Yesterday, the Census Bureau came out with a report that provides
a compelling window on poverty and health in America.
It’s somewhat modestly titled “Income, Poverty and Health
Insurance Coverage in the United States, 2007.” I would suggest it deserves a headline that
does justice to its sweep, perhaps “Connecting the Dots: Health and Poverty, America’s
Shifting Priorities, 1960-2007.
Begin with this chart:
At first glance, what is most striking is how well President
Lyndon B. Johnson’s “War on Poverty” worked in the late 1960s. Seniors–who were then the poorest group in
the U.S– benefited most. The share of Americans over 65 scraping along
somewhere below the poverty line plummeted from roughly 30 percent in 1965 to
just over 15 percent in the early 1970s. Johnson made Medicare and Medicaid
legislation a priority, and when it passed Congress in 1965, it made an
enormous difference.
The War on Poverty also helped kids: the share of the
nation’s children trapped in poor households fell from roughly 23 percent in
1965 to 15 percent during the Carter years.
By contrast, look at what has happened during the latest
economic cycle. As the Economic Policy
Institute’s Jared Bernstein points out, “Despite
strong overall economic growth, the
cycle that began in 2000 and ended late last year has turned out to be “one of
the weakest on record for working families.”
Today, our children are our poorest citizens. Since
President George W. Bush took office, the number of children living in poverty
has climbed from 16 percent to 18 percent. In other words, a larger share of
American children are poor today than in the early 1970s –when the nation was mired
in a deep recession.
“Overall” from 2000 to 2007, “the poverty rate
grew from 11.3% to 12.5%,” Bernstein notes. “In contrast, poverty rates fell
significantly in the 1990’s.” The period
from 2000-2007 marks a span when one would have expected prosperity to “trickle
down.”
Instead, the dollars shot straight upstream, like a school of salmon heading
back to their breeding ground. Bernstein quotes income analysts Piketty
and Saez [MS Excel]
who show that “after falling with the
stock market bust of 2001, the average income of the top 1% grew about
50% in real terms from 2002 to 2006,” from roughly $850,000 to $1.3 million .”
He adds: “Coming on top of the long-term trend in rising inequality since
the late 1970s, this recent surge has resulted in the second highest level of
income concentration on record going back to 1913, as the richest 1% of
households held 23% of income in 2006. The only year of greater income
concentration was 1928 (24%).”(That, of course, marked the end of another era,
the Roaring Twenties—which would give way to The Great Depression.)
As for the middle-class, from 2000 to 2007 median household income fell
by more than $2,000 to $50, 233.
What does all of this have to do with health?
The Uninsured, Medicaid and the Underinsured
The Census Bureau report attempts to put a happy face on U.S.healthcare by announcing that the percentage of Americans who are uninsured
declined in the last year–from 15.8 percent of the population to 15.3 percent. But as Jonathan Cohn points out over at The
New Republic:
“. . . .before anybody gets the idea that we no longer need health care reform,
take a closer look at the numbers. Enrollment in private insurance continued to
decline in percentage terms, mostly because the percentage of people
with employer-sponsored coverage fell from 59.7 to 59.3 percent. The
reason the overall numbers look good is rising enrollment in public insurance
programs, particularly Medicaid.”
The fact that more people are
eligible for Medicaid is not good news. This only confirms that the ranks of
the poor are growing. (Over the past seven years, eligibility rules were not
relaxed in most states; in many states they were tightened.)
Meanwhile, as the 21st
century began, the number of Americans
protected by employer-sponsored insurance slid while health care spending sky-rocketed.
In the 1990s, HMOs kept a lid on spending by saying “No” to many
treatments. Trouble is, they denied
coverage for effective as well as ineffective treatments. By the late 1990s,
the backlash against managed care was so strong that insurers loosened their
restrictions. As a result, from 1999 to 2005, the amount that insurers laid
out for medical care rose by 8 percent to 8.5 percent a year.
They passed those compounding costs
along, of course, in the form of higher premiums. Before long, many small
employers found that they could no longer afford insurance; others shifted
costs to employees in the form of higher co-pays and deductibles. Keep in mind
that over the same span, the average worker watched his wages fall.
But the
problem is not simply that 45.7 million Americans are uninsured. Recently, the CommonWealth Fund reported that from
2003 to 2007 the number of underinsured adults in the U.S. rose by 60 percent.
“Much of this growth comes from the ranks of
the middle class,” the Fund explains.. “While low-income people remain
vulnerable, middle-income families have been hit hardest. For adults with
incomes above 200 percent of the federal poverty level (about $40,000 per year
for a family),” the share of underinsured has nearly tripled since 2003. As
the Fund defines it, someone is underinsured if they spent 10 percent or
more of their income (or 5 percent if they were low-income) on out-of-pocket medical
expenses, or if they have deductibles
that equaled 5 percent or more of their income.
In other words if you earn $50,000, think you have insurance—but still have
to pay $5,000 out-of-pocket on medical treatments that your policy doesn’t
cover—you might thank again. Does that piece of paper really deserve to be
called “insurance”? Similarly, if you
earn $40,000 and have a $3,500 deductible, you may well feel that you cannot afford to use your policy. You skip mammograms
and Pap smears. You don’t have your eyes checked. This is “insurance” in name only.
Yet with wages flat to down in recent years and premiums sky-rocketing, more
and more Americans cannot stretch their budgets far enough to afford full,
comprehensive coverage. Still, they are luckier than families struggling to
survive below the poverty threshold.
The Relationship
Between Poverty and Life Expectancy
Life expectancy is one important measure of the health of a
nation’s citizens.
On this score,
the graph below
is shocking—not because it shows that the U.S. spends far more on health care
than other countries (see the right-hand axis) — or that average life
expectancy is lower (see how the light purple bars line up against the
left-hand axis). We know this. What is
startling is to see when it comes to life
expectancy, only Cuba, Cyprus, Ireland and Portugal trail the U.S.
Source: The Big Picture
When Barry Ritholtz posted this graph on his
highly-regarded financial weblog, The Big Picture, he observed
that “this is the most embarrassing story never told. Even more
embarrassing is that no one seems to care.”
One reason many Americans shrug off charts like these is because they
believe that the differences between say, Switzerland,
and the U.S.
can be explained by the fact that our population is more “heterogeneous.” In other words, they believe that African
Americans, Latinos and other minorities “drag down” our scores.
But as HealthBeat revealed here, even if
comparisons are limited to white Americans, we trail other OECD countries. Among Caucasians, when it comes to infant
mortality we rank 22nd. If
you look at the percentage of white mothers dying during childbirth, we place
19th. In terms of life
expectancy, when compared to men in other developed countries white men in the
U.S, rank 22nd,, white
women, 19th.
How can this be?
One might assume that the fact that so many Americans are uninsured—or
underinsured—explains our poor health. But it turns out that lack of access to
medical care accounts for only 10 percent of premature deaths (see pie chart
below).
Many would be quick to point to the
fact that many Americans don’t exercise enough and eat too much. And they would
be right—behavior is important. But
there is one factor undermining the nation’s health that we just don’t like to
talk about in polite society: Class. When it comes to health, class matters.
“Health is influenced by
five [factors]— genetics, social circumstances, environmental exposures,
behavioral patterns, and health care,” explains Dr. Steven Schroeder, a professor at the
University of California at San Francisco, where he directs the Smoking Cessation
Leadership Center “When it comes to
reducing early deaths, medical care has a relatively
minor role. Even if the entire U.S. population had access to excellent
medical care — which it does not — only a small fraction of premature
deaths could be prevented.” [my emphasis]
Schroeder offers the chart below to illustrate his point.
Where the patient lives—social circumstances and environment—explain 20
percent of premature deaths, while behaviors such as smoking account for
another 40 percent. And those behaviors
are, in turn, closely correlated to the patients’ income and education.
Where a Patient Stands on the
Socio-Economic Ladder Matters Most
Indeed, as a 2002 article in Health
Affairs
observes, according to the National
Center for Health Statistics, “the most consistent predictor of the
likelihood of death in any given year is level of education; persons ages 45–64 in the highest
levels of education have death rates 2.5 times lower than those of
persons in the lowest level. Poverty,
another strong influence, has been estimated to account for 6
percent of
U.S. mortality.”
Income inequality takes a toll.
A 1999 study in the British Medical Journal reveals that “each 1 percent rise in income inequality (the income
differential between rich and poor) is associated with something on
the order of a 4 percent increase in deaths among persons on the low
end.”
This begins to explain why the U.S.does so poorly in international health comparisons. For when it comes to income
inequality, the gap between the wealthiest Americans and the poorest is much
wider than in other nations.
Economic Inequality, Mental Illness and
Behavior
The chart above, which was presented by Dr. Michael Wilks, president of the
Standing Committee of European Doctors, at heWorld Health Care Congress last
spring, suggests a correlation between the prevalence of mental illness (left axis) in
a given country, and economic inequality (bottom axis). It turns out that the U.S.is
an outlier in both categories.
When you compare the incomes of the wealthiest 20 percent to the bottom 20
percent in other developed countries, the ratio tends to fall somewhere between
5:1 and 6:1. In the U.S.,
the ratio is roughly 9:1. In the U.S., the
poor are much poorer and the affluent are much richer. Meanwhile over 25 percent of Americans suffer
from some form of mental illness, including depression.
What is the link between poverty and mental illness? “Studies
have linked poor health to the constant stress of a lower-class
existence — a lack of control over one’s life circumstances,
increased social isolation, and the anxiety brought about by a
subjective feeling of being of low social status (all of which can
be compounded by racism).” Schroeder reported in a NEJM study titled
“Class – The Ignored Determinant of the Nation’s Health.”
“Physiologically,”
he explained, “stress appears to trigger a neuroendocrinologic response
that is beneficial in the short term but over the long run can
weaken the body’s resistance to illness.”
We know that depression and
other forms of mental illness are strongly linked to poor physical
health, as well as self-destructive behavior such as excessive drinking and smoking.
At least 50 percent of the 2 million Americans with severe mental illness abuse
illicit drugs or alcohol, compared to 15 percent of the general population,
according to the Alcohol, Drug Abuse, and Mental Health Administration.
As for
tobacco use, “The facts about
smoking and mental illness are stark,” says Schroeder. Almost half of all cigarettes sold in the United States(44 percent) are consumed by people suffering
from some form of mental illness. This is both because so many people who are mentally
ill smoke (50 percent to 80 percent, compared with less than 20 percent of the
general population) and because they smoke so many cigarettes a day — often
three packs.
Where
you live also influences health. When
poverty is concentrated in certain neighborhoods, the air itself
can be hazardous to your health, with neighborhoods like the Bronx reporting high rates of respiratory disease. .In addition, these areas “are
often dangerous and have high
crime rates, with substandard housing, few or no decent medical
services nearby, low-quality schools, little recreation, and almost
no stores selling wholesome food,” Schroeder observes. This means that the residents, no matter what
their race, income, or education, have little chance to improve their lives and engage in health-promoting behaviors.”
Many blame the poor for being obese, arguing that they foolishly spend money
on expensive high calorie “junk food”when they could be preparing less expensive
high quality foods. But as Professor Adam Drewnowski, Director of the NIH RoadMap Center for Obesity Research illustrates in the chart below “energy-dense foods cost less;
nutrient-rich foods cost more. Quite
simply, high-carb, high-fat foods are much more affordable than fresh fruit,
vegetables fish and other proteins. And
they tend to be even more expensive in grocery stores in poor neighborhoods where
pricey items turn over slowly and may spoil before they sell.
Source:
Food Choices and Diet Costs : An Economic Analysis, Adam Drewnowski, Ph.D.,
Director, NIH RoadMap Center for Obesity Research, Professor of Epidemiology
and Medcine, School of Public Health and Community Medicine, University of
Washington
Meanwhile, finding a place to exercise in the ghetto can be difficult. “Gyms
are too expensive for low-income families; exercising
outdoors can be dangerous, and in inner cities, public schools often lack
playgrounds and gymnasiums,” Schroeder observes. Public school lunches
in poor neighborhoods also tend to be made of ingredients that are cheap and high in fat, carbs and calories.
Until we are willing to raise taxes to pay for school lunches that include lean,
ground sirloin, fresh strawberries, and smoothies made with fresh blueberries, safe outdoor playgrounds, school gymnasiums
(and gym teachers), subsidized green
markets, and well-lit, well-policed jogging paths–perhaps we should stop blaming
the poor for being overweight.
Poverty and Spending on Social Programs
As Wilkes’ chart above demonstrates, most other developed countries are
largely middle-class. In the
U.S.
we accept much bigger gaps between the haves and the have-nots. The chart below shows, as a result, that a
much larger percentage of
U. S.
children live below the poverty level. (Child poverty is defined as children
living in households where income is less than 50% of household median income
within each country. In the
U.S.
median household income is $54,800; a child living in a household where joint
income falls below $27,400 would be considered poor.)
This difference can be explained by
the fact that in other developed countries the affluent pay a significantly
higher share of their income in taxes, and those revenues are used to create a
social safety net.
The blue line in the chart above illustrates
the correlation between expenditures and child poverty rates for all countries.
Individually, the Nordic countries —Sweden, Norway, and Finland— stand out, with child poverty rates between 2.8% and 4.2%. The United
States is once again, the outlier. We spend
the smallest share of GDPon social programs
and have the highest rate of childhood poverty — five times as high as the
Nordic countries.
Delivering the 117th Shattuck Lecture before the Massachusetts Medical
Society last year, Schroeder connected the dots: “One reason the U.S.does
poorly in international health comparisons may be that we value
entrepreneurialism over egalitarianism. Our willingness to tolerate large gaps
in income, total wealth, educational quality and housing has unintended health
consequences. Until we are willing to confront that reality, our
performance on measures of health will suffer.”
“It is arguable that the status quo is an accurate
expression of the national political will — a relentless search for
better health among the [upper] middle and upper classes,” Schroeder
added. “This pursuit is also evident in how we consistently outspend
all other countries in the use of alternative medicines and cosmetic
surgeries and in how frequently health ‘cures’ and ‘scares’ are
featured in the popular media. The result is that only when the
middle class feels threatened by external menaces (e.g., secondhand
tobacco smoke, bioterrorism, and airplane exposure to
multidrug-resistant tuberculosis) will it embrace public health
measures. In contrast, our investment in improving population health
— whether judged on the basis of support for research, insurance
coverage, or government-sponsored public health activities — is
anemic.
This in part because “the disadvantaged are less well represented
in the political sphere here than in most other developed countries,
which often have an active labor movement and robust labor parties,”
Schroeder continued. “Without a strong voice from Americans of low
socioeconomic status, citizen health advocacy in the United States coalesces around particular illnesses,
such as breast cancer, human immunodeficiency virus infection and
the acquired immunodeficiency syndrome (HIV–AIDS), and autism. These
efforts are led by middle-class advocates whose lives have been
touched by the disease. There have been a few successful public
advocacy campaigns on issues of population health — efforts to ban
exposure to secondhand smoke or to curtail drunk driving — but such
efforts are relatively uncommon.
“Little is likely to change,” Schroeder
acknowledged, “unless low-income families have a political voice and use it to
argue for more resources to improve health-related behaviors, reduce social disparities, increase access to health care, and reduce environmental
threats. Social advocacy in the United States is also fragmented by our notions of race and class. To
the extent that poverty is viewed as an issue of racial injustice, it ignores the many whites who are poor, thereby reducing the ranks
of potential advocates.”
Indeed, both racism and “identity politics” has divided poor
African-American and poor white Americans, blinding many to their common
interests.
“The relatively limited role of government in the U.S. health care system is the second explanation,” Schroeder argued, for
the lack of attention to public health in the U.S. . . . “The American emphasis on the value
of individual responsibility creates a reluctance to intervene in
what are seen as personal behavioral choice”
“Given that the political dynamics of the United States are unlikely to change
soon and that the less fortunate will continue to have weak
representation, are we consigned to a low-tier status when it comes
to population health?” he asked
If we paid more attention to public health, and the poor,
Schroeder concluded, we could “enhance the productivity of the workforce and
boost the national economy, reduce health care expenditures, and
most important, improve people’s lives.
“But in the absence of a strong political voice
from the less fortunate themselves, it is incumbent on health care professionals, especially physicians, to become champions for the population.”
This does not mean that health care professionals can solve
the problem. But they can lead the way in focusing attention on public health–
and the fact that poverty and poor health are blood relatives.
The second half of this past creeps up on the central issue I’ve been wrestling with over the past year: health care reform as defined in the current debate (insuring the uninsured) does not begin to get at the underlying causes of ill-health in our society. Neither would a politically acceptable way of eliminating the third of health care spending that is waste. James Lardner, before he went over to OSI, spent years writing about the health consequences of inequality with little resonance in the media and only occasional attention in the medical literature. But his central observation holds: if you want to hold down health care spending, the best program in the U.S. would be one that creates a better distribution of income and a reduction in the social savagery that marks our society.
Thanks for reminding us what really matters in health care. I agree with Merrill(Goozner I presume?)
My own “health care plan” is a jobs program where all able adult US citizens are provided meaninfull, safe, and healthy lifelong employment.
But a $2 trillion dollar plus disease care industry that has duped Americans into believing they you must be dependent on them for good health is extremely hard to turn around.
Slowly US vox-populi might be awakening to these realities. Very slowly.
Be Well,
Dr. Rick Lippin
Southampton,Pa
ralippin@aol.com
Merrill–
Yes, yes, and yes.
I agree–poverty is the biggest problem we face, both in the U.S. and world-wide.
When you look at education, healthcare, even racism, poverty is the underlying cause of so much suffering.
Yet at some point in the 1980s, the whole idea of a war on poverty fell out of fashion. (As James K. Galbraith puts it in his new book, The Predator State: “American in 1980 had compassion fatigue.”)
So instead of writing directly about poverty, I write about healthcare. People are interested in healthcare and it is a way that I can address inequailities. I also think that healthcare, like
education is enormously important: without your health and an education, you cannot pursue the opportunities a democracy offers.
That siad, I think everyone interested in healthcare should read Steve Schroeder’s 2007 Shattuck
Lecture once a year. He cuts to the very heart of what is wrong, saying the things that people rarely acknowledge.
You say that you’ve been wrestingly with the fact that unviersal coverage is not going to solve hte problem. I,too, am very worried that we will wind up getting “health care reform” that simply means that everyone has some sort of insurance —based on what they can afford.
And bipartisan reformers will say that we have succeeded.
But it is possible, I think, to cut the waste, redistribute the dollars, and wind up with a system that provides equitable, relatively effective care for everyone.
As you suggest, many would find such a redistribution of our health care dollars politically unacceptable.
Then, again, many found the civil rights movement politically unacceptable. Yet it happened.
I’m not saying that real reform can or will happen in the next couple of years. I’m thinking in terms of a 10-year horizon.
In the meantime, I’d like to see Medicaid and SCHIP folded into Medicare, providing better protection for our youngest and poorest citizens, while waiting for true healthcare reform.
What you all are saying, in effect, is that public health and medcine must be married together to maximize the health of the population. our peculiar brand of health care payment — public and private — has simultaneously fostered the growth of a “disease care” industry, as Rick puts it, while ignoring the underlying socio-demographic factors that go into poor health. These factors are traditionally the domain of public health efforts. But we have no botton line in our system — nobody is responsible for the costs of neglecting the public health sector — so poor health habits become externalities in the health care market that can be ignored.
while the war on poverty succeeded in reducing the percentage of Americans who were poor, it apparently failed in its efforts to empower them, despite a structure via the community action program to do that.
the result is that folks with power get more. how else to explain the creation of Part D which gave added protection to the only segment of our population where health insurance is already universal.
not surprisingly, even as Part D becomes familiar, bankruptcy among seniors is exploding.
your analysis is stellar, but I fear you’re preaching to the choir here.
“But a $2 trillion dollar plus disease care industry that has duped Americans into believing they you must be dependent on them for good health is extremely hard to turn around.
Slowly US vox-populi might be awakening to these realities. Very slowly.
Be Well,
Dr. Rick Lippin’
—————-
I think this is a good description of the underlying belief drivers that caused the predicament, but who/what fostered this take-care-of me dependency? Does following the money help find out, and was this an intentional addiction to ??medical care or just a result of the human condition? To get a handle on a real and successful healthcare system solution, these underlying blame and cause issues will have to be deciphered and made known!
I remember getting a phone poll 17 years ago from Physicians for Social Responsibility. The pollster wanted to know what PSR should take up now that the Cold War/ Nuclear Weapon issue was losing traction.
Physicians should address income inequality. And we could do it by looking first at ourselves. After you feed the kids and have a modicum of comfort(probably less than a 5000 sf home)the rest of our greed does foster suffering. And I believe the medical profession is deeply affected by this malaise, as much as the population in general.
As a family doc I want to promote quality, appropriate care. But the specialty techno driven demand is a tide I cannot buck. Neither can I recruit a young doc to join me for the wage I earn. Nope, we are in an unsustainable cycle in Medicine. And we traditionally conservative physicians are not providing leadership here.
Still, polls of docs show >50% favor single payer. Unfortunately, like Universal access is seem as the easy solution for uninsured, I’m afraid this is seem as a cure for the malaise in the profession. The real cure is going to be a much more difficult reflective process. Whom do we(healthcare) serve? Who decides the priorities? What do we mean by health ?
Shannon, ng, jim, rick, ddx:dx
Thanks for your comments.
Shannon- Good to hear from you.
-Yes, in this country, “public health” and “medicine” are seen as separate domains, And the M.D.s tend to look down on the MPhs.
In other countries, where the governement is more involved, health and “the public health” are seen as one.
This goes back to the fact that we tend to look at things individually rather than collectively. So if a
$4,000 procedure might help one out of 1,000 people, we believe that, as a matter of public policy, Medicare should cover it. Because after all “I might be that one.”
In other countries, policy-makers would say that if its effective for only one out of 1,000 (and the other 999 will suffer whatever side effect or risk is entrailed without benefit) it does not make sense, as a matter of public policy, to cover it.
But it’s not really a matter of ignoring “poor health habits.”
The poor don’t have bad habits. The poor live in places where, as Schroeder points out, it’s very difficult to develop good habits- the fresh fruit and vegetables aren’t available or are over-priced; the polluted environment has left you with respiratory problems, and even if you could breathe, there is no safe place to exercise.
I left out another part of Schroeder’s essay where he points to reserach showing that even if only look at poor people who don’t drink, smoke, and are not obese, while they are healthier than the smokers, they still die earlier than the rest of us.
So we have to stop blaming the poor for being poor. Environment and mental illness (particularly depression) has a lot of do with shaping behavior. And ghettos of concentrated povery are very hazardaous to the health of the inhabitants.
Jim– The war on poverty did empower some poor people–some got out of the ghetto during those years. (The black upper-middle class and black middle-class was much smaller in those days. It was just getting started, with the exception of pockets like D.C. that has had a group of educated, relatively affluent blacks for a long time.) Many of those who “got out of the neighborhood” and got a college education in the 1960s (when it was much easier to get full scholarships based on need)helped form today’s black middle-class and upper-middle class.
In the early years “Head Start” was giving poor kids a head start.
But then, everyone began sending their kids to nursery shcool (which wasn’t at all commonplace in the late 50s and early 60s) and so kids from Head Start no longer had an edge.
More importantly, in 1980, Reagan purposefully broke the unions by firing the air traffic controllers.
In the past, the unions did speak for the poor–or at least the white working poor.
But in the 1970s and particularly the 1980s, corporate interests took over and replaced the people’s interests. (See James K. Galbraith’s very good new book “The Predator State”)
I’m not entirely preaching to the choir. Some people who read this blog don’t agree with me on many of these points–but they keep reading. And I value their readership.
And a post like this is apt to be cross-posted other places where it will reach a more diverse audience.
Also, in a few weeks I’m going to be posting regularly on another website aimed at a more general and younger audience, which means I’ll be reaching a more diverse group.
This won’t change what I’m doing here . . I’ll write more about it when I begin
NG– in terms of blame and cause I think it’s less a matter of individual blame and cause and more a matter of our society’s collective willingness to let the country slide into greater and greater inequality.
At the same time, those of us who can afford it have become dependent on what Dr. Rick calls “the disease industry”—believing that it can cure everything–as if somehow, we can beat death.
Rick–
You are right a $2 trilion disease care industry is very hard to turn around. So much money is at stake. And so much money is concentrated in relatively few hands.
Nevertheless,as more people become aware that this system is not working in their interest they may be ready for change. It’s a process of education which, as you suggest, will take time. Much time.
I can’t help but think of this quote, which I posted on this blog about a year ago, shortly after I began HealthBeat:
Below an excerpt from a review of The Truth About Health Care, by David Mechanic. (The review is written by Rob Cunningham and appears in Health Affairs, September/October 2007.)
“At some point we as a nation will have to decide whether we wish to design our health care system primarily to satisfy those who profit from it or to protect the health and welfare of all Americans.” Mechanic speculates that “anything is possible if the public begins to appreciate how little it gets for what it really pays.”
But even as reform begins to rise again on the political agenda, the preponderance of the evidence in this book says that a majority of American prefer pluralism and individual liberty to ‘the tedious business of working together . . .’”
Ddx:dx– I couldn’t agree more that physicians need to lead the way here.
As I’ve said before, I also think we need to boost the pay for primary care–and not by 5 percent.
We need a raise of probably 20 percent to 30 percent –or forgiveness of student loans–if you are going to attract a colleague.
And that means cutting pay for some of those high-tech, not very effective procedures.
But it’s not just the pay, it’s a matter of working conditions and whether PCPs feel they are doing meaningful work.
Using nurse practioners to screen cases and take easy cases (you’ve seen the patient in the last six months and he just needs a re-fill) would help slow the hectic pace.
PCPs and public health experts also need to get together. (This is why I chose a combination of the two groups for my Working Group on Medicare Reform.)
I also think that physicians could be involved in fighting inequality–for instance, if professinal associations urged all doctors to take a certain percentage of uninsured and Medicaid patients. (I also believe that Medicaid should be folded into Medicare so that doctors receive the same reimbursements they receive for taking Medicare patients.)
If everyone took a few, you would be able to give these often difficult patients the time they need–and this would be satisfying work.
I’m also hoping that Medicare reform will help
fight the “specialty techno-driven demand.”
According to data I’ve seen, the obesity (defined as a Body Mass Index of 30 or higher) rate for the U.S. population 15 years old and older is 31%. Only Mexico and the UK are even close at 24% and 23%, respectively while the rates across Western Europe range from 9% to 14%. The obesity rate in both Japan and South Korea is a mere 3%. Even if we exclude the poor from the calculation, the U.S. obesity rate is still probably far higher than anywhere else. The reasons probably have a lot more to do with differences in diet that are driven by culture and not economics. Even within the U.S., there are significant regional differences such as more fried food consumed in the South. Out of necessity, people in other advanced countries use mass transit more than we do, they probably walk more and/or are more likely to ride a bike to travel short distances.
Schroeder’s chart that shows health status driven 40% by behavior and 30% by genetics suggests to me that even if we get universal health insurance coverage, it is not likely to move the needle on life expectancy very much, and the differences between the U.S. and other countries are not all that large to begin with.
As for greater income inequality and more poverty in the U.S., there is also greater economic opportunity and dynamism. Millions of people work their way out of poverty through education and hard work. Not nearly so many are poor for their entire lives. The U.S. is more diverse, and it has a much better record of assimilating immigrants than elsewhere. If the European societies with their extensive social safety nets (paid for with very high taxes) and less income inequality are so great, why aren’t millions of people trying to move there?
Barry–
If you look at the numbers, you’ll find that income mobility in the U.S
has stalled:
From the NYT book on class and mobility: “And new research on mobility, the movement of families up and down the economic ladder, shows there is far less of it than economists once thought and less than most people believe. [Click here for more information on income mobility.] In fact, mobility, which once buoyed the working lives of Americans as it rose in the decades after World War II, has lately flattened out or possibly even declined, many researchers say.”
(If you click on the link it takes you to a series of graphs here http://www.nytimes.com/packages/html/national/20050515_CLASS_GRAPHIC/index_03.html
(One graph shows that “Mobility slowed between the 70s and the 80s–and again between the 80s and the 90s.
(One study, by the Federal Reserve Bank of Boston, found that fewer families moved from one quintile, or fifth, of the income ladder to another during the 1980’s than during the 1970’s and that still fewer moved in the 90’s than in the 80’s. A study by the Bureau of Labor Statistics also found that mobility declined from the 80’s to the 90’s.)
You ask: Why don’t more Americans move to Europe?
Many believe the myths about the U.S. (for example, that we have the best health care in the world.)
More importantly, unlike Europeans and Canadians, very few Americans speak another language fluently–which makes moving to another country as an adult very difficult.
(Most Europeans under 45 speak at least two languages–many speak 3 or more).
Even in the U.K., many Americans feel awkward–as if the British are speaking a different language.
That said, better-educated Americans began emigrating in the early 1990s according to Money magazine: (1994)
“Even more disturbing, the people who are leaving the U.S. include some of the country’ s wealthiest and best-educated native-born citizens. Consider: — As many as 250,000 people emigrate from the U.S. each year, up from approximately 160,000 a decade ago, according to estimates by Census Bureau officials and experts at the U.S. Immigration and Naturalization Service (INS). — These days, as many as half of those who emigrate are native-born Americans, say government officials, while an estimated 80% of those who left for good between 1900 and 1980 were former immigrants returning home. — Among college-educated Americans and those who earn $50,000 a year or more, an astounding one in four reports that he or she has considered moving to another country, according to an exclusive MONEY poll taken this spring (margin of error: plus or minus 3.1%). — There’s evidence that more skills are draining from the country than are entering it. For example, a 1990 U.S.-Canadian Government study of migration shows that American immigrants to Canada were nearly 50% more likely to hold college degrees than the general U.S. population or than Canadian immigrants moving here.”
MOre recently, there was this report:
“More than 3 million Americans plan to move to another country and another 17 million are considering it, according to study by New Global Initiatives Inc.
“The numbers were far higher than we expected,” says Bob Adams, CEO of New Global Initiatives, which provides services to clients with projects in emerging markets. “They are clear evidence that migration is not a one-way street from poorer nations to the U.S. The global migration picture is far more complex than that.”
“The study is based on Zogby surveys conducted in 2005 and 2006 of more than 100,000 adults who were asked if they planned to relocate to another nation for more than two years for reasons other than a job or military/government service.
“The most often mentioned reasons for moving to another country were the desire to live in a less-stressful environment, concerns the United States is moving too far to the right, and the desire for change, adventure and new challenges.
“The 25-34 age group is the segment most interested in relocating.
“Europe is the most popular destination for those planning to leave.”
On Obesity– You will notice that in those parts of the ountry where people typically eat high fat, high calorie food, they also are much poorer (South Carolina, for example) than in regions where people eat more fresh vegetables, fruit, fish, etc.
“Culture” is almsot always a function of economics.
Southern Italy, for example, has traditionally been much poorer than Northern Italy and in Southern Italy food is much heavier in carbs, dishes made with bread and pasta, pasta and potatoes,
heavy tomato sauces, and more oil. The farther north you go, the leaner the cuisine (and I’m not talking about nouvelle, I’m talking about traditional).
The same is true of the U.K. The Irish traditionally ate potates at every meal–and were generally fatter than the English. Is this beacause the Irish just loved potatoes and didn’t like lamb? No potatoes were all that they could afford.
In Japan, by contrast, economic inequality is not accepted. Traditioanlly, Japan has preferred full employment to high return on capital. So there has been realtively little true poverty.
Reserach also shows that “food insecurity” plays a role. In roughly 11% of U.S. housholds adults and children are not certain that they are gong to get enough food today or tomorrow. This means that when food is available, you eat up.
As for heatlhcare moving the dial on life expectancy, the gap between the U.S. and other developed countires is important. Imagine if your wife died in childbirth –the incidence of maternal mortalitiy in the U.S. compared to other countires is shocking and much of that has to do with poor prenatal care.
Maggie says
“At the same time, those of us who can afford it have become dependent on what Dr. Rick calls “the disease industry”—believing that it can cure everything–as if somehow, we can beat death.”
Actually the fear of death does indeed drive our immature dependency on both organized medicine and for that matter organized religion.
Dr. Rick Lippin
I blame it all on Coca Cola. Try this chart showing per capita consumption by country. Only Mexico is higher than the US, but the chart doesn’t say which Coke products are included.
http://www.thecoca-colacompany.com/ourcompany/ar/pdf/perCapitaConsumption2007.pdf
Even if Mexico is higher, I don’t think they use high-fructose corn sweetener to the extent that it is used in the US.
(I’m only being slightly sarcastic.)
Dr. Rick–
I agree that the fear of death is more extreme in this country.
This is part of what others call
“American optimism”–that
feeling that we can beat anything.
Up to a point optimism is a very good thing–until it
becomes denial.
Europeans (and people in many other countries) have gone through so many wars, so many catastrophes . .
they don’t feel invincible.
Americans feel immortal the way young people feel immortal; we’re a young country,
And we have invented explanations as to why we’re immmortal: we have the best healthcare in the world . . . I could go on . . .
Maggie
I agree with you completely on why American’s fear death more than other cultures.
This fear of death in all cultures drives dependency issues
I once read a quote that the way a culture treats death is the surest indicator of how it will design its health care system.
Dr. Rick Lippin
Southampton,Pa
ralippin@aol.com
When I first came to Canada, there was a lot I didn’t know.
I came home one evening to a dark apartment with no power. My room-mate asked, “Didn’t you pay the Hydro?” I said, “Of course I did, I paid it yesterday, down at City Hall Waterworks Department.”
My room-mate laughed at me, and then told me that in Manitoba, where almost all our electricity comes from dams dotted all over the province, “hydro” wasn’t water, it was short for hydroelectric.
This brings me to the US habit of discussing health insurance. “I can’t go to the doctor, I have no insurance,” I hear from my nephew.
In addition to “… a disease care industry that has duped Americans into believing that you must be dependent on them…” is the much worse deep-rooted blending of health insurance with health care in American’s minds. This sounds pretty weird to people in countries with single-payer health.
Nice blog with good information. I think maintaining a good health record always saves the time and health to be maintained in a good manner.
Poverty, Health and Political Priorities: 2000 to 2007
Today, our children are our poorest citizens. Since President George W. Bush took office, the number of children living in poverty has climbed from 16 percent to 18 percent. In other words, a larger share of American children are poor today than in the…
health care is still needed to support the stability of our health, especially for children. In addition, we also need an insurance company as collateral