derifatives

My Healthcare Thoughts: Infant Mortality

Most of the arguments I've seen for more government involvement in healthcare are outcome based. "Poor people without health insurance are dying because of preventable diseases, and government provided healthcare will stop this." Most seem willing to agree that if an expanded government system weren't going to improve health outcomes, there wouldn't be a reason to have it. And many even agree that if government involvement weren't going to improve health outcomes reasonably strongly relative to how much it cost and relative to other ways to improve human welfare, it wouldn't be a great idea. This post will be the first of several exploring to what extent people are dying in this country because of a lack of access to healthcare.

One of the primary metrics people like to mention is infant mortality. Quoting Reid [pp. 33-34]:

Perhaps the most tragic indicator of America's troubled health care system is the number of newborns who die each year. This statistic is called infant mortality, or neonatal death. It generally refers to babies who die within one year of birth. To me, that seems the most painful thing that could ever happen: The expectant parents go through the anticipation and sheer joy of watching their baby develop in the womb, enter the world, join the family — and then have to bury a tiny corpse a few weeks later. Surely any decent health care system would develop effective mechanisms to avoid neonatal death. But out of twenty-three wealthy countries, the American health care system ranks dead last when it comes to keeping newborns alive. Our rate of infant mortality is more than twice as high as the rate in the top-ranked countries, Sweden and Japan. A key reason, as we'll see in later chapters, is that other rich countries offer free prenatal and neonatal care for every mother and every baby.

According to wikipedia, the baseline infant mortality rate is 6.3 [out of 1000] in the United States, making us 33rd in the world in infant mortality. Switzerland, Germany, France and Belgium all fall in the range of 4.1-4.3, with the UK coming in at 4.8. Japan, Sweden and Norway are at 3.2-3.3. [Throughout these posts, I will tend to ignore statistics from very small countries, such as Iceland or Singapore.]

It is often stated or implied that the high US infant mortality rate is a consequence of our unequal healthcare system, and that many of these deaths could be prevented with better prenatal and postnatal care. If premature births or infant deaths could be easily prevented by better access to moderately priced government-provided healthcare or nutrition, we might expect the infant mortality rate for people on Medicaid and WIC to be roughly in line with those of the European countries we seek to emulate. Medicaid has been in operation since the 1970's, and approximately 40% of US births are financed by Medicaid. While some studies do show a positive effect of Medicaid and WIC on infant mortality, I have not found any data indicating that people receiving prenatal and postnatal care via Medicaid and WIC experience Western European-style infant mortality rates. I would welcome such data if you have it, but I would think if it existed it would be widely trumpeted. In fact, this Minnesota Department of HHS study seems to indicate that the overall infant mortality rate for Medicaid births is substantially higher than for non-Medicaid.

If you believe that expansion of government provided or financed healthcare programs would reduce infant mortality rates to Western European levels, it seems you must believe one or more of the following:

• People on Medicaid have much lower infant mortality rates than the average US rate. I have seen no data that supports this.


• The current Medicaid system somehow does not constitute "access to care," and an expanded system would somehow deliver care to everyone that is much better than what Medicaid delivers now. This would essentially be an admission that Medicaid doesn't do a good job of providing care; while this may be possible, if true, it hardly argues for further government involvement. Medicaid has had 30 years to work on this.


• A large fraction of total births are currently to people who are uninsured AND these people have very high infant mortality rates AND these people, when given government coverage, would have infant mortality rates substantially lower than the current Medicaid population. I cannot rule this out based on the numbers alone, since I cannot find data on the fraction of uninsured births or their infant mortality rates, but the conjunction seems highly unlikely to me.

If lack of access to healthcare is not the major cause of our high infant mortality rate, what is the cause? For starters, comparing infant mortality rates can be nontrivial, as some countries [including France] "do not report all live births of babies under 500 g and/or 22 weeks of gestation." This could lead to substantial differences in reported infant mortality rates. Even more important is the confounding issue of premature births. The US has a very high rate of premature births, and premature babies are much more likely to die. According to the CDC, "If the US had Sweden's distribution of births by gestational age ... the US infant mortality rate would be one-third lower." One third lower would put us smack in the middle of a pack of large European countries with national health care. So if you really want to get the infant mortality rate down, you have to either greatly increase the survival rate for premature babies [which is already relatively good in the US] or greatly decrease the fraction of premature babies.

The causes of preterm birth are not well-understood. There seems to be a strong correlation with factors such as lifestyle and socioeconomic status well before pregnancy, such as very young or very old mothers, unmarried mothers, and mothers who have health problems . Fertility drugs can also play a role. Note that if access to healthcare by itself prevented premature births, we would see fewer premature births and better infant mortality for Medicaid births, which we do not.

Summary: While infant mortality is a tragedy, and the US infant mortality rate is in fact very high, the discrepancy between the US and European countries can be largely explained by a difference in premature birth rates, which are likely in large part caused by demographic and behavioral factors that are not under the direct control of the healthcare system. Given that we have a large population that already has access to healthcare via Medicaid and WIC, and that this population does not have European-style infant mortality rates, it is difficult to conclude that an expansion of government healthcare to cover the rest of the population would on its own lead to a large drop in infant mortality.