Six

 

Health Care Index

Rank of United States among eleven wealthy countries in health system performance (2013): 11

Rank of United States among the countries of the world in annual per capita public and private health care spending (2013): 3

Life expectancy in years of a typical US citizen (2012): 79

Rank of United States out of 224 countries in average life expectancy (2015): 43

Administrative costs as a percent of hospital spending in the United States/Canada (2011): 25.32/12.42

Number of Black/white deaths per 1000 in the first month of life (2013): 7.46/3.34

Number of Black/white deaths per 1000 in the first year of life (2013): 11.11/5.06

Number of Black/white children under two who contract bacterial meningitis per 100,000 (2005): 26/11

Cost of Prevnar, a vaccine that prevents diseases (ear infections, pneumonia) caused by pneumococcal bacteria per dose (2014): $136

Amount of revenue that Pfizer, the monopolist and sole manufacturer, realized from Prevnar in 2013: $4 billion

A perfect contradiction was on display in Washington, DC, in 2009 at a political rally called by the Tea Party Patriots. Participants came together in universal opposition to the Affordable Care Act, but their messages varied. “Obamacare Is Slavery,” said one sign, and “Don’t Tread on Me!” said another. There was also a large two-sided banner with one face reading “No to Socialist Medicine,” and the other demanding that the government “Keep Your Hands Off My Medicare!” Of course, Medicare, like the Veterans Administration hospitals and the benefits that members of Congress enjoy, is predicated on something that most people want: good health and a health care system that delivers for all. Everyone is vulnerable to the vagaries and unpredictabilities of life, and so all of us benefit from the security that comes from being insulated from the financial shock of serious injury or illness, even if many of us will never suffer that fate; all of us gain when people get the low-cost health care they need at a price that we can jointly afford. It’s not complicated. And it is indeed mildly socialistic—the system is still driven by profiteers and predators.

Those are the same ideas that motivate the drive for a single-payer health system: equalize the financial risk between the healthy and the sick, the well and the wounded, take all profit and market incentives out of the system, crush the health insurance racket, and create a simple social contract built on shared costs and guaranteed benefits. Medicare is an imperfect but sensible single-payer health care plan for the elderly and the disabled. It’s similar in conception to national health care in Canada and throughout the industrialized world.

Of course Medicare—government-run health insurance for the elderly—was fiercely opposed by conservatives and political reactionaries when it was proposed half a century ago: “We are against forcing all citizens . . . into a compulsory government program,” said one; it’s nothing less than “socialized medicine,” and, if implemented would mean that “one of these days, you and I are going to spend our sunset years telling our children, and our children’s children, what it once was like in America when men were free.”

That was the demigod of today’s political right, Ronald Reagan, speaking before he’d entered electoral politics, and his comments echoed right-wing opposition to Social Security in the 1930s (a plan to “Sovietize America”) and the minimum wage and mandated overtime pay (“Communism, Bolshevism, fascism and Nazism”). Here we go again.

Medicare has its problems, no doubt, many of them inflicted from the start by its opponents: It lacked a drug provision that could resist skyrocketing costs, and it prohibited preventive care like Pap smears and mammograms and flu shots for seniors (which it now pays), leading to more serious problems down the road, and making the emergency room—the worst place to receive primary care—the first stop for many people. Medicare pays for hearing exams for the elderly—50 percent of seniors have some hearing loss—but not hearing aids, so unless you have $1,500–$7,000 available, you go without. Twenty percent of people diagnosed with dementia, overwhelmingly poor people, are in fact suffering hearing loss.

Six times in the last several decades serious attempts have been made to develop and legislate a single-payer, universal health care system—Medicare for all! Each attempt failed, and each defeat relied on the powerful health predators and profiteers successfully coupling single-payer with “socialism,” a political concept whose meaning has been so warped that it now connotes dictatorial, fascist, despotic, repressive, undemocratic, severe, tyrannical, top-heavy, bureaucratic, authoritarian, rigid, controlling, entangling, alien, foreign, French, orthodox, and godless governance by the Devil’s own spawn. YIPES! WE’RE ALL GONNA DIE! No one wants that!

Yet people on Medicare express overall satisfaction with the system year after year, and compared to the tangled swamp of corporate medicine we slog through on our way to age sixty-five, it’s no wonder. So, if Medicare is good for sixty-five-year-olds, why not sixty-year-olds? And if sixty, why not fifty? Down we go. It turns out that strong majorities favor just such a direction—some form of public option or single payer—but the corporate elites and their representatives in both major political parties wage a long and endless war on people’s right to comprehensive health care. Some in the pay of the rackets push to privatize Medicare, others support increasing premiums and co-pays, chipping away at service, and shifting costs to working people. But none of them question the logic of the market or corporate medicine, and all of them allow the insurance and pharmaceutical industries to author or veto all health-related legislation. Big Pharma is in the business of business; health and wellness is the last thing on its agenda.

So the Tea Party banner demanding hands off my mildly socialist Medicare ironically rallies the troops against anything that smacks of affordable and available medical care for everyone. Other ironies abound: Americans pay two and a half times more per capita than other industrialized nations in health care costs, visit doctors less frequently than Europeans, go to hospitals less often, have fewer doctors per capita, experience lower life expectancy and childhood immunization rates, and are twice as likely to be deeply, deeply dissatisfied with their health care. The United States has more than enough money, state-of-the-art physical plants throughout the country, technology that is the envy of the world, twelve million health care workers, superbly educated doctors and nurses and technicians—and a shitty system. What went wrong?

***

The short answer: capitalism. Good medicine at its heart requires trust and an assumption of honesty and fairness; the market requires nothing more or less than profits for shareholders. The near-total corporate capitalist capture of health care incentivizes bad behavior: a primary care doctor ordering a battery of tests of questionable medical value because fee-for-service makes it profitable, or an obstetrician performing an unneeded Caesarian section because that procedure brings in more money only makes sense if dollars—and dollars alone—are the standard of care. Unnecessary medical tests (and procedures) are to the health industry what alcohol is to the hospitality industry: the Midas touch, everything turning magically to gold.

It’s estimated that more than 90 percent of lower back pain cases are best treated with physical therapy, but doctors and hospitals routinely recommend expensive MRIs and then refer patients to orthopedic surgeons who often propose unnecessary, sometimes dangerous or harmful, and even more costly surgery. There’s little profit in physical therapy, and, similarly, while home nursing is much more effective in treating chronic conditions like COPD (chronic obstructive pulmonary disease) and diabetes than hospital visits, there’s no profit incentive in home nursing. And so it withers on the vine.

The health care marketeers lie in public, devise make-believe disorders and promote them through public relations and clever advertising, and then deal meds at the open-air drug bazaar to treat invented afflictions. Erectile dysfunction is now a fact of life, so I’ll leave that one alone—except to note that Viagra is covered by Hobby Lobby’s health care plan and birth control is not. But who knew millions of men are also suffering from a “medical condition known as low-T?” “Known as” by whom, you might ask; well, known as low-T by the drug runners who made the condition up. Here is their sales pitch: “If you’re forty-something and just feel blah sometimes, out-of-focus, lacking energy, and not as charming as you thought you were at twenty, maybe it’s not you . . . maybe it’s low-T. Here, just apply this special underarm deodorant filled with testosterone for a few weeks and you’ll be the life of the party once more. Oh, and we should warn you to keep this out of the reach of women, children, and household pets, wash thoroughly after applying, and (sotto voce) be aware that this product may cause uncontrollable itching, hearing loss, temporary blindness, sneezing, hiccups, rectal bleeding, tumors, athlete’s foot, dry mouth, suicidal thoughts, stroke, heart attack, hair loss, night sweats, crippling gas, adult-onset acne, attention deficit disorder, fever, moodiness, frequent nose hemorrhages, gagging, facial tics, vertigo, burning sensations in your testicles—no worries, we have pills for each of those too. If you have an erection lasting more than seven days call this toll-free number and we’ll rush you the antidote for that at reduced cost.”

The United States is the only industrialized country in the world in which it’s legal to advertise prescription drugs to the public. It serves no public health interest whatsoever, but it does indeed serve corporate wealth: antidepressants alone represent a $10 billion market; half of all Americans are taking prescription drugs at any given moment, and one in ten is taking more than five; millions of youngsters are taking prescription drugs for ADHD, including fourteen thousand children ages two or three. We are all potential customers; even babies are the drug fiends the old dope peddlers hope to hook for the future. And the drug manufacturers have succeeded in laying the groundwork for an unprecedented heroin epidemic, which arose in part from the overprescription of opioids, or prescription pain medication, like OxyContin. It was reported in Fortune magazine in November 2011 that “254 million prescriptions for opioids were filled in the U.S.”—enough to “medicate every American adult around the clock for a month,” according to the federal Centers for Disease Control and Prevention (CDC). According to Fortune, opioids “generated $11 billion in revenues for pharmaceutical companies.” This helps explain their fierce opposition to the relatively mild standards issued in early 2016 by the CDC in an attempt to address the record number of deaths from opioids in 2014: 28,647.1

The disorders are galloping forward, with the drug dealers conveniently on hand with just the thing to solve your problem. A headline in the satirical Onion warns of a growing epidemic among children that seems less and less far-fetched: “An estimated 20 million U.S. children,” it asserts, are believed to suffer from a “poorly understood neurological condition called YTD, or Youthful Tendency Disorder.” The article details the early warning signs of YTD, including sudden episodes of shouting and singing, conversations with imaginary friends, poor impulse control with regard to sugared snacks, preferring playtime and flights of fancy to schoolwork, and confusing oneself with animals and objects like airplanes. A mother whose child was recently diagnosed with YTD expresses guarded relief: “At least we know we weren’t bad parents,” she says hopefully. “We simply had a child who was born with a medical disorder.” She will be at the drug bazaar soon to get her kid hooked up.2

***

The market in health care has created a deeply unequal system that stretches from the shameful state of mental health care to the tawdry patchwork of nursing home care, from disdain for the poor to the war on women. The market—like all markets—creates winners and losers, and not surprisingly the biggest winners are the rich, and the biggest losers are those traditionally oppressed and exploited: descendants of enslaved people, First Nations peoples, recent immigrants from impoverished countries, people of color, women, and poor and working people. Health disparities are everywhere, and universally appalling: 25 percent of Black mothers get no prenatal care during the first trimester of pregnancy (and 6 percent get no care for the entire nine months) compared to 11 percent (and 2 percent) of white mothers; mortality rates during the first year of life are fourteen per one thousand for Black children and six per one thousand for whites; by the age of thirty-five months, 25 percent of Black children and 16 percent of white children have not received standard vaccinations; in poor Black urban neighborhoods in California there is one physician for every four thousand residents compared to one in twelve hundred in white neighborhoods.3

Martin Luther King Jr. noted, “Of all the forms of inequality, injustice in health is the most shocking and the most inhumane.”4 Health disparities focus a hard lens on our avowed values, revealing monstrous contradictions in a society that claims to value equality. It is wrong and shameful that one’s zip code, for example, can be the strongest predictor of whether a person will suffer chronic lung disease.

Inequities between men and women are monstrous in the capitalist industrialized health system. Women’s judgments about reproduction and birth are strictly policed by the state and the mobilized mob; this policing now includes a broadly accepted sense that a doctor and a hospital provide the best care during childbirth, while a mother is always cast as a potential risk to her baby or a danger to be managed (“Don’t drink wine during pregnancy” and “Women of a certain age should always assume they are pregnant!”). Since 2011 more than 280 laws have been enacted in thirty-one states restricting women’s access to reproductive health.5 These laws make access more costly, more difficult (with mandatory wait times and multiple visits), and more humiliating.

***

Market-driven health care is also pauperizing us: 50 percent of personal bankruptcy filings in the United States are directly related to medical costs and bills. Industries from auto to airlines, as well as public entities from states to municipalities, claim they cannot meet financial or contractual obligations to employees because of the staggering costs of corporate health care. Compare Canadian and US auto industries and one thing stands out: health care as a contractual benefit (the United States) as opposed to a public trust (Canada) is extraordinarily stupid. US auto companies cannot meet the costs while a small segment of the organized working class is afforded a privilege that splits them off from other workers, and most people simply cannot track down adequate or reasonably priced insurance.

The market incentivizes corruption and fraud, and here’s a case in point: Florida governor Rick Scott founded a holding company in 1987 and bought two El Paso, Texas, hospitals. Over the next several years he added hundreds of hospitals and medical centers, including Chicago’s venerable Michael Reese, and in 1994 he purchased Tennessee-headquartered HCA and its one hundred hospitals and merged the companies to create Columbia/HCA. In 1997 federal agents announced that they were investigating whether Columbia/HCA had committed Medicare and Medicaid fraud. Scott immediately resigned as CEO, and three years later the Justice Department announced that the company he had founded and enriched himself with agreed to pay $840 million in criminal fines, civil damages, and penalties for among other things billing Medicare, Medicaid, and other federal programs for tests that were not necessary or had not been ordered by physicians, attaching false diagnosis codes to patient records to increase reimbursement to the hospitals, illegally claiming nonreimbursable marketing and advertising costs as community education, and billing the government for home health care visits for patients who did not qualify to receive them. The Justice Department settled a series of similar claims with Columbia/HCA in 2002 for an additional $881 million. The total for the two fines was $1.7 billion. Michael Reese Hospital was stripped and sacked—it went from 1,100 to 450 beds the moment Scott took it over, clinics were shuttered, and huge numbers of employees laid off until he took it into Chapter 11 bankruptcy protection, shaking off billions in debt, including $860,000 in unpaid taxes and $4.7 million in unpaid utility bills. Rick Scott was and still is very rich.

The market is also remarkably wasteful: An average nurse spends 33 percent of her time on documentation for insurers; the United States spends twice as much as Canada and Europe on administrative costs; 3 percent of Medicare costs go toward administration compared to 40 percent of individual insurance costs.

Our friend Joel Westheimer was visiting us from Canada when a phone book–sized document arrived for me in the mail explaining a set of choices and options I had related to my health insurance. He laughed and pulled out a plastic card from his wallet—his Canadian national insurance card. “This is it, and it’s all I have,” he said, a little meanly, I thought. “It includes dental, medical, drugs, vision, the whole kielbasa.” As I worked my way through the book over the next few hours, Joel would occasionally look up from his laptop, smile patronizingly, and wave his card in my direction.

“Obamacare,” the Affordable Care Act, delivered health care to millions—a good thing since life without health care is punishing in countless ways—but the cost was high: Health care was delivered even more firmly into the grasping hands of insurance and pharmaceutical companies, the idea that health care is a product (as opposed to a right) was more firmly entrenched, and affordable health care for all became an even more distant goal. Once the Obama administration abandoned some form of public option—fiercely opposed by the health profiteers—the game was up.

Walk-in clinics once ridiculed as “Doc in a Box” medicine have “mushroomed into an estimated $14.5 billion business, as investors try to profit from the shifting landscape in health care,” according to the New York Times.6 This is a hot topic on Wall Street as “private equity investment firms, sensing opportunity, invest billions in urgent care and related businesses.” Patients are in and out in about thirty minutes and the average bill is $155 per patient per business. Do the math: “thirty or thirty-five exams a day and the money starts to add up.” “Urgent care” has “a crucial business advantage over hospital emergency rooms,” which are legally required to treat anyone who shows up: urgent care facilities refuse Medicaid patients and turn away the uninsured unless they pay cash upfront.7

The corporate health industry marches on: the price of childhood vaccines has skyrocketed in recent years. Pfizer, which has monopoly control over Prevnar, a vaccine that prevents diseases (ear infections, pneumonia) caused by pneumococcal bacteria, took in revenues of nearly $4 billion in 2013. Prevnar costs $136 per dose, and every child in the United States is required to have four doses before entering school.8

The market transforms a relationship of common interest into a relationship of antagonists. Pharmaceutical corporations lobby and win a provision in the drug law that prohibits the government from negotiating drug prices on behalf of the public, and bingo! Big Pharma reaps billions in profit. The market introduces deductibles, higher and higher co-pays, and restrictions and caps on coverage, and the market creates malpractice by developing an adversarial space between provider and patient. What was once human and natural becomes monetized and cheapened. Capitalism—the “free market,” private enterprise—can’t manage a decent health care system, and it never will.

Health care must be taken back from the grasping hands of the profiteers and taken to a higher ground appropriate to the project itself: everyone has the right to a standard of living adequate to health and well-being, including food and clothing, housing and medical care, and security in the event of circumstances (unemployment, sickness, disability, old age) beyond their control. Everyone has the right to lead a healthy life in a healthy community. Everyone has the right to life, liberty, and the pursuit of happiness—in the language of human rights, the highest available standard. It’s time to organize ourselves to transform a system so blatantly destructive to these ends and institute a new community of associative living that will guarantee those rights to all.

***

On September 12, 2008, at a debate of Republican hopefuls cosponsored by the Tea Party and CNN, Representative Ron Paul was asked what our response ought to be to be if a thirty-year-old man who had chosen not to purchase health insurance found himself in need of intensive care. Mr. Paul said, “That’s what freedom is all about—taking your own risks.” Well, then should society let him die? A few in the audience shouted “Yes!” Just as Mr. Paul was quietly saying, “No,” and elaborating that friends along with kindly medical folks and charitable groups might want to step in to help the lad.9

Political discussion and public policy often turn on questions of ideology expressed as competing comparisons that frame our points of view. If accepted common sense regarding health care holds that it’s like any other individual consumer good—a television set or a radio—then our current system makes some sense. It taps into deeply held cultural beliefs about individual responsibility and cost, competition, and free enterprise. But if the analogy shifts, if health care is considered not so much a consumer product like all others but a universal human right, like the right to bodily integrity and public safety, then a different set of deeply held beliefs—about fairness and shared or community responsibility—move toward the front.

Challenging the insistent dogma of common sense is always a risky business—it involves disrupting unanticipated but linked fields, and it raises related questions: If universal health care is a human right, what else might be? If the accepted, market approach to doing health and medicine is suddenly suspect, what else in our public life is rendered unreliable? We enter an open space of rethinking and negotiation—a space where we must rely not on rules so much as on our moral intuition, our commitment to the dignity of persons, our belief in equality, and, yes, our reordered and evolving common sense.

Absent this capacity to raise risky questions and challenge the common conventions of our times, we would likely be burning witches and suffering slavery today. The capacity to wonder and to challenge belongs to all of us—making and remaking meaning is our acutely human condition—and it is the special province of rebels who are called to resist dogma, to expand inquiry, to raise queer questions. Our vocation is to try to shake free of the seductions and anesthetizing effects of the modern predicament, and that includes the seduction of common sense.

Let’s flip the script and change the frame. Let’s organize to replace cruelty and callousness with compassion, sister love, and fellow feeling. Let’s fight to live up to the better angels of ourselves. Free and universal health care for all!