Diversity and Health Care
Ezra Klein got the following question doing some live-chatting:
Lexington, Va.: Hey Ezra – I really enjoyed your article, but I’m wondering, with all the references to European-style health care, what role homogeneity plays in the success of these systems? Many European countries are far less diverse (economically, ethnically, etc.) than the US, and going beyond Europe, Japan’s population is almost entirely homogeneous. Don’t these systems that you have mentioned depend largely on the ease of applying universal care to a population that doesn’t vary from person to person like the US does?
Ezra Klein: Not really. Some of those countries are more and less diverse than others, for one thing. And it’s not as if Montana, which isn’t very diverse, has an awesome health-care system. It’s arguably the case that there are fewer political obstacles in a more homogenous system because it’s easier for voters to feel connected to one another. But there’s no real reason national health insurance should work with 20 percent diversity but not 35 percent diversity.
To back this up with a bit more in the way of demographic information, there’s no objective measure of which society is “most diverse” but I think in a commonsense way the most ethnically and religiously diverse European country is probably France, which is also the country with what’s probably the best health care system. In a different sense of diversity, Belgium is strongly binational, which creates a lot of problems, but hasn’t prevented them (or Canada for that matter) from constructing a reasonable health care system. Meanwhile, citizens of super-homogenous Japan are extremely healthy but my understanding is that their health care system actually delivers a pretty low standard of care.
I think what you can say about America’s diversity and health care is that segregationist sentiment was a major impediment to creating a universal health care system back in the 1930s, 40s, and 50s as there was fear that a national health care system would come under pressure, like the military, to be desegregated
37 Responses to “Diversity and Health Care”
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July 27th, 2009 at 4:50 pm
It’s a little simpler than that even. Racial resentment in the US has been a huge obstacle to social democracy, full stop. Because, basically, it’s undermined the assumption that the “less fortunate” are also “people like me.”
One hopes we’ve gotten over that. I guess we’ll find out.
July 27th, 2009 at 4:58 pm
I think in a commonsense way the most ethnically and religiously diverse European country is probably France
Maybe ethnically, but religiously France is becoming overwhelmingly atheistic. Same with Japan. I wonder if there’s a link there?
If you believe in guardian angels (like 70% of Americans) and in heaven, perhaps you don’t value health care as much?
July 27th, 2009 at 5:01 pm
The subtext of that question makes my skin crawl.
July 27th, 2009 at 5:05 pm
Meanwhile, citizens of super-homogenous Japan are extremely healthy but my understanding is that their health care system actually delivers a pretty low standard of care.
Japan is #1 in life expectancy so that seems rather unlikely.
July 27th, 2009 at 5:06 pm
The subtext would make my skin crawl too. If I could figure out what the hell it was. Brown people are less healthy, or something?
July 27th, 2009 at 5:07 pm
That’s the thing. Every interpretation I try to put on the author’s question makes me feel racist.
July 27th, 2009 at 5:12 pm
“Don’t these systems that you have mentioned depend largely on the ease of applying universal care to a population that doesn’t vary from person to person like the US does?”
Key point – here in the United States each of us is a unique individual. Over there the foreigners are all pretty much alike.
July 27th, 2009 at 5:15 pm
the most diverse country isn’t france, it’s switzerland. french protestants, french catholics, german protestants, german catholics, italian catholics, and 25% of the population consisting of non-swiss nationals of diverse provenance.
July 27th, 2009 at 5:16 pm
Completely O/T, but this ‘Birther’ thing is getting more and more hilarious:
http://thinkprogress.org/2009/07/27/resolution-hawaii-birther/
After Limbaugh, Republicans now have to pledge loyalty to the teabaggers and birthers. How long until the KKK demands its due?
July 27th, 2009 at 5:24 pm
Well, it is the case that the U.S. has much more economic *inequality* than a lot of countries with universal healthcare—I suppose that’s a sort of “diversity.”
I don’t see how this is relevant to whether government-run healthcare would be workable, though it might be relevant to assessing the evidence that the U.S. system is really inefficient. Perhaps high inequality explains why our exorbitant spending doesn’t translate into measurable population-level benefits. Maybe most of our spending goes to relatively few people. So even though the population-level numbers are unimpressive, maybe the fraction of the population that’s spending all the money does have measurably better outcomes.
I don’t know, though, why high inequality would go to the workability of healthcare reform. If anything, it should make it easier: because of high inequality, the marginal cost of new government programs for most voters is steeply discounted.
July 27th, 2009 at 5:45 pm
Yglesias,
According to my 2001 World Fact Book, France is still 87% white, unlike the US which is only 60% white (the other 40% being mostly black and mestizo).
Los Angeles is the most diverse city in the world, and also has the lowest index of social trust.
———–
Multiculturalism doesn’t make vibrant communities but defensive ones.
“In the presence of [ethnic] diversity, we hunker down. We act like turtles. The effect of diversity is worse than had been imagined. And it’s not just that we don’t trust people who are not like us. In diverse communities, we don’t trust people who do look like us.” —Harvard professor Robert D. Putnam
It was one of the more irony-laden incidents in the history of celebrity social scientists. While in Sweden to receive a $50,000 academic prize as political science professor of the year, Harvard’s Robert D. Putnam, a former Carter administration official who made his reputation writing about the decline of social trust in America in his bestseller Bowling Alone, confessed to Financial Times columnist John Lloyd that his latest research discovery—that ethnic diversity decreases trust and co-operation in communities—was so explosive that for the last half decade he hadn’t dared announce it “until he could develop proposals to compensate for the negative effects of diversity, saying it ‘would have been irresponsible to publish without that.’”
In a column headlined “Harvard study paints bleak picture of ethnic diversity,” Lloyd summarized the results of the largest study ever of “civic engagement,” a survey of 26,200 people in 40 American communities:
When the data were adjusted for class, income and other factors, they showed that the more people of different races lived in the same community, the greater the loss of trust. ‘They don’t trust the local mayor, they don’t trust the local paper, they don’t trust other people and they don’t trust institutions,’ said Prof Putnam. ‘The only thing there’s more of is protest marches and TV watching.’
Lloyd noted, “Prof Putnam found trust was lowest in Los Angeles, ‘the most diverse human habitation in human history.’”
http://www.amconmag.com/article/2007/jan/15/00007/
July 27th, 2009 at 5:53 pm
How might diversity affect the universality of health care? Do doctors need to take different anatomy courses for black patients or something?
July 27th, 2009 at 5:53 pm
I wonder why Ezra can’t just knock that out of the park like he would with any other incredibly racist question. After all, the reason modern medicine works at all is that we are basically the same- all the arteries and veins are in the same place on every person, the serum chemistries should all fall into narrow ranges of normal, etc etc.
And when it comes to a society, what could be more homogeneous than America, home of the white bread, the corn flake, the processed meat shipped coast to coast, and the Red Delicious apple, which is the same in every supermarket in the land? We drive the same cars on the same roads to the same jobs at the same companies selling the same damn things to each other nationwide until we just want to SCREAM!
Except for a few African Pygmies and possibly some inbred Mormons, people are physically just as homogeneous world-wide as they are in their own living room. In terms of external factors, America is the largest and most homogeneous society the world has ever known.
Except, unfortunately, people without money (that’s half of us) do not have access to healthcare, higher education, or, typically good jobs and housing. That could be changed, if we want to.
July 27th, 2009 at 5:57 pm
@11: a classic example of the difference between correlation and causation.
Does ethnic diversity decrease trust? Or do reactionary racists ranting about ethnic diversity decrease trust?
Hmm. Who can say? I will say this, though — I’d rather sit next to just about anyone “black” or “mestizo” (??) than next to you, brother.
July 27th, 2009 at 6:10 pm
“They don’t trust the local mayor, they don’t trust the local paper, they don’t trust other people and they don’t trust institutions,’ said Prof Putnam. ‘The only thing there’s more of is protest marches and TV watching.’”
And the same thing would have been true of the Los Angeles of the 1920s, even though it was then the LEAST diverse of America’s major cities. (Los Angeles before WWII explicitly prided itself on being the most Anglo of major American cities). In fact, Los Angeles’ civic institutions have always been extremely corrupt and the population always extremely distrustful no matter how diverse or not the city was, precisely because the primarily Anglo Los Angeles elite repeatedly and visciously abused and manipulated any amount of trust offered to them.
Oh, and by the way, Steve Sailer can go suck it.
July 27th, 2009 at 6:13 pm
Japan is homogenous? What about the Ainu, the true people of Japan, you racist otaku freak!
I apologize, I just wanted to call someone an otaku freak because I find it amusing.
July 27th, 2009 at 6:22 pm
“Among soldiers and college football players, for instance, co-operation between the races is up due to an increased emphasis on a common transracial identity as Christians.”
Since modern fundamentalist Christianity emerged precisely in 1910s/1920s Los Angeles (for example, see Charles Fuller, Biola University, Lyman Stewart and his seminal underwriting of The Fundamentals, Aimee Semple McPherson, etc), that would indicate that 1920s Los Angeles would have been the MOST trustworthy city of the time. Instead, of course, Los Angeles in the 1920s was corrupt to a ludicrous degree, to the point where a police chief fired 20% of his own department for corruption.
July 27th, 2009 at 6:30 pm
The reality-based community.
July 27th, 2009 at 6:50 pm
Japan is homogenous? What about the Ainu, the true people of Japan, you racist otaku freak!
I apologize, I just wanted to call someone an otaku freak because I find it amusing.
The Ainu aren’t the true people of Japan any more than the Irish are the true people of Britain – they were a people particular to the distant northern islands who existed alongside the Yamato Japanese until they annexed northward to expand grain production. The “true” indigenous people of Japan would be the Jōmon, who seem to have disappeared around 400 BC after the Yayoi in-migrations that later coalesced into Yamato culture.
That’s the thing about showing off your pedantry; there’s always a bigger pedant.
July 27th, 2009 at 7:08 pm
Challenging the widely held view that race is a ”biologically meaningless” concept, a leading population geneticist says that race is helpful for understanding ethnic differences in disease and response to drugs.
The geneticist, Dr. Neil Risch of Stanford University, says that genetic differences have arisen among people living on different continents and that race, referring to geographically based ancestry, is a valid way of categorizing these differences.
http://www.nytimes.com/2002/07/30/science/race-is-seen-as-real-guide-to-track-roots-of-disease.html
July 27th, 2009 at 7:34 pm
I would say THE obstacle. It’s at the bottom of all the manipulations that enable the ownership class to bamboozle the serfs into voting against their own interests.
July 27th, 2009 at 7:48 pm
There is a substantial body of research that indicates that more diverse societies have more difficulty developing a substantial welfare state, see for instance this
http://www.j-bradford-delong.net/articles_of_the_month/W8524.pdf
paper by Alberto Alesina and Edward Glaeser attempting to explain why Europe has a much larger welfare state than the US. There seem to be three popularish reasons for why this might be difficult. 1) more diverse societies tend to find it more difficult to agree on priorities. 2) people have higher levels of altruism towards members of their in-groups and naturally form in-groups on the basis of race, 3) people have higher levels of altruism towards members of their in-groups and politicians (and others) seek to exploit differences in race to further their own agendas, not hard to believe. I can believe all three although find 1 & 3 less depressing and believe they are probably the most important. I also saw a study showing that Canada have been far more successful at fostering pan-ethnic identities amongst their citizens than the US which would seem to imply that diversity need not necessarily lead to the collapse of the welfare state.
July 27th, 2009 at 8:45 pm
France is definitely not a “homogenous” society.
There is a large, mostly white, Muslim minority that is not well integrated, to put it mildly, and quite large minority of African black, who are much more culturally distinct from the white European majority than “African-Americans” from the majority here (but somehow I never heard about political problems in France involving Black Africans).
Some measure of diversity could be given by a sign on a bank in Germany informing that the bank workers cannot open bank vault in about 20 languages. Instructions how to pay for public transit fares are in about 10 languages — I guess they take the risk that, say, Albanians will not do it correctly.
July 27th, 2009 at 8:54 pm
This question is stupid, but it at least touches on a real point: the countries with health systems (and other examples of social spending) that are the most successful have much lower poverty rates than the United States. The UK has comparable poverty rates, and might be a better comparison when we’re talking about achievable costs and benefits. A lot of folks who want increased public health care complain when conservatives bemoan the various flaws of the NHS… they say that other countries do it better so why won’t we? I think we tend to protest too much on that point; instead, we should’ve spent the last decade and a half vigorously defending the NHS and countering arguments against it (that tend to cherry pick things like months of survival with pancreatic cancer or whatever) instead of saying that it’s unfair to only look at the UK.
July 27th, 2009 at 8:54 pm
Canada is as ethnically diverse as the US with the added attraction of being officially bilingual etc. It hasn’t stopped Canadians from constructing a system that serves everybody not just the well-off.
You guys need to wake up and catch on that insurance companies are calling the shot.
Its about the health of your nation, not shareholder profits.
July 27th, 2009 at 9:09 pm
Johnnyk,
It’s not my nation – not any more. I’d sooner secede than be a part of this sinking ship.
July 27th, 2009 at 11:22 pm
“I’d sooner secede than be a part of this sinking ship.”
Davis: Best news I’ve ever heard. There’s the door.
July 28th, 2009 at 1:37 am
The implicature is totally racist. It’s about heterogeneity in skin color, and nothing else.
But let me speak frankly, Mr. Shankly: Southern religion is a huge problem here (@Why oh why). I mean, the South is, but the South sans its religion would be (and would have been) a much more tame creature
July 28th, 2009 at 1:40 am
@Serial Catowner
“And when it comes to a society, what could be more homogeneous than America, home of the white bread, the corn flake, the processed meat shipped coast to coast, and the Red Delicious apple, which is the same in every supermarket in the land? ”
A good song for your post (and one of my fav bands):
http://www.youtube.com/watch?v=5J8BLNXIExg
July 28th, 2009 at 6:46 am
While Japan probably does have lower standards of care than other countries (I don’t know, the worst I’ve had here was a cracked rib), it’s probably more due to the cultural tendency to not question authority. Just goes to show, there’s more than one variable kin assessing health care.
I’m currently in Malaysia on vacation and had a very interesting conversation just now with an activist journalist friend of mine, discussing the wealth/income disparity between the three major ethnic groups. There’s also no health care here, her poor mother just had a stroke and they’ve got no way to pay for it.
July 28th, 2009 at 6:51 am
France most ethnical and religious diverse? What the hell did the blogger drink? Or maybe spent to much time in cheap hostels in Paris?
July 28th, 2009 at 7:08 am
Why is it that whenever some right winger is moaning about diversity he always assumes that minorities want to live specifically around him? As a brown person who has lived in the more and less ethnically diverse west coast and midwest, I can say that no one ever moves anywhere thinking “if only I can live next to a guy who isn’t comfortable around people who aren’t the same color as me!” Diversity happens when people find an opportunity to do something in another location. More often than not, it is economic. Religious and political freedoms can also be a strong incentive. And with the exception of very conservative muslims, it has worked out well. India, China, Japan, Vietnam, Korea, and plenty of other nations have diasporas of neither the same ethnicity or religion as their host countries to high measures of success. And as many people have already noted, you need only look to the odd fact that Canada, Toronto in particular, has not exploded into a race war or failed state to see how this can easily work out.
July 28th, 2009 at 7:40 am
Diversity just doesn’t work. I know I don’t want to live in such a sewer.
———–
Multiculturalism doesn’t make vibrant communities but defensive ones.
“In the presence of [ethnic] diversity, we hunker down. We act like turtles. The effect of diversity is worse than had been imagined. And it’s not just that we don’t trust people who are not like us. In diverse communities, we don’t trust people who do look like us.” —Harvard professor Robert D. Putnam
It was one of the more irony-laden incidents in the history of celebrity social scientists. While in Sweden to receive a $50,000 academic prize as political science professor of the year, Harvard’s Robert D. Putnam, a former Carter administration official who made his reputation writing about the decline of social trust in America in his bestseller Bowling Alone, confessed to Financial Times columnist John Lloyd that his latest research discovery—that ethnic diversity decreases trust and co-operation in communities—was so explosive that for the last half decade he hadn’t dared announce it “until he could develop proposals to compensate for the negative effects of diversity, saying it ‘would have been irresponsible to publish without that.’”
In a column headlined “Harvard study paints bleak picture of ethnic diversity,” Lloyd summarized the results of the largest study ever of “civic engagement,” a survey of 26,200 people in 40 American communities:
When the data were adjusted for class, income and other factors, they showed that the more people of different races lived in the same community, the greater the loss of trust. ‘They don’t trust the local mayor, they don’t trust the local paper, they don’t trust other people and they don’t trust institutions,’ said Prof Putnam. ‘The only thing there’s more of is protest marches and TV watching.’
Lloyd noted, “Prof Putnam found trust was lowest in Los Angeles, ‘the most diverse human habitation in human history.’”
http://www.amconmag.com/article/2007/jan/15/00007/
July 28th, 2009 at 7:42 am
after the Yayoi in-migrations that…
You misspelled “yaoi”.
July 28th, 2009 at 11:01 am
“but my understanding is that their health care system actually delivers a pretty low standard of care”
What?! UHC, that incorporates the most advanced medical technology available, long, healthy lives, not to mention the variety and choice available —
Do you have any argument, data, or anything to back up this statement???
July 28th, 2009 at 12:05 pm
You know something weird is gong on when they call you crazy because you don’t trust the mayor. “What? You don’t trust Hizzoner? You don’t believe everything you read in the paper? You don’t think the bank is thinking only of you? You still count your change? What kind of paranoid freak are you?”
Well, call me crazy, but from now on I’m going to regard Putnam with a great deal of distrust, because what he’s deploring is simply healthy skepticism. Nobody ever suffered from thinking things over and reading the fine print before they signed, but members of the Jewish community who trusted Bernie Madoff because he was also a member of the Jewish community literally lost billions. Try telling them now that distrust is bad for their health, and their response might be bad for your health.
Should there be more skepticism in large communities? Of course there should. The concept of ‘mayor’ might be perfectly adequate to a town of 100,000 and hard pressed to serve well a city of 8 million.
The darkest days of American cities were when white Catholic police ran the city for the benefit of a WASP financial elite, with a cheering squad of daily papers. It should be a lesson to us all.
July 28th, 2009 at 3:03 pm
33 Davis Says: your comment is misleading. I’ve read those papers. That research found that diversity did reduce trust, but it was a relatively moderate to minor factor compared to other community level factors. It is a distortion to say that research found that diversity was a major or the major factor.
Furthermore, Putnam needs a refresher course is statistics. The actual models he estimated could not have found the interactions and other complex effects he claimed when he interpreted his own analysis. He wildly overinterpreted and misinterpreted his own regressions, which is sad. He needs to work with a competent statistician. He seems to be in over his head when doing regression analysis.