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Health and social insecurity

GJ Boris Allan

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.

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)

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, “Grin and bear it” series (1961)

[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.]

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 (2000s)

[For the gay and lesbian community, the Whitman-Walker Clinic describes itself as “a non-profit community-based health organization serving the Washington, DC metropolitan region.”]

US laws and leaders often reinforce the widespread belief that US society is notable in multiple ways for being thoughtless and uncaring (and aggressive, and dangerous, and ...).

[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.]

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. An amazing example of a thoughtless and uncaring statement by a politician is that of Tommy Thompson, a senior member of the executive branch of government (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 – 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)

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

Thompson was in a powerful position in the first GW 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 – political ideology 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). We might wonder why private health care companies are such large contributors to political parties and their surrogates, but then a possible reason became more obvious when Bush said:

... 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 is 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) [My emphasis]

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)

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. Erstwhile Republican presidential candidate Rudy Giuliani wrote:

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 (as with Lichty) seemed to be one 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. However, there can be no such thing as a “free” market in the USA, because 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.

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, 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)

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

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 (78.00 years) is less than that of, say, France (80.59 years), 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, infant mortality rates show the USA with 6.37 deaths and France with 3.41 deaths (per 1000 births).

[Figures for life expectancy and infant mortality are taken from the CIA’s The World Factbook, and are 2007 estimates.]

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, (28 July 2005)

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

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, on signing into law the bill that introduced Medicare, noted what Truman had said in 1945, and then he 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?

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