More important than our circadian rhythm: Creating a society that is safe and has health care for all

The New York Times, in addition to covering world and local news, has a lot of “feature” type news, generally appealing to educated, urban, and often higher income people, especially in New York, who are a large percent of its readers. Obviously its Arts coverage reflects the enormous NY arts scene, but also frequently seems to be more in-depth, designed to appeal to an even smaller group. Similarly, while its health coverage often includes news and opinion pieces on the social inequities in health care, on community risks (such as gun violence), and on policy issues, it also includes pieces aimed at what might be called “individual health self improvement”, sometimes involving new(ish) research.

An example is the recent front-page piece on “Circadian Medicine”, that reports on research about following our “body clocks” to get the greatest health benefits from how we do things like eat, exercise, etc. It starts with a look at the effort to move toward permanent daylight savings time and how this affects our personal and work lives.  Of course, this is ultimately a sociocultural issue; the amount of light and dark each day is unchanged, but the question is when our particular area decides to do things. Farmers and ranchers, for example, do not work based upon the time it says on the clock. If we wanted to, we could work from 9 to 6 instead of 8 to 5 rather than changing the clocks.

What is actually more important about this piece, to me, is that it goes on to emphasize how individuals can (possibly) improve their health by choosing the correct time of day to do their health-inducing activities. It is thus yet another effort to look at what each of us can (provided we have the education, autonomy, money, and time) do to make our individual selves healthier. Maybe. Such emphasis is not wrong per se (except, of course, when it is wrong, as has been, for example, our obsession with taking vitamin supplements when we are not vitamin deficient, as see F. Perry Wilson on Medscape, “It’s official: vitamins don’t do much for health”). The real issue is that it is a distractor, in that it focuses upon something that is perhaps slightly beneficial for some people (or not) but will not have a major impact upon the health of the public or the populace, taking our attention away from focusing on the very many major serious things that do have a significant effect upon the health of the public, and that we, as a people, could do something about.

 Like what? Let’s start with some data that should be scary: Among wealthy countries, the US is the only one that has seen a leveling-off and decrease in life expectancy, as reported by “Our world in data”. I have reported on this trend several times previously (Lower life expectancy in the US: A reflection of racism, classism, and social inequity April 29, 2022, Decreasing life expectancy in the US: A result of policies fostering increasing inequity, November 29, 2019) and examined some of the various proposed explanations. Case and Deaton, among others, suggest that the increase in the death rate (particularly among less affluent whites) are “deaths of despair”, mediated through the use of substances (alcohol, tobacco, opioids and other drugs). No doubt these are major contributors, but there are also others. One that has many people very concerned, as it should, is the ubiquity of gun violence in the US. This is a major contributor to death rates in populations such as young males, where suicide and homicide are very important causes of mortality. Most of us can reel off the names associated with major episodes of mass shootings, especially school shootings like Columbine, Sandy Hook, and Uvalde, but these are the tip of the iceberg. An interactive story in the Times documents the 63 “mass shootings” (four or more people shot) in May 2022 alone, and there were 65 in June, and 25 in July -- and as of only July 8 when this was published! And this does not count the many more deaths where “only” one to three people were killed! In the wake of Buffalo and Uvalde, Congress finally passed a very weak gun law. It did break an impasse, but in the minimal amount of restriction it places on gun ownership and carrying, it reinforces the idea that “America is a gun”, as in Brian Bilston’s poem. Any other country with only one major mass shooting has reacted much more dramatically and effectively. While articles continue to appear, such as the Op-Ed of Patti Davis describing the reaction (in her) and lack of reaction (in the nation) to the shooting of her father, Ronald Reagan, 41 years ago, we still are in thrall to the gun lobby and to folks who truly believe that they are at risk if they don’t have and carry guns that they make it easy for those who are going to create major violence and death.

And what about when we get sick? We – Americans – are as a group less able to access care than people in those other countries because we don’t have universal health insurance or access. Dr. Aaron Carroll, in an Op-Ed on July 7, emphasizes the impact of health insurance deductibles, noting that it is not just the uninsured but the underinsured, for whom deductibles are a major obstacle (along with other inappropriately-designed out-of-pocket payments) who suffer from not being able to access medical care, especially in time. The numbers that he cites for deductibles, and for co-payments and co-insurance, are amazingly high, as is the impact that it has on the health of those affected. For example, “The good news is that the A.C.A. limits these [out-of-pocket expenses] in plans sold in the exchanges. The bad news is that they’re astronomical: $8,700 for an individual and $17,400 for a family,” and for people in Medicare drug plans “a simple $10 increase in cost-sharing, which many would consider a small amount of money, led to about a 23% decrease in drug consumption.”

The fact that it is the Medicare drug plan (Part D) that is cited here is not coincidental; it, along with both Medicare Advantage (Part C) and the newer REACH (formerly DCE) program implemented by CMS (the Center for Medicare and Medicaid Services) are the portions of the Medicare program focused on providing profit to investor-owned companies rather than health care to American seniors. A recent report by the Urban Institute on Geographic Predictors of Medical Debt, in Health Justice Monitor, shows, unsurprisingly, that those areas with the highest concentration of poor, uninsured and underinsured people, and people with chronic diseases have the highest level of debt. And the lowest level? Those areas with the highest concentrations of people over 65. This, of course, is the only part of the general US civilian population that has essentially universal health insurance, despite the efforts of the programs above to decrease or dilute it. Although this seems worth mentioning, the Urban Institute did not; maybe they thought it was obvious.

But in this country nothing is obvious to most people and needs to be pointed out.  This includes our legislators, federal and state, to whom often the only thing that seems obvious is who is contributing to them. With all respect, we need to be focusing less upon our body clocks and circadian rhythm and more on the things that made a real difference in our nation’s health.

We need to decrease the availability of semi-automatic guns with high-capacity magazines. We need government policy focused upon creating well-paid, good-benefit jobs that will decrease “deaths of despair” rather than maximizing corporate profit. And we need high-quality universal coverage and access to health care for all our people. What we do not need are more programs like Medicare Advantage, Medicare Part D, and REACH that channel public tax dollars to private enterprises as profit.

What we do need, we needed long ago, and we need it now.

Lower life expectancy in the US: A reflection of racism, classism, and social inequity

One of the things that most fuels self-deception is imagining that we should be living, or maybe even still live, in what we imagine was a better past. Of course, the past was not always better – in fact, it was overall, for most people, worse – but our minds repress the bad and remember the good from when we were children, as I have discussed in my other blog, “Life, the Universe, and a Few Things” (Brooklyn Nostalgia, August 21, 2011). Sometimes there is a conscious effort, a movement if you will, to block out the really bad things that have happened in the past not only from our individual memory but from our history books and schools. Clearly, this is happening now with regard to the primary founding evils in US history, extermination of the indigenous inhabitants (Native Americans, Indians) and slavery. That these were real is incontrovertible. That they were horrific, inexcusable, and must be remembered both to honor the victims and prevent recurrence should be obvious. But the effort to suppress teaching of this history, parallel to suppressing teaching about the Holocaust (which is not suppressed in Germany) is ongoing, vicious and wrong. To add insult to injury, advocates are adopting the language of microaggression, justifying their racist efforts to whitewash history with ostensible concern for “making white children feel bad about themselves”.

This is, in addition to every other evil and reprehensible aspect of it, also a way to divert those children – and their parents – from knowing and worrying about the things that they should be worried about, such as climate change and nuclear war. And the incredible inequities in American society (not to mention the world!) that have actually led to terrible social and individual outcomes. For example, the drop in life expectancy in the US. Yes, drop. People living shorter lives than they used to. Due in part to the COVID pandemic, but due in the US more to the vast inequities in wealth, social support, access to health care, jobs, use of harmful substances (such as alcohol, opioids, and tobacco) and every other determinant of health. What this has to do with self-deception and living in the past is the false idea that things are always, automatically, better in this country, the USA, a belief that persists in the face of evidence.

Of course, some things were, in fact, better in this country for earlier generations, some of whose members are still alive and sentient. America may not have always welcomed its immigrants, even those from Europe, and viciously and continuously repressed and oppressed members of many minority groups (particularly Natives and the descendants of Black slaves), but in the first half of the 20^th century, major parts of life were often better here for poor people than in many other countries. This was even more so after World War II, when the economies of most of the rest of the developed world were destroyed but the US' was intact, with no wars fought on its soil. This resulted in great success for US manufacturers (no competition!) and other benefits. One was life expectancy, due in large part to better nutrition. In the second half of the 20^th century it was widely observed that children of immigrants were bigger than their parents, because from infancy they were better nourished. Then, even later, at the end of that century and into the 21^st, some of the major causes of premature death saw a decline, mainly tobacco use.

But the premature death rate in the US is going up, life expectancy is going down. An important paper, published in 2014 in the Annual Review of Public  Health by Mauricio Avenando and Ichiro Kawachi, ‘Why do Americans have shorter life expectancy and worse health than people in other high-income countries?’, provides extensive documentation and discussion, including a supplement with several tables comparing life expectancy among different countries (a representative one, Female Life Expectancy at 40, is reproduced here).

 

While it has long, forever, been true that the life expectancy of underserved minority populations was less than for white people, the decrease in life expectancy for the “majority” group was shockingly revealed by data provided in 2015 by economists Anne Case and Angus Deaton, “Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century”, and has been demonstrated for larger and larger portions of the US population. As I noted in this blog (Rising white midlife mortality: what are the real causes and solutions?, November 14, 2015) this was a shock for those who held to the belief that it was only true for minorities (and in perverted way, found this reassuring). Indeed, while the life expectancy for Black Americans was and is still shorter than for whites, it was slowly rising while for many whites (of course, especially lower-income whites) it was dropping. Case and Deaton, noting the large increase in mid-life death (kind of an oxymoron, but meaning “middle age”) attributed this to “deaths of despair”, specifically due to opioids and suicide. On November 29, 2019 I wrote about an article by Steven Woolf and Heidi Schoonmaker, “Life Expectancy and Mortality Rates in the United States, 1959-2017” (Decreasing life expectancy in the US: A result of policies fostering increasing inequity), and I noted that, amazingly, women in lower income groups born in 1950 had shorter life expectancies than their mothers born in 1920!

Woolf and his colleagues RK Masters and LY Aron have recently come out with a new publication looking at life expectancy in the US and other OECD countries for 2019-2021. (Note: at the time of publication, the paper, in medRxiv, had not been peer-reviewed). They found that the pandemic shortened the life expectancy in almost all countries, but

US life expectancy decreased from 78.86 years in 2019 to 76.99 years in 2020 and 76.60 years in 2021, a net loss of 2.26 years. In contrast, peer countries averaged a smaller decrease in life expectancy between 2019 and 2020 (0.57 years) and a 0.28-year increase between 2020 and 2021, widening the gap in life expectancy between the United States and peer countries to more than five years.

In addition, ‘The decrease in US life expectancy was highly racialized: whereas the largest decreases in 2020 occurred among Hispanic and non-Hispanic Black populations, in 2021 only the non-Hispanic White population experienced a decrease in life expectancy.’ So while in 2020 the most vulnerable populations took the greatest additional hit from COVID, by 2021 they were slowly recovering, while white populations continued to lose life expectancy.

So why? This may be cognitive dissonance for the self-deluding, or racist, or narrow-minded, or those who think “America is always better”, but it is true. And the reasons for it are the inequities of American life, much of which is detailed in the Avenando and Kawachi paper, as well as Masters, Aron, and Woolf. We do not have universal health insurance, and we do not have universal access to health care. Even many “insured” Americans have very poor insurance, many Americans do not have geographic or physical access to health care services, and thus many people forego health care altogether or until it is too late. Our infant mortality rate is far higher than that of comparable countries. We still have large numbers of people who are “food insecure”, which often means chronically hungry and undernourished, not to mention those who are “housing insecure”, often homeless. And we have phenomenal income inequities which have grown tremendously since the 1980s Reagan assault on the social safety net. A paper by economists Emanuel Saez and Gabriel Zucman, widely covered, shows examples of this: since 1982 the wealth of the 0.00001% (18 families!) has increased from 0.1% to 1.2% of all US wealth.

 

Just from 2009-2022 the wealthiest American has gone from $40B to $265B, while average income has decreased from $54,283 to $53,490, and the minimum wage ($7.25/hr) has stayed the same! So the US remains an outlier, with great social and economic inequity, poorer health, and shorter (and decreasing) life expectancy. You can believe what you want in terms of political and social theory, but you have to be willing to accept the consequences.

I find these consequences, completely unnecessary, intolerable.

The Political is Personal: Corporate power, social isolation, and the health of the nation -- Part 1

This talk was delivered on April 16, 2018, at the 29th Conference on Primary Care Access, Monterey California.

                                   

Our society has increasingly become about isolating people and making them feel alone, thus decreasing, and sometimes almost eliminating both social cohesion and any sense of social solidarity. This may seem most obvious when people – not just young people – don’t hear us because they have earbuds in, or walk into us on the street because they are staring at their phones, or worse yet, are looking at their phones while driving – but it is much more serious and profound. In his seminal 2000 book, “Bowling Alone”, Robert D. Putnam re-introduced the term “social capital” (previously used by Alexis deToqueville, John Dewey, Jane Jacobs, and others), to describe a sense of social solidarity and support, the absence of which erodes civil society and decreases political participation. Ways that it is manifested include fewer extended families living with or near each other, greater geographic mobility, and more emphasis by people on their individual, rather than community or even family, lives and achievements. More and more studies point to “loneliness” as a key variable in our health. Evidence has also linked this increased separation to worse health status.

Importantly, this isolation is not simply an organic development in our society. It is also a core manifestation of very late stage monopoly capitalism. What we have today: monopoly (or at least oligopoly) corporations stifling competition, more and more mergers and takeovers with concomitant rises in prices, and stagnant or decreasing standards of living even for most of those living in the richest country on the globe. The stock market may go up, but most people’s lives are not getting better.

Socially, this has resulted in us feeling alone, separated from others and often feeling as if we are nothing but the targets of marketing campaigns that urge us to buy-buy-buy and trade in what we have on something newer – and better! Nothing is exempt, every protest or revolutionary idea is commoditized, from Che Guevara posters to the feminist movement to protest music to environmental concern – all becomes grist for the profit mill. The only challenge for the corporations is how to get us to spend more while paying us less.

More than Adam Smith, or David Ricardo, or Milton Friedman, or any other political philosopher or economist, the world we are living in and moving towards was predicted by George Orwell. 1984 describes massive superpowers in a continual war that provides the justification for suppression of dissent domestically, and the overall thought-control of the state. Does it sound at all familiar? We see some examples of this in the CDC being told it cannot use certain terms, in restrictions on journalists’ reporting, and the refrain of “fake news” every time those in control do not like what the “true news” is.

The only real threat to this status quo would be if people got together and organized, whether against war and nuclear weapons, climate change, the obscene increase in wealth inequality, racism, or health and access to health care. Therefore every effort to do so, from “Occupy” to #Black Lives Matter to the Standing Rock opposition to the Dakota Access Pipeline, to the struggle for universal health care, to, most recently, the struggle to get control of guns and stop or decrease killings both in schools and in the community (#enoughisenough) is challenged and demeaned, and efforts are made to break them up. We are repeatedly told that we are not our brothers’ keepers, that we should not be paying “more taxes” to ensure that our fellow Americans (not to mention people in the rest of the world) are fed, housed, clothed, warm, and educated. Indeed, sometimes even kept alive – see the rising mortality of white Americans (Case and Deaton). White Americans, specifically low-income white Americans, are the only group for which mortality is rising, although it is critical to note that the absolute mortality rate of minorities, especially African-Americans, remains much higher. Even when the things that we feel are in fact shared by many or most others, this is kept secret by the pro-corporate media. When a NY Times poll on taxes shows that most people feel that they pay too much in tax, and that the wealthiest pay too little and should pay more, only the first is reported. So each of us who feels that way thinks we are alone. It prevents us getting together.

 

How does this manifest in health? I have already mentioned rising mortality. While much of this has been tied to the “opioid epidemic”, it goes deeper; opioids, and other substances, including alcohol, tobacco and other drugs, may be the mechanism of death, but the root causes are social. As a society, for many of us, we have lost our jobs, we have lost our sense that our children’s lives can be better, and too often we have lost hope. Our social structures have not just withered, they are actively being destroyed.

The dominant narrative changes to meet these structural needs, and almost always plays on the racism upon which this country was founded. For example, during the “War on Drugs”, the assumption was that users were mostly minority and were called “addicts” and were at fault and were to be punished; now that users are more and more white and have had their drugs prescribed by physicians, they are “victims”. When a white man commits mass murders by gun or bomb (as recently in Austin, Las Vegas), he is the problem – troubled, mentally ill. When a minority or Muslim person does, it is a reflection on their race or religion.

In fact, they are all victims, and we are all perpetrators..

The ACA helped many people gain financial access to medical care, but even if it is not completely dismantled, that care is becoming less accessible, and costs are going up for many patients. Medicaid, and even Medicare, are in the sights of those who are seeking ways to fund the enormous tax cuts that they passed for the wealthiest individuals and corporations. People continue to go without health care, especially without prevention and early diagnosis and treatment, the kind of care that family physicians, provide. The US remains the only industrialized country without a national health system, insurance, or service, and our thought leaders continue to insist that such a program is inaccessible.

In a recent JAMA article, Papinicolas, Woskie, and Jha compared the costs of care in the US to ten other wealthy countries. They observed that the US has “administrative costs” (including profits) almost 3 times that of other countries, that we pay more for procedures and for drugs, and that a big part of the problem is that we have a higher percentage of poor people. Shockingly, the coverage in the NY Times, especially by the headline writer was, in the online edition “Why Is U.S. Health Care So Expensive? Some of the Reasons You’ve Heard Turn Out to Be Myths”, and perhaps even more inaccurately in the print edition, “United States healthcare resembles rest of world”.

What? Anyone who has been to this conference before, anyone who is awake, in fact, knows this is not the case. To extract these headlines requires both careful cherry-picking of the data, as well as including such falsehoods as “40% of US physicians are in primary care”. That would be news to all of us in primary care; it is, in fact, also known as the “Dean’s Lie”, maintaining that everyone entering Internal Medicine is in primary care, when 80+% become subspecialists and more than half the remainder hospitalists.

And what about the fact that we have so many people in poverty? Does this somehow excuse our high cost – and frequent inaccessibility – of care? Or should it, rather, be a wakeup call, an assertion that things are NOT OK, that we need less inequality and, like the other countries studied, a better safety net to ensure that not only medical care but the major social determinants of health – housing, food, warmth, education, safety – are in place for all Americans. Pundits persist in their “unaffordable” argument although it strains credulity in the time of trillion dollar tax cuts, and continue to use un-Americanism as a justification for avoiding “socialized medicine”. Apparently, to them, Americanism includes the right to do without health care, be sicker, and die younger.

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To be continued...