Are faith and health care substitutes?

"Every single 1st world nation that is irreligious shares a set of distinctive attributes. These include handgun control, anti-corporal punishment and anti-bullying policies, rehabilitative rather than punitive incarceration, intensive sex education that emphasizes condom use, reduced socio-economic disparity via tax and welfare systems combined with comprehensive health care..." Gregory Paul and Phil Zuckerman.

People in countries with more public health care spending are, on average, less religious.

The plot below shows the inverse relationship between public health care spending (as a proportion of the total) and the proportion of the population attending a religious service once a month or more -- the relationship is strong and statistically significant.  

 

Attend monthly or more = -0.67*public health care spending + 0.84. Coefficient on spending significant at p=0.006. The data used to create these plots (downloadable here) is taken from the World Values Survey (for religious attendance) and the World Bank (for health care spending). 

This next plot shows the positive relationship between health care spending and the proportion of the population who never or practically never attend a religious service. Again, the relationship is strong and statistically significant.

 Never or practically never  =  0.54*public health care spending -0.09. Coefficient on spending significant at p=0.001. Data downloadable here.

But correlation is not causation.

Even a cursory inspection of the scatterplots reveals that the religion/health care relationship is driven, in part, by the fact that most rich countries tend to have well-developed public sectors and low levels of religiosity, whereas poor countries tend to have more private provision and higher religiosity.

That relationship is readily apparent when we plot religious participation against per capita GDP. (The GDP data is for 2007, in $US). A smaller proportion of people in rich countries attend religious services monthly or more:

For those of you who care about such things, here are some regression results.

Dependent variable:
Attend monthly or more	Coef.	Std. Err.	t	P>t	[95% Conf.	Interval]
Explanatory variables:
Proportion Public	-.133	.219	-0.61	0.546	-.574	.307
loggdp	-.111	.021	-5.37	0.000	-.153	-.070
Constant	1.53	.164	9.28	0.000	1.195	1.86

When both the proportion of health care spending that is public and the log of per capita GDP are used to explain religious attendance, it turns out that log of per capita GDP is a strong predictor of attendance, but public health care spending is insignificant.

I interpret these results as follows: the relationship between public health care spending and frequency of religious observance that we see in the raw data is largely explained by differences in religious observance between high and low income countries.

The same pattern is observed if we instead focus on those who never or practically never attend religious services:

Dependent variable: Never or practically never attend	Coef.	Std. Err.	t	P>t	[95% Conf.	Interval]
Explanatory variables:
Proportion public (of total health care spending)	.234	.149	1.58	0.122	-.065	.534
Log per capita GDP	.067	.014	4.77	0.000	.039	.095
Constant	-.517	.112	-4.64	0.000	-.742	-.293

Richer countries could be less religious for any number of reasons - for example, higher levels of education, a super-abundance of alternative forms of entertainment, or a rise in the opportunity costs of church going as wages increase.

There are also any number of reasons why richer countries might tend to have higher levels of public health care provision. They generally have well-functioning - or reasonably well functioning - systems of revenue generation and government infrastructure. People tend to live longer in rich countries, creating a greater need for care for older people, who can't always afford to pay for their own care. People are more mobile and have fewer children; the family is typically less important as an economic unit.  Health care is a normal, or perhaps even a "luxury good" - as countries get richer, the demand for health care increases sharply.

But whatever the reason, the fact that economic development affects both religiosity and public provision creates a correlation between the two variables in the raw data, even if there is no causal relationship.

But even once we control for economic development, there is a small - albeit statistically insignificant - relationship between health care spending and religion. Now there are probably more possible explanations for this relationship than there are countries in our data set, so we can never seriously test these alternative theories. But this is a blog post, so I'll just throw two out there.

My first explanation is religious competition. Economists who study religion have hypothesized the presence of a single dominant established church creates religious "monopolists." And monopoly, everywhere, tends to be inefficient. The religious competition model predicts that the presence of an official state church would tend to lead to a decline in religiosity.

At the same time, however, a state church can cooperate with government in the development of a welfare state (the so-called "Christian democratic" welfare state). Or religiously and culturally homogeneous societies -- i.e. those who share a common religion -- might find it easier to agree to fund and provide services through government. The idea is that when people are alike, and have the same tastes and values, it is easier to reach a consensus on the role of government.

These stories, taken together, explain the religious observance/health care correlation seen in the data. Countries like the United Kingdom with an established church (the Church of England) have high health care spending and low levels of religious observance; the US has lively religious competition, high observance and low spending. But these stories tell us that any health care/religious observance correlation arises because religious competition affects on both observance and the role of government. According to the religous competition story, there is no causal relationship between public health care spending and observance. (Note that I have no empirical evidence at all to support this story - recall that even the relationship between observance and public health care spending is statistically insignificant once per capita GDP is controlled for. So you can read it as an economist's fairy tale).

My second explanation is that there is a direct relationship between health care and faith. As I have argued before, churches provide social insurance, thus to some extent substitute for government-provided social insurance. I can see the argument that churches can substitute for welfare and other forms of income support. Religious communities reach out to the needy, providing food, and shelter, and clothing. But hip replacements?

Actually Paul and Zuckerman, the people quoted at the beginning of this post, appear to agree with the churches-as-social-insurance explanation, arguing "For instance, the absence of universal health care encourages the utilization of faith-based medical charities. The latter, as well intentioned as they are, cannot provide the comprehensive health services that best suppress mortality at all ages. But charities extend the reach of the churches into the secular community, enhancing their ability to influence society and politics, and retain and recruit members." It sounds implausible (and again, remember the relationship between public health spending and observance is statistically insignifcant controlling for per capita GDP). But there actually is something in the US called "parish nursing", where nurses provide basic public health care through religious organizations. 

The flip-side of the churches-as-social-insurance argument is the doctors-as-priests argument. A little while ago I wrote about the idea that doctors are "a new priesthood" - the search for health becomes a type of religious ritual. A doctor and a prescribed course of treatment - pills, yoga, eat this, don't eat that - substitute for the structure that religion imposes on our lives.

But perhaps there's a simpler explanation.

Without public health care, people are more inclined to get down on their knees and pray that God keeps them - and their families - safe and well.

Comments

[Determinant]

Two things. First, the Church of England is Established in the sense that it is explicitly subordinate to Parliamentary control, though that is rarely exercised nowadays. The appointment of bishops on the Church of England has even been removed from direct Prime Ministerial control thanks to Gordon Brown, a member of the Church of Scotland which is Presbyterian. He had religious qualms about making those appointments.

More important is the Tithes Commutation Act, 1870 which removed the payment of tithes (compulsory church taxes, often paid in kind) to Church of England parishes. The Church of England may be established but it receives no monetary support from the government that other churches don't and hasn't for 150 years.

Second, what's so strange about religious hospitals? How many St. Joseph's Hospitals to we have in Ontario? The Sisters of St. Joseph, aka the Grey Nuns were extremely active in this area. Their work was charitable though like most charities it wasn't universal in coverage and there were always gaps. Most hospitals founded before WWII had a religious backing at one time. Toronto's Hospital for Sick Children was founded by Elizabeth McMaster, wife of William McMaster who founded the university of that name. The McMasters were Baptists and McMaster University was a Baptist foundation.

Canadian health care has always had a strong religious component.

[Frances Woolley]

Determinant:

This blog post is about the idea that the differences between the US and Canada in terms of religious observance are due to differences in the amount of public health care spending.

Your observations are interesting, but I don't see how they relate to the topic at hand. Do you agree or disagree with the proposition that public health care spending has an impact on religious observance? Why?

[Frances Woolley]

Determinant, I have not appreciated the tone of your recent comments on the blog, and have unpublished your most recent comment.

[hosertohoosier]

I'm going to echo Determinant's remarks on the connections between religion and public healthcare in the Canadian case. Public healthcare first emerged in the prairies, promoted by the NDP. However, this wasn't the urban granola-munching Birkenstock-wearing NDP of today. Prairie CCF'ers/NDP'ers were strongly influenced by the social gospel. The two towering figures of the party (Woodsworth and Douglas) were ordained ministers. And while election survey data from that era does show the NDP supporters to be least likely to attend church (of the three national parties), Liberals - who actually implemented Medicare - were the most likely. For those voters (many of the Quebec Catholics), Medicare was not a substitute for private charity.

I do think there is something interesting here - I was struck with an interview I recently saw of Rick Santorum, for instance. He challenged the view that you can simply have small government. Rather, he suggested that without government, you need morally upright people (in part to provide charity).
However, I think the content of different religions (or of different factions within religions) is worth exploring.

There is a tradeoff for churches in terms of accepting a greater public role in the provision of social welfare. On the upside, they accomplish the social welfare goals that most religions endorse. On the downside, religious organizations lose their ability to influence the moral habits of poor people, who would otherwise be reliant upon private charity. For social gospel protestants, or liberation theology Catholics, the upside outweighs the downside. Not so for people whose faith more heavily weights moral purity. In North America, the awakening of the 1960s is important in this respect. The evangelical turn of many Christians allowed a realignment of religious voters with the right (though as late as 1976, the Democrats were able to win the evangelical vote).

[Livio Di Matteo]

Hello Frances:
Interesting post. Just a few quick thoughts. One of the roles of religion in economic development that I've come across is as a network to provide economic opportunities via social contacts. Along with the official role of religious organizations in care provision, there is also the informal role that social groups provide for one another. In poorer countries, religious organizations may provide more formal health services in lieu of better developed public care. In addition, those same religious congregations may be providing health support services for each other because of their better developed social group and friends via care visits, meals, etc...There may be medical benefits to social interaction opportunities provided by organized religion. You may also want to divide your sample of countries into developed and less developed (say a per capita GDP of 3,000-5,000 dollars U.S. as the dividing line) to control for if higher income countries also spend more on public health care because of differences other than income. The income elasticity of health spending, both public and private, is generally positive.

[Frances Woolley]

hosertohoosier - the public-health-care-erodes-religion idea seems to be circulating among evangelical protestants - that's how I heard about it anyways. It offers a coherent explanation of why people would oppose a policy - better health care coverage - which appears to be in their interests.

Livio - thanks for the comments. If I was taking this forward the next thing that I'd do is control for major religions/denominations. E.g. it puzzled me that Iran has a relatively low rate of people attending monthly or more. But then I thought - the World Values Survey is sampling both women and men, and perhaps women don't attend services that often. In general, different religions expect different degrees/types of religious practice. Also given the repression of religion during the communist era it would make sense to include a 'former communist country' control.

[Jacques René Giguère]

Montral La Presse columnist Pierre Foglia may have said it best
"When there is justice, there is no need for charity."

[Nick Rowe]

Jacques: but didn't David Hume, IIRC, say it exactly the other way around? If there is charity, there is no need for justice? (Very loose translation, of course.)

[Min]

I wonder about fatalism in a culture. To what extent is fatalism associated with both religion and low national income?

[Patrick]

If your religion tells you to go implement social justice (e.g. MLK), then universal health care of some form sorta flows naturally from that. On the other hand, if your religion tells you that material success, and thus ones ability to buy health care, is a proxy measure of moral rectitude, then something like universal health care will be viewed as promoting sin. After all, those who were on the straight and narrow and in tight with the Lord would be prosperous enough to pay for a doctor.

[Frances Woolley]

Patrick - "If your religion tells you to go implement social justice (e.g. MLK), then universal health care of some form sorta flows naturally from that."

So if it turned out to be the case that, in general, an increase in religious belief caused a reduction in support for universal health care, does this mean that, on average, religions do not support social justice- that is, they prefer charity?

Are there many religions that actually equate material success with moral rectitude? Yes, that view is sometimes associated with Protestantism, but there's that line along the lines of: It is easier for a camel to go through the eye of a needle than for a rich man to enter the kingdom of God. The theologian at the other end of the sofa points out that you don't need religion to point out the value of money, that's pretty obvious. Religions are more likely to preach the value of abstinence, sacrifice, deferring pleasure. Because we need to refrain from eating the seed corn (or the marshmallow), but it's hard.

Min - I think someone wrote something about this recently. I suspect it's important.

Jacques, Nick - nice.

One other possible avenue for the link between increased GDP and never practicing religion is the secularization of holidays and festivals. The question asks "apart from weddings, christenings and funerals, how often do you attend religious services?"

In a country where all sorts of festivals and holidays, e.g. the Festival of Light, still have religious significance and are celebrated in their religious context, then you won't get many people saying that they never or practically never attend religious services.

But when Hallowe'en stops being the warm-up to All Saints Day and starts becoming an excuse to eat chocolate, when Easter is no longer an opportunity to celebrate Christ's resurrection and starts becoming an excuse to eat chocolate, when Christmas no longer an opportunity to celebrate the birth of Jesus and starts becoming an excuse to eat chocolate... The point is, when holidays are commercialized and detached from their spiritual origins then there's less reason to attend religious services.

[Determinant]

http://www.adherents.com/loc/loc_vermont.html

Following on from Hosiertohoosier, Vermont, which recently enacted a single-payer health system has, as is typical for New England, a high proportion of United Church of Christ or Congregationalist, with 4% of the population as members and they have largest number of church buildings in the state. The UCC is the most liberal mainline Protestant church in North America. They public a sex education program for churches to run that puts everything else I have ever seen to shame. The public school system can't hold a candle to it.

The United Methodist Church, also liberal especially when it comes to social programs to ameliorate poverty (a historic Methodist interest), claims the allegiance of 5% of Vermonters. The Roman Catholic Church claims 25%. A warning that reports of "membership" with respect to churches is very context dependent. You will see far more marginal, nominal Catholics than people who claim to be marginal Methodists for reasons that are not strictly relevant here.

The combined total of the UCC and the UMC is 9% which matches up nicely to their equivalent, the United Church of Canada north of the border, as does the reported Catholic sample. So Vermont is very much like Canada religiously. And we both have single-payer systems.

Going south, you won't find many United Church of Christ members or churches in a southern state like Georgia. The UCC descends from the Pilgrims of Plymouth fame so it's common in New England but not elsewhere. Down south the largest Protestant church is the Southern Baptists who wouldn't even think of running the UCC's sex-ed curriculum and have recently rescinded the provision for women's ordination. I don't believe they support single-payer health care either, or just prefer not to even discuss it whereas the United Church of Christ will happily do so.

Religion is a reflection of a person's attitudes and it serves to shape and strengthen those attitudes. "Social Gospel Protestants" like the United Church of Canada, the United Methodist Church and the United Church of Christ have a long history of advocating for socially progressive laws so given Vermont's demographics the fact that it now has a single-payer system is not surprising.

[Determinant]

Meant to add: This is why Georgia is filing suit against the Obama health plan and while Vermont is implementing its universal Green Mountain Care plan.

[Jacques René Giguère]

Frances:
Didn't Halloween, Christmas and Easter ( all pagan feasts to begin with before they were kidnapped by the new Church, along with local deities transformed into local saints and the mass conversions of priests),lose their religious significance before becoming chocolate celebrations?

In the former meaning of words, "charity" was very close to "justice", the three virtues being faith, hope and charity.

Catholicism and other Christian denominations with hierarchical state-like structure (inherited from the Roman empire, up to the division into diocese, one bishopric for each governorate) lead themselves more easily to modern centralized systems. Moreover,Catholic theology puts emphasis on good deeds while most Protestant insist on faith alone.

Determinant: indeed, you can easily be a marginal (usually known as "cultural") Catholic. Most Québécois are. Our former heavy Catholicism was far more a way of creating our own cultural space than about discussing theological niceties.
As the Italian said to the Mormon missionary:"How can I believe in your god? I don't even believe in the Real One!"

[Determinant]

No argument on that one. But when you ask people to self-identify for religious surveys, you get really high Catholic numbers and low Protestant numbers, but the Catholic numbers don't match actual counts of Sunday attendance.

Plus most Protestant churches ask you to make a Profession of Faith before becoming a Member, which in churches organized along Presbyterian lines like the United Church of Canada grants a person a vote in the Congregational meeting and the ability to stand for committees, including the Session which is heavily involved in Sacramental administration.

Plus your name is added to the Congregational Roll and the congregation's Presbytery Dues, the money we pay towards the higher courts, Presbytery and Conference increases. I chair my church's Session and we have been trimming the roll of people who have died, moved or can't be contacted. A name costs us $20/yearin Presbytery dues so we keep our Roll accurate.

Counting heads in church to determine attendance and allegiance is not a simple business. Different churches mean different things by "membership" and how "sticky" their self-identification is. Church membership is not like citizenship, you have it or your don't.

[Frances Woolley]

Jacques Rene - "Catholicism and other Christian denominations with hierarchical state-like structure (inherited from the Roman empire, up to the division into diocese, one bishopric for each governorate) lead themselves more easily to modern centralized systems..."

Absolutely. That was the idea I was getting at in the post when I talked about established churches. There's a large public policy literature that talks about this.

On holidays losing their religion significance prior to chocolatification - do you mean their original pagan, pre-Christian significance? Or their Christian significance? I don't actually know what the trends on church attendance in Canada are.

The discussion on differing attendance rates suggests that the extent of religious belief might be sensitive to the measure of faith used.

Determinant, that church governance information is interesting.

[Jacques René Giguère]

Frances:
The Christian one. We are , in a way, slowly reverting to paganism. I don't mean human sacrifices ( we have better uses for virgins and according to public rumor in my classes they seem to be very scarce). I mean, we are ditching the theological mumbo-jumbo. we have, in modern civilized social-democratic countries at least ( U.S. South not being a MCSDC), built a workable application of Christianity while understandinging that belief in ,let's say in all respect for believers, transubstantiation or virgin birth is unnecessary for an efficient welfare state.
So we can get back to celebrating nature. And xocolatl is after all, in its very name, the gift of the gods...

[Determinant]

"Absolutely. That was the idea I was getting at in the post when I talked about established churches. There's a large public policy literature that talks about this."

Whoah, whoah, whoah. There is a huge minefield here.

Take two established churches, the Church of England and the Church of Greece. The Church of Greece (Orthodox) has its clergy paid by the state at teacher's salary rates. It also has church taxes that fund it; other Christian denominations get a very cold reception in Greece by the state. Roman Catholics, for instance, find it very hard to get corporate recognition for their parishes and have constant property trouble in Greece.

The Church of England, OTOH, has not received tithe (property tax) income since 1870, receives no church taxes and no state funding at all like the Church of Greece does. It is subject to parliamentary control in some areas but these controls have been greatly weakened since the 1920's. There has been no legal religious intolerance by the UK since Catholic Emancipation in the 1830's.

The true test of Establishment is a) does the church in question receive state funding through taxes and b) does the state actively discriminate in favour of its established denomination.

Unless you are the Royal Family in England that answer is no for all practical purposes. In Greece the answer is yes.

Furthermore, before we get onto the centralization idea, for most churches that are not the Roman Catholic Church that simply isn't true. In churches organized along Presbyterian lines like the United Church of Canada, that emphatically is not the case. We are a bottom-up church. So is the Presbyterian Church in Canada and the Baptist Conventions. So, for that matter, is the Church of Scotland which does not accept state control in any matters spiritual, the last vestiges of this were removed in 1929. The matter of State interference in Church affairs caused the Great Disruption in 1843.

In Presbyterian churches in order to change doctrine one iota you have to have a Remit, which means passing a measure at the national court (General Council in the United Church) then sending it down to Presbyteries where it has to get a 2/3 majority and also to individual church Sessions where it also has to get a 2/3 majority of all Sessions. Then it has to go back to General Council again for another approval at the next triennial Council. The whole process comes from the Church of Scotland and was enacted in the 1690's.

The Anglicans, even though they have bishops have had elected synods with large lay representation since the 1850's. They are very much democracies though not as much as the United Church is.

The Roman Catholic Church is much more of a top-down organization, every other large church is much more bottom-up. That's just history.

When it comes to churches the general rule I hope to have illustrated above is that for every way of doing things there is someone else doing things the exact opposite way. Christianity is a minefield of diversity.

[Frances Woolley]

Determinant -

This is how an economist thinks.

Look at churches. Look at their market share (% of population who adhere to a particular church). The hypothesis is: when one church has most of the market share - "there is a single dominant established church" - it won't be as efficient at producing religious activity among the population. Just as Rogers, with a large share of the cable TV market, has a voice recognition phone system that is difficult to use.

These various aspects of churches' institutional structures are only relevant to this post the extent that they impact the degree of religious competition and/or the interaction between church and state.

(And 90% or more of the readership will have assumed that I used established in the #1 most common sense of the word: "Established: 1. (of a custom, belief, practice, or institution) Having been in existence for a long time and therefore generally accepted.
2. (of a person) Recognized and accepted in a particular capacity.")

But in the context of the Church of England - from a policy point of view, the fact that the Lords Spiritual continue to represent the Church of England in the House of Lords, and have the power to vote on and speak on legislation - which they do in fact use - means there's a pretty good case for saying that they still have some ability to influence policy. And historically, of course, they have had much more.

And when you own as much land as the Church of England does, the need for taxpayer support is reduced somewhat. The big issue in England is the maintenance and preservation of church properties - and there is government funding for that, through the National Lottery.

[Determinant]

The National Lottery also goes to non CoE places, of which there are many like the Methodist Church's Westminster Central Hall. I also subscribe to a religious chat board with tons of Church of England members, my information comes from interaction with them personally.

What I have attempted to illustrate is that religious adherence surveys are very unreliable. They ask about identity and culture and different churches have different ways of expressing that. That drastically reflects the survey results, a point which Jacques seconded. What is meant by membership, adherence and attendance in a survey is cultural-context specific and there is very little way to control for that.

Second, that tangent on centralization was not helpful and went against the evidence. I can understand why Jacques would bring it up given his background, my rebuttal was that other churches do things differently, much differently and other large churches have been bottom-up organizations since the 1600's. That was Reformation theology and history.

I do feel that that tangent was straying from economics into theology and I wanted to provide counter evidence to show that the tangent was unhelpful.

Third, Established has a specific meaning in church contexts. The CoE currently gets very little state favouritism. The Church of Greece gets much more. The Church of Sweden was recently Disestablished officially but it still the largest church in Sweden. My point is to look past the "Established" label and identify actual state supports and preferment for a specific church, to identify the underlying economic substance.

Fourth, and this is still true, church membership is culture-specific. The reason there are so many churches in North America is that both the US and Canada are immigrant societies. It even explains the difference in church rankings. For instance the second largest Protestant church in the US is the Evangelical Lutheran Church of America, which is Scandinavian and German in background. It's counterpart in Canada is fifth nationally. The second largest Protestant church in Canada is the Anglican Church. German and Scandinavian immigration was much heavier to the US than to Canada while we had more English and Irish immigration. The Anglican and Lutheran churches in both countries flip places in the rankings. There are many other examples.

Lastly, there is the matter of doctrine. Churches do not change their ideas as easily as business do their products. When you regard your beliefs as a truth, it follows that you won't convince everybody if you stick to your ideas. You can't be all things to all people. In fact being faithful to your ideas may require you to let some people go. It happens, a lot.

I am trying to show you the diversity and depth when it comes to religion. The hypothesis and test you proposed Frances overlook so much that directly impacts on results and how that are measured that I feel they need to be illustrated more fully.

[Rachel Goddyn]

I have lived most of my life in Vancouver and I stopped going to church as soon as my parents would let me. But when I lived in Louisiana for 6 months I joined the Unitarian Universalist Church because in the deep south church is where you make social connection. There were no community centres, few play grounds, no public pools. Also I decided to homeschool my son for the time we were there rather than trying out their questionable school system. All the metal detectors around the school doors were rather off putting. The UU church was great with activities of all kinds and friendly like minded folk. It is certainly true that the lack of public facilities, though not health care, make me go to church.