Public Comment

During one of the so-called debates staged by the Democratic Party National Committee last fall another candidate asked Bernie Saunders -- in a tone implying the absurdity of the idea -- how he expected to fund a universal national health care system which was projected to cost half a trillion dollars over ten years. In a real debate Saunders would have had time to ask why the United States, though among the wealthiest nations, is the only "developed" country in the world that (supposedly) cannot afford universal health care -- while its cizizens pay twice as much per capita as other developed nations' for a private for-profit health care system which delivers third world public health rates. As John Kenneth Galbraith wrote in 1981, "no one should assume that American election campaigns are conducted in a context that allows candidates any inconvenient freedom of speech." But while America infants and mothers die in childbirth at levels worse than Turkey's or Cuba's or over 30 other countries, because America "can't afford" to do better, earlier this year, a few months after those "debates," Congress, without substantive discussion and in a matter of hours, voted six trillion dollars to buoy up Wall Street after its latest and largest funny-money bubble collapse thus adding over a half trillion dollars to the wealth of a few dozen billionaires in a few weeks. 

In 1917, commenting on the fact that one tenth of Americans owned nine tenths of the country's wealth (just as today), Thorstein Veblen pointed out that the only way to preserve such a system is to insure the ignorance of its victims -- its prey. A key method for insuring this result is the collaboration of "both" political parties with what Veblen's generation called the "kept press" to prevent such proposals from appearing on the national agenda or being substantively considered in Congress. 

Germany had national health care in 1883, England in 1911, Canada in 1972, but this matter has been entertained by Congress barely three times in these 140 years -- and blocked every time. In 1934 FDR's New Deal legislative program swept aside the proposal as "impractical." In the late 1940s the AMA and other interested parties blocked President Truman's initiative for national health care, hiring the public relations firm Whitaker & Baxter which coined the ostensibly opprobrious phrase "socialized medicine"to help the successful campaign to defeat it. During President Obama's administration, when an overwhelming consensus of Americans (67%) favored a single-payer system (as we still do), the administration and both parties in Congress collaborated in delivering, instead, a system designed to perpetuate and reinforce the predatory investor-profit system. 

In accord with Veblen's dictum, these fundamental facts -- and indeed the entire history of how America has come to be the only "developed" country in the world without universal health care -- are kept little known. So too are the consequences for America's public health yielded by this 100-year blockade -- notwithstanding the present pandemic's tendency to expose them. This essay aims to alter this meticulously contrived ignorance, principally by reviewing and summarzing two watershed investigations of the facts. 

In 2009 two British epidemiologists, Richard Wilkinson and Kate Pickett, published The Spirit Level, a study correlating and comparing statistical measures of public health and social well-being with the distribution of wealth among 23 developed nations and each of all fifty of our United States. Their work summarizes and coordinates hundreds of different studies of specific factors by thousands of investigators -- epidemiologists, demographers, sociologists, economists -- rates of physical health (infant mortality, maternal death in childbirth, life expectancy, major disease prevalence and mortality, etc.), mental health, obesity, teenage pregnancy, educational access and performance, comparative stability of community life, social trust and distrust and malaise, drug abuse, violence and crime, imprisonment and severity of policing and punishment, and social and economic mobility. Their investigation conclusively demonstrates that, across the board, rates of public health and social well-being correlate closely and strongly, cross-culturally and pervasively with the distribution of wealth. Their conclusions have been attacked, misreported, twisted and obfuscated, but their factual basis is plain, firmly evidenced and irrefutable. The more equitable the distribution of wealth, the better is a society's public health and social welfare as a whole. The more unequal the distribution, the worse for the society as a whole. 

Remarkably, this holds true whether societies are, on average, at large, comparatively rich or poor. It is not the absolute level of average income or of average wealth that matters, but the degree of equity or inequity in its distribution across the population. America's average income is high compared to some of these 23 nations but our social conditions, along with our distribution of wealth, consistently rank at the bottom or near it. Often, in fact, our conditions of health and social well-being are worse than countries that fall well below the 23 examined in their study. The much lower average income in Cuba is, by comparison, far more equitably distributed, and Cuba's statistics significantly surpass America's. Cuban infants and childbearing mothers have markedly better chances of survival than American infants and mothers, and so on. And conversely, the more nearly egalitarian a society's distribution of income and wealth, the more its social conditions improve -- across the board. The same trend shows in comparisons among our fifty states. 

Another remarkable feature revealed by Wilkinson and Pickett's analysis is that the consequences of maldistribution of wealth for public health and social well-being tend to impact the entire population, individual income notwithstanding. In most respects these consequences are not proportionately worse for the poorer members of a society alone, they are worse across the entire spectrum of the population, except possibly for tiny wealthy elites (which are difficult to assess statistically, in any case) who can insulate themselves from some of these consequences -- with "concierge" health care, gated "communities," chauffeurs and bodyguards, etc. Otherwise, for all but these very few -- and in many ways for them also -- maldistribution of wealth negatively impacts society as a whole individually across all strata of economic status. 

In both these respects, Wilkinson and Pickett's study suggests that societies behave, physiologically, psychologically, and socially, as integral organisms. In these dimensions, we are all in it together and we all suffer together or thrive together. We may persuade ourselves that we are doing better than some -- and the steeper the pyramid the easier this illusion comes, for some -- but cross-cultural comparison reveals the reality. All levels of a society do better or worse depending on its overall degree of economic equity. Consistently, across the entire span of the 23 most "developed" nations and by every measure, America's economy produces and perpetuates the least equitable distribution of wealth and the sorriest conditions of public health and social welfare. This is a systemic problem of very long standing. 

In the words of our Constitution's Preamble an essential goal of our government is declared to be to "promote the general welfare." Wilkinson and Pickett's investigation shows that in this crucial respect, which bears on all our lives and livelihoods, our children's and grandchildren's, on our communities and on the future of our country, we are coming up seriously short. It utterly demolishes the assiduously fostered myth of the international superiority of the American standard of living. America's tiny elite does very well indeed; Americans at large do not. We have the most billionaires, and third world health rates, the world's largest prison population, and the first world's shoddiest social welfare support system. 

A look at America's health care system reveals some of the reasons why this situation exists and persists. As befits the second largest sector of America's economy, the prices Americans pay its investor-owned health care "industry" top the world at $10,209 per capita in 2018. "We are number one." Health care costs Germans (at number 5) 56% of what we pay, costs the French 48% (#11), and costs Italians 35% (#20). But America's public health rates fall far below all these countries and many more. In 2017 we were #55 in infant mortality, #47 in maternal death in childbirth, #43 in life expectancy, and so on. 

Bismarck created Germany's public health system in 1883. "Both Germany and Great Britain adopted comprehensive programs of social-insurance legislation, the former as early as the 1880's, and the latter in a series of laws culminating in the National Insurance Act of 1911. By 1914, Western Europe generally had accepted the principle of social-welfare legislation with programs that included workmen's compensation for industrial accidents, health and unemployment insurance, and old-age pensions. Much of Europe thus seemed to be moving toward greater social and economic as well as political democracy." In the 1880s and after, American scholars returning from study and research at Germany's world-leading universities began to circulate these ideas here, but they did not get far. Why America did not and still has not followed Europe's (and Canada's) clearly successful examples, and what the metropolitan elite's system of monopoly corporate finance has created instead, and how, is the subject of Christy Ford Chapin's scholarly investigation, Ensuring America's Health: The Public Creation of the Corporate Health Care System (Cambridge, 2015). This densely documented study reveals a century of determined profusely funded expert connivance on the part of medical associations, trade groups, medical schools, lobbyists and legislators, corporations and corporate law firms, insurance corporations, finance and financiers, with finance, and the investor elite it serves, coming out on top. 

In the first decades of the twentieth century Americans relied for health care, insofar as they could, on medical practitioners in private practice and, increasingly, on local physician groups operating multi-specialty clinics which contracted with dues-paying community groups -- small businesses, fraternal organizations, mutual aid societies, church groups, neighborhood clubs, union locals, and local individuals -- to provide yearly medical attention as required. Being small and local kept their administrative costs to a minimum and their reputation among their patients, local doctors and hospitals provided effectively direct oversight of their performance. 

The 1920s witnessed the financial consolidation and monopolization of numerous hitherto local American public-service businesses -- public utilities, transit systems, grocery stores, department stores, drug stores, bakeries, breweries, etc. Chapin documents the American Medical Association's efforts, beginning during these years, to establish that medical care would be provided strictly through individual practitioners on a fee-for-service basis. Local group-plan clinics were hindered and suppressed by gaining control over hospital admissions boards and refusing them access, and over state licensing and medical school admissions to limit the number of practicing and new doctors. (As a lasting consequence, one third of America's physicians today are foreign born and educated.) During the 30s and 40s, as community clinics succumbed to the assault and public demand for insurance rose accordingly, the AMA compelled insurance companies willing to offer policies to adopt their fee-for-service model rather than the clinic plan. Under the clinic plan, members' dues effectively created small local mutual insurance groups, each with its local funding pool, without entailing the costs of nationwide centralized administrative bureaucracies and staff, large-scale regimes of financial control, cartelization and monopoly, and such like "overhead." 

In 1933 President Franklin Roosevelt's original New Deal legislative program side-tracked public health insurance proposals as "impractical." In 1938, however, facing dicey Congressional elections while sunk in the second trough of America's Great Depression (the world's longest, it lasted 12 years), the second Roosevelt Administration found it expedient for the Department of Justice to file an antitrust suit against the AMA over its suppression of physician group clinics -- but the case disappeared into the fog of war. In 1939 the California Medical Association fought an expansively funded battle to defeat a proposal for state health insurance. Lack of widely available effective health care, along with degraded social conditions and malnutrition, took their toll. Second World War Selective Service induction examinations classified 30% of draftees as "unfit for military service." During President Truman's second term the AMA and other interested parties defeated his national health care initiative, continuing their opposition through the 50s and beyond, while their critics "publicized the AMA's receipt of $10 million in research funds from the tobacco industry" to help thwart the spectre of socialized medicine. 

With national and state public health care blocked, public demand for insurance continued to build and "AMA leaders found their most reliable political collaborators among commercial insurers" who were prepared to cooperate with their fee-for-service model and who proceeded to restructure health care as a money-making business subordinate to corporate control. As with life insurance, for elite interests a major attraction of the private insurance model is that it serves to funnel nationwide premiums to "the Northeast" and place them under centralized control for the use of consolidated finance, financiers, investors and speculators. The medical system's corporate investor overseers have consistently placed their pecuniary interests above those of public health, patient service and even physicians' medical concerns, and devoted vast sums in politics and media, overtly and covertly, to sabotage initiatives for change and to enforce their for-profit agenda. "Socialism" was their war-cry from the start and "universal health care" their bête noire. It is well known that health care without predatory corporate investor profits is a communist menace. 

America's health care industry is "organized for profit" in the first place and yields "high costs and fragmented care." "In comparison with alternative arrangements, the insurance company model has delivered medical services less efficiently and more expensively" and drives up "costs by separating the delivery of care from the financing of care." The way "it has structured patient and service provider incentives" is the primary means by which its costs have been inflated -- to the increase of administrative compensation and investor profits. Wilkinson and Pickett's study shows the long term and present-day results for Americans' health compared with other nations. 

Once some form of Medicare legislation became inevitable (1965), insurance companies and others worked to limit its coverage to seniors and minimize the level of support it would offer so as to create a market for "supplementary" private insurance. "Influential Social Security expert [federal bureaucrat] Wilbur Cohen advised fellow reformers [sic] that partnering with insurance companies would create a [sic] politically palatable program." "The final bill guaranteed that for service providers, Medicare would be a government-funded version of the existing insurance company model ... with a program that increases demand for physician services while allowing doctors to charge generous fees. There was no mechanism for restraining costs." 

Nevertheless, "doctors increasingly lost autonomy to practice as they saw fit and witnessed a growing share of system revenues diverted to administration costs and third-party organizations" [sic]. During the 50s, general practitioners still made house calls and a practice comprising four doctors might typically employ one secretary for appointments and correspondence. As the insurance system took hold the need for office staff increased dramatically while physician-patient interactions were increasingly constricted and regimented. "In contrast, insurance companies emerged from the Medicare fight with augmented political and economic power." And, best of all, Medicare would be funded by a charge levied on seniors' Social Security benefits, themselves funded in the first place by a poor tax which exempts elite income sources (dividends, interest, capital gains, etc., as well as their "earned income" above a low ceiling). Meanwhile in 1953, once the first Republican administration after the New Deal took office, business's "equal contribution" to Social Security was made tax deductable. 

The Affordable Care Act of 2010 (which has proven to offer most people nothing of the sort) left the foundations, premises and practices of this system in place and increased opportunities for investor profits by reinforcing industry monopoly markets. In Canada, whose national public health system has shamed America for many decades, insulin costs one tenth what it does across the border. Here, under the regime of America's for-private-profit system, with congressional legislation safeguarding pharmaceutical corporation patent and market monopolies and liability-exposure, "a study shows that of the 100 biggest pharmaceutical corporations two-thirds spent at least twice as much on marketing as on research and development, with 43 spending five times as much, and 27 ten times or more." "Marketing" expenses not infrequently include perks, junkets, honoraria and other euphemized kickbacks for prescribers. 

Pursuing a similar agenda at a higher level on behalf of the same investor interests, in 2018 "analysts" at New York finance bank Goldman Sachs advised their pharmaceutical corporation clients that research leading to life-long therapies for diseases promises a brighter future for profits and dividends than does discovering cures. Goldman Sachs described such therapies as offering a more "sustainable" strategy -- a "chronic" strategy, you might say. And in March 2020 Wall Street investment bankers took the golden opportunity presented by the crisis onset of the corona-virus pandemic to "press health care companies" to raise their prices -- thus also raising the question whether there is a degree of flagrant abuse, parasitic greed and flaunting predation that Americans will ever effectively determine is not sustainable. Meanwhile, America's suicide rate has increased by one third since 2000. As it bears on social conditions, this amounts to a very bad review. And it does not include additional millions of deaths by the slow suicide of despairing alcoholism and opiate addiction (in recent decades a promising new growth market for American pharmaceutical corporations and a real boon for their investors). 

The local community clinics of the early twentieth century sprang from and embodied the same spirit of collective mutual aid that was key to the American progressive-populist tradition's vision of a cooperative commonwealth -- the spirit that created such frontier practices as barn-raisings. Many clinics had their origins in association with populist-progressive community organizations. But in placing community health before profit and eschewing the guild monopoly methods that suppressed their clinics, these doctors also participated in the oldest traditions of the healing arts. 

Physicians practiced as priests of Asclepius and Apollo in ancient Greece. In Egypt their god was Imhotep. Typically, pre-modern cultures consider healers in the guise of wise men and women, a little uncanny, unworldly (shaman, wizard, mage or witch), as adepts of an arcane craft, akin to magic, working close to the hidden inner springs of life, affected with its spiritual mystery and so owing a natural reverence and allegiance to the art of medicine, a devotion which necessarily takes precedence over the worldly preoccupations of the marketplace and pecuniary calculation. "The temple is holy because it is not for sale." In this view, the human body is holy also (and it is not for sale) and the healer and his art partake of this sacral dimension. He may ask a fee, even a large one from an affluent patient and, equally, he may treat the poor gratis or, on country rounds, accept a dozen eggs, a hare or a honeycomb, or find a sack of potatoes on his porch come harvest time. More than a few American doctors today maintain this tradition as best they can, on the margins, against the current, insofar as the health care industry does not prevent them. Many find it a losing battle. 

In contrast with all other developed nations today, what is peculiarly American (if it really is "American") is the health care industry's programmatic and all-pervading intrusion of organized greed into the precincts of this ancient and sacred art and its essentially priestly functions, through the systemic connivance of finance, corporate law, politics, media and the academy. Self-described "health care" corporations buy up and close hospitals the same way J.P. Morgan bought and shut down blast furnaces and steel mills to consolidate the monopoly of U.S. Steel. It's called "creative destruction" in the jargon of Wall Street vulture fund investors. 

In the last year of Washington's first administration, John and Abigail Adams paid a worried visit to Manhattan where their New Yorker son-in-law was up to his neck brokering land deals amid "a wave of business failures." In the aftermath of a "rage of speculation" punctuated by Wall Street's first post-independence credit bubble collapse, "terrible is the distress," Abigail wrote her sister, "from the failure of many of the richest people." John called the city's money-mad demonic spirit "Mammon." A century later, during the hard years between the Crash of 1893 and the Panic of 1907, amid the wreckage of the People's Party watching the climactic enthronement of metropolitan elite corporate finance in consolidated dominion over America's economy and government, populist-progressive activists revived this personification or avatar of all-mastering, all-consuming fanatical greed. Perhaps they got the word from their colleagues in the Social Gospel movement, who got it from Jesus. Confronting Wall Street's established temple of the Almighty Dollar, triumphant uber alles, they employed "Mammon," as Adams does, to voice and to bear witness to the sense, the belief that there are values properly governing human affairs which are not reducible to pecuniary terms, principles which from the beginning -- "we hold these truths to be self evident" -- inform the core of American ideas about liberty and democracy, society and government. As Lincoln put it, "Liberty before property; the man before the dollar." 

REFERENCES 

Richard Wilkinson & Kate Pickett, The Spirit Level: Why Greater Equality Makes Societies Stronger (New York, Bloomsbury Press, 2009). 

Christy Ford Chapin, Ensuring America's Health: The Public Creation of the Corporate Health Care System (Cambridge University Press, 2015). Unless otherwise indicated quotations are from Chapin. 

These sources are quoted ad hoc: 

John Kenneth Galbraith, A Life In Our Times (Boston, Houghhton Mifflin, 1981) p. 297 quoted. 

Thorstein Veblen, An Inquiry into the Nature of Peace and the Terms of its Perpetuation (New York, Huebsch, 1917) p. 151 & 293 quoted. 

Arthur A. Ekirch, Jr., Progressivism In America: A Study of the Era from Theodore Roosevlt to Wooodrow Wilson (New York, New Viewpoints, 1974) quoted on history of European social welfare legislation. 

On the New Deal's shaping of congressional initivatives see John Flynn, The Roosevelt Myth, (New York, Devin-Adair, 1948), a detailed eye-witness account by a major progressive activist of the era. 

Future Supreme Court Justice Charls Evans Hughes chaired the 1905 New York State Armstrong Committee's investigation of the character and use of consolidations of insurance funds in the hands of financiers. 

Emily Rauhala, "As price of insulin soars ..," Washington Post June 14, 2019 -- www.washingtonpost.com. 

"RN Report: Pharma Giants Spend Far More on Marketing, Sales Than They Do on Research and Development," www/nationalnursesunited.org (October 21, 2016), reporting a study by the Institute for Health and Socio-Economic Policy. 

Amy Martyn, "Goldman Sachs warns biotech clients that curing patients may not be 'sustainable" Consumer Affairs (April 13, 2018) www.consumeraffairs/com/news. 

Lee Fang, "Banks Pressure Health Care Firms," The Intercept, March 19, 2020 www.theintercept.com/2020/03/19/. 

Chuck Collins, Omar Ocampo, Sophia Paslaski, "Billionaire Bonanza 2020" at inequlaity.org (April 23, 2020) 

John and Abigail Adams are quoted from Page Smith, John Adams (New York, Doubleday, 1962). 

Lincoln's maxim is quoted from Ray Ginger, The Bending Cross: A Biography of Eugene Victor Debs (Rutgers University Press, 1949; rpr. Russell & Russell, 1969).