Beyond the mandate

MARCH brought frenzied attention to Barack Obama's health law. The Supreme Court heard arguments over its constitutionality. Outside the court, supporters waved their neatly printed posters and tea-partiers waved their scrawled, angry ones. The ruckus centred on Mr Obama's mandate to buy insurance. America is the rare Western country without a universal insurance scheme. But, as a new study points out, a lack of insurance is only part of America's health problem.

On April 3rd the University of Wisconsin and the Robert Wood Johnson Foundation, a philanthropic outfit, released a new report on health in America's counties. The report is part of a string of efforts to sort through the mounds of data on health and the factors that affect it. The jumble of information does not reveal a perfectly clear picture. But it begins to illuminate the particular nature of America's health and why it is so dismal.

America, it is often noted, spends more on health care yet has worse results than other rich countries. Its infant-mortality rate, for example, is double that of Sweden, Germany and France (to name only a few). A closer look reveals conflicting trends within America itself. A recent ranking of states' health, sponsored by the foundation of UnitedHealth, America's biggest insurer, was filled with contradictions. America is making good progress to reduce smoking and the toll of infectious disease, yet diabetes rates are climbing and tens of millions remain uninsured. The north-east is a picture of health compared with the South. Vermont, New Hampshire and Massachusetts are among the five healthiest states; Mississippi, Alabama and Louisiana are the lowest. Resources vary wildly from one state to another. Massachusetts has 192 primary-care doctors for every 100,000 people; Idaho has just 78. Behaviour is similarly spotty. In Florida whites are 30% more likely to smoke than blacks. In Minnesota the reverse is true.

The new report takes an even closer look, inspecting data for more than 3,000 counties. The authors, led by Bridget Booske Catlin of the University of Wisconsin, rank each state's counties according to health outcomes: premature death, poor mental and physical health and low birth weights for babies. Separately, they examine the factors that influence health, such as clinical care, income and behaviour.

Wide gaps existed within each state. The five least-healthy counties generally had more than twice the teenage birth rate of the five healthiest counties, and more than twice the share of poor children. Within counties, factors seem to contradict one another. In Putnam, New York's healthiest county, 29% of adults are obese, compared with 28% in the Bronx, New York's least-healthy county. Putnam also has higher rates of binge drinking—21% compared with 14% in the Bronx. Yet the Bronx has lower education rates, eight times the rate of teen pregnancies and New York's highest concentration of fast-food restaurants. Lack of insurance, therefore, is only part of the puzzle.