USA Child (0-4) and Adult (55-74) Mortality and % GDP-Health Expenditure and the Other Western Countries 1989-2015. America needs an “National Neighbourhood Health Service”

Purpose: To analyse how effective was the USA, compared to Other Western Countries (OWC) in reducing premature deaths 1989-2015. Design: This population-based study is a cost-effective model of fi scal input into health related to clinical outputs, recognising socio-economic factors infl uence health outcomes. Using World Bank data for total % GDP-Expenditure-on-Health, and, WHO data for Child (0-4), Adult (55-74) and Age-Standardised-Death-Rates rates per million America is compared with OWC. Cost-Effective Ratios (CEF) are calculated and Confi dence Intervals (95%) tests USA against each OWC. `Excess’ deaths are calculated between the most and least expensive health systems. Setting: Twenty Other Western countries. Patients: National populations. Outcomes: USA highest current total %GDPEH 16.8% and highest average of 12.7% and UK lowest 7.1% over period. USA Child (0-4) highest at 1249pm, OWC averaged 803pm. Fourteen countries had signifi cantly bigger reductions than America. USA Adult (55-74) mortality was highest at 12,554pm, OWC averaged 9,835pm. Fourteen countries had signifi cantly bigger reductions than USA. Excess Deaths: America failed to match UK total mortality rates yielding 488,273 excess deaths, of which 12,613 were children. Cost-Effectiveness-Ratio: America had smallest CER 1:113, OWC averaged 1:270, an USA to OWC ratio of 1:239. UK CER was 1:323 producing a USA: UK ratio of 1:2.86. Conclusion: America’s health system more expensive as Britain’s and signifi cantly less effective than most OWC. The USA needs to change its socio-economic political mind set’ if it is to match the `half price’ NHS and move towards an American style `Neighbourhood National Health Service’. Keymessages: Implications for Policy makers: 1. policy makers in the USA need to re-think their present confi guration and funding of their health services. 2. should confront the question, can any nation continue spend 17.1% GDP on health bearing in mind the challenges posed by longevity, yet still have the poorest clinical outcomes of the 21 Western nations. Whilst at the same time the richest nation on earth has the widest relative poverty in the West. 3. examine the fi ndings of the USA `excess deaths’, compared to the lowesthealth funded country, the UK and challenge politicians to be less doctrinaire and react to the evidence. 4. recognising that the USA is a continent with incredible social variation, they need to think outside the box and reject isolationist stereotypical thinking, otherwise the inconsistencies in the USA will worsen and possibly destabilise.


Introduction
The recent debate about repealing the Affordable Health Care Act (Obama Care) was based upon the argument that it was ineffi cient and that there were rising complaints about rising costs [1]. This might be seen as a reasonable economic question because it has long been known that the USA spends more of its %GDP on health than any other country [2,3]. So the question can be translated into asking, does the USA get a good return on its fi nancial investment into health care? This raises the further question, what would be the criteria on which to make such judgements. It is argued that in the last analysis health care's clinical outcome measure is to reduce premature deaths, in particular Child Mortality Rates (CMR: 0-4years) and mortality Rates of people aged 55-74. If a country can reduce deaths in these age bands, it would make a substantial contribution to reducing premature death and improving life expectancy [4]. Thus we juxtapose CMR (0-4) and what we categorise as Adult Mortality Rates (AMR) of people in the age-band 55-74. In addition, any changes in total deaths rates are examined of all age-bands, which are based upon the WHO category of Age-Standardised-Deaths-Rates (ASDR) [4].
Thus we can compare the USA, with the twenty Other Western Countries (OWC) in regard to economic input into health care-the total %Gross-Domestic-Product-of-Expenditureon-Health (%GDPEH) based on World Bank data 2 , and health outputs in changes in Child (0-4), Adult (55-74) and all deaths (ASDR) based upon WHO data [4].
However, it is recognised that there are confounding infl uences from pre-existing social determinates that impact upon health outcomes, which needs to be considered within the context of underlying health issues in the various population and comorbidities [5]. There are of course a range of public health and socio-economic issues, which impacts upon health outcomes, especially in regard to children, linked to relative poverty [6][7][8][9]. It is however, recognised that relative poverty is a very broad category and the actual mechanism of how it affects children's health is not fully understood. From a number of clinical studies more specifi c factors related to poorer child health outcomes have been established. These include low birth weight [10,11], parental smoking [12], drug and alcohol misuse [13], living in deprived polluted areas [14], social inequalities associated with poorer education, anti and post-natal care [6][7][8][9]15] and belonging to an ethnic minority [16]. Though the above factors are themselves linked to relative poverty in the West [2,[6][7][8][9][10][11][12][13][14][15][16]. Moreover, the UN Millennium goals recognised that the aim of reducing child mortality by 2% pa also required the need to reduce relative poverty [2]. There is a debate surrounding measures of poverty, between relative, as in the West and absolute poverty more often found in the developing countries [17,18]. We use the World Bank Income Inequality, the difference between the top and bottom 10% of incomes, as a surrogate measure of relative poverty, not least because it is country -specifi c [19].
However, the central focus of this study is to answer the question of whether the USA %GDPEH achieves as much as the OWC, in relation to health expenditure and crucially in reducing mortality outcomes over the period 1989-91 v 2013-15, which is the latest available international mortality data [2]. A simple economic model is postulated of contrasting fi scal input %GDPEH [2], against the clinical outputs of reducing the three mortality categories based upon the latest WHO data [4].
Earlier work has shown an unexpected fi nding that although the USA has long had the highest %GDPEH of all Western countries it has poorer health outcomes than many OWC [3,6], which have been described as "the US health care paradox" [20,21], of a health system that is predominately funded from `Private' (employment or personal insurance related) than `Public' sources coming from State or Federal avenues [22]. This appears related to the problems of a predominantly private insurance model, as even within the Affordable Care Act, the insurance company needs to make a profi t. Therefore, because of market uncertainty, it has been shown that costs will need to be higher to account for previous illnesses and medical unknowns and under-lying conditions [5,[23][24][25][26], than in a predominately direct-taxation based service as such a service as the British National Health Service (NHS) which provides a free health care at the point of delivery, irrespective of any pre-existing conditions. Indeed, as will be seen although the confi guration of health services varies across the twenty countries reviewed, with the partial exception of Greece and Switzerland, every other country's health funding comes predominately from direct taxation [22].

The study has two working null-hypotheses
There will be no statistically signifi cant differences between the USA and the Other Western Countries (OWC):-in reducing child (0-4), adult (55-74) mortality and ASDR, that is total allage mortality, and, countries' cost-effectiveness in reducing mortality 1989-91 v 2013-15. and `Public' (state and federal) funding [22], and, the combined Private and Public sources which is the nation's total %GDPEH (including health and social care) [2,22]. It is the total %GDPEH that will be used for cross national comparisons. This was reported for 27 separate years during the period between 1980 and 2015 2 . Some countries did not report %GDPEH every year but the number of any missing years are indicated in table (1).

Socio-Economic Factors
To illustrate changes in %GDPEH over time, the tables shows the baseline year 1980 and the years 2000, 2010 and then 2015 the latest available year. As will be seen, every countries' %GDPHE rose substantially since 1980 [2]. The Private and Public percentage of GDPEH is given for the index year 2015, which combined is the total %GDPEH, which is used in the international comparisons. Furthermore, the percentage of GDPEH is taken as a broad practical indication of the fi scal priority each nation gives to its health care. Moreover, a country acts as its own control over the comparative period for both fi scal and clinical outputs.  [4]. The results will be placed within the context of economic inputs into health which is each country's total national %GDPEH.
Comparative baseline years are the 3year average of 1989-91 and the index years of 2013-15, which is the latest available data 4 . A few countries have slightly earlier index years than 2013-15 which are noted in the tables.
Child-Mortality-Rates (0-4). CMR are calculated from the numbers of deaths in 1year olds (<1) and the 1-4years olds, from which a CMR 0-4 is calculated per million (pm) per population [4]. This is an appropriate measure as all 21 Western countries were signatories to the UN Millennium Goals objective of reducing CMR (0-4) by 2% per annum [27], refl ecting the UNICEF (2001) view "that in the last analysis child mortality rates are an indication of how well a nation meets the needs of its children" [28]. Moreover, the UN Millennium objective was also linked to reducing poverty, which was recognised as a feature associated with child mortality, even in the richer countries [6][7][8][9]28].
In regard to Adult Mortality Rates (AMR 55-74) the analysis focuses upon reducing mortality of people aged 55-74years rates per million of population, which would make an especially major contribution to further improving life expectancy and reducing premature deaths in the countries reviewed [4].
Total mortality rates are analysed via the `Age Standardised Deaths Rates' (ASDR), which includes all the age bands from <1year to 75+years, based upon all-age death rates standardised on the World Standard Population [4]. The WHO reports in rates of per 100,000 however we adopt the increasing use of rates per million (pm) of which avoids the use of the decimal point reported in rates per hundred thousand [4].
It is recognised that there may also be different prevailing disease patterns in the various countries infl uencing mortality results but this is minimised as in effect each nation is its own control over the period. Thus, partially controlling for any prevailing socio-economic features related to health outcomes [6][7][8][9] . Moreover, based upon WHO 10 th edition of International Classifi cation of Diseases, resolves any issues about cause of death as the study is concerned with total mortality rates within the age-bands, not their diagnostic category [4].
To determine any statistical signifi cant difference in the mortality rates over the period Confi dence Intervals (95%) are used to test outcomes between each of the OWC and the USA whose results are shown in the fi nal column of the mortality tables.
Cost-Effective Ratios (CEF): CER are based upon the level of reduced Age-Standardised-Death-Rates (total allage mortality) rates over the period, divided by the average %GDPHE of that nation over the period. However, caution is required in interpreting the results as CER can be infl uenced by the laws of diminishing returns as it is easier for countries with initially higher rates to make greater gains than countries Confi dence Intervals showed that the USA had greater reductions in AMR (55-74) than Greece and Japan but fourteen OWC had signifi cantly bigger falls than America, including the UK, the lowest funded %GDPEH (Table 3). It is notable that every OWC had a signifi cantly bigger reduction in all-age mortality (ASDR) over the period than America (Table 4).

Average West Countries (-USA) 1866 -788 -58%
# Indicates failed UN millennium goals.  In 2015 there were a total of 2,726,630 deaths in the USA. American ASDR rates were 18%higher than the UK, the USA failing to match British rates means there was an excess of 488,273 deaths across all the ages. This included an excess of 12,613 American children's (0-4) deaths, as the USA failed to match British child mortality rates.

Discussion
It is reiterated that the major limitation to the study is that we cannot explain why the highest health-spender, the USA, has the highest mortality in all categories. Nor can we crossreference the results in terms of the socio-economic infl uences on health outcomes other than to place them in the wider context of relative poverty, as measured by Income Inequality 19 . Nonetheless, we can reject the null hypotheses that there will be no signifi cant differences between the USA and twenty other Western countries in regard to reduced mortality and costeffectiveness over the period.
Over the years, the USA increased its %GDPEH and on average the USA spent 55% more of its GDPEH than the OWC.
On average its child mortality was 59% higher, its adult death 27% higher and its total ASDR rates were 26% higher than the other Western nations. Whilst over the period fourteen other countries had signifi cantly bigger reductions in child and adult mortality respectively than the USA and even worse America has a signifi cantly poorer ASDR outcomes than all the other countries. This it must be reiterated is despite the USA having far higher and increasing percentage GDP expenditure going to health over the period. On these criteria the American health care system is the most expensive and ineffective and ineffi cient in the Western world.
It may be that this disproportionate high %GDPEH is undermined by the simple fact that the USA has considerably wider income inequality than the other Western countries [3,19]. This points towards the impact of relative poverty upon health outcomes, which can be evidenced from a close perusal of This raises the question, should the USA increase even further its %GDPHE or primarily address the poverty issues related to people from poorer backgrounds, a feature found in every Western country but more marked in the USA [6,8,9,33,34].
One unexpected fi nding merits comment, namely that GDPEH from USA `Public' sources was higher than eleven other counties `Public' %GDEPH, including the UK. Is this a further indication that the under-lying insurance model of the USA system is problematic?

Possible Explanations for USA system weakness
In addition to the underlying social conditions impacting upon US mortality rates is the problem that the US health system suffers both from a lower level of productive effi ciency and the signifi cant market failure of asymmetric information [20][21][22][23][24][25][26]. This is because the USA has high administrative costs due to higher spending on more nonclinical staff, and duplicates often unnecessary investigations, indeed it has been estimated that then US system spends an excess of $150 billion on these additional administrative insurance-linked costs [35] .
In addition is the relative over-use of the latest technology which further reduces productive effi ciency [36,37], though whether this is due to American patients being more ill than in the other countries cannot be determined here. Moreover, many US physicians have the perverse incentive of earning additional income by ordering imaging studies such as MRI scans and CT scans which has resulted in diagnostic tests increasing at an annual rate of roughly 10 per cent per year [37,38]. A prestigious McKinsey Global Institute Study estimated that US health care providers earned as much as $25 million from profi ts on self -owned facilities providing laboratory, imaging and other services 39 . Consequently, the production function for US healthcare is empirically demonstrated, to be signifi cantly below that of the mainly universal direct taxation system, whilst Garber goes as far to describe the US system as "uniquely ineffi cient" [39]. Furthermore, insurance costs are high because of the market failure of asymmetric information. This results in higher insurance premiums as the insured have more information about their health than the insurer, who to mitigate potentially unlimited costs, need to increase their premiums signifi cantly because of possible pre-existing conditions [20,[23][24][25][26][35][36][37][38][39][40][41]. Equally, many people were unable to obtain full insurance due to known chronic medical conditions and who are on relatively low incomes, rather than pooling the risk collectively as with tax-based systems [2,38,40,41]. Such America citizens fall outside the system, possibly contributing to higher national mortality than other Western countries. Consequently in fi scal and clinical terms, the USA achieves less with more, whilst the UK, with its National Health Service (NHS) achieves proportionately more with relatively less. Indeed the NHS, compared to the USA, could almost be described as a half-price system, with the UK to USA %GDPEH odds ratio of 1:1.79.
The Affordable Health Care Act was surely right in principle but the insurance model still diverts too many resources from clinical care to the for-profi t medicare agencies who compound the problem [42]. Despite the greater inclusiveness of Obama Care, the systematic problems inherent in an insurance model remain, with recent complaints from insurance companies supporting AHCA, they have diffi culty in making a profi t [41]. Hence it is still more expensive than a direct taxation system and has not produced the improvement that was hoped for [38][39][40][41]. Indeed, a JAMA study found continued criticism of the cost of AHCA from 21% of Democratic and 63% of Republican respondents who support the repeal of the AHCA [1], but whether given more time, this might change under Obama Care is too soon to determine. So, does the USA get a good return on its investment in health care -the answer must be a resounding no.
The Case for Change: It is acknowledged that in terms of clinical excellence, at its best American medicine is amongst the leaders of the world but these results show that despite vast sums expended on health the money clearly does not reach the citizen eff ectively or how else could the supporters of the present system explain the `excess' of US deaths compared to almost `half-price' NHS? Moreover, President Trump claims to be the fi rst businessman to occupy the White House and as a businessman the need for a good return on a major fi nancial investment would be almost formulaic. Yet clearly, in terms of health outcomes, the USA has actually fallen behind other Western countries over the period, which is a poor return on the vast amounts of money going to health care. Quite apart from the impact of prevailing inequality has upon health and social outcomes -surely there is a need for a major radical rethink?
In terms of health care systems, it appears to outsiders the two major US political parties have trapped themselves in ideological silos but perhaps there are vested interested in maintaining the present system as a progressive direct taxation system clearly would be cheaper for the nation. However whether the evidenced-based argument could overcome the USA political misunderstandings about `Government' intervention into health care might be incompatible to the USA tradition, is uncertain? But it is suggested the comparative mortality argument has not been made.
When listening to some USA media presentation during the fi rst election of President Obama and his hopes for Òbama Care, his opponents accused him of wanting to bring in something like Britain's NHS, which was characterised as `socialised medicine' and by inference, un-American. British people hearing this would not recognise this distorted description of the NHS and such rhetoric stops balanced public health analysis and creates prejudiced stereotyping. Yet paradoxically, the NHS can claim to be similar to the great American tradition of neighbourliness and community, eulogised in many Hollywood epics, where people rally round in hard times to support other citizens in trouble. This in effect is the underlying principle of the NHS. So the USA might well adopt its own style of a Neighbour Helping Health Service system -an American NHHS, as all neighbours / citizens contribute through progressive taxation, to help each other at the point of need, which is of course a reciprocal support system and is far more cost-effective and community cohesive.
That the NHS is such a reciprocal and cost-effective system often goes unrecognised by the proponents of an insurance based model. In summary, in terms of reducing deaths, a neighbour / community orientated National Health Service is a model superior in cost and outcome than the current American insurance model, which profi ts from the ill-health of American people. Indeed, based simply upon mortality rates, every one of the other twenty Western nations is superior to the United States health care system, compounded by having the worst Income Inequality in the Western world [3,19].
The USA failure to meet the UN Millennium goals for reducing under-fi ve mortality, with its association with relative poverty 5 , should be the greatest spur for change in the richest country in the world and these results support the clarion call that "abolishing inequality is a necessity to realise child mortality targets" [45].
These general fi ndings, along with excess four-hundred thousand plus `excess' deaths, compared to British rates, are likely to be very unwelcome information as they challenge entrenched stereotypes and ideologies but evidence must speak truth to power. We leave the last word to that great American founder, William Penn who was a forerunner of public health, who said "It is a reproach to Government and Religion to suff er such poverty and excess", almost prophetic when considering the excess of American deaths compared to Britain and of course most of the other Western countries.