et al., 2010a). Mackenbach and Garssen (2010) argue that the Netherlands emerged from the period of stagnation because of improved funding of health care, which contributed to more appropriate use of health care.

Mackenbach and Garssen (2010) report that after 2002, the mortality rate in the Netherlands dropped steadily in all older age groups with the exception of the very oldest men, those over 90. The authors eliminate a number of potential causal factors—prevalence of disease and disability, environmental factors such as air pollutants and winter temperatures, health behaviors, and poverty rates—because they did not improve during the appropriate time period. However, substantial changes occurred in health care in the Netherlands during this period. These included modest increases in the percentage of the elderly receiving influenza vaccinations, seeing medical specialists, and using prescribed drugs, as well as sharp increases in the numbers of older men and women admitted to hospitals. There was also a significant drop in the percentage of older adults who died within a year of being admitted to the hospital. These improvements in various health care factors accompanied—and were, presumably, the product of—sharp increases in health care spending in the Netherlands, where health care expenditures per person, in nominal prices, grew by more than 40 percent between 1999 and 2003. Changes in health care organization also occurred during this time. For instance, more aggressive treatment of stroke became common as specialized stroke units became available on a large scale beginning around 2000. There is evidence as well that end-of-life practices in the Netherlands changed significantly within a short time. From 2001 to 2005, euthanasia, assisted suicide, and the withholding or withdrawing of life-prolonging treatment became less common, and the alleviation of symptoms and the use of continuous deep sedation became more common. Correspondingly, the percentage of deaths in which life-prolonging treatment was withheld or withdrawn fell (Mackenbach and Garssen, 2010).

It should be noted that evidence for the conclusion drawn by Mackenbach and Garssen (2010)—that the most likely explanation for why life expectancy accelerated in the Netherlands beginning around 2002 was increased use of the health care system due to a sharp increase in government spending on health care—is mainly circumstantial. It is based on excluding other possible explanations and on how well the health care explanation fits the evidence.

The implications for the United States are not at all clear. Since U.S. health care expenditures are already substantially higher than those of the Netherlands and Denmark, increased spending or emphasis on health care at older ages in the United States would not necessarily result in an acceleration of life expectancy.



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