the poorest, definitely, I do think affordability is a contributor, especially for you know, if we think of again, some risk like hypertension meds or diabetes meds. This can be very expensive and and taking those is important to like to limit your your likelihood of, you know, an adverse outcome. So I think affordability is something that's important.

Ashish Jha: 00:14:32

And then the opioid crisis, other forms of violence, gun violence, car accidents, all of that has been a contributor, especially for young people, and deaths among young people, and then both environmental effects as well as chronic stress. I mean, thanks so much for coming by and trying to tease this apart for us, this is sort of the big question everybody asks, Why do Americans live shorter lives? I think there's a lot more work to be done to really tease this apart, but you're doing some of the very best work on this. So I want to say thank you for the work, and thanks for coming by. Thank you. Thank you for having me. All right, so you've been listening to another episode of a moment in health where we talked about, who does Medicaid cover, and it's primarily kits, and we talked a little bit about Alyssa belinsky's great paper on what's causing the huge increase in maternal mortality in the United States. And it turns out, actually, maternal mortality in the United States has been relatively flat over the last 20 years pre pandemic, and what was causing it was really the addition of this new check box. So that's good news, that matern mortality was not going up. But there are some real challenges. Things got worse in the pandemic, and there are these real disparities. And then, last but not least, we heard from Professor Irene Papanicolas of the Brown School of Public Health talking about really a synthesis of a lot of work she's been doing trying to understand, why do Europeans live longer than Americans? It's complicated. There's a bunch of things going on, but anyone who gives you a simple explanation that like, Oh, it's this, or it's that, realize they're probably trying to sell you something, and it's a complicated issue, and we got to work on all of them, from public health to better access to better foods, etc. All right, thanks for joining us. We'll be back again very soon for another moment in health. You.