Social Policy: How Wide a Transatlantic Gap?

Everybody knows that the United States has no universal system of health insurance. As a result, 15% of its population is not covered. There is no question that being uninsured is unfair and brutal.

But let us look at the macro outcomes of this supposedly awful system. Let us look at incidence, mortality and survival rates. Americans turn out to be relatively and surprisingly healthy and well-serviced by their healthcare system.

This statement is not intended as a defense of the current health insurance system in the United States. It is, however, to suggest that if the results presented here were anonymized and you were asked to pick the country that has no national health insurance system, you might not necessarily pick the United States.

For almost all diseases, the incidence rates and the number of years lost to sickness are firmly in the middle of the European spectrum. That holds for strokes, as it does for heart disease, measured, in this case, as years lost.

Let us also look at cancers. If we take all cancers together, incidence rates are high in the United States. That could indicate noxious lifestyles or genetic predisposition.

However, it could also suggest a more vigilant system of diagnosis, that is to say that existing cancers are found and leave a trace in the statistics. And it might suggest better treatment, insofar as more victims survive to be counted.

Whatever the reason for high American incidence rates, cancer mortality rates are surprisingly low, falling toward the bottom of the European scale.

In other words, whatever the cause of high cancer incidence rates may be, in fact Americans do not die of cancer more than Europeans. Indeed, they do so quite a bit less so.

Much the same holds for survival rates. For the four major cancer killers (colorectal, lung, breast and prostate cancer), all European nations have worse survival rates than the United States. Either those Americans diagnosed with cancer are dying of other unrelated causes — or the care they receive must be beneficial.

Of course, these figures include the fact that 15% of Americans are not insured — and presumably receive substandard care.

If that could be factored out so that we were measuring the actual effectiveness of the U.S. healthcare system for those it covers, these figures would look even better.

That health care is not universal in the United States is deeply regrettable. But from a macro-health point of view, it does not seem to matter much.

It either means that health care and its availability do not mean as much to our chances of surviving into old age as the medical establishment would like us to believe — or it means that, in fact, the United States has some sort of de facto quasi-universal health system, although accomplished very inefficiently and at extremely high cost.

Let's move on to other forms of social policy. There, we see once again that the United States fits broadly into the lower half of the European spectrum. It may not be Sweden, but it is comparable to Italy, Switzerland, Ireland or the Netherlands.

Some of the benefits provided are on the low end of the European spectrum — unemployment benefits, for example.

However, if you look at total public spending on such benefits per capita, the United States ranks above the UK, Greece, Italy and Iceland.

For others, like public spending on childcare (as a percentage of GDP), the United States fits comfortably into the middle of the European spectrum.

As a fraction of the total economy, U.S. public social expenditure narrowly makes it into the European norm, sneaking in above Ireland. But because the U.S. GDP is greater than all European nations’, the per capita spending figures are higher than this rank suggests, coming above Portugal, Greece, Spain, Ireland and Iceland.

Public social spending means monies channeled through the state. In the United States, this is undeniably at the low end of the European spectrum.

But other avenues of redistribution are equally important: voluntary efforts, private but legally mandated benefits — and social spending channeled through taxes.

If we take all these together, the U.S. welfare state is more extensive than is often realized: The total social policy effort made in the United States falls precisely at the center of the European spectrum.

The Swedes allot almost twice the U.S. fraction of their GDP to social policy. But the actual spending per citizen in the United States is only about 30% less than in Sweden.

If we shift our focus to education, the contrasts across the Atlantic are, if anything, reversed. A higher percentage of Americans have graduated from university and from secondary school than in any European nation.

U.S. adults are, in this sense, better educated than Europe's. And in terms of total spending on education, the United States lavishes more money per child at all levels than any West European nation.

Europeans often believe that good U.S. schools are private — and serve only an elite. Yet, American education is, if anything, less privatized than most European systems. The percentage of American students attending private institutions at all levels is at the center of the European scale.

Simone de Beauvoir was convinced that Americans do not need to read because they do not think. Thinking is hard to quantify, reading less so. And read the Americans do.

The percentage of illiterate Americans is average by European standards. There are more newspapers per head in the United States than anywhere in Europe outside Scandinavia, Switzerland and Luxembourg.

The long tradition of well-funded public libraries in the United States means that the average American reader is better-supplied with library books than his peers everywhere outside of Scandinavia and a few other small nations.

They also make better use of these public libraries than most Europeans. The average American borrowed more libraries in 2001 than most of his European peers.

Not content with borrowing, Americans also buy more books per head than any Europeans for whom we have numbers. And they write — or at least publish — more books per capita than most Europeans.

Now let us go from high to low, from books to bookies, or crime. U.S. popular culture is fascinated by violence. Whether “The Godfather” or the TV series “The Wire”, the image America broadcasts about itself is that it is crime-ridden and violent.

Most foreigners have been content to accept that analysis at face value. Not that it is entirely untrue.

A horrendous number of murders is committed in the United States, almost twice the per capita rate of the nearest European competitors, Switzerland, Finland and Sweden. That is without question. Nor is there any doubt that the United States locks into prison a far higher percentage of its population than any of its peers.

But in most other respects, the United States is a peaceful and quiet place by European standards. The percentage of the population victimized by property crime, for example, is lower than in the UK and Italy.

For assault, the rate is in the middle of the European pack. Drug use in the United States is also well within the European scale — except for cannabis, which is a bit beyond the UK level. Opiate abuse is at the center of the European spectrum, as is white collar crime, like fraud.

For the fraction of the population victimized by all forms of crime, the U.S. figures fall in the bottom half of the European scale.

Editor’s Note: This is Part II of a five-part series adapted from THE NARCISSISM OF MINOR DIFFERENCES by Peter Baldwin, published by the Oxford University Press. Copyright 2010 Peter Baldwin. Reprinted with permission of the author.

Read Part I here.