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...

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.