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Healthcare considerations in the American decline

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 "A heart that's full up like a landfill.  A job that slowly kills you.  Bruises that won't heal.  You look so tired, unhappy.  Bring down the government, they don't speak for us.  I'll take a quiet life, a handshake of carbon monoxide."

The existential sorrow in Thom Yorke's voice has never sounded as poignant as it does today in "No Surprises", a track of lonely capitulation on Radiohead's monolithic   OK Computer.  The song evokes images of helplessness and retreat in the face of globalization and corporate capitalism.  The accompanying music video features Yorke's head in a bubble helmet that slowly fills up with water (1).  The symbolism in both the lyrics and the video has become increasingly relevant since the record's release fifteen years ago.


Healthcare in a democracy
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Some call it America in Decline and it's a theme that has been explored extensively over the recent years, months, and weeks (2) (3) (4).  The idea is obviously met with skepticism.  In order to understand it, we have to put it in perspective and define a context.  What exactly is America and what's in decline?

It remains the richest country in the history of modern civilization.  It controls the most powerful and comparatively advanced military machine ever assembled: a likely result of spending more than the rest of the world combined (5).  The two characteristics are intimately related.

Indeed, the idea that the accumulation of wealth inculcates suspicion and the need to defend it has even been discussed by 6th   century philosopher Boethius in   The Consolation of Philosophy:   "the wealth which was thought to make a man independent rather puts him in need of further protection" (6).  In fact, the need for institutional protection of private property is one of the most heavily explored topics of classical liberalist thought and framed much of the debate during the United States' formative period.  We like to think that the nation was founded on principles of total equality and personal liberty.  But the chief concern among the framers was how to create a system where landowners can remain landowners without having to worry about greedy peasants.

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The concept rapidly generalizes to capital accumulation today.  Wealthy and privileged members of society want the government to perform its intended function which is to protect their assets.  What would have previously been labeled agrarian reform is basically equivalent to progressive taxation.  However, any rational politician will cater to privileged interests especially when legislative positions are virtually bought in the current system.   The collection of votes is now regarded as a secondary consequence of properly financing an electoral campaign.

Social reforms that benefit the overwhelming majority of the population--where political power is least concentrated--are marginal issues that require populist demonstration in order to enter the political arena.  The civil rights movement, the feminist movement, and the AIDS movement are just a few examples.  That these were issues that could not be influenced by voting highlights a particularly sinister illusion of franchise.  We vote for politicians that seem relatable given their stance on satellite issues.  Presidential candidates will resort to tactics such as showing up on MTV discussing underwear in order to clinch the youth culture vote.  In other venues he'll discuss how to be tougher on crime or how to withdraw from some foreign conflict in some vague number of years.

But where's the candidate that speaks to immediately relevant issues such as access to health care or proper retirement benefits?  The former example is pretty striking, actually.  Government sponsored medical coverage has been a prominent domestic concern for almost 40 years (7) (8).  Even a recent 2009 NY Times/CBS News poll suggested that 72% of the population were in favor of a government administered health insurance program that would compete with current private plans (9).

Furthermore, there's no longer any doubt that a public option would drastically reduce health costs and thus relieving some of the burden on consumers.  A 2003 study published in the   New England Journal of Medicine   concluded that health care administration costs account for 31% of health expenditures in the U.S. which comes out to almost $300 billion.  Canada's administration costs, on the other hand, makes up 16.7% of their total health expenditures (10).  The high costs of U.S. health administration are a direct result of having to navigate the extreme complex channels of billing and reimbursement through private insurers.  As one would expect, the system's complexities are tailored to minimize payouts to consumers and simultaneously maximize profits.

The U.S. has very little to show for its insanely expensive health arrangement.  Its per capita costs are twice those of other advanced OECD nations (11).  However, it ranks pretty low in health outcomes such as infant mortality and and life expectancy (12).

And the burden on the general population is, indeed, quite severe.   Two landmark 2009 studies by Harvard physicians David Himmelstein and Steffie Woolhandler were able to show that the extraordinary costs of healthcare and insurance impose crushing financial burdens and leave many who cannot afford insurance to die.  They found that 62.1% of bankruptcies filed in the United States in 2007 had medical causes.  This value is sharply contrasted with an estimated 8% in 1981 and 46.2% in 2001.  80% of the 2007 figure had health insurance and most were well-educated and middle-class (13).  Furthermore, the researchers were able to link the lack of health insurance to 45,000 working-age deaths per year in the U.S. and conclude that the uninsured are 40% more likely to die than those with private insurance (14).  This figure, too, is in sharp contrast with a 1993 estimate of 25% (15).  The spectrum of health outcomes parallels socioeconomic status as one would expect, but the worsening trends and sheer quantity of deaths are so morally alarming that they cannot be ignored.

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The outlook is even more depressing when we examine a recent U.S. Census Bureau report which revealed a striking racial distribution of uninsurance.  21% of blacks and 31% of Hispanics in the U.S. are uninsured compared to 11.7% of whites (16).  This, too, is not that surprising.  The proportions are probably similar for those who drive Range Rovers, but we have to remain cognizant of the fundamental difference between the two commodities.

The consequences of private administration of healthcare are fairly predictable.  A corporation's chief concern will always be self-sustenance and growth.  Consumer benefit is only a priority when it contributes to the two main goals.  The touted virtue of free market efficiency is based on the symbiotic relationship between consumer benefit and corporate profit.  Unfortunately, it's not really a free market.  The government is continually prohibited from acting as a significant competitor even though most of the population agrees that it should be.  Because of the fundamental difference between health and Range Rovers as commodities, consumers do not have the option of simply boycotting the product or choosing a competitor and thereby placing downward pressure on costs.  Saying no to healthcare is simply anti-human.

Furthermore, patent-protected pharmaceuticals will sell at premiums with markups sometimes up to a thousand percent.  It's often argued that patent protection and value markup are required in order to fund research and development.  However, we cannot ignore the costs of advertising, marketing, lobbying, and profit margins.   The economist Dean Baker has done significant work in exposing the inefficiencies and deceitful practices of the pharmaceutical industry that ultimately harshen the financial burden on the general public (17).  He has argued for several years that publicly funded research for the development and distribution of patent-free drugs would be far more advantageous than the current system that spends an estimated $300 billion per year on prescription drugs.

The prospects for change are pretty bleak given the virtual disenfranchisement of the general population which brings us back to American decline.  Media-propagated illusions are partially responsible.  The current debate surrounding Obamacare is a ripe example.  Government-sponsored insurance is not even on the agenda and the public is led to believe that the Affordable Care Act and its guaranteed coverage is the solution we have long waited for.  This illusion is based on the false dichotomy between Democrats and Republicans.  It's a bad joke, really.  Obamacare is modeled on the Massachusetts health plan the origins of which trace back to the Heritage Foundation (18) (19).  It was implemented by then-Governor Mitt Romney.  I'll spare the irony.

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The stick and the carrot.

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