for example, a ranking by the world health organization of health care system performance among 191 member nations, published in 2000, ranked canada 30th and the u.s. 37th, and the overall health of canada 35th to the american 72nd. the who did not merely consider health care outcomes, but also placed heavy emphasis on the health disparities between rich and poor, funding for the health care needs of the poor, and the extent to which a country was reaching the potential health care outcomes they believed were possible for that nation. in an international comparison of 21 more specific quality indicators conducted by the commonwealth fund international working group on quality indicators, the results were more divided. one of the indicators was a tie, and in 3 others, data was unavailable from one country or the other. canada performed better on 11 indicators; such as survival rates for colorectal cancer, childhood leukemia, and kidney and liver transplants. the u.s. performed better on 6 indicators, including survival rates for breast and cervical cancer, and avoidance of childhood diseases such as pertussis and measles. the 21 indicators were distilled from a starting list of 1000. the authors state that, "it is an opportunistic list, rather than a comprehensive list." some of the difference in outcomes may also be related to lifestyle choices. the oecd found that americans have slightly higher rates of smoking and alcohol consumption than do canadians as well as significantly higher rates of obesity. a joint us-canadian study found slightly higher smoking rates among canadians. another study found that americans have higher rates not only of obesity, but also of other health risk factors and chronic conditions, including physical inactivity, diabetes, hypertension, arthritis, and chronic obstructive pulmonary disease. while a canadian systematic review stated that the differences in the systems of canada and the united states could not alone explain differences in healthcare outcomes, the study didn't consider that over 44,000 americans die every year due to not having a single payer system for healthcare in the united states and it didn't consider the millions more that live without proper medical care due to a lack of insurance. the united states and canada have different racial makeups, different obesity rates and different alcoholism rates, which would likely cause the us to have a shorter average life expectancy and higher infant mortality even with equal healthcare provided. the us population is 12.2% african americans and 16.3% hispanic americans (2010 census), whereas canada has 2.5% african canadians and 0.97% hispanic canadians (2006 census). african americans have higher mortality rates than any other racial or ethnic group for eight of the top ten causes of death. the cancer incidence rate among african americans is 10% higher than among european americans. u.s. latinos have higher rates of death from diabetes, liver disease, and infectious diseases than do non-latinos. adult african americans and latinos have approximately twice the risk as european americans of developing diabetes. the infant mortality rates for african americans is twice that of whites. unfortunately, directly comparing infant mortality rates between countries is difficult, as countries have different definitions of what qualifies as an infant death. another issue with comparing the two systems is the baseline health of the patients for which the systems must treat. canada's obesity rate of 14.3% is about half of that of the united states 30.6%. on average, obesity reduces life expectancy by 6–7 years. a 2004 study found that canada had a slightly higher mortality rate for acute myocardial infarction (heart attack) because of the more conservative canadian approach to revascularizing (opening) coronary arteries. cancer numerous studies have attempted to compare the rates of cancer incidence and mortality in canada and the u.s., with varying results. doctors who study cancer epidemiology warn that the diagnosis of cancer is subjective, and the reported incidence of a cancer will rise if screening is more aggressive, even if the real cancer incidence is the same. statistics from different sources may not be compatible if they were collected in different ways. the proper interpretation of cancer statistics has been an important issue for many years. dr. barry kramer of the national institutes of health points to the fact that cancer incidence rose sharply over the past few decades as screening became more common. he attributes the rise to increased detection of benign early stage cancers that pose little risk of metastasizing. furthermore, though patients who were treated for these benign cancers were at little risk, they often have trouble finding health insurance after the fact. cancer survival time increases with later years of diagnosis, because cancer treatment improves, so cancer survival statistics can only be compared for cohorts in the same diagnosis year. for example, as doctors in british columbia adopted new treatments, survival time for patients with metastatic breast cancer increased from 438 days for those diagnosed in 1991–1992, to 667 days for those diagnosed in 1999–2001. an assessment by health canada found that cancer mortality rates are almost identical in the two countries. another international comparison by the national cancer institute of canada indicated that incidence rates for most, but not all, cancers were higher in the u.s. than in canada during the period studied (1993–1997). incidence rates for certain types, such as colorectal and stomach cancer, were actually higher in canada than in the u.s. in 2004, researchers published a study comparing health outcomes in the anglo countries. their analysis indicates that canada has greater survival rates for both colorectal cancer and childhood leukemia, while the united states has greater survival rates for non-hodgkin's lymphoma as well as breast and cervical cancer. a study based on data from 1978 through 1986 found very similar survival rates in both the united states and in canada. however, a study based on data from 1993 through 1997 found lower cancer survival rates among canadians than among americans. a few comparative studies have found that cancer survival rates vary more widely among different populations in the u.s. than they do in canada. mackillop and colleagues compared cancer survival rates in ontario and the u.s. they found that cancer survival was more strongly correlated with socio-economic class in the u.s. than in ontario. furthermore, they found that the american survival advantage in the four highest quintiles was statistically significant. they strongly suspected that the difference due to prostate cancer was a result of greater detection of asymptomatic cases in the u.s. their data indicates that neglecting the prostate cancer data reduces the american advantage in the four highest quintiles and gives canada a statistically significant advantage in the lowest quintile. similarly, they believe differences in screening mammography may explain part of the american advantage in breast cancer. exclusion of breast and prostate cancer data results in very similar survival rates for both countries. hsing et al. found that prostate cancer mortality incidence rate ratios were lower among u.s. whites than among any of the nationalities included in their study, including canadians. u.s. african americans in the study had lower rates than any group except for canadians and u.s. whites. echoing the concerns of dr. kramer and professor mackillop, hsing later wrote that reported prostate cancer incidence depends on screening. among whites in the u.s., the death rate for prostate cancer remained constant, even though the incidence increased, so the additional reported prostate cancers did not represent an increase in real prostate cancers, said hsing. similarly, the death rates from prostate cancer in the u.s. increased during the 1980s and peaked in early 1990. this is at least partially due to "attribution bias" on death certificates, where doctors are more likely to ascribe a death to prostate cancer than to other diseases that affected the patient, because of greater awareness of prostate cancer or other reasons. because health status is "considerably affected" by socioeconomic and demographic characteristics, such as level of education and income, "the value of comparisons in isolating the impact of the healthcare system on outcomes is limited," according to health care analysts. experts say that the incidence and mortality rates of cancer cannot be combined to calculate survival from cancer. nevertheless, researchers have used the ratio of mortality to incidence rates as one measure of the effectiveness of healthcare. data for both studies was collected from registries that are members of the north american association of central cancer registries, an organization dedicated to developing and promoting uniform data standards for cancer registration in north america. racial and ethnic differences the u.s. and canada differ substantially in their demographics, and these differences may contribute to differences in health outcomes between the two nations. although both countries have white majorities, canada has a proportionately larger immigrant minority population. furthermore, the relative size of different ethnic and racial groups vary widely in each country. hispanics and peoples of african descent constitute a much larger proportion of the u.s. population. non-hispanic north american aboriginal peoples constitute a much larger proportion of the canadian population. canada also has a proportionally larger south asian and east asian population. also, the proportion of each population that is immigrant is higher in canada. a study comparing aboriginal mortality rates in canada, the u.s. and new zealand found that aboriginals in all three countries had greater mortality rates and shorter life expectancies than the white majorities. that study also found that aboriginals in canada had both shorter life expectancies and greater infant mortality rates than aboriginals in the united states and new zealand. the health outcome differences between aboriginals and whites in canada was also larger than in the united states. though few studies have been published concerning the health of black canadians, health disparities between whites and african americans in the u.s. have received intense scrutiny. african americans in the u.s. have significantly greater rates of cancer incidence and mortality. drs. singh and yu found that neonatal and postnatal mortality rates for african americans are more than double the non-hispanic white rate. this difference persisted even after controlling for household income and was greatest in the highest income quintile. a canadian study also found differences in neonatal mortality between different racial and ethnic groups. although canadians of african descent had a greater mortality rate than whites in that study, the rate was somewhat less than double the white rate. the racially heterogeneous hispanic population in the u.s. has also been the subject of several studies. although members of this group are significantly more likely to live in poverty than are non-hispanic whites, they often have disease rates that are comparable to or better than the non-hispanic white majority. hispanics have lower cancer incidence and mortality, lower infant mortality, and lower rates of neural tube defects. singh and yu found that infant mortality among hispanic sub-groups varied with the racial composition of that group. the mostly white cuban population had a neonatal mortality rate (nmr) nearly identical to that found in non-hispanic whites and a postnatal mortality rate (pmr) that was somewhat lower. the largely mestizo, mexican, central, and south american hispanic populations had somewhat lower nmr and pmr. the puerto ricans who have a mix of white and african ancestry had higher nmr and pmr rates. impact on economy this graph depicts gross u.s. health care spending from 1960 to 2008. in 2002, automotive companies claimed that the universal system in canada saved labour costs. in 2004, healthcare cost general motors $5.8 billion, and increased to $7 billion. the uaw also claimed that the resulting escalating healthcare premiums reduced workers' bargaining powers. flexibility in canada, increasing demands for healthcare, due to the aging population, must be met by either increasing taxes or reducing other government programs. in the united states, under the current system, more of the burden will be taken up by the private sector and individuals. since 1998, canada's successive multibillion-dollar budget surpluses have allowed a significant injection of new funding to the healthcare system, with the stated goal of reducing waiting times for treatment. however, this may be hampered by the return to deficit spending as of the 2009 canadian federal budget. one historical problem with the u.s. system was known as job lock, in which people become tied to their jobs for fear of losing their health insurance. this reduces the flexibility of the labor market. federal legislation passed since the