In the NYTimes today, Nick Kristof argues that the period in US history where life expectancy gains were the greatest were during the 1940s and he argues that these gains can be attributed to increases in access to health services that occurred around this time period. While interesting, and certainly a nice theory, unfortunately, this theory is not supported by the majority of empirical research on this topic. Here are just my two cents on why I think this argument is flawed.

To start, a bit of background to set the stage. From 1900 to 1988, US life expectancy increased from 47 to 75 (Lee and Carter, 1992). Kristof suggests that it is difficult to pin down the biggest gains in life expectancy due to low data reliability, but vital statistics data for the United States have been available in complete form since the early 1930s. Prior to this period, these data were available for only a handful of states for an additional 30 odd years, but for the most part our data on life expectancy, is actually quite good throughout most of the 20th century. Relative to the areas where I work, the data in the United States on Life Expectancy is what I would consider excellent.

Using this data, most demographic studies of life expectancy during the first half of the 20th century have shown tremendous declines, but these declines occurred at a relatively constant rate throughout this time period. The following figure, taken from a paper by Lee and Carter in the Journal of the American Statistical Association (87(419): 659-671) shows this graphically. It would be hard to argue that the 1940s were that much different from other decades.

Also lots of other things were happening during this time period that likely influenced life expectancy, so it is hard to attribute any change to one factor. During the late 1930s we saw the introduction of sulfa drugs and shortly thereafter we also saw the rapid increase in availability of penicillin and other antibiotics, which arguably also had impact on life expectancy. From 1940 to 1946, the price of a dose of penicillin dropped from $20 to $0.55. A new working paper by Seema Jayachandran, Adriana Lleras-Muney, and Kimberly Smith estimates that the increases in life expectancy from sulfa drugs alone accounts for 0.4 to 0.8 years of the gains in life expectancy seen during the late 1930s and early 1940s.

Most of the debate about the rapid declines seen during the early 20th century focus on including rising living standards, better nutrition as the source of life expectancy gains. Rarely is increased access to health services taken too seriously during this time period. Medical innovation is generally not seen as a major contributor until the second half of the 20th century (see for example, Cutler 2004).

Finally, and perhaps the most depressing piece of news to health folks out there, there is actually little evidence that the introduction of health insurance improves health outcomes in the short-run. The biggest benefit from increased financial risk protection against health shocks is generally that – financial risk protection. In an excellent study of the impact of the introduction of Medicare on health and financial outcomes, Amy Finkelstein and Robin McKnight has shown that Medicare had little impact on elderly mortality but it did provide substantial risk protection, which alone is a very important outcome.

I say all of this, not because I am arguing against increased access to health insurance in the United States – I am all for it. But rather, I make this point because I think there should be greater admission that health reforms to increase access to health services may not lead to health improvements. I frequently hear the argument that the health reforms seen in Ghana over the past half decade have done little to improve health outcomes, and I am always amazed at the degree to which people believe that this is a necessary outcome to measure the success of these reforms. Utilization of health services appears to have improved and satisfaction also seems to have increased, but so far we know less about its impact on either health or financial risk protection. It would not surprise me in the least if we cannot measure any discernible impact on health but that is not the only criteria that matters.

The relationship between access and health outcomes is certainly a tricky one, and unfortunately not one that is well understood. But I do know, that simple association does little to help anyone’s case: just providing access is not enough.

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5 Responses to “Is good health all about good access?”

  1. April says:

    Thanks Karen. I'm so glad you took the time to explain what's wrong with Kristof's logic.
    Increasingly I wish he would stick to advocating about the importance of issues (development, health policy) and refrain from taking positions on the solutions. He doesn't have time it seems, or perhaps the inclination, to get the latter bit right. And given how many people read his stuff, it's not helpful.

  2. Bill Savedoff says:

    I was surprised by Kristof's claims, too. Didn't sound like any version of explanations for health improvements that I could recall and you did a nice job of covering the best pieces out there on the issue.

    I'm intrigued by your last point: improving access can be promoted for its own sake. The Health sector is complex. Everything is related to everything. So it makes sense that policy advocates will push a particular policy in terms of its effect on health outcomes (even if tenuous) or economic productivity (another direction that allows people to talk about 'investing in health). Yet, I'm deeply troubled by pushing the advocacy to those extremes. I'm glad the health reform passed. I'm not happy with Kristof's cavalier attitude toward the evidence.

  3. Karen Grepin says:

    Bill and April, thanks for the comments.

    Bill, to answer your last question, I agree that it makes sense or is even useful for policy advocates to push for health reforms to improve health or economic productivity, even if the evidence is weak. What I worry about is that it opens up the doors for people to be critical that the reforms were a failure, when it fact it may have had an impact in other areas. A broader view of the benefits of financing reforms might be more helpful in this case.

  4. Anonymous says:

    I agree that financial protection is an often overlooked benefit of health insurance expansion, and the Finkelstein/McKnight paper nicely casts doubt on the notion that expanded access will reap immediate dividends in terms of better health. But isn't there an important longer-term story as well? Insurance expansion can induce technological advances (a la Weisbrod), a key driver of improved health outcomes in the modern era, and Card et al. in QJE 2009 found evidence that Medicare does indeed save lives.

  5. Karen Grepin says:


    I totally agree: long-term impacts could look very different than short-term impacts. The Kristoff argument was definitely a story about short-term impacts, hence those comments. I think health reforms in long run can affect health, not just through the adoption of new technologies, but also in terms of how systems become accountable to citizens over time.

    The Card et al. and Finkelstein/McNight papers both make important contributions to our understanding of how the Medicare affects mortality. I think the aggregate impacts at the population via the introduction of a new program was again closer to the argument that Kristoff was making and the more relevant policy question in this case. Both make important contributions.

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