When pundits and activists look at life expectancy data, they often find that the US has a lower life expectancy at birth than other wealthy countries. The common response is to then immediately assume that the United States must have lower life expectancy rates because it lacks so-called "socialized medicine."
Never mind, of course, that government spending on health services is higher in the US than in nearly every other country, and is anything but a "free-market" health care system. The fact that the role of the private sector is relatively larger in the US, however, often serves as a point of fixation for those who favor even greater government intervention in the US health-care markets than already exists.
Blandly pointing to life expectancy data as evidence of the superiority of government-run health care systems fails to take into account all the real factors that go into a measure like life expectancy. In truth, life expectancy and mortality are determined by numerous factors other than the delivery system of health services. These include the prevalence of smoking, physical environment, physical activity levels, the use of opiates, and obesity. That is, in a country where daily habits and social conditions foster more overweight, drug-abusing people, any health care system will be starting out with a less healthy population in general — even before any treatment options are even considered.
RELATED: "Life Expectancy: If Denmark Were a US State, It Would Rank Equal To or Worse Than Sixteen US States" by Ryan McMaken
Moreover, the presence of an increasingly limited private sector in the delivery of medical care is hardly the only way that the US differs from a variety of other wealthy countries. One could just as easily point to two other factors in which the US tends to stand apart from its peers — and which are likely relevant to the topic at hand: obesity rates and automobile usage. Those looking to blame "not enough socialized medicine" for lower life expectancy levels must therefore ignore the possibility that daily habits around personal transportation make a difference on health.
Indeed, given that obesity is more prevalent in the United States than in nearly every other country, this factor has been especially notable in helping to explain differences in life expectancy in the US compared to other nations.
As Samuel Preston and Andrew Stokes conclude in their study "Contribution of Obesity to International Differences in Life Expectancy": "The high prevalence of obesity in the United States contributes substantially to its poor international ranking in longevity." Similarly, in a separate study, Preston, Stokes, and Yana Vierboom found that as Americans became heavier from 1988 to 2011, and this "has reduced life expectancy at age 40 by 0.9 years in 2011 and accounted for 186,000 excess deaths that year." They conclude that obesity has become a significant factor in slowing down improvement in US life expectancy compared to other countries.
Some might respond to these findings that life expectancy might improve more if only there were more health care services delivered at lower prices. This purely hypothetical notion can't be disproven, of course, but we also know from experience that frequent usage of health care services is not the key ingredient in better health outcomes when related to obesity issues.
For example, we've long known that many immigrant groups have lower obesity rates and higher life expectancy than the native-born population in spite of having less access to health care services. As I noted in a 2015 article on alleged links between poverty and health outcomes, new immigrant groups become more obese and less healthy the longer they are in the country. This happens in spite of the increasing income that comes after immigrants establish themselves in the new host country.
American Cars and Obesity
In an odd way, we might even conclude that immigrant groups become victims of their own success as they become more acclimated to American habits of easy calorie consumption, eating out, and sedentary lifestyles — all of which are enabled by higher incomes and more access to entertainment and consumer products.
Indeed, we see internationally that richer countries become more obese. As incomes rise to higher levels, food prices tend to repeatedly fall relative to overall income. Moreover, "the density of fast food restaurants," "reductions in time for preparing meals," and declines in "job strenuousness" become contributing factors, as does an increase in the abundance of snack foods and high-calorie foods such as those containing animals fats.1
All of these factors tend to accompany increasing economic prosperity.
Another major factor appears to be increasing reliance on personal automobiles for personal transport. Obviously, it doesn't take a long or complex train of logic to understand that frequent use of automobiles often leads to less physical exertion overall. Easy access to automobiles can be linked to less of a reliance on more physically demanding forms of transportation such as walking, biking, or even taking public transport — which usually requires some walking. Users of automobiles rarely need walk beyond the driveway or the curb.
In a 2011 study by Sheldon Jacobson, Douglas M. King, and Rong Yuan, the authors found that vehicle usage and national obesity rates correlated "in the 99-percent range."
In a post-study interview, Jacobson remarked:
"If we drive more, we become heavier as a nation, and the cumulative lack of activity may eventually lead to, at the aggregate level, obesity," he said. ... Jacobson chose annual vehicle miles traveled as a proxy for a person's sedentary time because inactivity is most obvious when you are sitting in a car.
"When you are sitting in a car, you are doing nothing, so your body is burning the least amount of energy possible," he said. "And if you are eating food in your car, it becomes even worse."
And just how much more do Americans drive than residents in other countries? The indicators suggest a substantial difference.
Americans have typically traveled far more miles by passenger cars than is the case in European countries:
Taking the EU as a whole, as of 2008, we find that passenger kilometers per capita in the US totaled more than 23,000 while the total was under 10,000 in the EU.2
Moreover, Americans tend to walk less and use bicycles less, when not using machine transport3 :
These high levels of travel by passenger car are made possible in part by a high level of automobile ownership. According to Adam Millard-Ball and Lee Schipper, in a study of "eight industrialized countries," in the "US there are about 700 cars per 1,000 people (which is more cars than licensed drivers), and about 500 cars per 1,000 people" in the other countries measured. Other studies show an even larger gap, with researcher Todd Litman concluding: "In 2009 the U.S. had 802 vehicles per 1,000 population, which is much higher than most peer countries." Using 2016 numbers from the European Union, and from the US and Canadian governments, we find that the total number of passenger cars per capita is more than 25 percent larger than Italy, the country with the second-largest number of passenger vehicles per capita4 :
The takeaway here is that Americans drive much more and walk rarely, thus creating conditions more ideal for a rising obesity rate — which then leads to more disease and to higher mortality. As Jacobsen, et al., found, the combination of declining physical exercise and rising vehicle usage are likely both key in rising obesity rates, and reversing the trend would require changing both factors:
Our analysis has suggested that reductions in driving may lead to reductions in obesity and thus that efforts to reduce automobile travel may have the added benefit of reducing obesity rates. It should be noted, however, that this likely require reductions in driving to be accompanied by increased use of active modest such as walking or cycling — the substitution driving by increased use of telecommunications, or simply spending more time in bed, would not have the desired effect.
Improving Health by Accident: The Cuban Experience
In a recent article in the journal Health Policy and Planning, authors Gilbert Berdine, Vincent Geloso, and Benjamin Powell noted that one of the reasons that life expectancy in Cuba remains relatively high is due to its lack of automobile ownership.
Specifically, a lack of automobile usage leads both to fewer traffic accidents and to residents engaging in more strenuous exercise. Looking at the decline in car usage in Cuba following the collapse of the Soviet Union — which caused a severe economic crisis in Cuba — researcher Iris Borowy concluded that the forced increase in walking and bicycling accidentally improved the health of Cubans. Borowy isn't blind to the negative effects of Cuba's economic crisis in this period. Nevertheless, the data does suggest that the necessity of greater physical exertion in daily life in this case did lead to less obesity and cardiovascular disease.
Borowy's research highlights one other auto-related factor as well. She notes that a decline in auto ownership led to a drop in auto accidents:
[C]ar ownership is heavily restricted in Cuba and as a result the country’s car ownership rate is far below the Latin American average (55.8 per 1000 persons as opposed to 267 per 1000). A low rate of automobile ownership results in little traffic congestion and few auto fatalities. In Brazil, where the car ownership rate is 7.3 times above that of Cuba, road fatalities reduce male and female life expectancy at birth by 0.8 and 0.2 years.
In this respect, as with physical exertion related to automobile use, the US has the opposite problem to that found in the post-Soviet Cuban contraction.
According to the World Health Organization, the United States has automobile mortality rates well above those of other countries to which it is so often unfavorably compared in terms of life expectancy.
For example, the road traffic death rate in the US per 100,000 is 10.6. Among Western European countries, the country with the highest traffic death rate is Belgium, with a rate (6.7) that's more than 30 percent below the American rate. Even countries that one would think would have similar road traffic deaths because of similar geographies — such as Canada and Australia — have road traffic death rates well below that of the United States .
Source: Table A2, Violence and Injury Prevention tables at World Health Organization.
As with obesity, road fatalities are not an insignificant factor in overall life expectancy, and are found to be a contributing factor to declining life expectancy in both the US and the UK. A 2013 study found that "transport injuries" contributed 18 percent toward a "life expectancy shortfall" found in men under 50.
Combining the realities of automobile accidents with the widespread usage of automobiles, we end up with a fatter, more accident prone population likely to die sooner. That's not a recipe for a longer life expectancy. But it's also not a problem that can be solved by simply throwing a few more tax dollars at a government health-care system.
- 1See: "The social and economic determinants of obesity: an empirical study in Italy" by Alessandro Banterle and Alessia Cavaliere. (https://ageconsearch.umn.edu/bitstream/90889/2/CavaliereWNote.pdf)
- 2See "EU energy and transport in figures, 2010 statistical pocketbook." Published by the European Union.
- 3David R. Bassett, Jr., John Pucher, Ralph Buehler, Dixie L. Thompson, and Scott E. Crouter. "Walking, Cycling, and Obesity Rates in Europe, North America, and Australia" in Journal of physical activity & health. November 2008
- 4For an accurate measure of vehicle ownership, it is important to include the "light trucks" category as included in the Federal Highway Administration statistics. See Todd Litman's articles "Be Careful with Statistics" (https://www.planetizen.com/node/58169) and "The Future Isn't What It Used To Be: Changing Trends And Their Implications For Transport Planning." (http://www.vtpi.org/future.pdf). Given that nearly half of passenger cars in the Us are light trucks this changes statistics substantially. Litman writes: "The World Bank defines cars as 'road motor vehicles, other than two-wheelers, intended for the carriage of passengers and designed to seat no more than nine people,' but U.S. vehicle statistics separately report cars and light trucks (which includes vans and sport utility vehicles), together called automobiles. In North America about 45% of the automobile fleet consists of light trucks," For the graph on 2016 auto ownership rates, I have combined US data (found here: https://crashstats.nhtsa.dot.gov/Api/Public/ViewPublication/812537) with Canadian statistics for vehicles "weighing less than 4,500 kilgrams" (https://www150.statcan.gc.ca/t1/tbl1/en/tv.action?pid=2310006701) plus EU auto statistics: (https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Passenger_cars_in_the_EU ). "Per 1,000" measures are calculated using 2016 population estimates in each jurisdiction.
