Actually, the U.S. is NOT spending more than any other country on health

Old News: US spends more on healthcare, gets worse results

We Americans are first in the world when it comes to per capita healthcare spending, and yet we don't live as long (we're in 51st place), more of our mothers die in childbirth (we're in 47th place), more of our babies die in their first year of life (we're in 50th place) ... well, you've seen the statistics, and they aren't pretty.

Interesting Spin on Old News: Medical and social spending should be seen as a whole

"The truth is that we may not be spending more," wrote Elizabeth H. Bradley and Lauren Taylor in a 2011 New York Times article—"it all depends on what you count." If you count "the combined investment in health care and social services," such as "rent subsidies, employment-training programs, unemployment benefits, old-age pensions, family support and other services that can extend and improve life," we're in 10th place among developed nations. To compare:

For every dollar we spend on health care, we spend an additional 90 cents on social services. In our peer countries, for every dollar spent on health care, an additional $2 is spent on social services. So not only are we spending less, we’re allocating our resources disproportionately on health care.

Bradley, a professor of public health at Yale, and Taylor, formerly a program manager at the Yale Global Health Leadership Institute, believe that healthcare (primarily intervention after a health problem has occurred) is less effective than social services (primarily services that may prevent health problems) in keeping a nation healthy.

Unfortunately, we Americans do it backwards, and our ratio of healthcare spending to social spending is getting worse. In their forthcoming book, The American Health Care Paradox: Why Spending More Is Getting Us Less (November 2013), Bradley and Taylor write that for every dollar Americans spend on health care, we spend only an additional 60 cents on social services. Here's a picture of OECD spending compared with US spending:

Really Disheartening Current Situation: Many US legislators are trying to cut back social spending

Republicans in Congress are trying mightily to reduce or eliminate food stamps, for example. Yesterday the Health Impact Project (in collaboration with the Robert Wood Johnson Foundation and the Pew Charitable Trust) released a white paper called "Health Impact Assessment of Proposed Changes to the Supplemental Nutritional Assistance Program" (translation: the program formerly known as food stamps). Two scary sentences from the 218-page document:

Using a model employed by the U.S. Department of Agriculture to administer SNAP, Mathematica Policy Research conducted an analysis of how many people could lose eligibility or receive lower benefits under the proposed policy changes in H.R. 1947 and S. 954. Under the changes proposed in H.R. 1947, as many as 5.1 million people could lose eligibility for the program.

 Lest you think this has nothing to do with health care, the document points out that

it is well established in the literature that food insecurity (defined as difficulty in obtaining enough to eat) increases the risk of diabetes, heart disease, and depression or anxiety in adults; and asthma, cognitive impairment, or behavioral problems in children. Children in food-insecure families are more likely to be hospitalized in early childhood than those from food-secure households. Medical costs related to food insecurity in the United States amount to as much as $67 billion per year in 2005 dollars.

At the same time, Republicans in Congress are still trying to repeal the Affordable Care Act.

Hey, let's go back to 1900 before any of those lefty innovations got started!

No income tax! No government-backed social welfare programs! No Department of Health and Human Services! No Department of Education! No Medicaid or Medicare! No Social Security! No Maternal and Child Health Program!

Paradise, right?

Except that if you were lucky enough to make it to age 20, your lifespan was 62 if you were a white male, nearly 64 if you were a white female, and a lot lower if you weren't white at all. Worse, you had a 23% chance of dying before your 20th birthday. And out of 100,000 women who gave birth in 1900, 600-900 died (compare with 21 in the U.S. today).

Well, that's one way to keep Social Security from going broke...

ONE GOOD TURN by Kate Atkinson

Two years after the windfall in Case Histories that left Jackson Brodie a wealthy man, he's in Scotland with his girlfriend, who's involved with Edinburgh's Fringe Festival.

A shady character who calls himself Paul Bradley--sometimes--is there too, driving through a crowded street, when suddenly a scruffy actor steps out in front of his rented Peugeot. Bradley brakes and swerves, a blue Honda Civic bumps him from behind, the driver gets out and comes after him with a baseball bat, and a laptop computer sails out from the onlookers and clips the Honda driver on the shoulder.

The Honda driver disappears. Nobody can remember what he looked like. Only one person took note of his car's license number: Jackson Brodie.

Enough said. Detective stories are meant to be read, not summarized. Kate Atkinson's plots are intricate and full of surprises. Her characters are nearly believable and usually hilarious. I'm not sure whom I liked better, Gloria the moralist ("If it had been up to her she would have summarily executed a great many people by now--people who dropped litter in the street, for example, they would certainly think twice about the discarded sweet wrapper if it resulted in being strung up from the nearest lamppost") or Martin the feckless crime writer (his current novel "felt even more trite and formulaic ... than his previous books, something to be read and immediately forgotten in beds and hospitals, on trains, planes, beaches").

Not to mention Tatiana the dominatrix, Archie and Hamish the teenaged thieves, Louise the frazzled detective, Richard the insufferable guest, Graham the mob-connected builder...

If it weren't for the fact that Atkinson tells a great story and keeps the pace brisk, I'd probably classify One Good Turn with literary fiction, not only for her witty style but also for the way she deftly probes her characters' motivations. I just wish she were bothered by comma splices. After all, as she herself pointed out, "Gloria liked rules, rules were Good Things."

But that's a forgivable flaw, even for this former English teacher and editor. Atkinson ranks right up there with P.D. James and Donna Leon as an author I love to spend my evenings with. James, who has written 16 mysteries, will turn 93 next week. Leon, who has written 22 Commissario Brunetti mysteries, is almost 71. Atkinson, with only 4 Jackson Brodie mysteries so far (© 2004, 2006, 2008 2011), is a mere 62. Ms. Atkinson, it's time for another one!
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The publisher figured One Good Turn would be a good title for book clubs, so there are a couple of pages of rather tedious questions at the end. I agree that book clubs could enjoy this book, and I in no way blame Ms. Akinson for the questions.

The color of justice

Oddly, I wasn't there the night George Zimmerman shot Trayvon Martin. I wasn't in the jury box either. Some commentators, like Ezra Klein and Ta-Nahesi Coates, are saying the not guilty-verdict was appropriate according to Florida's "stand your ground" law. (Note that they are not saying that the Florida law is appropriate; Klein uses the word outrageous).

If this verdict was appropriate, though, what about verdicts in cases that were similar except for the color of the defendant? What happened to the "stand your ground" law when the jury reached its verdict against Marissa Alexander--an African American woman from Jacksonville?

And anyway, why should fear of attack justify shooting to kill? It didn't in the case of  John White--an African American man from Long Island, New York--who shot a (white) teenager in 2006 (accidentally, he says, when the boy was trying to grab his gun).

John White, it appears, had good reason to fear the boys who showed up on his doorstep that night. That's probably why the governor commuted his sentence after he had served five months. And White no doubt should have served some time, according to New York law--his gun was unregistered, and if he hadn't been holding it when he went to the door, a scuffle probably wouldn't have escalated into manslaughter.

But, some say, the only thing that stops a bad guy with a gun is a good guy with a gun. Is this true?

• Imagine that Trayvon Martin lived by that principle and was also armed when he met George Zimmerman. Imagine they both pulled out their guns and fired, and Zimmerman went down. Do you think the jury would have found Martin guilty?
• Imagine that Marissa Alexander's husband had come after her with a gun. Would she then have just fired warning shots? And if she had actually killed him, what would her sentence have been? Remember than Florida allows capital punishment, and that Governor Rick Scott recently signed a bill that speeds up the process.
• Imagine that the boys who came after John White's family had all had guns. Would they have used them? Would White have been able to stop them?
• Imagine that none of these people had guns. Who would be dead? Who would be in jail?

As it is, two boys (who may have been innocent) are dead because they frightened armed men (who may have been innocent, apart from the fact that they were holding guns). One man (who looks pretty darn guilty to me) is still alive because an armed woman decided to shoot in the air instead of at him. Two African-Americans were found guilty. One man with a whiter face was found not guilty.

America, we have a problem with race. And with guns.

"Honoring David Neff, The Gentleman Scholar," by Katelyn Beaty

I want my friends to see this lovely tribute to my husband by his former coworker and our friend Katelyn Beaty. I linked to it on Facebook, but the Christianity Today firewall didn't let everybody read the whole thing. So here it is, in flagrant violation of copyright. If you subscribe to CT, you can also read it there, with better formatting.

Honoring David Neff, The Gentleman Scholar

A tribute to Christianity Today's esteemed editor in chief.

Katelyn Beaty

When I started in 2007 as CT's copy editor, I had three go-to grammar guides: The American Heritage Dictionary, The Chicago Manual of Style, and David Neff.

It turns out the last guide was also the best. After spotting a misplaced comma or extra hyphen, David would walk down to my office, kindly and clearly explain the linguistic law behind the change, and point me to the right cms entry. And also throw in a historical tidbit, just for fun. I trusted his wisdom so much that I began asking WWDD?—"What Would David Do?"—before tricky editing projects, as no doubt many staff have over the years.

Conversations like these underscore why editor Mark Galli named David "a gentleman and a scholar" at a June board meeting honoring David's legacy. In various leadership roles (six of them!) over 28 years, David kept this magazine centered on the Cross when many voices co-opted the word evangelical for political ends. Yet David also made sure CT's firm theology bore witness to social issues of the day, calling Christians to bring the Good News to all members and segments of society. The gentleman-scholar's fingerprints are all over two key documents of evangelical thought: "For the Health of the Nation" (2004) and "An Evangelical Manifesto" (2008).

David's fingerprints are also all over this ministry. Some prints worth noting here: helping to launch sister magazine Books & Culture; prepping a forthcoming Spanish edition of CT; mentoring former and current staff who are shaping religious journalism in their own key ways; representing CT in dialogues with Jews, Mormons, and Muslims; and in countless seen and unseen ways, raising our bar of journalistic excellence. This doesn't even touch on David's roles outside this ministry (as trustee of the Robert Webber Worship Institute, husband of LaVonne, and choirmaster of St. Barnabas Episcopal Church).

As I write this, David is packing up his office, preparing for retirement. And I am thinking of what the halls will be like without his wisdom, insight, and vast body of knowledge gracing them. I am thinking of our staff birthday celebrations, and wondering who will hum to get us all singing "Happy Birthday" on the right note. We anticipate many good things ahead for David (he says that a Definitive History of Evangelical Protestantism is not in the plans, though I have my doubts). But we well know that we're losing a gentleman and a scholar who got ct singing on the right note for nearly three decades. May we carry on the tune well.

CASE HISTORIES by Kate Atkinson

Having run out of mysteries by Donna Leon and Michael Connelly and C.J. Sansom and P.D. James and Peter Lovesey, I am deeply grateful to whichever of my bibliophilic friends recommended Case Histories (2004). As Stephen King gushes in his front-cover blurb, "Not just the best novel I read this year, but the best mystery of the decade."

From the start, the story sounded eerily familiar: a child gone missing over 30 years before; three feuding sisters; a weird cat lady next door. About halfway through the book, I finally Googled Jackson Brodie, the private eye who was working this case along with several others.

Oh right - a year or two ago, my husband had recommended a Masterpiece Mystery episode because it starred Jason Isaacs, known to Harry Potter fans as Lucius Malfoy. David thought I would want to see how he looked with dark brown hair. (Stunning!)

It was a good show, and I plan to watch more episodes now that I've read the book. I also plan to read the next three Jackson Brodie books, and no doubt some of Kate Atkinson's other novels as well. The woman can write!

Jackson is a typically depressed private detective -  divorced, bitterly at odds with his ex, absent-mindedly devoted to their eight-year-old daughter, trying (but not too hard) to give up smoking, taking on jobs that are "either irksome or dull" because he needs the money. Originally from the north of England, he now works in Cambridge, where for 12 years he was on the police force. He's attractive (and attracted) to women, but there's no love in his life.

He was currently seeing more of his dentist than he had of his wife in the last year of their marriage. His dentist was called Sharon and was what his father used to refer to as "stacked." She was thirty-six and drove a BMW Z3, which was a bit of a hairdresser's car in Jackson's opinion, but nonetheless he found her very attractive. Unfortunately, there was no possibility of having a relationship with someone who had to put on a mask, protective glasses, and gloves to touch you.

He wishes he could throw it all over and escape to France.

Jackson doesn't show up until page 45, however. Up to that point we learn about three case histories - the missing child (1970), a murdered 18-year-old girl (1994), a young mother who goes berserk and - does what? (1979) - with which he will eventually be involved. We suspect the stories are somehow intertwined.

When it comes to detective stories, I have a couple of pet peeves. One is overcomplexity: I like to be able to follow a story without taking extensive notes (I eventually quit reading Elizabeth George, who is a fine novelist, for just that reason). My other pet peeve is shifting viewpoints. Very few novelists are able to switch from the mind of God to that of the detective to that of the criminal without sounding like poorly edited amateurs.

Kate Atkinson managed a complex plot and over half a dozen viewpoints without ever causing my pet-peeve alarm to buzz.

Because so many viewpoints are represented, Case Histories is not a procedural, though a certain amount of detective work is involved. Neither is it a thriller, though it includes a few fights and one big explosion. It would be misleading to call it a psychological novel: though it's literary, it's by no means a navel-gazer. There are many puzzles in the multiple stories, but the emphasis isn't on whodunit. I guess I'd just call it a brilliant detective story and resist adding subclassifications.

Atkinson's characters, like most people we know, are simultaneously tragic and comic. I suspect that she, like Jackson, believes that her job is "to help people be good rather than punishing them for being bad."

And maybe that's why - apart from the author's obvious skills in plotting, characterization, and literary style - I really liked this book. Despite all the human frailty and downright evil portrayed in it, the underlying tone is optimistic. Sometimes it's even laugh-out-loud funny.
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Warning: There's enough sex in this book - most of it pretty amusing - that you might not want to read it aloud to intergenerational family groups.

Teen Mamas

My daughter Molly and I are still talking about why America's infant mortality rate is so high. Molly found that when it comes to prenatal care (the lack of which is an obvious factor in our high mortality rate), the biggest gap between Americans and Europeans occurs in the first trimester - and that half of the American mothers who got no early prenatal care didn't even know they were pregnant.*

Didn't know? What were they, children?

Could be.

I took the UN data from 2006 and compared mothers' ages in the United States, France, Sweden, and Italy. Then I made these charts. Start reading just past 12:00 (0%: though there are births to women between 45 and 49, there are too few to register on a pie of this size) and go clockwise.

In the United States in 2006, 10.7 percent of births were to mothers between the ages of 15 and 19. (The good news is that five years later, in 2011, only 8.3 percent were to mothers in that age group.)

By contrast, in Italy only 2.7% of births were to teenagers:

... in France, only 2.1%:

... and in Sweden, just 1.4%:

 

According to the March of Dimes, the highest infant mortality rate in the United States is to mothers under the age of 20 (9.7 deaths per 1,000 live births). That's nearly twice as high as the rate for American mothers in their 30s (5.6 deaths per 1,000 live births).

Sadly, it's the teen mamas who are least likely to get adequate prenatal care, most likely to have preterm babies, and most likely to lose their babies before the babies' first birthday.

What is America doing wrong? What are France, Italy, and Sweden doing right?** Can we learn from them?
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*These links are to articles written in the 1990s. We were unable to find more recent data comparing prenatal care in Europe and America; if you know where to find some, please let us know.

**In case you're wondering, the U.S. abortion rate is higher than France's or Italy's and about the same as Sweden's. So abortion isn't the explanation.

Infant mortality - why is America in 51st place?

[Picture by Brian Hall, Wikimedia Commons]

After I blogged about expensive American childcare earlier this week, my daughter Molly directed me to a March of Dimes web page showing the extremely high rate of preterm births in the United States. "Born Too Soon," a 124-page report issued in 2012, "ranks the U.S. 131st in the world in terms of its preterm birth rate of 12.0 per 100 live births, almost tied with Somalia, Thailand, and Turkey. Nearly half a million babies are born too soon in the U.S. each year."

According to a 2009 report from the Centers for Disease Control, "the main cause of the United States’ high infant mortality rate when compared with Europe is the very high percentage of preterm births in the United States" - in spite for the fact that "infant mortality rates for preterm (less than 37 weeks of gestation) infants are lower in the United States than in most European countries." In addition, "infant mortality rates for infants born at 37 weeks of gestation or more are higher in the United States than in most European countries."

It costs a lot to keep those preterm babies alive and healthy.  According to a 2012 article in The Lancet as reported by US News, infants born prematurely account for "12 percent of U.S. live births per year, but their care consumes close to 60 percent - or $6 billion - of total spending on initial neonatal care."

How effective is the spending? Quite, if you compare America to Poland: for every 10 preterm American babies who die, says a CDC report, about 15 Polish babies die. Not so much, if you compare America to Sweden: for every 10 preterm American babies who die, fewer than 8 preterm Swedish babies die.

Here's the question: why does America have so many preterm babies?

• Is it because American mothers are waiting to have babies until they're older? So are Western European mothers. In fact, the birthrate for women ages 40-49 is higher in most Western European countries than in America (you can check it out here).
• Is it because Americans are really into assisted reproductive technology, which is more likely to produce twins or triplets? According to the CDC, just over 1% of American babies born in 2011 were the result of ART. However, "in Belgium, Slovenia, Denmark, Netherlands and Sweden more than 3.0% of all babies born [in 2009?] were conceived by ART" (source: European Society of Human Reproduction and Embryology).
• Is it because "20 percent of U.S. women (18.7 million) ages 19-64 were uninsured in 2010, up from 15 percent (12.8 million) in 2000, according to a new [2012] Commonwealth Fund report on women's health care"?

That's my best guess: a lot of our babies come early because their mothers can't afford prenatal care. And because so many of us think it's somehow un-American to provide good quality healthcare for everyone, we end up spending huge amounts to save the babies who, lacking prenatal care, are born before their time.

Sadly, our efforts are too much, too late. Though we spend more than twice as much on childbirth-related expenses as any other country in the world, our newborn infants have a higher death rate than newborns in some 50 other countries.

Economically, this is a stupid approach to childbirth. Morally, it is reprehensible. For bereaved families, it is tragic.

How to make childbirth safer for mothers and infants (hint: not by spending more money)

"American Way of Birth, Costliest in the World." 

That's the headline of an article by Elisabeth Rosenthal in yesterday's New York Times. The article includes a chart comparing childbirth costs in seven countries. In the United States, the average amount paid for a conventional delivery in 2012 was $9,775; for a Caesarean section, it was $15,041. Those are the highest prices for childbirth anywhere in the world.

To get an idea of just how high, I made a chart using the figures in the NYT chart. Childbirth costs in the other six countries range from 21 to 43% of US costs, even though American women typically spend far less time in hospital.

This chart is based on prices that are actually paid, whether by individuals, insurers, or the government. [Chart by L. Neff; data from the International Federation of Health Plans 2012 Comparative Price Report]

You'd think America's higher costs would mean that American women and infants get better care. Not at all. "Despite its lavish spending," Rosenthal writes, "the United States has one of the highest rates of both infant and maternal death among industrialized nations." And among lots of other nations as well: according to the CIA's World Factbook, 50 countries have a lower infant mortality rate than the US, and 47 countries have a lower maternal mortality rate.

 Here's some comparative data in graph form. The longer the line, the more dangerous the country is for mother and child.

South Africa is so dangerous for childbirth that its graph line would not fit on this blog page. For every 1,000 births, there are 56 infant deaths. For every 100,000 births, there are 400 maternal deaths. [Chart by L. Neff; data from WHO]

Rosenthal mentions one reason that high costs often do not translate into low death rates: "The fact that poor and uninsured women and those whose insurance does not cover childbirth have trouble getting or paying for prenatal care contributes to those figures." I decided to use the Gini Index - a scale that measures "the degree of inequality in the distribution of family income in a country" - to compare the seven countries in the NYT graph. Here are the results:

South Africa's red line is missing because for every 100,000 births in that country, there are 400 maternal deaths. The chart would have had to be six times wider to accommodate the data. [Chart by L. Neff; data from CIA and WHO]

Wow. I didn't expect the results to line up so neatly, but there you have it: The more inequality in a country's  distribution of family income, the more mothers and babies die in childbirth. Of the 136 nations reported by the CIA, South Africa is #2 on the inequality list. Chile is #15, the United States is #41 (that means that 40 countries have less income equality than the US, while 95 countries have more). Britain, France, the Netherlands, and Switzerland, at numbers 60, 101, 111, and 117 respectively, all have significantly more income equality than the US.

Number 136, the nation with the least inequality of all, is Sweden. Swedish infant and maternal mortality rates are even lower than Switzerland's - in spite of the fact that Sweden spends about 1/3 less per capita on healthcare.