In this post I recast the visual display of international health care expenditures. For select OECD countries, this clearly shows the growth of average costs has been moderating while U.S. cost-growth has been accelerating. The graph methodology is discussed along with a caution about marginal thinking. A conjecture is presented as to why the OECD cost-growth is moderating followed by a couple thoughts for action. Continue reading
“We spend far more on health care than other peer countries yet have worse outcomes. Why is U.S. health care so expensive?” I’m sure you’ve encountered similar statements, maybe even expressed it yourself. It occurs often, including by knowledgeable people and health-related institutions. However, it’s a fallacy because it confuses health care with population health. Continue reading
The context here is unemployment and educational attainment statistics, while the themes include the importance of a degree, how aggregating data can misinform, and trusting your lying eyes.
What unemployment statistics convey can be different than what you witness at street level. For example: my daughter, Linda, has a bachelor’s in education and can’t find work. Anna, a barista at the local cafe has a BA in Psychology; Candice who works the bakery counter next door to the cafe has a BA in Journalism. These three young women are educated, articulate, and dependable. They want challenging creative work but their capacities are not anywhere near taxed. Those are just three examples. I’m sure you encounter many similar. Wait, please allow me one more. Continue reading
A couple days ago Mike Konczal posted a Congressional Budget Office graph of Federal receipts and outlays relative to GDP, a graph, he wrote, we should “keep in mind about the current budget situation.”[i] I found the graph insightful but thought I’d like to see a longer timeline.
The revised graph, given here, starts with 1929, goes through the Great
Depression and World War II, and on to September 30, 2012. Looking at those 84 years, my first observations are: there are far more outlays greater than receipts than going the other way, over 80% of the years we spent more than we took in; from the end of WWII through 1974, outlays and receipts were tightly coupled; a persistent divergence begins with 1975 and except for the final bubble years continues to the present; after the peak in 2000, average receipts trend downward and outlays trend up; and the Great Recession, which we’re still experiencing regarding jobs, foreclosures, and debt, has the second highest deficit spending, though that’s improving.
This extended display of receipts and outlays gave me a better sense of context for where we’re at now (the deficit has been worse—I knew that but it helps to see it—and deficit spending has been the rule, especially for 34 out of the last 38 years). It added to my understanding. Hopefully it will also add to yours.
A PDF of this post is here.
Added on Jan 26: There’s a similar chart at the Tax Policy Center but it includes state and local receipts and expenditures. The graph given above is just federal. So if your interest is, e.g., the Federal deficit, then the above graph is germane.
Paraphrasing Robert Lewis Stevenson from his essay, “Truth of Intercourse”, to tell the truth is to convey a true impression. At odds with this, the word `entitlement’ is sometimes used in a way that misinforms.
So would you spend a lot of money to redefine a word? Probably not, even if you had it to spend. Well, you may not have known, but just in the past five years, 2007-2011, Peter G. Peterson spent nearly a half-billion dollars on his campaign to cut back the `entitlement’ programs, Social Security, Medicare, and Medicaid.[i] In the process he continued to contribute to redefining `entitlement’. Continue reading
Our environments of education, living, and work manifestly determine our health and are often referred to as Social Determinants of Health (SDH). The social determinants are in addition to our genes and behaviors. They are external attributes, rather than internal. What I find striking about international comparisons is other developed countries promote healthier SDH and have superior population health outcomes. Why is the U.S. different? Continue reading
Is the AHDI v. Conservatism Model Reasonable?
The previous post presented a linear model of the American Human Development Index versus conservatism. This is obviously a simplification of reality. The statistician, George E. P. Box, once said “All models are wrong, but some are useful.” The empirical model considered, besides being a simplification, cannot be based on a direct measure of neoliberalism/individualism because that measure doesn’t exist and so a proxy is used, itself subject to uncertainty. (Self-identifying as politically conservative can have multiple meanings depending on the respondent.) What’s more, the trend is across 50 states introducing further uncertainty. Surely no one doubts that New Hampshire has a different culture than Texas; what might be taken as conservatism in one state may well be different in another. Still, the trend looks genuine and useful. Is it robust? Continue reading
A Note about Causality
In personal conversations about the previous post a couple people brought up reverse causality: states that are less healthy might tend toward conservatism. As I see it this misses the point, the notion that political ideology influences public policy which in turn affects the lives of ordinary people. Presenting graphs like the first post and the next few which associate conservatism with outcomes is not about ideology directly causing bad results in the sense that bacteria cause cholera. Ideology is not the root or deepest cause. Rather, neoliberal and extreme individualistic beliefs—what the graphs’ “conservatism” measure stands for—influence policies that affect social structures which can contribute to the prevalence of, e.g., child poverty. For me, it is analogous to the British nineteenth century belief that bad air caused cholera. For decades before and after the famous 1854 London epidemic the prevailing ideology generally prevented Britain from correctly dealing with the root cause of cholera, contaminated food and water, resulting in many thousand preventable early deaths. Similarly, I see the connections portrayed in these first few graphs as representing false beliefs which on average lead to poor results.
Human Development Index
Consider the following graph. The horizontal axis presents the Gallup measure of conservatism, the percent of people in each state who self-report as conservative. The vertical axis represents an index of human development, how well we are doing. Its values range between 0 and 10. This Human Development Index is based on a composite of three dimensions and calculated for each of the 50 states. Each circular marker in the graph represents a state’s joint value. For example, the marker at the far right stands for Alabama with an Index value of 4.1 and where almost half of the population, 49.4%, self-identify as conservative; at the far left with percent conservatism of 27.1% is Hawaii. The trend line is the regression fit. The statistics in the upper right corner are for readers who might want to see them. They can be helpful but are not essential to understand the graph. The trend shows that as reported conservatism increases the Human Development Index gets worse.
The UN has used a Human Development Index (HDI) since 1990. Rather than just looking at a measure of a country’s economy such as GDP, the HDI summarizes in a single number how well ordinary people are doing. It is based on the three dimensions, longevity, access to knowledge, and standard of living. The American Human Development Index (AHDI) shown above is an adaptation of the UN’s HDI. It was developed by the Social Science Research Council specific for the US and each of the 50 states. The Council notes that the AHDI is not comparable to the UN’s international version. The HDI is for entire countries, almost 190 of them. Also, instead of the HDI’s dimension, access to knowledge (namely, mean years of schooling for adults and expected years of schooling for children), the AHDI averages educational degree attainment and school enrollment for age 3 and above. Both indices target “access to knowledge” but use different measures.
The next post, in a week, leaves 10 southern states out of the regression to see how the relationship between AHDI and conservatism changes.
Note: A PDF of this post is here.
Medicaid is on the table again. This is good, and in principle so are the discussions related to costs and policy intentions. Nevertheless, my view is that too much of the conversation has been at the 20,000 foot level, kept aloft by ideologies. Here are my impressions of what’s being said: We will not go along with a massive increase of the Medicaid program, especially under Obamacare, and furthermore such entitlement programs weaken us as a people. Meanwhile different voices assert: There is a need for Medicaid, cutting it back will hurt our most vulnerable populations. Expansive commentary about Medicaid has been elevated since the Supreme Court ruled on the Affordable Care Act in late June and boosted again beginning early September by Bill Clinton’s speech at the Democratic National Convention.
Let’s drop down a few thousand feet. Using data freely available on the Internet, the accompanying chart gives a more detailed view. The chart’s three plots all share the same horizontal axis, the percentage of people in each state that self-identify as politically conservative. The vertical axes represent child poverty, coronary heart disease, and Medicaid expenditures. The average trend lines are highly significant. In one sentence, the chart shows health needs increasing while providing for those needs through Medicaid deceases, all as the concentration of conservatism deepens.
Here is the context. Child poverty is both about children’s current health and a determinant of future health. It is the human-society equivalent of a canary in the coal mine. Children raised in poverty, on average, have more health problems both as children and as adults. And poor children are more likely to grow up to be poor, almost one-half become poor adults. As for heart disease, over the past 30 years there’s been a marked reduction in mortality rates. This is a major health-care success story. Nevertheless, coronary heart disease is still the leading cause of death in the United States and the most expensive to treat. Poor children, and adults with coronary heart disease, are a large part of the Medicaid caseload and budget. Nationally children make up about two-thirds of Medicaid beneficiaries while adults account for over two-thirds of the costs, a good part surely due to heart disease.
The prevalence of child poverty and coronary heart disease changes with the sway of conservatism as it moves across the states. Additionally, the chart provides a glimpse of the nation’s vigor. Not shown is that the two health outcomes correlate with other impairments of health, such as diabetes and poor health status. Thus child poverty and coronary heart disease can also be viewed as population-health indicators, not just isolated outcomes.
So what’s driving the strong relationship with conservatism? I submit it is the dual ideologies—which have elevated status in the United States—of unregulated markets and individualism. The belief that the market rules and everything has a price, that competition is the wherewithal, that we’re totally self-reliant, and all that’s worthwhile derives from great men so that an unequal society is a good society. I use conservatism as a proxy. If direct measures had existed, the horizontal axis of the chart would have been more accurately labeled “neoliberalism and extreme individualism.”
The average trend lines over the 50 states show that relative to conservatism there is less provision for health as the need increases. It is the lack of resources that weakens us. We would not expect to have a thriving garden without good soil, favorable climate, and attentive care. Are we less than a garden? We also require supportive conditions to flourish. People who think otherwise have their head in the clouds.
Note: A PDF version of this post is here.