How Does U. S. Health Care Compare?

The post at RealClearPolitics by physician Roger Stark on the rankings of the U. S. health care system by the World Health Organization and the Commonwealth Fund caught my eye. As should surprise no one the rankings are heavily dependent on what you value most. Since the WHO places almost 2/3s of the weigh of its ranking on having a single payer health care system, the U. S. scores relatively low. How does it do in other areas?

Cardiovascular disease, such as heart attack and stroke, remains the leading cause of death globally and in the United States. Research from the Kaiser Family Foundation shows that the 30-day mortality rate after admission to the hospital for a heart attack patient is 4.9 percent in the U.S. compared to a 5.8 percent average for five other industrialized countries. The stroke numbers are similar with a 4.1 percent mortality rate in the U.S. compared to an average of 6.4 percent in five similar countries.

The combination of all cancers is the second leading cause of death for virtually all countries. The Concord-3 study is one of the largest international cancer reports. Researchers examined records of 37 million patients and looked at five-year survival rates for 18 different types of cancer in both adults and children. Again, the U.S. ranked either first or in the top five countries in the most common types of cancer – breast, prostate, and lung.

The U.S. does fall behind other industrialized countries in certain health areas, such as premature death, longevity, and maternal mortality. The U.S. also has a high incidence of major physical trauma, such as gun violence and car crashes, as well as a significant rate of suicide. These trauma issues definitely contribute to poor longevity numbers in the U.S. However, they are a consequence of serious social problems and should in no way be a reflection on the health care delivery system.

Data from the Center for Disease Control and Prevention show that 74 percent of Americans are overweight and 43 percent are obese. Weight problems are associated with heart attacks, stroke, type II diabetes, and certain types of cancer. Maintaining an ideal body weight is a life-style choice and, again, should not reflect on the quality of a country’s health care delivery system.

I want to quibble with Dr. Stark’s observation about obesity to some degree. Contrary to Dr. Stark’s claim I think that maintaining an ideal body weight is multi-factorial with important factors including gender, age, heredity, culture, and, as Dr. Stark contends, lifestyle choice. I think that holding it up as solely a lifestyle choice is a step too far. Just for the record for my age I am categorized as being in the ideal weight range. I’m just about the same size as I was 50 years ago.

I do think that far too many Americans are overweight and obese with factors including all of those I mentioned above. It’s hard for me to compare what things were like 60 years ago with today since then I was in St. Louis, now I’m in Chicago, and the prevailing phenotypes in the two places were quite different and have changed dramatically over the intervening years. 60 years ago I was struck by how much fatter Chicagoans were than St. Louisans. I suspect that’s even truer now.

One thing unmentioned in Dr. Stark’s post is how much more Americans pay for the outcomes we do achieve than people in other countries do. Here’s a comparison for OECD countries:

I don’t know how to weight the factors involved in those differences. I’m sure it’s multi-factorial as well. I doubt as much of the difference is attributable to our lacking a single payer system as advocates for single payer systems like to believe.

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Russia’s Ultimatums

According to Pravda Ukraine has received three ultimatums from Russia:

  • демилитаризация Украины,
  • отказ вступления её в НАТО,
  • и прямые переговоры с ДНР и ЛНР.
  • demilitarization of Ukraine,
  • renunciation of joining NATO,
  • and direct negotiations with the the Donetsk and Luhansk regions (“People’s Republics”)

I’m not really sure of the implications of any of those or whether fulfilling them will actually satisfy Russia. For example, at least some of the warfare being conducted in the eastern Ukraine is being conducted by irregulars. What would demilitarizing them imply? And what would the objective of direct negotiations with the two regions be?

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Begun It Has

Last night (this morning Russian time) Russian President Vladimir Putin declared war on Ukraine and initiated his invasion in earnest. Reaction from the U. S. and Europe, as you might expect, has been shock and dismay. The Associated Press reports:

PARIS – French President Emmanuel Macron says France and its European allies did everything to try to head off the attack on Ukraine. He said that they will show “no weakness” in their response.

Macron said in a televised address to the nation Thursday that Russia’s attack is a “turning point in European history” and as a result “there will be profound consequences for our continent and changes in our lives.”

He said that “to this act of war, we will reply without weakness, we will reply calmly and in a determined and united manner.”

“We have tried everything to avoid this war but it is here and we are ready,” Macron said.

He said that sanctions will be “proportionate” to Russia’s military operations, targeting its economy and its energy sector.

According to the World Bank, Russia’s primary exports are oil and gas. Exports comprise about twice as much of Russia’s economy as our but, unlike the U. S., it runs a substantial trade surplus. Its largest trading partner by far is China. The Chinese response to today’s developments has been, as Christian Shepherd puts it in the Washington Post, “muted”:

China on Thursday denied backing Russia’s military assault in Ukraine as it treaded a cautious line in response to a conflict that many Chinese analysts just days before were predicting wouldn’t happen.

At a regular briefing, Chinese Foreign Ministry spokesperson Hua Chunying downplayed the suggestion that Beijing was supporting Moscow behind the scenes.

“As for American hints that Russia had China backing it up, I’m sure Russia would be pleased to hear it,” Hua said. “We won’t be like America and provide Ukraine a large amount of military equipment. Russia as a powerful nation also does not need China or other countries to provide [military assistance].”

Hua added that “China did not wish to see what happened in Ukraine today.”

In her remarks, Hua called out NATO for owing China a “debt of blood” over the bombing of the Chinese embassy to Yugoslavia by U.S. warplanes in 1999. Bringing up the more than 20-year-old incident was likely an effort to drum up anti-U.S. sentiment against the backdrop of the Russian attacks on Ukraine.

which you will recognize hearkens back to the points I have made here. I found this interesting:

Yun Sun, director of the China Program at the Stimson Center, noted Tuesday that the Chinese policy community appeared to be in “shock” at the sudden escalation of fighting after having “subscribed to the theory that Putin was only posturing and that U.S. intelligence was inaccurate as in the case of invading Iraq.”

For instance, in an interview on Tuesday, Ma Bin, a Russia expert at Fudan University in Shanghai, told the Chinese publication Yicai that the ball was in Ukraine’s court and “there would not be a war” because Russia still preferred a diplomatic resolution.

which is quite similar to what I have been saying but acknowledged was wrong. As is not particularly surprising, the Chinese blame us:

In the run-up to Putin’s announcement, China continued to blame the United States and NATO for being instigators of the conflict, brushing aside warnings from the White House about the Kremlin’s intention to invade.

“A key question here is what role the U.S., the culprit of current tensions surrounding Ukraine, has played,” Hua, the Foreign Ministry spokesperson, said on Wednesday. “If someone keeps pouring oil on the flame while accusing others of not doing their best to put out the fire, such kind of behavior is clearly irresponsible and immoral.”

Hua also rejected suggestions that China might adhere to U.S.-led sanctions against Russia, pointing to China’s long-held stance against the use of sanctions adopted outside of United Nations deliberations.

and the invasion is a consequence of “provocation from the United States”. China’s imports from Russia are greater than the next two importers, Netherlands and Great Britain, combined. The United States is the tenth largest importer of goods from Russia and our imports are a relatively small proportion of the whole. Belarus and Kazakhstan, each of whose imports from Russia are significantly greater than ours, are unlikely to impose trade sanctions against Russia.

A major question is how Germany will react. Deutsche-Welle remonstrates:

Russia’s invasion of Ukraine has major consequences for Germany’s foreign policy.

Following Russia’s attack on Thursday morning, German Chancellor Olaf Scholz took to Twitte to say:

“The situation is serious. The peace in Europe is built on not changing borders. We must return to these principles: State sovereignty is respected. Borders will not be moved.”

Foreign Minister Annalena Baerbock was more emotional, warning that the would would “not forget this day of shame.” “Germany is stunned, but not helpless,” she said, announcing a package of “massive sanctions.”

On Monday Scholz’s decision to put Nord Stream 2 on hold following Moscow’s recognition of the two breakaway regions in eastern Ukraine was itself an awkward U-turn for a chancellor who has not yet been in office for three months.

At the start of his tenure in December, Scholz was still describing the gas pipeline in the Baltic Sea — recently completed but not yet online — as a purely private economic project, even though it is owned by a company that the Russian state has a controlling stake in. Now, Nord Stream 2 proves to be very much the political tool that many of Germany’s geopolitical partners, especially the US government, had always seen it as.

The Kremlin’s move also leaves the policies of Scholz’s predecessor Angela Merkel in ruins. Following the annexation of Crimea in 2014, Merkel invested much effort into putting the Minsk Protocols into place: joining France in efforts to mediate between Russia and Ukraine and create a fragile peace.

Note that Germany’s suspension of the certification of the NS2 pipeline has no effect on present Russian-German trade. It had not come online. Whether Germany will take any action which bears present costs for Germany remains to be seen.

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The U. S. Welfare State

Believe it or not, people are writing about things other than Russia. For example, this post by Chris Pope at City Journal:

As part of a recent study on income disparities, Thomas Blanchet, Lucas Chancel, and Amory Gethin of the World Inequality Lab at the Paris School of Economics found that the United States “stands out as the country that redistributes the greatest fraction of national income to the bottom 50 percent.” This is not the American welfare state’s traditional reputation and seems to have come as a surprise to the left-leaning authors. How can it be so?

Government spending accounts for a smaller share of national income in the United States (35 percent) than in Europe (47 percent), but rates of public spending on education, health care, and benefits for the poor and disabled are similar. The greater cost of government in Europe results largely from its spending 11 percent more of national income on public pensions than the United States—which serves to crowd out private pensions that higher earners would have provided for themselves. To finance these state pensions, Europe imposes payroll and sales taxes at rates twice as high as in the United States. These additional taxes fall heavily on lower-income groups—making government bigger, while imposing higher costs on the poor.

summarizing:

For a while, the cost of the shift was masked by the rebound of ruined economies in the immediate postwar era. But over time, the expense of providing generous retirement benefits and comprehensive health-care services to all ballooned—tilting the bulk of government spending toward middle-class entitlements and eclipsing other spending priorities. France spends a much larger share of GDP (13.6 percent) on public pensions than does the United States (7.1 percent), owing to a lower retirement age (62 vs. 66) and disproportionately generous benefits for wealthier seniors. Yet, as 69 percent of American seniors receive private retirement benefits, incomes from private pensions in the U.S. (5.3 percent of GDP) are much higher than in France (0.3 percent), and the median disposable income of over-65s in the United States ($38,920) is also much higher than in France ($23,490).

There are some important differences. Health and education and, frankly, just about everything in which much of the payments come from the government, e.g. infrastructure, are much, much more expensive here than in just about any other OECD country. And a lot of the difference is because European countries are so heavily dependent on value-added taxes which, as they are implemented there, are very regressive.

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Strength and Weakness

Originally published in The Atlantic Tom McTague wonders how high a price “the West” will pay for Ukraine:

Russia is not Iran. Using sanctions as an economic weapon against Putin comes with real costs for the West, raising the troubling question of whether governments have the will to impose them in any meaningful way to begin with, or the capacity to endure the pain that might follow in the long term. Germany’s decision to suspend the Nord Stream 2 pipeline with Russia, for example, will directly lead to higher energy costs for its citizens, and the turmoil more generally will mean that Europeans in particular will pay increased heating bills at a time when the cost of gas is already sharply high.

In a sanctions war, there is a systemic weakness for the West. One European official involved in drawing up previous sanctions against Russia summed up the difficulty faced in the West. First, this official said, places such as Britain, where I am, are “remarkably constrained” in what they can do. London could seek to seize assets held by Russian oligarchs in Britain, but the Russian state is able to use the strength of London’s judicial system to tie the process in knots. The result is that, by being an open economy with strong rule of law, “you end up being the perfect place for bent money.”

More important, though, is the question of political will. Throughout the West, people debate not just the leverage any sanctions on Russia might offer, but how to ensure that they do not leave the West exposed. The result, inevitably, is a mix of measures that do not go far enough. The Biden administration, for example, has already reassured Americans that sanctions against Russia will not lead to a jump in energy prices. As the European official told me, Western governments are rarely open with voters about the costs of using a crisis to reduce corrupting entanglements with kleptocracies that have otherwise festered.

The problem is that although the West is richer than Russia, it remains vulnerable. Much of Europe is dependent on Russian oil and gas. Former Russian President Dmitry Medvedev has warned, for example, that Berlin’s decision to suspend the Nord Stream 2 pipeline connecting Russia to Germany will double gas prices in Europe. In Britain, prices are already rapidly increasing thanks to supply-chain restrictions and global energy-market ructions, so further rises would be politically toxic. Beyond oil and gas, analysts have suggested that Russia could limit the export of raw materials such as grain, fertilizer, titanium, palladium, aluminum, and nickel. It could also ban overflight rights for Western airlines traveling to Asia. Each move taken by Russia will likely be met with a response by the West, which could create a tit-for-tat spiral.

I in turn wonder if there is a “West”? I agree with the claim that Russia is a regional superpower, boosted to a global superpower by virtue of its nuclear arsenal. The Europeans are completely capable of handling the present problem themselves with U. S. support limited, effectively, to economic sanctions and negative reciprocity with respect to nuclear weapons. The question is will they?

If they won’t, there is no West, there is only the United States and we should start thinking very seriously about what our actual strategic interests are.

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The End of an Era

James Joyner has a pretty good round-up of media and pundit reactions to the events of yesterday at Outside the Beltway. He remarks:

From my vantage point, Putin has lost much more than he’s gained. Defying the West and recapturing some of the glory of the Soviet days may give him a short-term boost in domestic popularity but one would think further sanctions piled atop those that have been in place since 2014 will quickly overcome that. Russia is a pariah state now, having lost its seat in the G-8 and still retaining its Security Council membership because of a sclerotic system, not because it’s regarded as an equal player.

while William Galston, in his Wall Street Journal column declaims that it marks “the end of an era”, advising:

The U.S. faces challenges to its interests and principles on two major fronts, not one. It doesn’t have the luxury of redeploying military assets and diplomatic focus from Europe to Asia. The U.S. must focus on both fronts, but it is hard to see how it can do so without a larger military budget and a beefed-up governance structure in the White House, State Department and Defense Department.

and

Generations of postwar Europeans have convinced themselves the use of force is no longer necessary to settle disputes between nations. They believed diplomacy, backed by international law and institutions, was the 21st-century way of keeping peace.

Against this backdrop, the Russian invasion of Ukraine should trigger a crisis of European identity. If force is a permanent feature of international relations, the European Union must either take more responsibility for its own defense or admit that it has subcontracted this job to the U.S. indefinitely, along with some of the EU’s strategic independence.

It will certainly be interesting (in a “may you live in interesting times” sort of way) to see how both the White House and our European allies respond. Will President Biden’s Congressional caucus tolerate such a course correction? And what of the president’s other priorities, e.g. climate change.

Frankly, I doubt our European allies will react as Mr. Galston proposes. I think they’re far more likely to hold tight to their post-war fantasy than they are either to start beefing up their own militaries or “subcontracting its strategic independence”.

I also wonder how we’re going to manage expanding our military while remaining as dependent on consumer spending as at present. Not to mention dependent on China.

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Tread Carefully

As I look through the reactions of various pundits to the developments in Russia and Ukraine, I am struck by one thing. To the best of my knowledge every wargame of direct great power conflict has ended in a nuclear exchange. To my eye that means that we should tread very, very carefully. I hope people are aware of that.

It concerns me that so many seem to be urging us towards war with alarming speed. Selling newspapers isn’t worth it.

I also see a lot of dismissal of Putin and Russia. “Ivory Coast with nuclear weapons” has been mentioned again. I sincerely hope they don’t believe what they’re saying.

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Observations

While we wait for whatever catastrophes tomorrow may bring, I’d like to make two observations about the situation with Russia and Ukraine. First, I don’t believe the additional economic sanctions that have been placed on Russia in response to its invasion of Ukraine will have much impact. Indeed, I think they’re likely to be harder on the countries imposing the sanctions than they are on Russia.

Second, Europe is completely capable of dealing with the situation with little help from the U. S. Just not quickly. To the best of my knowledge at this point France has the only military among our NATO allies at the highest level of readiness and the French military is pretty overextended already. That’s the risk of the underspending on defense our NATO allies have been enjoying for decades. Now the risk is an issue.

Said another way at this point Russia can and will do pretty much whatever it wants to do.

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It’s an Invasion

The Guardian reports:

Joe Biden has now appeared at the podium in the East Room for his speech on Russia and Ukraine, after Vladimir Putin acknowledged the two self-proclaimed republics in Luhansk and Donetsk and ordered troops into the region.

The US president warned that Putin is “setting up a rationale to go much further” in Ukraine, predicting a larger-scale attack in the days to come.

“This is the beginning of a Russian invasion of Ukraine,” Biden said.

I was wrong. Russia is invading Ukraine. I still have no idea of how this ends let alone ends well.

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It Didn’t Have to Be This Way

I find myself in the unexpected position of agreeing with Tom Friedman’s remarks in his New York Times column:

This is ugly, visceral stuff. Nevertheless, there is a back story here that is relevant. Putin’s attachment to Ukraine is not just mystical nationalism.

In my view, there are two huge logs fueling this fire. The first log was the ill-considered decision by the U.S. in the 1990s to expand NATO after — indeed, despite — the collapse of the Soviet Union.

And the second and far bigger log is how Putin cynically exploited NATO’s expansion closer to Russia’s borders to rally Russians to his side to cover for his huge failure of leadership. Putin has utterly failed to build Russia into an economic model that would actually attract its neighbors, not repel them, and inspire its most talented people to want to stay, not get in line for visas to the West.

We need to look at both of these logs. Most Americans paid scant attention to the expansion of NATO in the late 1990s and early 2000s to countries in Eastern and Central Europe like Poland, Hungary, the Czech Republic, Latvia, Lithuania and Estonia, all of which had been part of the former Soviet Union or its sphere of influence. It was no mystery why these nations would want to be part of an alliance that obligated the U.S. to come to their defense in the event of an attack by Russia, the rump successor to the Soviet Union.

The mystery was why the U.S. — which throughout the Cold War dreamed that Russia might one day have a democratic revolution and a leader who, however haltingly, would try to make Russia into a democracy and join the West — would choose to quickly push NATO into Russia’s face when it was weak.

He then includes a lengthy extract from correspondence with George Kennan from back in the 1990s:

I am going to share Kennan’s whole answer:

“I think it is the beginning of a new cold war. I think the Russians will gradually react quite adversely and it will affect their policies. I think it is a tragic mistake. There was no reason for this whatsoever. No one was threatening anybody else. This expansion would make the founding fathers of this country turn over in their graves.

“We have signed up to protect a whole series of countries, even though we have neither the resources nor the intention to do so in any serious way. [NATO expansion] was simply a lighthearted action by a Senate that has no real interest in foreign affairs. What bothers me is how superficial and ill informed the whole Senate debate was. I was particularly bothered by the references to Russia as a country dying to attack Western Europe.

“Don’t people understand? Our differences in the Cold War were with the Soviet Communist regime. And now we are turning our backs on the very people who mounted the greatest bloodless revolution in history to remove that Soviet regime. And Russia’s democracy is as far advanced, if not farther, as any of these countries we’ve just signed up to defend from Russia. Of course there is going to be a bad reaction from Russia, and then [the NATO expanders] will say that we always told you that is how the Russians are — but this is just wrong.”

It’s EXACTLY what has happened.

And that is one of the things I meant in my first post this morning by “botched foreign policy”. Thirty years ago we should have exerted our utmost efforts at incorporating the post-Soviet Russia into Europe. Instead we went out of our way, as the quote documents, to alienate post-Soviet Russia from Europe. But that’s not all

  • We should not have dismembered Yugoslavia into ever-smaller ethnic enclaves, moved NATO troops into them, and bombed Serbia.
  • We should not have invaded Iraq, a sovereign state, without Security Council authorization and without having been attacked by Iraq.
  • We should not have spent the last 20 years wearing down our military in Afghanistan.
  • We should not have deployed our own troops in Syria in aid of the anti-government rebels.
  • We should not have allowed ourselves to become dependent on China.

What’s the relationship between those mistakes and the present situation? The dissolution of Yugoslavia began with the EEC’s recognition of Croatia as an independent state. What right did it have to do that? Do you believe that today’s Russia would have approved that recognition by the United Nations? Or was that recognition an artifact of Yeltsin’s Russia? How can we complain coherently that today’s Russia has no right to recognize Donetsk as an independent state?

Is invading sovereign states that have not attacked us and pose no material threat to us right or wrong? After invading Iraq how can we complain coherently that it is wrong?

Is aiding rebels in opposition to the legitimate government of a sovereign state right or wrong? After our actions in Syria how can we complain coherently that Russia has no right to aid rebels opposed to the Ukrainian government?

And with respect to the other two bullet points, if you’re going to make out like a tall dog, you’ve got to be a tall dog.

Do I support Russia? Absolutely not. I agree with Tom Friedman’s conclusion:

Countries and leaders usually react to humiliation in one of two ways — aggression or introspection. After China experienced what it called a “century of humiliation” from the West, it responded under Deng Xiaoping by essentially saying: “We’ll show you. We’ll beat you at your own game.”

When Putin felt humiliated by the West after the collapse of the Soviet Union and the expansion of NATO, he responded: “I’ll show you. I’ll beat up Ukraine.”

Yes, it’s all more complicated than that, but my point is this: This is Putin’s war. He’s a bad leader for Russia and its neighbors. But America and NATO are not just innocent bystanders in his evolution.

I have no idea how the U. S. and our NATO allies will extricate ourselves from this mess. I agree with those who are saying we’re all going to lose.

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