Need good healthcare? Need it now? Short on cash? Be Icelandic.

Today on Facebook I posted a link to this article: "An American In Iceland Found A Lump On Her Body And Her Viral Twitter Thread Shows How Much Better Their Healthcare Is." If you've ever encountered the U.S. healthcare system, you might want to read the article too.

A reliably and sometimes knee-jerk conservative friend of mine left this comment on my post:

"Iceland has a population of 338,349, with practically no illegal (excuse me, undocumented) immigration. The Personal Income Tax Rate in Iceland stands at 46.30 percent. In addition, according to the Trip Savvy website, "VAT in Iceland is charged at two rates: the standard rate of 24 percent and the reduced rate of 11 percent on certain products. Since 2015, the 24-percent standard rate has been applied for almost all goods, whereas the 11-percent reduced rate is applied to things such as accommodations; books, newspapers, and magazines; and food and alcohol." One imagines it might be possible for the United States government to fund all sorts of things under a similar tax regime, not including state and local taxes. How much LIVING the average American would be able to do, however, is another question."

I'm not sure what he's saying there. If we had fewer immigrants, our healthcare system would be as good as Iceland's? If we paid more taxes, our lives would somehow be impoverished?

My friend is right, of course, that the U.S. has a much larger population than Iceland. He is also right that the U.S. has a higher percentage of immigrants: the U.S. population is 15.3% immigrant, whereas Iceland's is 12.5%. I don't know how many of those are undocumented; I do know that many economists have found that immigration (documented or un) is mostly beneficial. A report from the Wharton School (President Trump's alma mater) concludes, "Economists generally agree that the effects of immigration on the U.S. economy are broadly positive."

But let's look at some countries with a higher percentage of immigrants than the U.S. and see how they fare with regard to health and happiness. Here are seven. Ireland: 16.9%. Sweden: 17.6%. Austria, 19.0%. Canada, 21.5%. New Zealand, 22.7%. Australia, 28.8%. Switzerland, 29.6%. Golly, their healthcare costs must be enormous!

Well, no. The per capita yearly healthcare cost in those seven countries averaged $5,352 in 2017, or about half the per capita yearly healthcare cost in the United States, which was $10,209. The costs ranged from $3,683 (New Zealand) to $8,009 (Switzerland). (Iceland's cost was $4,581.)

Ah, but the U.S. has better healthcare, right? Maybe not. Interestingly, people in these seven countries have significantly longer lifespans than people in the United States. U.S. residents' average lifespan is 79.772 years. People in the other seven countries, on average, live three years longer, ranging from 81.884 years to 83.706 years (In Iceland, the average resident lives to 83.152 years). And if you think residents of those countries have to wait longer for healthcare, read the comments on the Iceland article.

But sheesh, those taxes! Yes, U.S. residents pay less tax and have more disposable income than residents of those other seven countries, on average. But the difference is not as great as it might appear, partly because those taxes pay for things that U.S. residents pay for out of pocket, and partly because the U.S. has much more inequality (multibillionaires have a way of skewing the averages). The Gini Index ranks 157 countries from #1--the most unequal--to #157, the most nearly equal. On their list, you want a high number. The U.S. is #39. The other seven countries range from #88 to #152 (Iceland is #141).

So how much LIVING can people in these seven countries do, compared with the average American? Well, with enormous healthcare costs and huge educational debt, life can be rough for average Americans. And when you and your neighbors are poor in a country run by obscenely rich people, you may not feel so good either. Maybe that's why Americans aren't as happy as people from those other seven countries. The U.S. took 19th place in the yearly happiness index. The other seven countries ranked at place 16 (Ireland), 11 (Australia), 10 (Austria), 9 (Canada), 8 (New Zealand), 7 (Sweden), and 6 (Switzerland). (Iceland came in at 4th place.)

Summary: Immigrants are not the reason for high healthcare costs. High costs are not a predictor of good care or good results. Low taxes are not a predictor of happiness.

If you want to terrify Europeans, just suggest replacing their healthcare system with one that resembles the U.S. system. President Trump didn't realize that a few days ago when he went to the U.K. and made comments that worried supporters of Britain's National Health System, but the strong blowback made him quickly change his tune.

America deserves a healthcare system that covers more people, costs less, and produces better results. I wonder why more Americans don't pay attention to systems that are already doing that.

Where industrious ants get dinner

You know Aesop's fable about the ants and the grasshopper. Conservative libertarians think it's scripture.

One bright day in late autumn a family of Ants were bustling about in the warm sunshine, drying out the grain they had stored up during the summer, when a starving Grasshopper, his fiddle under his arm, came up and humbly begged for a bite to eat.

"What!" cried the Ants in surprise, "haven't you stored anything away for the winter? What in the world were you doing all last summer?"

"I didn't have time to store up any food," whined the Grasshopper; "I was so busy making music that before I knew it the summer was gone."

The Ants shrugged their shoulders in disgust.

"Making music, were you?" they cried. "Very well; now dance!" And they turned their backs on the Grasshopper and went on with their work.

But this morning I saw something far more sinister than heartless ants. A grasshopper was caught in a spider's web, and the ants were eating him.

No wonder the ants wouldn't share their food.

They're going to miss the concerts, though. And when the spider is done with the grasshopper, they'd better watch out.

Papa don't preach - but family-friendly work policies would be nice

[Alfred Stevens, "The Widow," 19th c.]

"Single moms are rarer in America than France, Sweden, New Zealand, the UK, or the Netherlands" screams today's headline by Matthew Yglesias on vox.com.

"And honestly, it's no big deal," sighs an exasperated Swiss friend of mine, weary of conservative American Facebook memes. Unmarried mothers apparently do just fine in Switzerland (though admittedly the Swiss rate of 20.2% of births to unmarried women is considerably lower than the American rate of 40.7%).

Actually, though, it is a big deal in the United States, for several reasons.

1. An unmarried mother is not necessarily a single parent, and America has a higher percentage of single parents than any of those other countries.

Some couples choose not to marry, but they raise their children together. They are unmarried, but they are not single parents. Others marry briefly, but they divorce while their children are small. They become single parents.

The majority of children in France and Sweden are now born to unmarried mothers, but only about 20% live in single-parent families. Compare that to the United States, where over 40% of children are born to unmarried mothers, and about 30% live in single-parent families. America may have fewer unmarried mothers than France or Sweden, but it has half again as many single parents--and being a single parent isn't easy.

2. Single parents fare better in countries whose policies support working women than in the one developed country - the United States - whose policies don't.

And not just single parents. As Judith Warner details in an excellent New York Times piece published yesterday, women fare better in countries and states that mandate paid family leave (including maternity leave) and sick days; and that provide affordable early childhood education, child care, and workplace flexibility for all workers, not just highly paid professionals.

In other words, women in general - and single parents in particular - fare far worse in America than in any other developed country, because the United States is the only developed country that does not provide at least some of these benefits to all who need them.

3. America's haphazard family policies and programs have led to America's high rate of economic inequality.

Ms. Warner's article is titled "To Reduce Inequality, Start with Families."  We Americans, to our shame, have failed to support families, and our inequality score is 41 on the Gini scale (where 0 is perfect equality and 100 is perfect inequality)--worse than that of France (33), Sweden (25), New Zealand (36), the United Kingdom (36), the Netherlands (31), or Switzerland (34). "If we want to strike at the roots of inequality in America," Ms. Warner writes,

we’ve got to start at its source, in the family, at the very beginning of children’s lives. We have to make it possible for mothers — two-thirds of whom are now breadwinners or co-breadwinners for their families — to stay in the work force without the sort of family-related job interruptions that can greatly limit their lifetime earnings and even push some families into bankruptcy. We need to make it possible for all parents to give their kids the kind of head start that is increasingly becoming an exclusive birthright of the well-off.

4. As long as Americans refuse to provide the social supports that allow women to flourish, single- parent families - 86% of whom are headed by females - will continue to bear the brunt of economic inequality.

On April 20, the same day that Matt Yglesias listed unmarried motherhood statistics and Judith Warner's piece appeared in the New York Times, the Wall Street Journal published an article headlined "Ignoring an Inequality Culprit: Single-Parent Families."  In it, Robert Maranto wrote that "the strongest statistical correlate of inequality in the United States" is "the rise of single-parent families during the past half century." If only we could persuade poor people and racial minorities to get married, he seems to think, poverty would decrease, upward mobility would increase, and we would solve all manner of emotional, psychological, educational, economic, and behavioral problems.

To be sure, growing up in a two-parent family is a child's best hedge against poverty, not only in America but in the other OECD countries as well (even Switzerland). But the reality is that a high percentage of children around the world are growing up in single-parent homes.

And the shameful reality is that if those children are American, they will suffer more than they would if they were French, Swedish, British, Swiss, Kiwi, or Dutch. In spite of the fact that many Americans think America is a Christian nation. In spite of repeated biblical admonitions to care for families without husbands and fathers.

But Americans don't have to wait for health care ... do we?

[Lovis Corinth, Self-portrait with skeleton, 1896]

The Commonwealth Fund's just-released annual report on health care in 14 developed countries shows that, once again, America spends more than anybody else on health care--50% more per capita than the next-most-expensive nation, Norway, and 182% more than the least expensive nation in this survey, Italy.

Well, yes, say some proud Americans, and we get what we pay for. We have the best health care in the world.

Maybe not. Other surveys regularly report that Americans die younger than people in other developed nations. Commonwealth reports that America leads the pack in avoidable deaths per 100,000 population: 96 in America compared with 55 (France) to 83 (U.K.) in the other nations surveyed. I was surprised to learn that America has fewer doctors per 1000 population than all the other countries except Japan.

OK, say defenders of America's health care, but people in those other countries have to wait much, much longer to see a doctor, and they wait nearly forever for elective surgery such as hip replacement.

Nope.

Commonwealth surveyed wait times in eleven of the countries, and here's where America stands:

• If you're sick and need a same-day or next-day appointment, you're more likely to get it in Australia, France, Germany, the Netherlands, New Zealand, Sweden, or the U.K.
• If you need care after hours, you're more likely to find it in Australia, Germany, the Netherlands, New Zealand, Norway, Switzerland, or the U.K.
• America has a lot of specialists, but you're still more likely to get a speedy appointment with one in Germany or Switzerland.
• America is quick to schedule elective surgery, but not quite as quick as Germany and the Netherlands. France, New Zealand, Switzerland, and the United States are all a little slower than those two, but not by much.

Ethical question: If a nation has poor access to basic health care but good access to expensive specialized health care, what does that say about its priorities?

Practical question: If Germany, which spends about half of what the U.S. spends per capita on health care, can insure nearly everybody and still maintain speedier access to all forms of health care, why can't we?

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.