None of these suggestions will come as a revelation to the policy experts who put together Obamacare or to those before them who pushed health-care reform for decades. They know what the core problem is—lopsided pricing and outsize profits in a market that doesn’t work. Yet there is little in Obamacare that addresses that core issue or jeopardizes the paydays of those thriving in that marketplace. In fact, by bringing so many new customers into that market by mandating that they get health insurance and then providing taxpayer support to pay their insurance premiums, Obamacare enriches them. That, of course, is why the bill was able to get through Congress.
Obamacare does some good work around the edges of the core problem. It restricts abusive hospital-bill collecting. It forces insurers to provide explanations of their policies in plain English. It requires a more rigorous appeal process conducted by independent entities when insurance coverage is denied. These are all positive changes, as is putting the insurance umbrella over tens of millions more Americans—a historic breakthrough. But none of it is a path to bending the health-care cost curve. Indeed, while Obamacare’s promotion of statewide insurance exchanges may help distribute health-insurance policies to individuals now frozen out of the market, those exchanges could raise costs, not lower them. With hospitals consolidating by buying doctors’ practices and competing hospitals, their leverage over insurance companies is increasing. That’s a trend that will only be accelerated if there are more insurance companies with less market share competing in a new exchange market trying to negotiate with a dominant hospital and its doctors. Similarly, higher insurance premiums—much of them paid by taxpayers through Obamacare’s subsidies for those who can’t afford insurance but now must buy it—will certainly be the result of three of Obamacare’s best provisions: the prohibitions on exclusions for preexisting conditions, the restrictions on copays for preventive care, and the end of annual or lifetime payout caps.
Put simply, with Obamacare we’ve changed the rules related to who pays for what, but we haven’t done much to change the prices we pay.
When you follow the money, you see the choices we’ve made, knowingly or unknowingly.
Over the past few decades, we’ve enriched the labs, drug companies, medical-device makers, hospital administrators, and purveyors of CT scans, MRIs, canes, and wheelchairs. Meanwhile, we’ve squeezed the doctors who don’t own their own clinics, don’t work as drug or device consultants, or don’t otherwise game a system that is so gameable. And of course, we’ve squeezed everyone outside the system who gets stuck with the bills.
We’ve created a secure, prosperous island in an economy that is suffering under the weight of the riches those on the island extract.
And we’ve allowed those on the island and their lobbyists and allies to control the debate, diverting us from what Gerard Anderson, a health-care economist at the Johns Hopkins Bloomberg School of Public Health, says is the obvious and only issue: “All the prices are too damn high.”
1. Here and elsewhere I define operating profit as the hospital’s excess of revenue over expenses, plus the amount it lists on its tax return for depreciation of assets—because depreciation is an accounting expense, not a cash expense. John Gunn, chief operating officer of Memorial Sloan-Kettering Cancer Center, calls this the “fairest way” of judging a hospital’s financial performance.
2. In early February, Alice told Time that she had recently eliminated “most of” the debt through proceeds from the sale of a small farm in Oklahoma her husband had inherited and after further payments from Medi-Cal and a small life-insurance policy.
The Atlantic
FINALIST—PUBLIC INTEREST
The National Magazine Award for Public Interest celebrates stories that make a difference. Jean M. Twenge’s article addresses the widely shared fear—fostered in part, truth be told, by magazines—that older women are doomed to childlessness without medical intervention. Twenge’s own experience—three children born after her thirty-fifth birthday—belies this “baby panic.” But Twenge’s piece relies on more than mere anecdote. Instead it looks at the evidence, examines the dangers, and offers solutions. Now 157 years old, The Atlantic continues to flourish both in print and online. The National Magazine Award nomination for this piece—the judges called it “solid science reporting combined with compelling personal narrative”—was The Atlantic’s twenty-eighth in the last five years.
Jean M. Twenge
How Long Can You Wait to Have a Baby?
In the tentative, post-9/11 spring of 2002, I was, at thirty, in the midst of extricating myself from my first marriage. My husband and I had met in graduate school but couldn’t find two academic jobs in the same place, so we spent the three years of our marriage living in different states. After I accepted a tenure-track position in California and he turned down a post doctoral research position nearby—the job wasn’t good enough, he said—it seemed clear that our living situation was not going to change.
I put off telling my parents about the split for weeks, hesitant to disappoint them. When I finally broke the news, they were, to my relief, supportive and understanding. Then my mother said, “Have you read Time magazine this week? I know you want to have kids.”
Time’s cover that week had a baby on it. “Listen to a successful woman discuss her failure to bear a child, and the grief comes in layers of bitterness and regret,” the story inside began. A generation of women who had waited to start a family was beginning to grapple with that decision, and one media outlet after another was wringing its hands about the steep decline in women’s fertility with age: “When It’s Too Late to Have a Baby,” lamented the U.K.’s Observer; “Baby Panic,” New York magazine announced on its cover.
The panic stemmed from the April 2002 publication of Sylvia Ann Hewlett’s headline-grabbing book, Creating a Life, which counseled that women should have their children while they’re young or risk having none at all. Within corporate America, 42 percent of the professional women interviewed by Hewlett had no children at age forty, and most said they deeply regretted it. Just as you plan for a corner office, Hewlett advised her readers, you should plan for grandchildren.
The previous fall, an ad campaign sponsored by the American Society for Reproductive Medicine (ASRM) had warned, “Advancing age decreases your ability to have children.” One ad was illustrated with a baby bottle shaped like an hourglass that was—just to make the point glaringly obvious—running out of milk. Female fertility, the group announced, begins to decline at twenty-seven. “Should you have your baby now?” asked Newsweek in response.
For me, that was no longer a viable option.
I had always wanted children. Even when I was busy with my postdoctoral research, I volunteered to baby-sit a friend’s preschooler. I frequently passed the time in airports by chatting up frazzled mothers and babbling toddlers—a two-year-old, quite to my surprise, once crawled into my lap. At a wedding I attended in my late twenties, I played with the groom’s preschool-age nephews, often on the floor, during the entire rehearsal and most of the reception. (“Do you fart?” one of them asked me in an overly loud voice during the rehearsal. “Everyone does,” I replied solemnly, as his grandfather laughed quietly in the next pew.)
But, suddenly single at thirty, I seemed destined to remain childless until at least my midthirties, and perhaps always. Flying to a friend’s wedding in May 2002, I finally forced myself to read the Time article. It upset me so much that I began doubting my divorce for the first time. “And God, what if I want to have two?” I wrote in my journal as the cold plane sped over the Rockies. “First at 35, and if you wait until the kid is 2 to try, more than likely you have the second at 38 or 39. If at all.” To reassure myself about the divorce, I wrote, “Nothing I did would have changed the situation.” I underlined that.
I was lucky: within a few years, I married again, and this time the match was much better. But my new husband and I seemed to face frightening odds against having children. Most books and website
s I read said that one in three women ages thirty-five to thirty-nine would not get pregnant within a year of starting to try. The first page of the ASRM’s 2003 guide for patients noted that women in their late thirties had a 30 percent chance of remaining childless altogether. The guide also included statistics that I’d seen repeated in many other places: a woman’s chance of pregnancy was 20 percent each month at age thirty, dwindling to 5 percent by age forty.
Every time I read these statistics, my stomach dropped like a stone, heavy and foreboding. Had I already missed my chance to be a mother?
• • •
As a psychology researcher who’d published articles in scientific journals, some covered in the popular press, I knew that many scientific findings differ significantly from what the public hears about them. Soon after my second wedding, I decided to go to the source: I scoured medical-research databases and quickly learned that the statistics on women’s age and fertility—used by many to make decisions about relationships, careers, and when to have children—were one of the more spectacular examples of the mainstream media’s failure to correctly report on and interpret scientific research.
The widely cited statistic that one in three women ages thirty-five to thirty-nine will not be pregnant after a year of trying, for instance, is based on an article published in 2004 in the journal Human Reproduction. Rarely mentioned is the source of the data: French birth records from 1670 to 1830. The chance of remaining childless—30 percent—was also calculated based on historical populations.
In other words, millions of women are being told when to get pregnant based on statistics from a time before electricity, antibiotics, or fertility treatment. Most people assume these numbers are based on large, well-conducted studies of modern women, but they are not. When I mention this to friends and associates, by far the most common reaction is: “No … No way. Really?”
Surprisingly few well-designed studies of female age and natural fertility include women born in the twentieth century—but those that do tend to paint a more optimistic picture. One study, published in Obstetrics and Gynecology in 2004 and headed by David Dunson (now of Duke University), examined the chances of pregnancy among 770 European women. It found that with sex at least twice a week, 82 percent of thirty-five-to-thirty-nine-year-old women conceive within a year, compared with 86 percent of twenty-seven-to-thirty-four-year-olds. (The fertility of women in their late twenties and early thirties was almost identical—news in and of itself.) Another study, released this March in Fertility and Sterility and led by Kenneth Rothman of Boston University, followed 2,820 Danish women as they tried to get pregnant. Among women having sex during their fertile times, 78 percent of thirty-five-to-forty-year-olds got pregnant within a year, compared with 84 percent of twenty-to-thirty-four-year-olds. A study headed by Anne Steiner, an associate professor at the University of North Carolina School of Medicine, the results of which were presented in June, found that among thirty-eight- and thirty-nine-year-olds who had been pregnant before, 80 percent of white women of normal weight got pregnant naturally within six months (although that percentage was lower among other races and among the overweight). “In our data, we’re not seeing huge drops until age forty,” she told me.
Even some studies based on historical birth records are more optimistic than what the press normally reports: One found that, in the days before birth control, 89 percent of thirty-eight-year-old women were still fertile. Another concluded that the typical woman was able to get pregnant until somewhere between ages forty and forty-five. Yet these more encouraging numbers are rarely mentioned—none of these figures appear in the American Society for Reproductive Medicine’s 2008 committee opinion on female age and fertility, which instead relies on the most-ominous historical data.
In short, the “baby panic”—which has by no means abated since it hit me personally—is based largely on questionable data. We’ve rearranged our lives, worried endlessly, and forgone countless career opportunities based on a few statistics about women who resided in thatched-roof huts and never saw a light bulb. In Dunson’s study of modern women, the difference in pregnancy rates at age twenty-eight versus thirty-seven is only about 4 percentage points. Fertility does decrease with age, but the decline is not steep enough to keep the vast majority of women in their late thirties from having a child. And that, after all, is the whole point.
• • •
I am now the mother of three children, all born after I turned thirty-five. My oldest started kindergarten on my fortieth birthday; my youngest was born five months later. All were conceived naturally within a few months. The toddler in my lap at the airport is now mine.
Instead of worrying about my fertility, I now worry about paying for child care and getting three children to bed on time. These are good problems to have.
Yet the memory of my abject terror about age-related infertility still lingers. Every time I tried to get pregnant, I was consumed by anxiety that my age meant doom. I was not alone. Women on Internet message boards write of scaling back their careers or having fewer children than they’d like to because they can’t bear the thought of trying to get pregnant after thirty-five. Those who have already passed the dreaded birthday ask for tips on how to stay calm when trying to get pregnant, constantly worrying—just as I did—that they will never have a child. “I’m scared because I am 35 and everyone keeps reminding me that my ‘clock is ticking.’ My grandmother even reminded me of this at my wedding reception,” one newly married woman wrote to me after reading my 2012 advice book, The Impatient Woman’s Guide to Getting Pregnant, based in part on my own experience. It’s not just grandmothers sounding this note. “What science tells us about the aging parental body should alarm us more than it does,” wrote the journalist Judith Shulevitz in a New Republic cover story late last year that focused, laserlike, on the downsides of delayed parenthood.
How did the baby panic happen in the first place? And why hasn’t there been more public pushback from fertility experts?
One possibility is the “availability heuristic”: when making judgments, people rely on what’s right in front of them. Fertility doctors see the effects of age on the success rate of fertility treatment every day. That’s particularly true for in vitro fertilization, which relies on the extraction of a large number of eggs from the ovaries because some eggs are lost at every stage of the difficult process. Younger women’s ovaries respond better to the drugs used to extract the eggs, and younger women’s eggs are more likely to be chromosomally normal. As a result, younger women’s IVF success rates are indeed much higher—about 42 percent of those younger than thirty-five will give birth to a live baby after one IVF cycle, versus 27 percent for those ages thirty-five to forty, and just 12 percent for those ages forty-one to forty-two. Many studies have examined how IVF success declines with age, and these statistics are cited in many research articles and online forums.
Yet only about 1 percent of babies born each year in the United States are a result of IVF, and most of their mothers used the technique not because of their age but to overcome blocked fallopian tubes, male infertility, or other issues: about 80 percent of IVF patients are forty or younger. And the IVF statistics tell us very little about natural conception, which requires just one egg rather than a dozen or more, among other differences.
Studies of natural conception are surprisingly difficult to conduct—that’s one reason both IVF statistics and historical records play an outsize role in fertility reporting. Modern birth records are uninformative because most women have their children in their twenties and then use birth control or sterilization surgery to prevent pregnancy during their thirties and forties. Studies asking couples how long it took them to conceive or how long they have been trying to get pregnant are as unreliable as human memory. And finding and studying women who are trying to get pregnant is challenging as there’s such a narrow window between when they start trying and when some will succeed.
Another problem looms even larger: wom
en who are actively trying to get pregnant at age thirty-five or later might be less fertile than the average over-thirty-five woman. Some highly fertile women will get pregnant accidentally when they are younger, and others will get pregnant quickly whenever they try, completing their families at a younger age. Those who are left are, disproportionately, the less fertile. Thus, “the observed lower fertility rates among older women presumably overestimate the effect of biological aging,” says Dr. Allen Wilcox, who leads the Reproductive Epidemiology Group at the National Institute of Environmental Health Sciences. “If we’re overestimating the biological decline of fertility with age, this will only be good news to women who have been most fastidious in their birth-control use, and may be more fertile at older ages, on average, than our data would lead them to expect.”
These modern-day research problems help explain why historical data from an age before birth control are so tempting. However, the downsides of a historical approach are numerous. Advanced medical care, antibiotics, and even a reliable food supply were unavailable hundreds of years ago. And the decline in fertility in the historical data may also stem from older couples’ having sex less often than younger ones. Less-frequent sex might have been especially likely if couples had been married for a long time or had many children or both. (Having more children of course makes it more difficult to fit in sex, and some couples surely realized—eureka!—that they could avoid having another mouth to feed by scaling back their nocturnal activities.) Some historical studies try to control for these problems in various ways—such as looking only at just-married couples—but many of the same issues remain.
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