German Joys

U.S. Healthcare Lags in Preventing the Preventable

From Kevin Drum, a study that compares the 19 most highly-developed nations in the world on the basis of their success in preventing "amenable mortality," that is, deaths from preventable causes such as "bacterial infections, treatable cancers, diabetes, cardiovascular and cerebrovascular disease, and complications of common surgical procedures."  Kevin sums it up pretty well, so I'll just shamelessly reprint the original post, snark and all:

A pair of researchers has just published an update that compares various countries on their rates of "amenable mortality," defined as deaths that are "potentially preventable with timely and effective health care." In 1997, the United States ranked 15th out of 19 industrialized countries. So how are we doing now?

Answer: we're now 19th out of 19. The rest of the countries have improved their performance by an average of 16%, while the U.S., that well-known engine of healthcare innovation, has improved by only 4%. So now we're in last place.

But there's a bright side: at least our healthcare isn't funded by the government, like it is in France. Keep that in mind if someone you know dies of preventable causes. Their odds would have been a whole lot better in Paris, but who'd want to live in a socialist hellhole like that anyway?

This difference is likely explained not by the fact that American health-care is "worse" across the board, but that there are large gaps in America's health-care system that leave millions of people without easy access to preventive care.  "Public" hospitals, which provide care to the poor and uninsured, have been closing at a fast clip lately, according to the New York Times: "There are 300 fewer public hospitals today than 15 years ago, with hospitals having closed in Los Angeles, Washington, St. Louis and Milwaukee."

The same article describes treatment of a gunshot victim in the emergency room at Atlanta's Grady Memorial Hospital, which is likewise chronically underfunded, poorly-managed, and facing closure:

The ER did not have a working X-ray machine that night, so doctors had to roll in a portable one to locate the bullet. The X-rays were produced on film rather than digitally, causing a 10-minute delay in diagnosis. There were gurneys without wheels, and a computer system so outdated that doctors had to call up four separate programs to compile records on a single patient.

The very poorest Americans qualify for a government program called Medicaid which pays for their healthcare, but the case-by-case compensation rates for Medicaid are well below the actual cost of the care provided.  If a hospital has to finance the care of too many Medicaid and uninsured patients, and doesn't get enough well-insured patients to make up the resulting shortfall, it will simply go under.

As with America-Europe comparisons in so many other fields (education, political influence, etc.), the pattern in Europe is of stellar health care for the rich, and consistent access to reasonable quality health care for everyone else.  Reasonably good health care is all most people need, and its easy availability in Europe probably goes a long way to explaining the graph above.

In the U.S. there's even more stellar health care for the rich, pretty good healthcare for the middle class, and a drastic drop-off in quality and availability for the lower-middle class and below -- that is, people who cannot afford to pay for the medical services they need.  It's just speculation, but I rather doubt it's preventable deaths among America's upper-middle class that are reflected in the Commonwealth Fund study... 

Racial Diversity and Social Welfare Spending

The Boston Globe has a piece about American political scientist Robert Putnam's findings that racial and ethnic diversity tends to undermine social cohesion and civic participation. It features the following paragraph:

In a recent study, [Harvard economist Edward] Glaeser and colleague Alberto Alesina demonstrated that roughly half the difference in social welfare spending between the US and Europe...can be attributed to the greater ethnic diversity of the US population. Glaeser says lower national social welfare spending in the US is a "macro" version of the decreased civic engagement Putnam found in more diverse communities within the country.

Which led me to this review (.pdf) of Glaeser and Alesina's book (an earlier paper by the authors themselves making the same points is here (.pdf), which finds that voting systems and racial diversity explain most of the difference in social welfare spending:

Voting systems affect redistribution by changing the incentives of politicians. In majoritarian systems, where each politician represents a single electorate (as in the US and Australian House of Representatives), politicians' main incentive is to look after the interests of their local areas....

By contrast, under systems of proportional representation (as in many European countries and New Zealand), several politicians represent the same district. This leads to a different incentive rather than aligning themselves with a region, politicians tend to develop class-based affiliations, increasing the pressures for universal programs, which often redistribute resources from rich to poor....

The remaining difference in welfare spending, Alesina and Glaeser conclude, can be explained by the fact that the US is more racially diverse. A variety of studies on prejudice have shown that people tend to be hostile to those who are different from them along some salient dimension. Often, the most important dimension is race or ethnicity. In the US, a quarter of the population is African-American or Hispanic. In Sweden, 95 per cent of the population are of the same race, ethnicity and religion. The potential to exploit racial antipathy will therefore be considerably greater in the US than Europe.

That racial diversity is an obstacle to forging a common coalition around distribution from rich to poor has often been noted. Writing in the 19th century, Karl Marx and Friedrich Engels anticipated that America's ethnic divisions would impede the growth of a US socialist movement....

Race and redistribution are powerfully linked. Alesina and Glaeser show that US states that are more ethnically diverse tend to have more negative attitudes towards welfare, and lower levels of social welfare spending. The same pattern holds internationally countries with more racial and ethnic heterogeneity also tend to spend less on welfare programs. The simplest interpretation of this finding is that people are less generous to those who are different from them, but Alesina and Glaeser also highlight another factor: politicians who use racial hatred to discredit redistributive policies. Barry Goldwater, Pat Buchanan, Jorg Haider, Jean-Marie LePen and Pauline Hanson have all used hatred against racial minorities as a way of building an anti-redistribution constituency.

Fits in nicely with Goetz Aly's recent book on National Socialism (G), which argues that Hitler purchased the support of many sectors of German society with promises of social-welfare benefits. National Socialism was really this thesis turned into proactive policy -- ethnic non-Germans were killed or forced into slave labor, and their property was given to ethnic Germans.

To forestall comments from certain readers, let me note, obviously, that neither I nor any of the people cited in this message claim that social welfare programs are an expression of racism. This is just a possible explanation -- one that seems to be getting more convincing every year -- for the difference between American and European social welfare policies.

Vacation Policies in Europe and the USA

A recent report from the Center for Economic and Policy Research in Washington, D.C. compared government policy on paid vacation time among OECD nations. No surprises here; the chart says it all:

A couple caveats here: the report's authors don't seem to have considered U.S. state law. I suspect that that more liberal U.S. states probably do provide mandated paid vacation, and it might be helpful to know which ones do. Nevertheless, as the authors correctly note, there's no federal regulation on the subject, so states are free to act as they please. As for Germany, the authors note: "[T]here is only one national public holiday, German Unity Day. Other public holidays are determined on the state level, and vary between 0 and 16."

Of course, American workers do get holidays. As usual, though, the amount of vacation you get will vary with your social power:

On average, private-sector workers in the United States have about nine days of paid vacation per year, plus about six paid holidays. . . . .  [P]art-time workers, low earners, and workers in small establishments (fewer than 100 workers) are less likely to receive paid vacation and paid holidays, and when they do, these workers receive fewer paid days off. Lower-wage workers are less likely (69 percent) than higher-wage workers (88 percent) to have paid vacations.

Mandatory paid vacation is a classic welfare-state policy. Policies like these serve at least three functions. First, they ensure that everybody gets some vacation. Second, they 'signal' that leisure time is an important social value and policy goal. As the report notes, most European employers actually go above the minimum requirements voluntarily. Third, they ensure that the gap between rich and poor in vacation time does not become too large.

In any society, the highly-qualified or well-connected have a lot of autonomy concerning how much they choose to work. Of course, many choose to work extremely hard, but they don't have to; they can bargain away money and prestige in favor of leisure time (or time with the family) whenever they wish. It's the less-qualified, 'interchangeable' workers that get the short end when there are no policies to protect them. Put another way, if you're a low-skilled employee in Europe, you're not more likely than an American low-skilled employee to get more than the legal minimum of paid vacation. But, as we see, that legal minimum is very different...

Me Vote for Pretty Candidate!

I sometimes get a bit of grief for not responding to comments more often. Let me say that I follow the comments on this blog closely. I'm often delighted or amused by what I find there. Also sometimes irritated, which is also a good thing. However, anyone who's ever actually run a blog knows that the key to keeping up active readership is to post something new as often as possible -- preferably every day. My day job often leaves me little time to tend to good old German Joys. Thus, when I have limited time, that time is better used, on blogalicious grounds, to post something new.

However, I would like to take up some comments Don made about my post of a few weeks ago on Bryan Caplan's new book, in which Caplan concludes a lot of things (summary here), one of them that Northern European voters seem to be more rational than their counterparts in other democracies.

Don took issue with my description of European political discourse as more rational and well-informed than in the U.S.:

European discourse more politically sophisticated? What do you mean by discourse, Andrew? Conversations with your landlady, Stammtisch debates, German media discussions?

Let us consider U.S. media and blogs as an example of public discourse. One list of links can be found under http://aldaily.com/ on the left side. Many are international, but most are U.S. Now, compare that list to media and blogs under http://www.goethe.de/wis/med/lks/ enindex.htm#1734508. In terms of variety and depth, not to mention energetic creativity and breadth of scholarship, the U.S. is ahead IMHO.

Blogs aside, though, that's my story, and I'm stickin' to it. I have now followed current affairs in Germany and France for a few years, in the original languages. The difference in quality and depth of information available to the average person in those countries and in the U.S. is sobering. That's why I have no trouble accepting Caplan's thesis. I haven't read Caplan's book yet, but I'd wager what he's talking about is the fact that average Europeans generally have a more accurate idea of what their nations' policies are, and what the various political parties stand for.

There is no debate among political scientists that the average American voter is incredibly ignorant. Ilya Somin recently brough a lot of the strands of research together in this readable Cato Institute policy analysis: "When Ignorance Isn't Bliss: How Political Ignorance Threatens Democracy."* He quotes political scientist John Ferejohn: “Nothing strikes the student of public opinion and democracy more forcefully than the paucity of information most people possess about politics.”

Somin brings together literally dozens of examples of the ignorance of the average American concerning basic facts relevant to American domestic and foreign policy. Some examples:

• 70% of Americans, as of November 2004, did not know that Congress had recently expanded federal coverage for prescription drugs, the largest, and most highly-publicized domestic policy initiative of the Bush Administration.
• Just after the hotly-contested 2002 Congressional elections, only 32% of voters knew that the Republicans controlled Congress before that election.
• Just after the hugely-publicized takeover of Congress by the Republicans in 1994, 57% of American voters did not recognize the name of Newt Gingrich, the leader of the Republicans at that time.
• In 1964, only 38% of American voters were aware that the Soviet Union was not a part of NATO.

"Majorities," summarizes Somin, "are ignorant of such basic aspects of the U.S. political system as who has the power to declare war, the respective functions of the three branches of government, and who controls monetary policy." (p. 4)

And his examples are just the tip of the iceberg. According to a 2001 PIPA study, Americans estimate that America spends 20% of its annual budget on foreign aid, overestimating the actual amount by about 40 times. As Bryan Caplan points out in the essay I linked to, 41% of Americans think foreign aid is one of the two biggest items in the American budget. Not surprisingly, many Americans want the allegedly "massive" foreign aid budget cut. PIPA ran a survey before the 2004 Presidential Election (unfortunately, the link I have no longer works, but I saved a copy of the syllabus on my computer) in which Bush supporters, by large majorities, stated their incorrect beliefs that President Bush had signed the Kyoto Treaty, supported the creation of an International Criminal Court, and favored the inclusion of labor and environmental standards in trade agreements. 56% percent of Republicans now favor referring Darfur war criminals to the International Criminal Court, even though the President they (presumably still) support opposes American participation in the court. 68% of Republicans believed, incorrectly, that President Bush actually favored American participation in the ICC in its present form.

The examples could go on and on. This isn't a debate about which policies are wisest -- it's a debate about whether voters even know what the policies are. Huge numbers of Americans do not have basic information about the political process.

There are plenty of reasons for this, but I would chalk a large part of it up to American television, the main source of news for the average American. Except for a few channels, it's all for-profit. These stations are competing for viewers, which means they are under pressure to package news in ways that attract viewers. This means heavy on the sex, violence, and scandal, and keep it short and snappy. Average length of a story on broadcast nightly news in the United States: 138 seconds, including the anchor's introduction.

Does anyone really doubt this? It slaps every European visitor to the USA in the face as soon as they turn on an American television. It slaps me in the face every time I return to the U.S. When I traveled throughout the U.S. with European friends in the summer of 2001, they were amazed to see that every channel they switched to, in every hotel we stayed in (and in the waiting rooms and restaurants that had televisions blaring into them), the story was...Chandra Levy. Yes, Chandra Levy.

Laqueuer: Europe's Doomed. Moravcsik: Fiddlesticks!

This blog's been getting pretty dialectical lately, so let's have another thesis-antithesis post. Walter Laqueur pronounces on Europe's future in the Chronicle of Higher Education:

In brief, by the turn of the millennium, at the very latest, it should have been clear that Europe was no longer on the road to superpower status, but that it faced an existential crisis — or, perhaps more accurately, a number of major crises, of which the demographic problem was the most severe. That began to be recognized almost immediately, but there was confusion, because the crisis seemed intractable — it had been discovered too late. One could only hope that the newcomers indifferent or hostile to European values would gradually show more tolerance, if not enthusiasm, toward them, or that multiculturalism, which had been such a disappointment, would perhaps work in the long run.

Those were not exactly strong hopes, and they certainly do not explain the illusions of some foreign observers, particularly Americans, who continued to claim that the 21st century would be Europe's. They maintained that there had been a revolution in Europe, of which Americans were not even aware. Europe had a vision of justice and harmony very much in contrast to the American dream, which no longer existed. The European vision emphasized the collective, in contrast to the narrow stress on individualism in the United States. It preferred the quality of life to amassing money. Americans had to work harder than Europeans, had fewer holidays, did not live as long as the Europeans, and, generally speaking, enjoyed life much less. Europeans were selfless, it was argued. As one observer put it, power politics was a thing of the past; Europe's main weapons were justice and the law. Coming from Europe, that idea would spread all over the world and become the main instrument in world politics.

Now for the antithesis: Europe's doom isn't inevitable. Let's not forget that many who predict it also desire it, for a variety of reasons ideological and economic (not that Laqueur belongs in this category). If Walter Laqueur gets you down, I'd suggest Andrew Moravcsik's cautiously optimistic assessment:

To most who live in Europe—or have visited lately—all this [doomsaying] seems wrong, even absurd. As the European Union turns 50 this week, let us consider all that has been achieved. Europe arose from the ashes of the Great Depression and World War II to become whole and free. Half a century ago, only a utopian would have predicted that, today, one can traverse Europe from Sweden to Sicily without encountering a border control and—most of the way—using a single European currency. Or that a tariff-free single market would exist, cemented by a common framework of economic regulation.

Europe is now a global superpower of world-historical importance, second to none in economic clout. It has constructed one of the most successful systems of government—the modern social-welfare state, which for all its flaws has brought unprecedented prosperity and security to Europe's people. It is the single most successful advance in voluntary international cooperation in modern history. The original European Economic Community of 1957 has grown from its founding six members to 27, knitting together just under 500 million people from the western Aran Islands of Ireland through the heart of Central Europe to the Black Sea. Its values are spreading across the globe—far more attractive, in many respects, than those of America. If anything, Europe's trajectory is up, not down. Here's what the critics get wrong.

Now for my two cents. Laqueur thinks that opposition to America's foreign policy and values, especially as embodied by the Bush Administration, drove many commentators to overestimate Europe's prospects. It's a sort of wishful thinking: "I find Europe's approach so much more pleasing and consonant with my views, therefore it must be the wave of the future."

I don't disagree with Laqueur on many points. It's become clear that there are worrying fissures at the heart of many European countries. Further, Europe's stock (as a shining beacon of reason and conciliation compared to the U.S.) has hit a new high against the background of the Bush administration, but will fade once someone halfway competent enters the White House. I'm not quite as pessimistic about Europe's demographic future as Laqueur, but there's no doubt that a demographic time bomb is ticking, and the people who might be able to defuse it are still bickering bitterly with each other.

I'm a Europhile not because I think European values will prevail, but because I think they should prevail. Sure, Europe's social welfare systems do saddle it with some competitive disadvantages. That's why I found the parts of Jeremy Rifkin's European Dream -- the parts in which he assumed away these disadvantages -- so unconvincing. They're there, and they're found not only in some EU and national policies, but also in the mindset of many denizens of Europe. However, from what I have seen and experienced, Moravcsik's thesis holds: the competitive disadvantages are greatly outweighed by the benefits social welfare systems bring to European residents. And there's no question that many of the foreigners I talk to here in Germany are quietly impressed by Germany's social-welfare system. Many of the leaders of the countries these people come from promise their residents a welfare state, but Germany actually delivers one. As long as the vast majority of the world's population continues to prefer welfare-state models to unrestrained capitalism, the European dream will remain alive.

Offshoring Accountants, Engineers, and College Professors

Germany's a free-trade country, and so is America. All American economists are also feverish proponents of free trade. But lately a few have been getting nervous about the coming offshoring of the service industry. Prominent American economist Alan Blinder points out that free trade has begun destroying millions of service-industry jobs in the United States:

It's going to be painful because our country offers such a poor social safety net to cushion the blow for displaced workers. Our unemployment insurance program is stingy by first-world standards. American workers who lose their jobs often lose their health insurance and pension rights as well. And even though many displaced workers will have to change occupations -- a difficult task for anyone -- only a fortunate few will be offered opportunities for retraining. All this needs to change.

Hmm. Generous unemployment benefits, portable health insurance, and government-funded retraining schemes for displaced workers. Sound like any countries you know?

Germany Discusses Free Money For Everybody

The front page of my Zeit has a nice title: "The Dream of Money Without Work." It's a3-page special feature in the business section about the idea of a guaranteed minimum income for every citizen of Germany, provided without any conditions. You need not prove any sort of need or fulfill any conditions -- you just get a check in the mail. The idea has support among unlikely political bedfellows.

Tory "father-state" conservatives on the right, such as the CDU President of Thuringia Dieter Althaus, want to peg the basic income at under 700 Euro per month and call it something warm, fuzzy, and patriotically Christian-sounding: Solidarisches Buergergeld (citizen-money of solidarity!). The theory is that you'll save enough money by abolishing the costly state bureacracy that administers current welfare schemes to finance the additional amounts necessary. Left parties are also interested, although they would put the monthly sum higher and call it a Grundeinkommen (basic income).

Götz Werner, super-rich founder of the dm chain of drug supermarkets, is traveling the country propagandizing his version, which envisions payments as high as 1500 Euro monthly (which he concedes to be a "distant goal"). His primary motivation is to free humans from the compulsion to work, so that they can satisfy the artistic, literary, or humanitarian drives that really make their lives worth living. Werner is a follower of anthroposophy,  sort of German-language "spiritual science" founded by an Austrian philosopher in the early 20th-century (think a German version of Scientology, with its own schools and complex mythology).

Social Democracy Week Addendum

The United States and Great Britain placed last in UNICEF survey of 21 of the richest Western nations. Here's the graph that tells it all:

Reaction in Britain:

Today’s findings will be a blow to the government, which has set great store by lifting children out of poverty and improving their education and prospects. Al Aynsley Green, the children’s commissioner for England, acknowledges that the UN has accurately highlighted the troubled lives of children. “There is a crisis at the heart of our society and we must not continue to ignore the impact of our attitudes towards children and young people and the effect that this has on their wellbeing,” he says in a response today.

Europeans Marching Against Abortion?

Some people are famous for being famous, and others are famous for being Christian. All I know about David Kuo, for instance is that he is a Christian, that he was hired to work for George W. Bush's White House Office of Faith-Based and Community Initiatives, but quit when he concluded Bush wasn't serious about the White House's "promise to help religious groups serve the poor, the homeless and drug addicts." He then wrote a book about his experience.

He's still a Christian, though, and blogs about that fact. In a recent blog post, he relays the news that some American Christians seem to think Europe's population crisis could help the pro-life movement:

The difference...between Europe's abortion "wars" and US conflicts over abortion is motivation - European birth rates have been dropping and that has a lot of people - in government, in churches, in financial institutions - scared. Apparently, this growing move towards restricting abortion is an effort to address that problem. For a fascinating, detailed look at EU population issues (published by the EU), click here.

I'll relay the link without comment. Oh, wait with two comments.

First, I wonder how many European will find jarring to see a website devoted to religion (beliefnet.com) that is plastered with bright, shiny ads from profit-oriented companies selling weight-loss products and web services?

Second, Kuo reflects typically American wonderment at the notion that the government would actually pay somebody to have a baby. He deploys the "if Hitler did it, it must be bad" argument, noting sinisterly that the Nazis also had a policy of government rewards for particularly fertile mothers.

Now hold on a minute here -- Hitler also built excellent roads. Sometimes personally (see left). Should we destroy them all? Hitler was really nice to dogs. Should I start torturing puppies? Hitler was a non-smoking vegetarian. Should I start feasting on steaks and roasting my lungs with Gauloises? Hitler never married until hours before his suicide. Umm, how do I do the opposite of that?

OK, I'm sorry I made fun of David Kuo, who is probably a nice enough guy. I am sure I share his opinion of George W. Bush. Everyone go to his website, read his post, and leave comments. Come to think of it, please go visit his post leave tons of comments in German! Yes! Be sure to use really long words and lots of exclamation points! Mention Hitler's name over and over!

I bet that would brighten his day.

The German Niceness Subsidy

The German government showers money and benefits on people who have children.  They're allowed to take a"child-raising vacation" from work (i.e. to reduce their work-week to between 15 and 30 hours, if they choose), they get a per-child bonus called "child-money," and starting in 2007 there will be a new kind of "parent-money." 

As the Rheinische Post reports, this will replace 67% of one parent's income for a full year after a baby is born -- up to €1800 a month, which is extremely generous.  The previous "parent money" payments were much smaller.There's a catch, though.  To get the full year of parent money, the father has to be the one staying at home for at least two of the months.  That is, if only Mommy takes a "child vacation", she only gets 10 months salary replacement.  If the family wants the extra two months, the father has to take a 2-month (or more) child-vacation from work.   Some conservatives, and the Catholic Church,  are crying foul.  They say this new scheme intrudes too far into the family's constitutionally-protected ability to run its affairs, and will force a disorienting change in the baby's primary "contact person."  Others applaud the step.