DISCUSSION

The lack of universal access to health care in the United States undoubtedly increases mortality and reduces life expectancy. It is a smaller factor above age 65 than at younger ages because of Medicare, although health impairments that begin below age 65 will often carry over into that age interval. For the main causes of death at older ages—cancer and cardiovascular diseases—available measures do not suggest that the U.S. health care system is failing to prevent deaths that elsewhere would be averted. In fact, cancer detection and survival appear to be better in the United States than in other OECD countries.

Relatively high proportions of people in the United States with diagnosed high cholesterol and high blood pressure are receiving treatment. Survival rates following heart attack and stroke are also favorable in the United States, although 1-year survival rates following stroke are not above average. Treatment of diabetes, on the other hand, may represent a weakness in the U.S. health care system.

These facts relate to the performance of the health care system after a disease has already developed; they say nothing about disease prevention. Thus it is possible that the U.S. health care system does a much poorer job at primary prevention than the systems of other countries. The panel reviewed scattered evidence on preventive medicine in the United States relative to Europe, and it is not conclusive. Certainly the high prevalence of cardiovascular disease in the United States (see Chapter 2) is consistent with a widespread failure of preventive medicine. But it is also consistent with a high prevalence of smoking, obesity, and physical inactivity among Americans, or with a medical system that may be unusually effective at identifying and treating cardiovascular disease. Until international data systems are better designed to identify cases of cardiovascular disease and to follow them through treatment, survival, and death, it is impossible to identify confidently the roots of international differences in the prevalence of and mortality from cardiovascular disease. Cancer data systems are better developed and allow a more robust comparative assessment of the U.S. health care system. Whether the comparisons observed for cancer can be generalized to other diseases is, however, unclear.



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