A week or so ago, a fascinating health care study ricocheted aroundtheblogosphere, comparing death rates among 19 industrialized nations—and looking in particular at deaths that could have been prevented with “timely and effective” medical treatment.

Not too surprisingly, the study found that the US was the worst of the lot, with higher rates of medically-preventable deaths, and slower reductions in such deaths, than any other country studied. (No wonder we’re one of the developed world’s laggards on life expectancy.)

But when I dived into the data a bit, it looks to me as if our leaky health insurance system isn’t the only story behind our comparatively high death rates. In fact, medically preventable deaths aren’t even half the story of why people under 75 die.

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    • By the numbers:

    At last count, the authors concluded that some 110 out of every 100,000 US residents under the age of 75 die each year from causes that, in the study’s words, “should not occur in the presence of timely and effective health care.” Canada does much better, with just 77 such deaths per 100,000 residents. France, however, leads the way, with just 65 “medically amenable” deaths annually for every 100,000 residents. If the US had France’s “amenable mortality” rate, about 101,000 fewer Americans would die each year. (Ezra Klein’s take on this is just right: if an enemy nation targeted that many American lives—say, by blowing up a city the size of Boulder, Colorado, or targeting 30 World Trade Centers—we’d be at war in a heartbeat. But in this case the killer is a mixture of apathy and systemic political failure, so we let the deaths pile up, essentially unnoticed.)

    That’s all interesting (and depressing) enough. But what I found most fascinating in the study was the variation in deaths that are not considered “amenable” to medical care. Just what are these “non-amenable” deaths? Well, obviously, some are homicides and suicides; others are caused by car crashes, firearms accidents, and the like. A lot are heart attacks. Some are inoperable and untreatable cancers. The list, I’m sure, goes on and on.

    But the bottom line is that these non-amenable deaths are almost 3 times as important in determining whether we’ll live past 75 than are the small subset of deaths that medical care has a prayer of preventing.

    There are at least 2 ways of looking at this:

    • Non-amenable deaths predominate: The highest non-amenable death rate (Denmark’s 311 per 100,000 residents under 75 per year) was about 2.8 times as high as the highest amenable death rate (110 per 100,000 per year, in the US). Similarly, combining data from all 19 nations studied, the average non-amenable death rate (243 per 1000,000) was roughly 2.8 times higher than the average amenable death rate (87 per 100,000).

    • Non-amenable deaths are more variable: The gap between the best- and worst-performing nations for amenable death rates—deaths that could be prevented with effective medical treatment—was 45 deaths per 100,000 residents. But for non-amenable deaths—the ones that even the best medical care couldn’t prevent—the gap between the best (Japan) and the worst (Denmark) was about 125 deaths per year. So among industrialized nations, there’s nearly 3 times as much variation in the deaths that medical care can’t affect than there is for deaths that a good doctor can forestall.

    This last point bears repeating: nations differ far more in their non-amenable deaths—the ones medical care currently can’t prevent—than in amenable deaths. If you want to improve health, medical care is certainly important; but in the aggregate, it’s more important to look at deaths that medical care can’t affect.

    To illustrate further: in the figure below, the blue bars represent the “excess” non-amenable death rate for each country—that is, how much worse each country does than Japan, the nation with the lowest “non-health-care” death rate. And the red bars represent the excess “amenable” death rate—that is, how much worse each country does than France, the nation with the lowest amenable death rate. Quite obviously, the blue bars—the deaths that medical care couldn’t prevent—dominate the picture, both in absolute numbers and in variability.

    international mortality rates

    What do I take away from all of this? Well first off, there’s a lot more to health than health care. Improving our health insurance system is clearly important, but even a wildly successful health system reform is no guarantee of good health. In fact, if you waved a magic wand and improved the US “amenable” death rate to France’s, we’d still have the industrialized world’s third-highest death rate for residents under 75. We have just too many deaths from other causes for medical care alone to save us.

    Second, public health (writ large), rather than health care per se, may be the key to living longer, healthier lives. It’s the subtle forces—the way our suburbs and cities discourage walking and encourage driving; the lack of healthful food (and the low cost of junk food) that disposes us to eat poorly; the pervasive poverty and economic inequalities that dampen our spirits and our sense of community—that truly affect how healthy we are as a society. We could have the best medical care in the world, but it still wouldn’t make us a truly healthy nation. For that, we need not only a better system to cure us of our ailments, but more importantly, smarter ways to keep us from getting sick or injured in the first place.