A Tale of Two Cities: What's Happening in Cascadia?

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I'm an American (and Irish) citizen from Seattle and often think about the differences between my home and our friend to the north—Vancouver, BC. I've had the benefit of always having some kind of insurance (though I didn't always have coverage for contraception). I have never had to file for bankruptcy due to medical bills, despite a $45,000 case of appendicitis and a $35,000 birth. Unfortunately, those aren't universal experiences. 

I've always been fascinated how the United States, despite being so advanced and spending so much on healthcare, can still rank so lowly in health outcomes. When I talk to friends and family in the UK, Canada, or Ireland about our healthcare, they're often baffled at how our system runs. "You send the ambulance away? But why?" "Because it costs $500 and I can drive myself for much less." My son's birth was uncomplicated and I delivered him myself in the hospital's bathroom, but received a $35,000 bill for the trouble. One of my cousins delivered her baby a couple of weeks later in Northern Ireland, received excellent care, and never saw a bill for the process because healthcare there doesn't have a fee-at-point-of-service model. She didn't have to get "pre-authorization" to birth her baby because that isn't a thing. Her health insurance company didn't say her unborn child couldn't be insured because he didn't have a birthday yet because that is recognised as absolutely ludicrous everywhere but in the US.  

We know that health and healthcare are different (though related) things, but what are the outcomes of such different social policy landscapes on the health of the people that live there? Do government social policies really make for better health? Let's discuss! 

Personal Responsibility

In the United States, there is a pervasive belief in the power of hard-work and perseverance—the Protestant Work Ethic*—to attain prosperity. While this is well intentioned, it also fosters the dangerous Victorian mindset of poverty as a punishment for poor choices. As Dan Zuberi quips in his comparison on social policy and health outcomes in Vancouver, British Columbia and Seattle, Washington, there is a myth that if the poor just “followed the rules” that their poverty would evaporate. That, if they would just do things in the “proper order” and somehow got themselves into school that they could alter their own situation. [1] This, of course, neglects to account for the high cost of tuition and childcare, the danger of losing health insurance by taking time from work for education, and the way that said individual might pay for basic necessities like food and shelter during the academic terms required to finish a degree.

Americans are expected to “bootstrap” themselves to success, even if it means doing so without the luxury of having boots. To support this devotion to “self-sufficiency” the United States federal government in 1996 passed the Personal Responsibility and Work Opportunity Act (PRWOA), which created two-year maximum terms and five-year lifetime caps on social welfare benefits. [1]

This Act, while attempting to encourage women to remain in the workforce, also penalizes them for leaving unsafe working conditions to search for something more appropriate (that is, safer or higher paying). It forces women to choose between “the money necessary to feed, clothe, and house their children” and finding the best possible employment to support their families in the long-term. Sharon Hays in her Flat Broke With Children decries the PROWA as a, “cruel social experiment foisted upon a vulnerable and powerless group in U.S. society.” [1] Unsurprisingly, many of the politicians who hoped to encourage economic development with this bill have not had to live under the conditions that it creates. 

Putting yourself through school is really expensive (really, really, really expensive) and juggling the task with child-rearing is challenging on the best days. For my family, sending me to graduate school is certainly the right choice, though it means that I sometimes miss bedtime for several days in a row or have to travel for a week to present at conferences. I miss a lot and don't know how I'd accomplish it without a supportive partner to help fill the gap, but having a partner shouldn't be a requisite for participating in higher education. I'm not inherently smarter or more deserving because I'm in a legally committed relationship with another adult. 

Families First

In contrast, the government of British Columbia sees itself as charged with the welfare of the residents in the province. In the Families First Agenda, the government declares both that, “our duty to protect and care for B.C.’s most vulnerable citizens is one that our government takes very seriously,” and that, “every British Columbian believes helping those in need and less fortunate is the right thing to do.” [2] The governments of British Columbia and Canada provide a large number of subsidies to families to support a high quality of life including (but limited to):

  1. childcare assistance
  2. housing assistance
  3. utilities assistance
  4. nutritional subsidies
  5. partial and full premium subsidies for the provincial single-payer healthcare system
  6. an annual subsidy for art lessons and supplies
  7. worker training programs [2]

While Washington State struggles to cover the remaining 8.65% percent of its residents which remain uninsured even while we still have the ACA, [3] British Columbia has no uninsured residents, despite not automatically providing free medical care as other provinces do. The province provides 800,000 residents complete waivers of Medical Services Plan (MSP) premium and another 200,000 receive partial waivers to cover the premium costs. Among the hospitality workers which Zuberi interviewed, the Vancouverite workers saw healthcare providers more frequently, experienced better sleep, and lacked the persistent fear of a medical emergency decimating the family’s finances which their Seattleite counterparts faced. [1]

Washington State provides some childcare subsidies to sufficiently impoverished families for specific purposes, but many families in need do not qualify. [4] To help fill the gap, groups like the Seattle Milk Fund–established in 1907 to help make up the nutritional deficits in the diets of Seattle’s children—provide childcare assistance for low-income families with at least one parents studying full-time for their first degree at qualifying public institutions. [5]

While helpful for the families who meet the necessary criteria, many do not qualify. The low-end of full-time care for a newborn in Seattle is between $1,300-$1,600 per month. For half-time preschool for a three-year old, the cost is approximately $800-$1,300 per month, [6] depending on neighborhood and school. This is far beyond the reach of many low-wage workers. A full-time, minimum wage job earns $19,385 in a year before taxes, so even a “low” $9,600 for annual childcare expenses is beyond what they can pay.

Although parental leave is linked to increases in birth weight, lowered risk of premature birth and lowered risk of childhood death, [7] the United States does not guarantee even a single day of leave (whether paid or unpaid) to new parents. The 1993 Family Medical Leave Act (FMLA) has limited provisions for up to twelve weeks of unpaid leave for “qualified” employees and Washington State makes a further provision for twelve more weeks of unpaid leave when employees qualify and there is “medical need.” [8] The qualifications include working for an employer with at least fifty employees within a seventy-five mile radius and having worked at least 1,250 hours within the previous twelve months.

These provisions leave many parents who work less than twenty-four hours in an average week or for small businesses unable to take time after birth to care for themselves and their children.  According to the Bureau of Labor Statistics, only 11% of workers have access to paid family leave. [9] In a nation with a 32% cesarean rate [10] and only 50% of babies breastfeeding at six months, [11] that is far, far too many birthing parents returning to work immediately after birth.

British Columbian parents, conversely, are entitled to 18 weeks of leave from the federal government and 37 weeks from the Province after the birth or adoption of a child. This time allows parents to establish a breastfeeding relationship (which does not come easily to all dyads), to keep their child cocooned from diseases like rotavirus which are prevalent in childcare settings, and fosters bonding time between the mother and child. Additionally, first-time, low-income mothers receive home visits during their pregnancy and for up to two years postpartum from a public health nurse. [2] To be eligible for this leave, Canadian parents need only have accumulated 600 hours of employment, [12] far less than their American counterparts.

Safe Lives, Healthy Lives

Separating the health policies from the social ones in Vancouver—and Canada generally—is difficult because, to the Canadian federal and provincial governments, they are intertwined. Healthcare access, in that model, is both a social service and a social responsibility which the government is responsible for ensuring. Rather than a “race to prosperity” as exists in America (where there are, as in any race, winners and losers), the Families First Agenda calls for collectivism, asserting that everyone deserves to share in British Columbia’s prosperity and espousing the interconnectedness of social service availability and good health through exercises like “Why is Jason in the Hospital?” [13] The general availability of social support has, as in many nations, translated into positive health outcomes for Canadians. 

Cascadia Life Expectancy in Years (2014) [14]

Cascadia Life Expectancy in Years (2014) [14]

Vancouver and Seattle have a smaller life expectancy differential, but the divide between British Columbia and Washington State generally is much more stark, particularly along the border. Dan Zuberi attributes much of this gap to the ways in which Vancouver and British Columbia prioritize urban planning and social programs for its residents, meaning that Vancouverite workers make more money and thus experience a higher quality of life. When British Columbia families are struggling financially or facing hardship, “the current Canadian system provides nearly double the supplement to families in Vancouver as the U.S. system provides in Seattle.” [1]

When families face one struggle, such as a health crisis like kidney failure or cancer, the outcomes in workers’ lives are starkly different in the two cities. In Vancouver, medical premium assistance, paid family leave, and paid vacation time mean that a family is much less likely to go bankrupt from a setback. In the United States, medical bills make up the single largest antecedent of bankruptcy filings, accounting for 2,000,000 cases per year. This translates difference in priorities translates to British Columbia fare better in a number of other key metrics than Washington State including teen births, infant mortality, smoking, diabetes, and heart disease. I have included a table below for reference. 

While Vancouverite workers interviewed by Zuberi unanimously described their neighborhood as “nice,” Seattleite workers were more likely to report feeling frightened and being the victim of crime around their homes. [1] With regard to specifically to gun violence, a study comparing Seattle andVancouver found that, “Despite similar overall rates of criminal activity and assault, the relative risk of death from homicide, adjusted for age and sex, was significantly higher in Seattle than in Vancouver (relative risk, 1.63; 95 percent confidence interval, 1.28 to 2.08).” [23]

The Take Away

While Seattle is a fairly liberal city, it is still governed by federal and state laws, which view personal and governmental responsibility fundamentally differently than the Canadian federal and provincial governments do. The United States government, through its decision to enact policies like the PROWA and the American Health Care Act (ACHA) directly place the responsibility for protecting families upon individuals, rather than, as British Columbia does, looking at the collective good.

For improvement in health outcomes to come to the United States–particularly for women who experience the poorest health and work the lowest paying jobs–there needs to be a shift in the paradigm of priorities. The United States must begin to value the work and lives of women and low-wage workers. The mindset espoused by politicians and particularly conservative constituents that women do not deserve paid leave after birth is sharply contrasted with a 2010 study showing that 76% of Americans support paid leave (81% of women, 71% of men). [24]

Questions to Consider

  1. What steps are needed to move public policy to reflect the truth of public opinion on issues like paid maternity leave?
  2. In Washington State, 30% of high school students report symptoms of depression. [25] Mental healthcare is difficult to access and sometimes quite expensive. As we face the potential of mental health coverage being rolled back even farther, how can we help support healthier youths to ensure that we have healthier adults as they age?
  3. How can we help reshape public perceptions about the benefits of less popular (but needed) social programs like welfare and a living wage? Is it our role to do that? If it isn’t, should it be?

* I'll note here that I'm a practicing Roman Catholic, not a protestant. I don't think any religion (or lack of religion) is inherently harder working than any other. 

Bibliography

  1. Zuberi, D. Differences that Matter: Social Policy and the Working Poor in the United States and Canada. Ithaca, NY: Cornell University Press; 2006
  2. Families First Agenda. Provincial Government of Canada. http://www.familiesfirstbc.ca/learn-about-families-first/full-agenda/
  3. Hill, A. Washington uninsured rate drops to 8.65 percent. King 5 News. 17 July 2014. http://www.king5.com/story/news/health/2014/08/18/14031422/
  4. The Childcare Subsidy Programs. Washington State Department of Social and Health Services. http://www1.dshs.wa.gov/onlinecso/wccc.shtml
  5. Requirements. Seattle Milk Fund. http://www.seattlemilkfund.org/category/how-to-apply/requirements/
  6. Source: What I paid every month for Rónán to be in preschool. The childcare struggle is my life.
  7. Rossin, M. The Effects of Maternity Leave on Children's Birth and Infant Health Outcomes in the United States. Journal of Health Economics. Mar 2011; 30(2): 221–239. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3698961/
  8. Pregnancy and Parental Leave. Washington State Department of Labor and Industries. http://lni.wa.gov/WorkplaceRights/LeaveBenefits/FamilyCare/Maternity/default.asp
  9. Van Giezen, R. Paid leave in private industry over the past 20 years. Bureau of Labor Statistics. August 2013 http://www.bls.gov/opub/btn/volume-2/paid-leave-in-privateindustry-over-the-past-20-years.htm
  10. Menacker, F. and Hamilton, B. Recent Trends in Cesarean Delivery in the United States. Centers for Disease Control and Prevention. http://www.cdc.gov/nchs/data/databriefs/db35.htm March 2010.
  11. Breastfeeding Report Card. Centers for Disease Control and Prevention. August 2014. http://www.cdc.gov/breastfeeding/data/reportcard.htm
  12. Employment Insurance Maternity and Parental Benefits. Service Canada: People Serving People. Government of Canada/Gouvernement du Canada http://www.servicecanada.gc.ca/eng/ei/types/maternity_parental.shtml#eligible
  13. What Determines Health. Public Health Agency of Canada/Agence de la santé publique du Canada. http://www.phac-aspc.gc.ca/ph-sp/determinants/index-eng.php
  14. Indicator Update: Cascadian Life Expectancy Increases. Sightline. 6 March 2013. http://www.sightline.org/research/long-healthy-lives/
  15. Party Time! Excellent!. Sightline.18 June 2014 http://daily.sightline.org/2014/06/18/partytime-excellent/
  16. Infant Mortality. Kids Count Data Center: Project of the Annie E. Casey Foundation. http://datacenter.kidscount.org/data/tables/6051-infant-mortality#detailed/2/2-52/false/133,38,35,18,17/any/12718,12719
  17. Infant mortality rates, by province and territory (Both sexes). Statistics Canada. Government of Canada/Gouvernement du Canada http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/health21a-eng.htm
  18. State Highlights: Washington. Smoking & Tobacco Use. Centers for Disease Control and Prevention. http://www.cdc.gov/tobacco/data_statistics/state_data/state_highlights/2010/states/washington/
  19. Statistics. Heart and Stroke Foundation. http://www.heartandstroke.bc.ca/site/c.kpIPKXOyFmG/b.3644453/k.3454/Statistics.htm#heartdisease
  20. Diabetes 2014. Washington State Department of Health. http://www.doh.wa.gov/Portals/1/Documents/5500/CD-DIAB2014.pdf
  21. Summary Report on Health for British Columbia from Regional, Longitudinal and Gender Perspectives. Provincial Health Services Authority. March 2010. http://www.phsa.ca/NR/rdonlyres/393C9C55-F19E-49DF-A566-A48CFC8592A0/0/BCHealth_Indicators_Report.pdf
  22. Coronary Heart Disease 2013. Washington State Department of Health. http://www.doh.wa.gov/Portals/1/Documents/5500/CD-HRT2013.pdf
  23. Sloan, JH. Kellerman, AL. et al. Handgun regulations, crime, assaults, and homicide. A tale of two cities.
  24. Family Leave and Paid Sick Days. Institute for Women’s Policy Research. http://www.iwpr.org/initiatives/family-leave-paid-sick-days
  25. Mental Health 2007. Washington State Department of Health. http://www.doh.wa.gov/Portals/1/Documents/5500/GHS-MENT2007.pdf