Health Care Debate Still Needs Some Unpacking

As the debate over health care reform drags on, advocates on either side are amassing terabytes of data and heart-wrenching anecdotes to press their case. One day it's a horror story about a single-payer system abroad; the next it's a horror story about a health insurance company's denial of claims here. One side says U.S. health care is the best in the world; the other says it's an utter catastrophe.

All of the claims bear scrutiny. If medical care in, say, Western Europe were as terrible as conservatives insist, then by now voters there surely would have elected politicians who promised to reintroduce free-market discipline. To hear some conservatives talk, one also would be led to believe nobody in America ever has to wait more than a couple of days to see a specialist. That, of course, is absurd.

Claims from the left also require some unpacking. Take the intertwined problems of life expectancy and infant mortality. The U.S. ranks lower than many other developed nations on both measurements. Contrary to the assertion by many, however, this is actually because U.S. health care is, in some ways, far superior.

That only sounds nuts until you walk the issues back. So let's do that.

AMERICA'S poor showing on life-expectancy measures is intimately tied to its infant-mortality rate, which clocks in at six to seven deaths per 1,000 births -- versus three to four in Japan, Norway, or Germany. Higher infant mortality lowers average life expectancy, like this: If one person dies at 80 and another at 60, then average life expectancy is 70. But if one person dies at age 80 and another dies after only one month, the average life expectancy is 40.

America's higher infant-mortality rate is, however, not the national scandal some advocates of health care reform would have it be. In fact, it's quite the opposite -- for two principal reasons.

FIRST, THE U.S. is much more scrupulous about how it measures infant mortality: America counts a birth as a live birth if the infant shows any signs of life at all, no matter how small or premature the baby is. By contrast, many other developed nations simply write off extremely premature births as stillbirths. In Germany, an infant must weigh at least a pound to be counted as live at birth -- even if it is, well, alive at the time of birth. In France, any child born before the 26th week of pregnancy is counted as a stillbirth. In Britain, doctors recently rebuffed an anguished mother's plea to save her newborn. Too premature, they said. So in international comparisons, the U.S. actually ends up being penalized for trying harder.

Second, for several decades the U.S. made great strides in reducing infant mortality -- cutting it roughly 70 percent since 1970. In contrast to much of the developing world -- where the primary cause of infant mortality is dehydration from diarrhea -- the major cause of infant mortality in the U.S. is low birthweight brought about by prematurity: The CDC has found at least a third of U.S. infant mortality arises from complications of prematurity, and The New York Times reported in April that "the main reason for the high rate [of infant mortality in the U.S.] is preterm delivery, and there was a 10 percent increase in such births from 2000 to 2006."

Why has there been an increase in preterm delivery? Perhaps because American health care encourages prematurity through the use of fertility treatments. According to pediatric cardiologist Darshak Sanghavi, who wrote about the subject a couple of years ago in Slate, "better and more affordable medical care actually has worsened the rate of prematurity. The numbers of women using assistive reproductive technology doubled from 1996 to 2002. At least half of their pregnancies culminated in multiple births (twins or more), which are at high risk of premature delivery."

Sanghavi also notes that neonatal intensive-care units are "cash cows" for hospitals -- hence their proliferation across the country. A 2001 article in the journal Pediatrics likewise noted that "neonatal intensive care has experienced tremendous growth in the past 30 years," and that "the ever larger number of neonatologists also permitted an accompanying growth in units and beds as neonatal intensive care units (NICUs) diffused from academic medical centers into smaller and smaller community hospitals."

The growth and proliferation of expensive neonatal treatment is almost certainly one of the many factors accounting for the inflation of health costs overall -- albeit not one White House budget director Peter Orszag is likely to dwell on when stressing the need to "bend the cost curve" downward. But it hardly qualifies as evidence that, as reform advocates suggest, America pays more for health care than anyone else but gets less in return.

In short, then: Americans are trying to have more babies, they try to save every single baby who is born, and they count every single baby who isn't saved. Whatever problems U.S. health care has -- and it certainly has some -- those facts should be a source of pride, not shame.

My thoughts do not aim for your assent -- just place them alongside your own reflections for a while.

--Robert Nozick.

Contact A. Barton Hinkle at (804) 649-6627 or .