The most incisive guide to issues facing the American family today . . . An invaluable resource for anyone wishing to stay on the cutting edge of research on family trends.
-W. Bradford Wilcox
Associate Professor of Sociology, University of Virginia
When the Obama Administration and its Democratic supporters pushed through the radical 2010 reform of medical insurance known officially as the “Patient Protection and Affordable Care Act” and unofficially as “Obamacare,” they justified their one-party revolution in insurance as a way to rein in runaway health-care costs. To be sure, health-care costs have skyrocketed in recent decades, so dramatically in fact that no clear-eyed policymaker could deny the need to address the problem. Available evidence, however, indicates that the ACA has utterly failed to contain costs. But then that failure should surprise no one, for most policymakers simply do not know what good health looks like.
Their ignorance reflects their overly narrow focus. The architects of the ACA can see only two fundamental realities: the individual needing health care and the government (usually the Federal government) guaranteeing that care. Everyone else—including physicians, hospitals, and private insurance companies—must bend to these two realities.
These ACA designers, assert Republican critics, have failed to see how the economics of the marketplace affect health care, and in their economic blindness these designers have actually exacerbated the crisis in health-care costs while dramatically enlarging the size of government. These critics are right about how Obama and his supporters have expanded the Leviathan State. They are right, too, about the need to let the free market work. Yet Republicans have offered no satisfactory replacement. To be sure, they do advocate measures—such as block grants to the states and wider consumer choice—which would improve the health-care picture, but only at the margin.
But what is most inadequate about Republican criticism is that those advancing it seem generally to share with the architects of the ACA a fundamental blindness. They see, rightly enough, that Obamacare swells the Federal government. They cannot see that it perilously shrinks our social vision, leaving only the individual in sight. Like the Democrats who designed and enacted the legislation, Republican policymakers generally regard health as an individual matter. They differ from Democrats chiefly in wanting to give individuals freedom of choice, not state guarantees, in health care.
But the fundamental question in health-insurance reform remains: What is good health? Sane answers to that question are coming from neither Republicans preaching individualism premised on libertarianism nor Democrats preaching individualism safeguarded by big government. Good health can never appear more than very partially in the individual—whether that individual be male or female; black, white, brown, red, or yellow; rich or poor; old or young. The picture of good health is a family portrait. Good health appears fully only in natural families, each comprising a mother, a father, and children; families then embedded in a vibrant larger family network comprising grandparents and great grandparents, aunts and uncles, cousins, nieces, and nephews.
An understanding of good health focused narrowly on the individual is actually a symptom of disease, an ominous disease now threatening to cripple if not kill the American body politic. Real reform of health insurance will start only when those designing it recognize the dangerous illusion inherent in an individualistic understanding of health and then replace that illusion with a realistic vision of family-centered health. Only policymakers who recognize that good health is family health can reform medical insurance in a way that will reduce disease, reduce the costs of care when disease does strike, and reduce the need to rely on coercive government force to cover these costs.
No doubt policymakers Republican and Democrat come to the question of health insurance imbued with impulses fostered by our radically individualistic culture. But they should also come to that question willing to examine and learn from a very large body of epidemiological literature showing how social dynamics affect the health of the individual—and of the community at large. In a dozen ways, that body of literature shows that family life affects health profoundly. This same body of literature also establishes that when illness does strike, family life dramatically affects the likely costs and effectiveness of care. Finally, that literature establishes that it is family life that will determine how many productive citizens America can count on to help bear future public burdens in health care.
The Family Portrait—The Picture of Good Health
Whether they focus on the pregnant woman, the infant, the child, the adolescent, the young adult, the middle-aged adult, or the elderly, epidemiologists see ample reason to care about how family life affects health and health care. For family ties—parent-child, husband-wife, sibling-sibling—foster good health and provide low-cost palliative care when health fails. The sundering or fraying of these family ties incubates disease and forces those who suffer from it to rely on professionals for all of their care. Seeing the effects of family life on health and health care does not require advanced training or sophisticated research—these effects are so obvious that anyone with open eyes can see them.
The picture of good health begins with the family around the baby’s cradle. The mother bent tenderly over the tiny infant in that cradle, the father looking solicitously on, brothers and sisters gathered lovingly around—that is what good health looks like.
But good health means not simply that families bring children into the world but also that those families care for those children. No one will find the picture of good health in a day-care center. For while children in day care may be in the hands of people who are conscientious and well-trained, they will not be in the hands of anyone who loves them like their mother loves them.
The day-care center is actually a strikingly unhealthy place. This unhealthiness is manifest in part in the elevated incidence of communicable diseases found there, an incidence so high that it has repeatedly attracted the attention of epidemiologists, who worry especially about the antibiotic-resistant microbes that day care incubates. But the more disturbing manifestation of unhealthiness emerges in a French study noting the striking similarity between the epidemiology of the day-care center and the epidemiology of the orphanage. The parallel epidemiology of these two institutions reflects the absence from both of what every child needs for optimal good health: namely, a caring mother.
For the first months of a child’s life, the caring mother breastfeeds that child. Pediatricians around the world recognize in the breastfeeding mother the picture of good health, seeing in it the promise of numerous nutritional, neurological, and immunological benefits for the young child. Nor does the mother quickly disappear from the picture of a child’s good health. In the years that follow infancy, it is the mother of the child who prepares him nutritious and well-balanced meals. It is the mother who ensures that he engages in vigorous outdoor activity. It is the mother who sees that he avoids excessive indulgence in sedentary activities such as TV-watching or video-game playing.
Though perhaps somewhat less visible than mothers, fathers prove just as essential to the picture of good health. Indeed, mothers struggle to remain fully in that picture unless they are married to the father of their children. Researchers have repeatedly concluded that married mothers are much more likely than unmarried mothers to breastfeed their children. Part of the reason for this linkage emerges in the inverse correlation researchers see between maternal employment and breastfeeding. Without a father as breadwinner, how can a mother be at home to breastfeed? The same kind of natural dynamic no doubt lies behind the research showing that married mothers are more successful than unmarried mothers in giving their children the kind of good nutrition that wards off childhood obesity. Nutritionists and epidemiologists increasingly recognize the picture of good health in the family dinner table provisioned not by a fast-food restaurant but rather by a homemaking mother. And since research has further established that full-time employment compromises a mother’s efforts to prepare such food, we should expect to see a bread-winning father in this picture as well.
Adolescent children often strain the parent-child bond, but their health and well-being continue to depend on it. Empirical studies have decisively concluded that teenage children enjoy better physical and mental health if they live in an intact, two-parent home than if they live in a single-parent home. In part this finding reflects the way that regularly eating dinner with the family fosters the well-being of adolescent children: not surprisingly, family dinners occur more often in households with two married parents than in households with just one parent. Because intact two-parent families foster good mental health among their adolescent children, it comes as no surprise that such intact families also shield those children from health-threatening experiments with drugs, alcohol, and tobacco. Living in an intact family even wards off teen suicide.
The health benefits of growing up in an intact family persist among young-adult children. Among this group, a new family tie begins to supplant the parent-child tie as the conduit of good health, as young adults form their own enduring marriages. For relatively young adults and for older adults, an intact marriage fosters good health, mental and physical. The medical evidence linking marital status to health status is strong and very well established. As early as the late nineteenth century, British scholar William Farr recognized the health-enhancing effects of wedlock, writing, “Marriage is a healthy estate. The single individual is more likely to be wrecked on his voyage than the lives joined together in matrimony.” And a mountain of twentieth- and twenty-first-century empirical science has confirmed that nineteenth-century conclusion. One team of twenty-first-century researchers summarized the evidence succinctly: “Marriage has powerful and pervasive health benefits.”
To be sure, the health-fostering effects of marriage appear stronger among men than among women. But even for women, the wedding band provides a powerful barrier against ill health. In part, the health-fostering effects of wedlock have been traced to better health habits and better nutrition among the married. But the sources of these effects spring from even deeper wellsprings: researchers have established that compared to unmarried peers, married men and women sleep better, experience healthier nightly drops in blood pressure, and maintain more robust immune systems.
While the health-protecting effects of marriage last into old age, no one—married or single—lives forever. Before succumbing to death, older men and women typically suffer from various chronic illnesses incident to age. But those who are still in intact marriages are much less likely than the divorced or single to need prolonged and costly institutional care in a hospital or nursing home. Elderly individuals who have reared large families can also rely on care from adult children in a way that those with few or no children cannot. And when death finally does come, those who have maintained a lifelong marriage and have raised a large family are likely to pass on with many loving faces surrounding their deathbed. For mortals, such a deathbed, circled by a surviving spouse joined by affectionate children, delivers the final picture of good health, the kind of good health that transcends generational limits, summing up in the circumstances of death what it truly means to live.
Lamentably, the number of Americans who die outside the bosom of the family has grown in recent decades, chiefly because the number of Americans who live out their lives within family relationships has dwindled. And in the growing number of lonely individual Americans, dying surrounded by no one but professional strangers, we see perhaps the most pathetic symptom of our national ill health.
While the reasons for the decay of family life in modern America are many, the social blindness of our policymakers surely deserves a high place on the list. The family must suffer when Democratic and Republican policymakers alike look for the picture of good health in the individual, not in the natural family, and family suffering is particularly manifest in recent census data indicating that American birth rates have dropped to unprecedented lows. Not coincidentally, American marriage rates have also plummeted.
This decay in family life and the birth dearth it has occasioned threaten health care in two obvious ways. First, it reduces the number of spouses and adult children who can care for the aging. Second, it skews the dependency ratio such that Medicare quickly loses all semblance of fiscal viability, compelling policymakers either to cut benefits deeply or to impose heavy tax burdens on the young. The paucity of young people further threatens health care in a less obvious way: a dwindling in the numbers of young people inevitably means fewer creative innovators to give society new vaccines, cancer treatments, and medical technologies.
Despite this demographic threat, the architects of the ACA have made it a high priority to provide women with access to 18 different types of subsidized contraception, even incorporating measures to compel employers to violate their religious principles by offering such coverage. Americans now find themselves in the most arid demographic desert we have ever seen, yet policymakers are working overtime to ensure that everyone has 18 different kinds of umbrellas.
To be sure, policymakers recognize the dependence of a child on his mother. But despite the evidence that day care puts children and their families at risk of the same diseases that plague orphanages, the ACA does nothing to help families keep their young children at home. Quite otherwise. Advocates of Obamacare have promoted it by arguing that its provisions make health insurance more affordable for the growing army of low-paid workers who offer non-parental childcare.
And in the provisions affecting adults, the individualism of Obamacare actually punishes those who try to form the ties of complementarity and interdependence that define a marriage, the very foundation for a healthy family. Couples experience this punishment when they discover that the premium structure incorporates a sizeable “marriage penalty,” forcing married couples to pay more for medical coverage than they would pay if they were two unmarried individuals.
This anti-marital bias predictably reflects the thinking of radical feminists, who view marriage as an impediment to women’s career advancement, and of pro-homosexual ideologues, who wax enthusiastic about “marriage” when it takes the strange and inherently sterile form of a same-sex union. Research may have shown that such unions are much more fragile and prone to rupture than are heterosexual unions, but the Obamacare advocates affirm them because they entail no complementary gender roles.
Integral to the ACA, the radical feminist-homosexual ideology simply does not allow for the healthy economic dependence of a mother on a father while she cares for the young child. It hardly allows for the child at all. Despite the looming peril of our national birth dearth, the ACA not only pushes publicly subsidized contraception but also creates what many regard as a deliberately devious system for allowing public money to slide without overt and official approval into the coffers of those performing elective abortions.
With our national marriage and fertility rates at all-time lows and our national divorce rate still running close to the all-time high it hit two decades ago, policymakers and public-health experts have every reason to worry about the increasing difficulty of meeting health-care needs in the decades ahead. As the percentage of Americans living in single-person households keeps climbing to unprecedented levels, the prospects for spousal or family care grow ever dimmer. The authors of one representative twenty-first-century study spoke frankly about how “single people may . . . be prone to adverse health behaviors.” Policymakers are beginning to shudder at the prospect of having to field an entire army of costly family health-care surrogates for millions of aging Americans with few or no family ties. A few well-informed analysts are even voicing fears of “intergenerational conflict” over this issue.
And the need for family-surrogate caretakers will surely grow even more acute in the decades ahead as the alarming epidemic of obesity among children and adolescents translates into epidemics of Type II diabetes, heart disease, liver disease, and endometrial cancer in an aging population with few or no strong family ties. Of course, the epidemic of child and adolescent obesity is itself the consequence of frayed and broken family ties.
Anyone with clear vision can see just how important family ties are both for preventing illness and for providing affordable care for the sick. But the architects of the ACA lack such vision. No matter what an individual’s weight, blood pressure, hematocrit levels, or pancreas function, a deracinated, spouseless, childless, family-less person is not a healthy person-—regardless of how many doctors, nurses, health-insurance bureaucrats, or political activists crowd in around him. The kind of human flourishing that fully merits the label “good health” emerges only in intact natural families.
Increasingly, epidemiologists are acknowledging as much, and they are beginning to worry about the health of the skyrocketing number of social atoms who lack family connections. Sane reform of health care can come only from those who can recognize the signs of good health in the natural family, and can diagnose the symptoms of illness in the rootless individual.
* * *
Family-friendly reformers of health care may not all advance identical policy agendas, but they will share a guiding vision. Those guided by such a vision will not press for subsidies for contraception. They will not scheme up ways to deliver covert public funding of abortion. Nor will they build a marriage penalty into their health-insurance rates. Rather they will look for ways to subsidize health care for intact marriages, especially child-rich intact families of three or more children. Further, they will cut health-insurance rates for families in which the mother stays home as a health-fostering homemaker.
Targeting health-care subsidies to intact families, especially child-rich intact families, may require policymakers to use the levers of government power. But some of these subsidies could actually come through the free market. Insurance companies already give rate discounts to married drivers, discounts which they rationally justify by pointing to statistics showing that married drivers get in fewer auto accidents than their single peers. A parallel line of logic would justify giving married men and women lower rates for health insurance. Medical researcher Harold Morowitz was indulging in a facetious joke when he commented, “If a man’s marriage is driving him to heavy smoking, he has a very delicate statistical decision to make.” But real epidemiology gives sobering substance to his jest. The same statistical logic that justifies lower health-insurance rates for non-smokers would give lower rates to men and women in enduring marriages. Parallel logic would similarly justify giving health-insurance discounts to families in which mothers stay home as homemakers.
To be sure, some of the health benefits enjoyed by the children of a homemaking mother may come too far down the road to matter to insurance executives fixated on short-term profits. What is more, because pregnant women and young children do need medical care, myopic analysts may similarly reject pro-natalist insurance subsidies as economically irrational. But since new life is ultimately our only source of the economic vitality necessary to sustain any system of medical insurance over the long haul, policymakers may need to intervene to give child-rich families lower health-insurance premiums.
Committed policymakers can work out the numbers and fine-tune the rate structures. But no amount of managerial finesse will ever compensate for social blindness. Real long-term health-insurance reform depends first of all on recognition that good health is family health and that family-subverting individualism is an ominous disease. In the portrait of a happy, child-rich family, we see the lineaments of the only health-care reform holding real promise for the decades ahead.
Dr. Bryce J Christensen is Professor of English at Southern Utah University and Senior Editor of The Family in America.
 Cf. “ObamaCare’s Failing Cost Control: The Law’s ‘Accountable Care’ Experiment Is a Bust So Far,” Wall Street Journal¸ October 19, 2014, Web.
 Cf. “Our Prescription for American Healthcare: Improve Quality and Lower Costs” and “Ensuring Consumer Choice in Healthcare,” Republican Platform: Renewing American Values, The Republican National Committee, n.d., Web, accessed May 4, 2015.
 Cf. A. Segonds-Pinchon et al., “Socio-demographic, Lifestyle and Cross-generation Predictors of Self-Rated Health of Mothers During Pregnancy,” Irish Medical Journal 100.8 : 7-12; Nadine Kaœnelenbogen et al., “Not Living with Both Parents Is Associated with More Health- and Developmental Problems in Infants Aged 7 to 11 Months: A Cross-Sectional Study,” BMC Public Health 15 (2015): 159, Web; Patrick M. Krueger et al., “Family Structure and Multiple Domains of Child Well-Being in the United States: A Cross-Sectional Study,” Population Health Metrics 13 (2015): 6, Web; Charlemaigne C. Victorino and Anne H. Gauthier, “The Social Determinants of Child Health: Variations Across Health Outcomes—A Population-Based Cross-Sectional Analysis,” BMC Pediatrics 9 (2009): 53, Web; Callie E. Langton and Lawrence M. Berger, “Family Structure and Adolescent Physical Health, Behavior, and Emotional Well-Being,” Social Services Review 85.3 (2011); 323-57; Erin E. Horn et al., “Accounting for the Physical and Mental Health Benefits of Entry into Marriage: A Genetically Informed Study of Selection and Causation,” Journal of Family Psychology 27.1 (2013): 30-4; Irene H. Yen et al., “A Community Cohort Study about Childhood Social and Economic Circumstances: Racial/Ethnic Differences and Associations with Educational Attainment and Health of Older Adults,” BMJ Open 3.4 (2013): e002140, Web; G.M. Garrison, M.P. Mansukhani, and B. Bohn, “Predictors of Thirty-Day Readmission among Hospitalized Family Medicine Patients,” Journal of the American Board of Family Medicine 26.1 (2013): 71-7; Kevin Kinsella and David R. Phillips, “Global Aging: The Challenge of Success,” Population Bulletin 60.1 (2005): 3-39; A. Mor et al., “Does Marriage Protect Against Hospitalization with Pneumonia? A Population-Based Case-Control Study,” Clinical Epidemiology 5 (2013): 397- 405; C.W. Seymour et al., “Marital Status and the Epidemiology and Outcomes of Sepsis,” Chest 137.6 (2010): 1,289-96.
 Cf. E.T. Martin et al., “Epidemiology of Multiple Respiratory Viruses in Childcare Attendees,” Journal of Infectious Diseases 207.6 (2013): 982-9; Ralph Cordell et al., “Infectious Diseases in Childcare Settings,” Emerging Infectious Diseases 10.11 (2004): e9, Web.
 Cf. Melissa B. Miller et al., “Prevalence and Risk Factor Analysis for Methicillin-Resistant Staphylococcus aureus Nasal Colonization in Children Attending Child Care Centers,” Journal of Clinical Microbiology 49.3 (2011): 1,041-7.
 Josette Raymond et al., “Sequential Colonization by Streptococcus Pneumoniae of Healthy Children Living in an Orphanage,” The Journal of Infectious Diseases 181(2000): 1,983-8
 Cf. Peter T. Donnan et al., “Prediction of Initiation and Cessation of Breastfeeding from Late Pregnancy to 16 Weeks: The Feeding Your Baby [FYB] Cohort Study,” BMJ Open 3.8 (2013): e003274, Web; Ban Al-Sahab et al., “Prevalence and Predictors of 6-Month Exclusive Breastfeeding among Canadian Women: A National Survey,” BMC Pediatrics 10 (2010): 20, Web.
 Cf. Sahab et al.
 Cf. Katherine W. Bauer et al., “Parental Employment and Work-Family Stress: Associations with Family Food Environments,” Social Science and Medicine 75.3 (2012): 496-504.
 Cf. Callie E. Langton and Lawrence M. Berger, “Family Structure and Adolescent Physical Health, Behavior, and Emotional Well-Being,” Social Service Review 85.3 (2011): 323-57.
 Cf. Kelly Musick and Ann Meier, “Assessing Causality and Persistence in Associations Between Family Dinners and Adolescent Well-Being,” Journal of Marriage and Family 74.3 (2012): 476-93.
 Jing Wang et al., “Socio-Demographic Variability in Adolescent Substance Use: Mediation by Parents and Peers,” Prevention Science 10.4 (2009): 387-96.
 Esme Fuller-Thomson, Gail P. Hamelin, and Stephen J.R. Granger, “Suicidal Ideation in a Population-Based Sample of Adolescents: Implications for Family Medicine Practice,” ISRN Family Medicine (2013): Article ID 282378, Web.
 Mary Elizabeth Hughes and Linda J. Waite, “Health in Household Context: Living Arrangements and Health in Late Middle Age,” Journal of Health and Social Behavior 43.1 (2002): 1-21; Mary Elizabeth Hughes and Linda J. Waite, “Marital Biography and Health at Mid-Life,” Journal of Health and Social Behavior 50 (2009): 344–58.
 William Farr, “Marriage and Mortality,” Vital Statistics: A Memorial Volume of Selections from the Reports and Writings of William Farr (London, 1885; rpt. Metuchen: The Library of the New York Academy of Medicine/The Scarecrow Press, 1975), 430–1.
 Amy Mehraban Pienta, Mark D. Hayward, and Kristi Rahrig Jenkins, “Health Consequences of Marriage for the Retirement Years,” Journal of Family Issues 21.5 (2000): 559–86.
 Jonathan T. Macy, Laurie Chassin, and Clark C. Presson, “Predictors of Health Behaviors after the Economic Downturn: A Longitudinal Study,” Social Science & Medicine 89 (2013): 8-15; Richard G. Watt et al., “Social Relationships and Health-Related Behaviors among Older US Adults,” BMC Public Health 14 (2014): 533, Web.
 Tea Lallukka et al., “Sociodemographic and Socioeconomic Differences in Sleep Duration and Insomnia-Related Symptoms in Finnish Adults,” BMC Public Health 12 (2012): 565, Web.
 Andrew Steptoe, Karen Lundwall, and Mark Cropley, “Gender, Family Structure and Cardiovascular Activity During the Working Day and Evening,” Social Science and Medicine 50 (2000): 531-9.
 Janice K. Kiecolt-Glaser, Jean-Philippe Gouin, and Liisa Hantsoo, “Close Relationships, Inflammation, and Health,” Neuroscience & Biobehavioral Reviews 35.1 (2010): 33-8.
 Cf. Kinsella and Phillips, “Global Aging”; Theodore J. Iwashyna and Nicholas A. Christakis, “Marriage, Widowhood, and Health-Care Use,” Social Science and Medicine 57 (2003): 2137–47.
 Cf. Clive Seale, “Dying Alone,” Sociology of Health and Illness 17 (1995): 376-92.
 Gretchen Livingston and D’Vera Cohn, “U.S. Birth Rate Falls to Record Low; Decline Is Greatest Among Immigrants,” Social Trends, Pew Research Center, November 29, 2012, Web.
 Wendy Wang and Kim Parker, “Record Share of Americans Have Never Married,” Social Trends, Pew Research Center, September 24, 2014, Web.
 Cf. “Cassandra of the Fed” [Editorial], Times-Picayune, March 1, 2004: B6.
 Cf. Peter Sulivan, “HHS: Insurers Must Cover All Birth Control,” The Hill, May 11, 2015, Web.
 Cf. Tom Copeland, “How the Affordable Care Act (Obamacare) Will Affect Family Child Care,” Tom Copeland’s Taking Care of Business, September 30, 2013, Web.
 Hans Bader, “Massive Marriage Penalties in Obamacare Health Insurance Exchanges,” Competitive Enterprise Institute, September 26, 2013, Web.
 G. Andersson et al., “The Demographics of Same-Sex Marriages in Norway and Sweden,” Demography 43.1 (2006): 79-98.
 Cf. “Taxpayer Funding of Abortion in Obamacare,” Susan B. Anthony List, 2012, Web.
 U.S. Bureau of the Census, “Person Occupancy Rates,” Historical Census of Housing Tables, U.S. Department of Commerce, October 31, 2011, Web.
 Laura Pulkki-Råback et al., “Living Alone and Antidepressant Medication Use: A Prospective Study in a Working-Age Population,” BMC Public Health 12 (March 2012): 236.
 Cf., e.g., Ken-ichi Hashimoto and Ken Tabata, “Population Aging, Health Care, and Growth,” Journal of Population Economics 23.2 (2010): 571-93.
 Joan C. Han, Debbie A. Lawlor, and Sue Y.S. Kimm, “Childhood Obesity—2010: Progress and Challenges,” Lancet 375 (2010): 1737-48.
 Cf. Alex Y. Chen and José J. Escarce, “Family Structure and Childhood Obesity, Early Childhood Longitudinal Study—Kindergarten Cohort,” Preventing Chronic Disease 7.3 [May 2010]: A50; George Osei-Assibey et al., “The Influence of the Food Environment on Overweight and Obesity in Young Children: A Systematic Review,” BMJ Open 2.6 : e001538, Web.
 Qtd. in James L. Lynch, The Broken Heart: The Medical Consequences of Loneliness (New York: Basic Books, 1977), 45–6.