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Health and social insecurity

GJ Boris Allan
2008-11-28 (Revised)

Millions of our citizens do not now have a full measure of opportunity to achieve and enjoy good health. Millions do not now have protection or security against the economic effects of sickness. The time has arrived for action to help them attain that opportunity and that protection. — Harry S Truman, Special Message to the Congress Recommending a Comprehensive Health Program (19 November 1945)

The absence of laws reveals a great deal about the nature of a society. For example, there is no US law (or common understanding) that says every person in the USA is entitled, as a right, to health care. The USA is full of people who are truly caring, but a surprising number of people with health care insurance do not seem to have a great deal of empathy with those who have no easy access to health care. Quite often those who are caring have to act to conteract problems that come with an uncaring system. When people proffer ideological pap like “Americans are still far and away the most generous citizens of the planet”[Laffer et al.(2008)] we have two questions to ask:

For example, one group of caring individuals at the Whitman-Walker Clinic displayed an advert in metro trains serving Washington, DC:1

Seven years ago, my son tested positive for HIV. He got very sick. He could no longer work and lost his health insurance. Thank goodness we found Whitman-Walker Clinic. Their doctors gave him superior medical care, free AIDS medications, and nutritional supplements to help him get his strength back. They saved his life. Now, his condition is stable and he is helping others who have HIV. I don’t know what we would have done without the Clinic. And I surely don’t know what I would have done without my son. [Agnes Langley] — Whitman-Walker Clinic, Promotional material (early 2000s) [My emphasis – no work, no health insurance]

US laws and leaders2 often reinforce the widespread belief in other countries that US society is exceptional in multiple ways for being thoughtless and uncaring. An astounding example of a thoughtless and uncaring statement by a politician is that of Tommy Thompson, US Secretary for the Department of Health and Human Services (HHS). About a year after the March 2003 invasion of Iraq we find Thompson displaying a disconnection from reality shared by many right-wing conservative ideologues:

“Even if you don’t have health insurance,” said Thompson, who toured medical facilities in the Iraqi cities of Baghdad and Tikrit on Saturday and Sunday, “you are still taken care of in America. That certainly could be defined as universal coverage. Every American’s health care is far superior to what the health care is in Iraq.” — Iraq Notebook, “Universal care is right for Iraq, Thompson says”, The Seattle Times (3 March 2004) [My emphasis]

Having health care that is superior to that of devastated Iraq is not difficult, and so what is point of the comparison? The true message for a US audience came with Thompson’s remarkable definition of universal health care. Remember that care for Agnes Langley’s son (who had no health care) came from a nonprofit group with a limited geographical reach, not from any traditional source, public or private. Thompson must not have read a report from the Institute of Medicine of the National Academies of Science:

… because they often delay seeking care and therefore have a later diagnosis, uninsured patients with breast, cervical, colorectal and prostate cancer or melanoma are more likely to die prematurely than are patients with health insurance. … Uninsured adults have a higher risk of dying before age 65 than do insured adults, resulting in roughly 18,000 excess deaths annually. … “Universal” means what it says. Everyone living in the United States should have health insurance. — Institute of Medicine, Insuring America’s Health: Principles and Recommendations (January 2004)

Or perhaps Thompson just ignored the report.

A year after he resigned in 2005 Thompson became president of Logistics Health Incorporated, a private-sector health-care company.

Thompson was in a powerful position in the first George W Bush administration as head of HHS, and he was not alone in his perception of the beneficence of US health care for those without insurance coverage. For example, the president did not see the difference between treatment for traumatic incidents such as accidents in the home or car, and treatment for chronic illnesses such as HIV or Alzheimer’s – ideological pap getting in the way of compassion (or empathy). Bush did not worry about access to health care, but he worried that the private sector might become less important in the provision of health care (and US private sector health care is easily the most expensive in the world).

Free markets and socialism

We might wonder why private health care companies are such large contributors to US political parties and their surrogates, but then the history of health care in the USA has always been highly political:

Medical science knows very little about your ailment, Mr Figby, except that it probably would be much worse under socialized medicine! — Lichty (George Lichtenstein) Cartoon caption, “Grin and bear it” series (1961)3

I mean, people have access to health care in America. After all, you just go to an emergency room. The question is, will we be wise about how we pay for health care. … the best health care policy is one that emphasizes private health. In other words, the opposite of that would be government control of health care. — George W Bush, Speech to Cleveland Chamber of Commerce, Cleveland, Ohio (10 July 2007) [My emphasis]

In the same speech Bush decried attempts to extend health coverage to more children by expanding the States Children’s Health Insurance Program (S-CHIP) because “the program is going beyond the initial intent of helping poor children. It’s now aiming at encouraging more people to get on government health care.” He supported, he said, helping poor children get insurance, which he thought was commendable, but this help was not to be at the expense of private sector health plans. In a later speech he explained that S-CHIP was:

…a program initially designed to help poor families afford health care for their children. I support that concept. … I believe government cannot provide affordable health care. … If Congress continues to insist upon expanding health care through the S-CHIP program – which, by the way, would entail a huge tax increase for the American people – I’ll veto the bill. — George W Bush, Speech to Roundtable on Health Care, Landover, Maryland (18 July 2007)

As more than one person commented, Bush and other Republicans did not acknowledge that the US president and many members of the US congress were recipients of socialized medicine, that is, they had health care at the federal health complex in Bethesda – though perhaps this is stretching the definition of socialized medicine a little far. Others supporting the extension of S-CHIP pointed to the US Veterans Administration (VA) as an example of socialized medicine. The VA is charged with looking after the needs of those who have left the military, subject to certain eligibility requirements, and the VA runs its own (federal) hospitals and other health-care facilities through the Veterans Health Administration (VHA) to produce the USA’s largest integrated health care system. “Unlike other federal health programs, VHA is a direct service provider rather than a health insurer or payer for health care” (Congressional Research Service, Veterans’ Health Care Issues in the 109th Congress, 27 June 2005). Those who wish to starve the government beast also wish to starve the VA and the people it serves, for example, one aspect of government spending to reform “is health-care costs, such as Medicaid, Medicare and Veterans Affairs hospitals” and the expedient method should not be by “politically suicidal, or at best difficult, efforts to ‘cut’ spending” but rather by “politically profitable ‘reforms’ of programs that will reduce their long-term costs” (Grover Norquist, “Government shrinkage goal”, The Wahington Times, 2 August 2006). Stealth starvation.

And then came the Bush veto:

Congress’s SCHIP plan is an incremental step toward their goal of government-run health care for every American. Government-run health care would deprive Americans of the choice and competition that comes from the private market. It would cause huge increases in government spending. … Congress knew that I would veto this bill, yet they sent it anyway. So on Wednesday [3 October 2007], I vetoed the SCHIP bill. — George W Bush, President’s Radio Address (6 October 2007) [My emphasis]

Bush was speaking in the months before the presidential primary elections started in January 2008, and his actions were an affirmation of Republican ideals, reinforced by Republican presidential candidate Rudy Giuliani:

The Democratic candidates for president believe in a government-mandated model that looks for inspiration to the socialized medical systems of Europe, Canada, and Cuba. … America has the best medical care in the world. People come here from around the world to take advantage of our path-breaking medicine and state-of-the-art treatments. — Rudolph W Giuliani, “A free-market cure for US healthcare system”, The Boston Globe (3 August 2007)

That government help was equivalent to socialism seemed to be one of Giuliani’s message, and that the USA was number one in medical care another message. Giuliani and many other Republicans say the cure for the system’s problems was the free market, but others (myself included) believe that the market had created the problems. Though there are true believers such as libertarians, conservatives (at all levels of society) who expound on the benefits of the “free” market often do so because they do not want to see their own wealth diminished, that is, they want to be free to continue to make money.

In the final days of 2008 there has been massive interference in the working of markets due to what has been termed the financial “meltdown” – and intervention has been worldwide. Depending upon political inclinations, the desired interventions can be: in support of banks and other financial companies, or in support of auto-making companies, or in support of people who cannot afford to keep their homes, or no support to anybody (with many others interest groups trying to get a slice of the pie).

There can be no such thing as a truly “free” market in the USA because, even before the 2008 crisis, conservative politicians of all parties tend to work to maintain existing vested interests, tend to be protectionist, and want to interfere in the workings of markets. The nature of the vested interests or the nature of what needs protecting varies, depending whether the person is a conservative Democrat or a conservative Republican.

More ideological pap has come our way: “we do believe in the idea of American exceptionalism” [Laffer et al.(2008)] (my emphasis) and “this nation is, in the words of our hero Ronald Reagan, ‘a shining city on a hill”’. What seems truly exceptional about the USA is the way some US Americans attach so much importance to the idea that the USA is exceptional. The use of the shining city quote from John Winthrop (A Model of Christian Charity, 1630) is a case in point, because Winthrop said that the colonists inhabited a shining city, not because they were exemplary but because “The eyes of all people are upon us”. If the colonists dealt falsely with God “we shall be made a story and a by-word through the world”. Reagan believed the USA was so exceptional that “God had a divine purpose in placing this land between the two great oceans to be found by those who had a special love of freedom and the courage to leave the countries of their birth” (Ronald Reagan, Speech: To Restore America, 31 March 1976).

Laffer et al decry the the health care systems of Canada and Cuba because they are governmental and universal. Using some strange logic that implies Canada is less free than the USA because of Canada’s universal coverage, they say free societies are healthier societies. “The best single measure of health in society is life expectancy” [Laffer et al.(2008)] and they state the obvious: South Korea (free) has a longer life expectancy than North Korea (not free), West Germany (free) had a longer life expectancy than East Germany (not free) prior to 1990, and so forth. They ignore the even more obvious (and inconvenient) fact that the 2008 estimate for Canada was 81.16 years and for the USA was 78.14 years (Cuba was 77.27 years).4

Getting health care

An interesting exercise in free markets is the phenomenon of bus trips made by US Americans (usually retired) across the border to purchase medications in Canada – Canadian prescription drugs are much cheaper than the same brand in the USA. After losing this vote of confidence in US health care, conservative politicians attempted to stifle that exercise of people’s freedom through legislation – but the reduction of freedom had to be in such a way that the intervention did not seem to protect drug companies at the expense of consumers. The hammer to nail down the lid on cheap medications was drug safety (playing to people’s insecurities). The Senate bill required US functionaries to certify the safety and effectiveness of prescription medicines imported from foreign countries. This would stymy people’s attempts to import drugs from outside the USA by increasing the effort needed to cross the border or to have the medication mailed.

One of the leading Republican sponsors of the Senate bill to stop importation of prescription drugs from Canada said:

This bill will meet the challenges of protecting American consumers and patients and usher in a new era of drug safety. — Mike Enzi, Press release(9 May 2007).

In the period 2001-2007, Senator Enzi received $174,000 in political contributions from drug interests,5 which is about $29,000 a year, or more than the 2007 official poverty threshold ($27,705) for a two-parent family with four children. Enzi’s takings were much less than the $520,694 received by Senator Richard Burr from those same interests – average donations worth more than the poverty threshold for any size of family. Politicians always claim that such contributions do not affect their voting behaviour. So what did Burr have to say about this bill?

“To accept the importation of foreign drugs is to open the door so that a cottage industry today becomes a major industry tomorrow in supplying counterfeit drugs,” said Sen. Richard Burr, R-N.C. — Associated Press, “Bid to Allow Drug Imports Advances” (3 May 2007)

If drugs from Canada are so potentially dangerous, why have we not heard of all those deaths in Canada – and why are levels of health better in Canada than the USA? As many US drugs are manufactured outside the USA, does that mean all drugs would have increased scrutiny? The House did not pass an equivalent bill.

Enzi, Burr, and others were in favour of a government intrusion into an individual’s health care decisions to interfere in what drugs doctors can prescribe and in where the prescription is filled, so would that “deprive Americans of the choice and competition that comes from the private market” to quote Bush (6 October 2007)? At about the same time as the Senate was debating banning imports, there was another debate – about whether the federal government should try to fix prices for drugs used by seniors. Both banning imports and fixing prices were government interventions into the market. Enzi supported intervention in imports (against the free market?), but not in price-fixing (for the free market?) – claiming free market negotiation, not price-fixing, would yield better results:

Making sure the government does not interfere by price fixing protects seniors and the disabled from having the government decide which drugs their doctors can prescribe. — Mike Enzi, Press release (April 12, 2007)

Though the Enzi’s positions seem contradictory, the one unifying theme is that both positions favour the health-care and pharmaceutical industries. Given his Senate voting history, the National Journal puts Enzi as the fifth most conservative Republican senator in 2007 (90.8th percentile).

Apart from government programmes such as Medicare and Medicaid, a “free” market in US private health care has produced a system in which most health insurance is job-related, in that the employee and employer pay for health insurance (almost a payroll tax). If an employer does not pay for insurance then employees have to fend for themselves and try to provide their own insurance. With so many children and working adults lacking health insurance, with such adverse consequences, those with insurance are worried about what happens if they lose their job, because then (sooner or later) they will lose their insurance. It was the ordinary person’s fear of being cast adrift from the health-care mainland that inspired the Whitman-Walker Clinic advertisement. Statements about governments not being able to provide affordable health care, or the USA having the best medical care in world, can provide solace for people with health insurance, even though they are concerned about losing their own health care. There are many worried people in a nation where a significant minority are without health insurance (15.7% of the total population in 2004, including 11.2% of children under 18), and the majority are worried about losing health insurance through leaving their job – or their employer stopping the provision of health insurance.

Even those with health insurance are not safe from worry. A father in Maine had a daughter with cystic fibrosis, and his job with a company that installed natural-gas lines provided health insurance. The insurance was not enough to cover the full cost of his daughter’s treatment, and Maine state health insurance paid for a good deal of his daughter’s expensive care. The father was promoted to foreman, and he discovered he was now over the income limit for the state health plan that helped with his daughter – with the result that he “worries that he’s about to lose the house where he lives with his wife and four children” (Joseph Shapiro, “Underinsured Struggle To Afford Health Care”, NPR Morning Edition, 20 November 2008). A sympathetic caseworker told him that he and his wife could get back the supplemental coverage – if he worked less, or if his wife stopped her part-time work.

An exceptional society

Worry itself has adverse affects on the health of both mind and body, and unhealthy people contribute to a morbid society. Many international health comparisons reflect badly on the USA despite Giuliani’s reassurance about the USA’s world leadership in health care. According to some people, the reason the USA does worse is that basically the USA is exceptional, in that it is a more unhealthy place to live: there is more stress in general, people work longer, the USA is a more violent society with a higher murder rate (extend the list as you please). According to this reasoning, life expectancy in the much richer USA is less than 45 other counties in the 2008 rankings, because US Americans are more likely to have worked longer and are more likely to be murdered (extend the list), not because health care is worse. Less influenced it would seem by higher hours of work and higher homicide, 2008 estimated infant mortality rates show the USA with 6.30 deaths, Canada with 5.08 deaths, and Cuba with 5.93 deaths (per 1000 live births).

Not all is lost in the cause of US “exceptionalism”, because:

Our infant mortality rate is driven by our high accidental death rate and our immigration stats. Socialized medicine is not going to help. It would likely make things worse given the crummy health care you get in places like UK. — Art Blair, in “Commentary”, Health Statistics: Infant mortality rate (most recent) by country, NationMaster.com (28 July 2005)6

Being worried about the future can lead to feelings of psychological insecurity (but not in every case). An individual with personal insecurity may compensate by being belligerent, may react in a paranoid manner, may become withdrawn, or may cope in some other way – belligerence is a common reaction. Ideologues, such as Bush or Giuliani, recognize that people are insecure and so respond belligerently for them. Possibly trying to justify a lack of intervention, one commentator said of people in the USA “We’re much less willing to have government make decisions for people than is the case in Canada and Europe. It’s a cultural difference.” (Paul Ginsburg, CBS Evening News, 22 June 2007).

Of course, given that the governments of most industrialized countries provide health care, at a lower cost, then statements such as “I believe government cannot provide affordable health care” or nobody wants “a government-mandated model” do not seem accurate, and their US belligerence antagonizes people in other countries – who do not believe in an unquestioned US hegemony. One might wonder if the assertion about “the crummy health care you get in places like UK” is an example of attack being Blair’s best defence against insecurity – but then, who knows?

Four years after the Lichty cartoon, on a more positive note, President Johnston signed into law the bill that introduced Medicare as part of his “war on poverty”, with Truman present. After repeating what Truman had said in 1945, and Johnson continued:

Well, today, Mr. President [Truman], and my fellow Americans, we are taking such action – 20 years later. … No longer will older Americans be denied the healing miracle of modern medicine. No longer will illness crush and destroy the savings that they have so carefully put away over a lifetime so that they might enjoy dignity in their later years. No longer will young families see their own incomes, and their own hopes, eaten away simply because they are carrying out their deep moral obligations to their parents, and to their uncles, and their aunts. — Lyndon B Johnston, Remarks With President Truman at the Signing in Independence of the Medicare Bill (30 July 1965)

Does Truman’s “Millions of our citizens do not now have a full measure of opportunity to achieve and to enjoy good health” still sound almost contemporary? Is this a healthy state of affairs?

Notes

1. The Whitman-Walker Clinic describes itself as “a non-profit community-based health organization serving the Washington, DC metropolitan region” and it works for the gay and lesbian community, concentrating on those at risk for HIV and AIDs.

2. Because what these leaders say is very important (especially about US laws) this discussion of health and social insecurity contains extensive quotes from some of the leaders.

3. The cartoon shows two doctors examining a patient in hospital: in 1961 John F Kennedy proposed a programme – the “socialized medicine” of the cartoon – that was to become Medicare.

4. Figures for life expectancy and infant mortality are taken from the CIA’s The World Factbook, and are 2008 estimates.

5. Figures for Enzi and Burr are given in “Senators who weakened drug bill got millions from industry”, USA Today (10 May 2007).

6. This comment was posted 14 February 2005, so is Blair referring to earlier data which were then replaced by the July 2005 figures? – taken from the CIA World Factbook. As with all web sites, this reference is potentially ephemeral.

References

[Laffer et al.(2008)] Arthur Laffer et al. The End of Prosperity: How Higher Taxes Will Doom the Economy – If We Let It Happen. Threshold Editions, 2008. Arthur B Laffer, Stephen Moore, and Peter Tanous.

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