Keeping It Central
From health care to education, what the United States can learn from poorer countries.
Humility is a wonderful thing, because it lets you learn. It's also not one of the traditional traits of the United States. Every year, we tell other countries what they should do in terms of national security, economic policy, and even social norms. But what would happen if we tried learning from them?
Humility is a wonderful thing, because it lets you learn. It’s also not one of the traditional traits of the United States. Every year, we tell other countries what they should do in terms of national security, economic policy, and even social norms. But what would happen if we tried learning from them?
We might have a much stronger nation. By some basic yardsticks of human development, the United States is not living up to its global reputation and economic might. To equip today’s Americans for success tomorrow, here are some areas where the performance of poorer countries suggests we could improve.
Health. What do Chile, Costa Rica, and Cuba have in common? They’re not just Latin American countries that start with C — they’re all countries with higher life expectancies than the United States. It’s well known that the United States lags behind wealthy countries in Europe and East Asia in this area, but several countries with far less money to spend on health also outperform us.
Even Sri Lanka, which spends about $100 per person annually on health care between the public and private sectors, managed 99 percent vaccination rates for diphtheria, tetanus, and pertussis (DTP), hepatitis B, bacillus, measles, and polio in 2012. The United States, which spends close to $9,000 on health care per capita, clocked rates of 95, 92, 90, 92, and 93 percent, respectively, which was mostly an improvement over 2011.
How is this possible? In Sri Lanka, the public health system is at once centralized and far-reaching. In the United States, access to health care depends on location, income, and myriad other factors.
The resulting infant mortality among American children, which was worse than in 11 former Soviet bloc countries, has not been the nation’s only health problem. Reducing deaths of children under 5 to zero would still have left the United States with a life expectancy lower than Chile’s and Costa Rica’s.
No, at almost any age, Americans are less healthy.
Relative to poorer countries, we eat far more fatty food — well, we eat far more, period. We also pay more for the same health care goods and services, in part because doctors have an incentive to prescribe the costliest ones and patients have little incentive not to accept them. We don’t even allow the government to buy products in bulk for Medicare and Medicaid. Think any of that might matter?
Education. It’s not news that the United States lags far behind many European and East Asian countries in reading, math, and science. It is news, however, that the list of those countries now includes Vietnam. Don’t feel too bad — the Vietnamese, with their strong educational tradition, outscored quite a few rich countries on the most recent tests through the Program for International Student Assessment (PISA). And the tests cater to students trained by rote memorization, which doesn’t necessarily augur for future success as innovators and entrepreneurs.
But then again, Poland — which has an educational system more similar to ours — also finished high above the United States, spending about the same percentage of GDP on education, and thus far less per pupil. That said, spending per pupil varies widely across the United States. Adjusted for local prices, Vermont spends more than twice as much per public school student as California.
What can we learn from Poland? Sometimes it’s the simple things, like a uniform curriculum that mandates 18 classes a week of math and science for all students in grades 10 through 12, a greater emphasis on preparation for college, and a national shift away from vocational education. Centralized curriculums can save money through economies of scale in teaching materials and training, too.
Child welfare. American kids are better off than kids in the poorest countries, but not necessarily better off than kids in all poor countries. The problems occur from the start. Babies are more likely to enter the world with low birth weight in the United States than in Rwanda. The gross rate of enrollment in early childhood education (pupils of all ages divided by the population of children of statutory school age) stood at just 73 percent in the United States in 2011, lower than in dozens of other countries. Ghana manages 114 percent enrollment, Thailand 110 percent, Mexico 99 percent, and Suriname 88 percent. (Because children outside statutory ages can enroll, the gross figure can rise above 100 percent.) And all the way through to early adulthood, youths may face a higher homicide rate in the United States than in many poorer countries, especially in Asia.
Part of the problem is undoubtedly cultural. But the devolution of responsibility for the protection of children to the states may also play a role. Roughly one-quarter or more of children live in poverty in Alabama, Arizona, Arkansas, Kentucky, Louisiana, Mississippi, New Mexico, South Carolina, Tennessee, Texas, and the District of Columbia. Poor states, states with major cities in decay, and states with especially tight budgets tend to have the highest homicide rates — and almost all of the ones in the list above are among them.
There’s a common theme here. When national priorities aren’t actually taken care of at the national level, two things happen: First, some states lag behind others, and second, people in the leading states, where everything seems fine, don’t particularly worry about the laggards. But when everyone is taken care of at the national level — as in, say, Medicare — this disjoint can’t happen so easily. Standards are uniform and so, to a much greater degree than in state-managed systems like Medicaid, is funding. Most importantly, if the quality of service is lousy, even people in rich states will complain. Medicare is decent precisely because everyone gets it.
In many poorer countries, standards and funding for health, education, and child welfare are, like Medicare, the responsibility of the national government. Our system, by contrast, places much of the burden for these crucial contributors to well-being on the states. Some states just can’t hack it, and so the data make our nation look like a developing economy. But as the people of many developing economies know, centralization of strategy, standards, and funding is one of the best ways to move forward.
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