How the left is losing the COVID “war”

Guest post by Edgar Blaustein.  Originally posted at Medium.com

Can the left already be losing the political war regarding the COVID pandemic?

A look at the political impact of the current coronavirus crisis in the United States, the United Kingdom and France, and what it might portend for the left.

Hail to the chief! Pandemic as legitimization

Donald Trump’s, Boris Johnson’s and Emmanuel Macron’s rise to power share key similarities: lack of legitimacy, and, for Trump and Johnson, appeal to nationalist sentiments (MAGA, Brexit). Trump through lies, luck, and electoral math won the Presidency with less than a majority of voters. Johnson won through lies on Brexit (no hard borders, more money for health services). Macron won with less than a quarter of votes in the first electoral round. Nevertheless, the winner takes all systems in all three countries gave the victor complete control of the legislative and executive branches of their respective governments. Though lacking legitimacy, all three wanted to think of themselves, as great war leaders such as Churchill, Roosevelt or De Gaulle.

Unlike the World War II leaders, our modern day chiefs have had the leisure over the last several years to choose their wars. Trump’s initial attempts failed, as he was outmanoeuvred by Xi Jinping and Kim Jong-un. Trump and Pompeo sounded the drums of war with Iran, but Iran, notably through attacks on oil tankers and a Saudi refinery, stopped US escalation.

Johnson’s chosen enemy was the European Union, framed as a faceless foreign oppressor, trying to grind down the plucky English. But “getting Brexit done” ran up against barriers: no hard frontier” between the Ireland and Northern Ireland, and the impossibility of assuring economically vital free trade with Europe without membership in the European Union.

Macron’s struggle was against “recalcitrant” sectors that opposed his vision of the “modernisation” of France, clinging to “outdated” notions such as progressive taxation, unions, worker’s rights, public services, or a public retirement system. Macron had won most battles, but the ceaseless conflict — with the gilets jaunes, trade unions, students — had taken its toll, and at the end of 2019, Macron’s government was visibly suffering from wear and tear.

At the end of 2019, all three leaders were in difficulty. And then came the coronavirus.

The birth of the war against a virus.

German President Frank-Walter Steinmeier said “This pandemic is not a war. It does not pit nations against nations, or soldiers against soldiers. Rather, it is a test of our humanity.”

And yet, the three leaders wound up framing their reaction to a health emergency as a war. But the path that led them to the war paradigm was far from direct. Indeed, in a first phase, all three initially downplayed the risk of the pandemic. In a second phase, they for a short while followed the “herd immunity” strategy, letting the infection run its course. And then in a third phase, all declared war on the coronavirus.

The three leaders hesitated, contradicted themselves, changed discourse, lied about the lack of personnel protective equipment, were contradictory on the subject of tests, all in frantic efforts to avoid assuming responsibility for massive unemployment and tens of thousands of unnecessary deaths. Trump’s “I take no responsibility” will certainly go down in history.

The three tried to frame their failures as responsible action to find balance between the health and economic impacts. As the double health and economic crisis deepened, they pivoted to “communicating”, a difficult task, since several countries — South Korea, Taiwan, New Zealand, Germany, Viet Nam, the Kerala state in India, among others — have demonstrated that rapid effective action on health, combined with a strong safety net for workers, leads to optimal economic as well as health results.

There appears to be no simple left/right divide that explains which countries have been most successful in meeting the crisis. Some rightist or extreme right governments — Poland, Germany, Austria, Australia or Japan — have done better in dealing with COVID, than the Social Democratic governments of Spain or Sweden. It does seem that women leaders, whatever their politics — New Zealand, Taiwan, Germany, Iceland, Finland — do better than men.

The countries that did not act rapidly have had to impose lockdowns, a blunt medieval pandemic control instrument that dates back to the time when humanity knew very little about the science of disease. Lockdowns are in no way progressive, although progressives must respect them when there is no better alternative, as in the case of our 3 countries.

The combined health and economic crisis in these three countries represents a severe threat to the legitimacy of their leaders. The depth of the crisis and the loss of legitimacy of the governments has led many leftists to imagine that we are on the brink of radical change, even the end of capitalism. The remainder of this article will argue that this is not the case, and that whatever our long term goals are, in the short term we should focus on more immediate achievable victories.

COVID is worse for the left than the subprime crash.

The 2007–2010 financial crisis was triggered by the collapse of Bear Stearns and Lehman Brothers, in the very heart of the capitalist financial system. The “shadow bankers”, who engineered the 1999 repeal of the Glass-Steagall Act walked away with hundreds of billions in profits made during the decade of the expanding bubble, while the general public paid for the crisis when the bubble burst. At the time of the subprime crisis, many people (author included) thought that the bankruptcy of the capitalist system had been made evident to the majority, and that the way was open for radical change. The crisis gave rise to the occupy movements, their European variants such as “indignados”, and in part to the Arab Spring and “Nuit debout”.

The actual results over the last decade were the opposite of radical progressive change. Economic inequality increased, the hold of bankers on public policy expanded, the influence of the right wing press increased. Authoritarian regimes have come to power over half the globe. Democracy, trade unions, free press … all declined. As Naomi Klein has argued (“The Shock Doctrine: The Rise of Disaster Capitalism”), capitalists are generally better equipped than progressive forces to take advantage of a major shock. Furthermore, the specific nature of the COVID crisis makes a radical change even less likely than was the case in 2008.

• Capitalism did not cause COVID. Indeed, the modern capitalist system has contributed to the coronavirus pandemic, through globalisation-driven increases in travel, through accelerated exploitation of natural resources that increase interactions between wild animal populations and human activity, and through the neo-liberal sabotage of public health systems. Nevertheless, it is false, and harmful for progressive forces, to argue that capitalism caused COVID. Viruses, animal to human transmission, and long range trade all existed long before the emergence of capitalism.
• COVID weakens intergenerational solidarity. The lockdowns strike most heavily on the finances of the youngest, whose professional and economic situation is often fragile. In contrast, older people, a majority of whom have a stable retirement income, suffer most from the health risk of the double crisis. This divide in material interests, coupled with the lack of close links between generations, has led to a political divide.
• Weaken class solidarity. COVID divides workers by race, by class, and by type of work. The most obvious cleavage is between white collar workers who can telecommute, and essential blue collar workers who are exposed to sickness. Furthermore, since many of the essential workers are from minorities, this distinction is also of a racial nature: Black people are 4 times more likely to die than the general population in the UK, and 3 times more likely in the US.
• Increase oppression of women. In normal times, many two income families “outsource” the principal domestic tasks: childcare, cooking, cleaning. This has ended under lockdown. Furthermore, with schools closed, home schooling is a new domestic task. It is no surprise that women have assumed a major share of this increased workload.
• Physical distancing degrades the tissue of society. Staying 1 or 2 meters away from other people is a physical measure to prevent the spread of the corona virus. Breaking down social links is an unfortunate, and perhaps partially unavoidable, consequence. This frazzling of the tissue of society is harmful for progressives, since our main tools for collective action — demonstrations, public meetings, civil disobedience, strikes — are difficult or impossible for the moment. The rise of telecommuting will most likely make it even harder for unions to penetrate into tech related industries. Naomi Klein, in “How big tech plans to profit from the pandemic”, shows how the “tech bros” plans to make use of the crisis.
• Justify the permanent surveillance State. “Test, trace, isolate”, while essential to fight COVID, nevertheless involve public intervention into the private lives of citizens. Successful programs in China, South Korea, Taiwan and Hong Kong all involved massive privacy intrusions. China, in particular, has woven the COVID tools into already existing, widespread programmes of surveillance of citizens lives. We can expect that these surveillance tools and powers will be used against progressives.
• War on truth. Rightists have made a scale change in their war on truth. The chloroquine controversy, built on the basis of nothing, is just one example. Rightists no longer attempt to counter the truth, they simply bury it under a constantly growing pile of rumours, factoids and lies. Hannah Arendt, in “Lying in Politics: Reflections on The Pentagon Papers”, explains that the fog of lies aims to make both thinking and action impossible.
• Democracy, pollution, climate. It is clear that different strands of progressive movements will have lost ground and lost momentum during the pandemic. For instance, President Donald Trump signed an executive order to ease up on businesses that make so called “good-faith” attempts to follow regulations during the coronavirus pandemic. This text will not detail the many other cases of using the crisis to weaken democracy, and to sabotage regulations on the environment.

It thus appears that the specific nature of the COVID crisis will leave the left in a weaker position than was the case after the subprime crisis.

We are not in a pre-revolutionary period

Six months ago, the UK, France and the United States were led by men who, even if they were stumbling, were strongly supported by at least a substantial minority that was enthused by their nationalistic, racist, xenophobic fear mongering. Certainly — as shown by Bernie Sanders, Jeremy Corbyn or Jean-Luc Mélanchon — there were also substantial minorities of mostly young people that give enthusiastic support to reformist candidates critical of capitalism. Nevertheless, the three radical reformists have all lost elections to more conservative politicians: Sanders lost to Biden, Corbyn to Johnson and then Keir Starmer, and Mélanchon to Macron and Le Pen. From these results, we conclude that the support for substantial reforms stems from perhaps 20% of the population, far from the overwhelming large majority that could be the basis for a mass movement for radical, post capitalist change.

The COVID crisis paradoxically weakened the political support for the three Presidents, while at the same time — for reasons outlined above — weakening the tactical capacity for action by the anti-capitalist left. In this context, the killing of George Floyd and the BLM and related movements swept across all three countries. From the point of view of the author, the BLM movements are radical in character, but reformist in their demands, mostly seeking limited reforms of a democratic nature: the right for people of color to live without fear of being harassed, beaten or killed by police. The achievements of the ’60s civil rights movement shows that this and related BLM demands are hugely important, and nevertheless achievable within the current political and economic system.

Since the end of decolonisation and the wars in South East Asia almost half a century ago, the left, with the exception of victories on women’s and LGBTQ rights, has lost more struggles than it has won. Today, over half of our planet’s inhabitants live in countries controlled by different types of authoritarian, xenophobic and racist regimes.

The left desperately needs short term victories to reverse the drift towards authoritarianism. While the current situation is not in general favourable for progressives, the specific nature of the COVID crisis in the three countries could lead to victories on specific objectives, such as the following.

• Rebuild public health systems, and public hospitals.
• Universal health care. Millions of Americans lost their health care when they lost their jobs. The spread of the virus in poor communities shows that health care must include undocumented workers and families.
• Vastly increase international cooperation on preventive health issues. We cannot avoid a future pandemic unless all countries, even the poorest, have the capacity to rapidly identify and isolate new diseases. We need a strengthened WHO. Even the most closed minded of capitalists can understand that spending a few tens of billions per year to build up world health systems would cost much less than the next pandemic.
• Increase protection of workers in times of unemployment, both through financial support, and effective retraining to allow workers to adjust to inevitable economic change. Again, a portion of capitalists would support such action.

The BLM movements show support exists for another category of actions, focusing on policing, and more broadly on systemic racism. Two types of measures should be within our reach:

• Measures to limit police violence in poor communities, such as always-on body cams, new rules for use of firearms, end of choke holds, effective surveillance of deaths of people in police custody, some kind of control on abusive stop and frisk, or transferring some police functions to unarmed civilians. These measures broadly correspond to the slogan “defund police”.
• Measures to reduce discrimination against minorities in employment and in the media. The actions of several large enterprises (for instance in the Facebook boycott) show that large parts of the capitalist class will support some measures.

Three other measures might be within reach.

• a guaranteed of a job or of a basic income. This would be cheaper than the current hodgepodge of measures, and would be a more effective countercyclical Keynesian economic shock absorber. Unfortunately, opposition might come as much from some workers as from capitalists.
• deepening of democracy, or at the least limiting of corruption.
• perhaps a more progressive tax system. Possibly a one time special COVID wealth tax on multi-billionaires, to repay the public borrowing during COVID. Spain may create such a a wealth tax. Perhaps some kind of reparations for slavery.

We should use the opportunity of the weakness of our rulers to fight for significant and achievable short term goals. We need victories to strengthen progressive movements, to improve our capacity to win future battles. We must at the same time keep in mind our long term goals, and use the experience we gain in short term struggles to develop common ideas on our vision for the future, our strategies, our alliances, our tools and modes of action.

This text benefited from the generous help of Robert van Buskirk and Jérôme Santolini, who kindly contributed, even though they disagree with major portions of the text.

Making contraception easy and available: we are going in the wrong direction!

It is 2017. It is more than 100 years since Margaret Sanger advocated for contraception, and more than 50 years since the oral contraceptive pill became available. The last two generations of women – and men – have never known a world where there was no effective form of contraception. They probably do not recall when even condoms, although “over the counter” (in that no prescription was required) were stocked “behind the counter” and required requesting them from the pharmacist often with (if you were young) a disapproving glare, and maybe worse, a raft of questions.

The verbal and physical indignations and worse, including even murder committed on unmarried women who got pregnant and were unable, of course, to have access to abortion should be things of the past. They are, horrifically documented in Dan Barry’s New York Times piece “The Lost Children of Tuam”. The film “The Magdalene Sisters” shows the intolerable treatment of girls who may not have even gotten pregnant but were, perhaps, just a little too familiar with boys. Both the Magdalene laundries and the mother-baby home in Tuam were in Ireland, which was perhaps extreme in the poverty, ignorance, and fast ties to the Roman Catholic Church, but the treatment of women in England and the US were also inexcusably harsh. The British drama “Call the Midwife” tells the story of an unmarried teacher who gets pregnant in the early 1960s and is fired from her job (morally unfit to care for children!), tries to self-induce abortion with a coat hanger, and almost dies. Finally, post-hysterectomy so that she will never be able to have children, she is driven out of town. The most sympathetic characters in the show see it as sad, but none indicate it is horrific, immoral, and inhuman. And this was commonplace, even in the 1960s and beyond.

We should not, in 2017, even be discussing the availability of contraception, not to mention whether it works. Amazingly, we are. Teresa  Manning, appointed by President Trump in May to be the director of the Office of Population Affairs, the main family planning arm of the federal government, is not only a former employee of two anti-abortion groups, but has expressed skepticism of the effectiveness of contraception itself! Manning, a lawyer and not a health professional (although this is not an excuse), is completely wrong. The data is in. Contraception dramatically decreases unplanned pregnancy (regardless of marital status). Time recently ran an article accurately describing the science titled “No, birth control doesn’t make you have riskier sex”. That is the truth, but in fact, even if it is was associated with riskier sex for some people, that would be no reason to restrict access to it. The more contraception is available, the lower the rate of bad outcomes of virtually all kinds. It even, of course, reduces the rate of abortion; in fact, the only two things ever to have been shown to significantly reduce the rate of abortion are comprehensive and accurate sex education and easy and cheap availability of contraception. Indeed, the degree to which contraception is effective in decreasing the incidence of unplanned and undesired pregnancy is directly related to the ease of its availability, including financial availability. Unsurprisingly, reducing the cost of and increasing the ease of access to contraception has the greatest impact on teens and on the poor.

So it is amazing that, in what The Atlantic refers to as “one of its boldest moves yet” (I don’t think that they meant it was positive, but “cowardly”, as well as “stupid” and “reactionary” come to mind as better adjectives) has reversed the ACA’s requirements that employers and insurers provide contraception at no cost to women. Politically, it is part of the administration’s efforts to dismantle the ACA piece by piece, since they were unsuccessful in doing it as a whole. Morally, it is an imposition of a minority’s religious values on the rest of us, and is particularly ironic being spearheaded by Donald Trump. It will cause great harm to individual women (and men) and to the society as a whole. Arguments that the cost of contraception is “only” $50 a month may wash with those in the middle class and up, but for poor women and teens, $50 a month is a lot. The most effective methods of contraception, IUDs and implants (collectively referred to as LARC, long-acting reversible contraception) may have a lower amortized cost over the use period but a high upfront cost that is unaffordable, without subsidies, for many women. (The reason, lack of cash on hand, is the same one that leads many poor families, as described by Barbara Ehrenreich in her wonderful and depressing book “Nickel and Dimed”,  to live in expensive weekly motel rentals – the overall cost may be more than an apartment, but the upfront cost, including deposits, rent in advance, etc., is prohibitive for them.) The impact on the teens who will be denied free access is described movingly by a pediatrician in Vox.

The other important impact of such a policy would – and perhaps will -- be on the economy. This is articulately addressed in a column by Bryce Covert in the NY Times, October 29, 2017. The reasons start with individual women, and the cost of purchasing birth control, money which will not be available for them to spend on other goods – with more than 57 million women using contraception, in one year that is $1.3 billion. But the larger impact is societal – women who cannot control their own reproduction, who do not know when and if they will get pregnant – are in a poorer position to contribute to the workforce and to the economy. Again, going back to the history I address at the start of this piece, we know this empirically, not just theoretically:

… a raft of evidence has definitively found that when women gained greater access to the pill in the late 1960s and early ’70s, they were able to delay marriage and childbirth and invest in careers through education, job training and staying in paid work….Legal access to the pill transformed the economy in that era. It increased young women’s labor force participation by 7 percent….about a third of the increase in how many women attained careers in fields like law and business was due to birth control. Women with earlier access to the pill also made 8 percent more than their peers, and the pill was responsible for about a third of the decrease in the gender wage gap by 1990.

And it is still critical. Perhaps Trump himself is just cynically pandering to his base, and probably much of that base depends upon contraception, women directly but men just as much. Opposition to contraception cannot be justified except by the small minority of religious purists (and of course they are welcome to not use it); opposition to making contraception easily and freely available is almost as bad, as it is completely discriminatory. It is still, as Covert describes,

…still playing the economic role that it did in the 1970s. About half of women who use it say they do so to complete education or to get and keep a job. Contraception is still increasing the share of women who get educated and get paid work, particularly prestigious jobs.

Easy and affordable (affordable for all those who need to use it, not just billionaires or even the upper middle class!) is not a “women’s issue”, it is not a “special interest” issue. It is a core need for people. People with the views of Teresa Manning should not be given center stage, and certainly not given authority over contraception. We need to guarantee permanent access to contraception for all, and for accurate sex education. 

Now.

We have a bill! The GOP's plan to cut taxes on the rich and health care for the rest of us

Every day it gets more difficult to write about the new “American Health Care Act” (AHCA) that has been introduced in the House of Representatives by Speaker Paul Ryan because every day there is so much more news about it, and so much more criticism of it that appears in the press. Even before its introduction, the bill was attacked for being likely to significantly increase the number of uninsured Americans while providing windfall tax cuts for the wealthiest.

It did not disappoint. Consistent with predictions, the nonpartisan Congressional Budget Office (CBO) estimates that initially 14 million people will lose coverage, with the number rising to 24 million in 10 years. These estimates are discussed in detail, and clarified, in “Deciphering CBO estimates” at the Kaiser Health News site. The largest number of people who will lose coverage will do so because of the changes – but let’s call them what they are, “cuts” – to federal funding of Medicaid (discussed by the Health Affairs blog), which would shift costs to the states, most of which will be unable or unwilling to absorb these costs. The 31 states that have expanded Medicaid to all those under 138% of the federal poverty level  under the Affordable Care Act (ACA) will be faced with having to fund a lot more from their own coffers; poor people in the states that have not expanded Medicaid eligibility will continue uncovered. The other group that will lose coverage will be those who have bought subsidized insurance on the ACA-created marketplaces and who will no longer be able to afford the premiums. Yes, the new GOP plan calls for tax credits to help pay premiums, but they will be far less than under the ACA and far from enough to cover the actual cost.

This change will have the biggest impact on the older, sicker poor who are not yet eligible for Medicare (and, while I we will not address it here, the GOP leadership certainly has plans for cutting Medicare!), whose premiums will go up because of two important changes the AHCA will make. It will end the “individual mandate” of ACA, so that those who feel that they do not need health insurance can pass on buying it, which means the pool of insured will lose those healthier people and have a pool more skewed to those who are sicker and will actually use health care. This will tend to drive premiums up for them, and the AHCA also allows insurers to charge 5 times as much to older people as younger. As reported by Thomas Kaplan and Robert Pear in the NY Times on March 13, 2017

Under current law, in 2026, a single 21-year-old earning $26,500 with an insurance policy that costs $5,100 a year would get a tax credit of $3,400 and would have to pay $1,700 of the premium. Under the Republican bill, that person’s share of the cost would drop to $1,450.

By contrast, a 64-year-old earning the same amount would fare much worse. That person’s $15,300 health plan would be offset by a $13,600 tax credit under current law, leaving the consumer responsible for $1,700. Under the Republican plan, health insurers would be free to charge older people more, raising that person’s premium to $19,500. But the tax credit would be only $4,900, and that person’s share of the premium would then be $14,600.

That’s a bite! And, ironically, as pointed out by Noam Levey in the Los Angeles Times (March 12, 2017), it will hurt Trump/GOP voters more than Democratic voters, because those Trump voters – and the counties and states which went for Trump in which they live -- are more likely to be in this older, sicker, group. This group of Republican voters did not like Obamacare because the premiums, co-pays, and deductibles were going too high and the coverage was not always great, especially for the plans they could afford. Trump, and the GOP, promised them high-quality, affordable coverage. These folks believed them. They voted for them. And they are not going to get it, certainly not from the AHCA. Levey notes that “…In nearly 1,500 counties nationwide, such a person stands to lose more than $6,000 a year in federal insurance subsidies. Ninety percent of those counties backed Trump…[a]nd 68 of the 70 counties where these consumers would suffer the largest losses supported Trump in November.” What can you do. Politicians lie. This one was a whopper.

What is the reason for this? Many of Congress’ and Washington’s leading “conservatives” say that they believe that the role of government should be as close to zero as possible, and certainly think that the government has no business being involved in the insurance marketplace to ensure that people without resources have health coverage; to them, the AHCA is too much like the ACA in that it actually makes some effort to help some people, if weakly. There are a few of these “conservatives”, in and out of Congress, who really believe this and act on such beliefs. Uniformly, they are not poor, are not close to poor, and are not likely to be negatively affected. There is a much larger contingent that only believe government should not help most people. They support legislation that benefits rich people, like the AHCA, which uses the money it will save (and the CBO says that it will reduce the deficit over 10 years by $337 billion) to give tax cuts, not evenly distributed, but very much skewed to the highest incomes. This is where the [mean] rich people come in; they fund the Congresspersons, and this is what they want. Rep. Michael Burgess (R, TX), Chairman of the Energy and Commerce subcommittee on health, is quoted in the Times on March 11 (“The GOP’s high-risk strategy for health law repeal”) as saying “If you ask someone to give up something, there will be resentment,” and he is correct. That it is regular people who are being asked to give up something by Mr. Burgess and his colleagues, so that his rich patrons can save even more on their taxes, is something he doesn’t focus on.

One of the most iconic differences between ACA and AHCA focuses on equity: the subsidies (and tax credits for those who paid taxes) under ACA were tiered to income. The tax credits that replace subsidies under AHCA are tiered to age. Of course, as I have noted, older people are more likely to be sick, but they are not all of the same need; some older people have lots of money, and some have none. The same is true for younger people, including those with medical need. In any case, the tax credits in AHCA will not, as demonstrated above, be sufficient for those without significant other resources to buy health coverage, even if they are in the more-highly-subsidized older group. The Times’ Alan Rappeport reports on March 16, “One certainty in health bill: tax cuts for the wealthy”, with 40% of the cuts going to the top 1%, and the bill providing the necessary basis for further tax cuts for the rich. Rappeport quotes Mike Mulvaney, the White House budget director: “We promised at the outset that we were going to repeal all of the taxes. Who cares if someone else benefits?” Well, maybe the people who will suffer for their benefit? The same issue of the Times contains a brief and informative piece by Mr. Pear, “Putting Republicans’ plan on the Obamacare scale”, examining the criticisms of ACA and how the AHCA solves them (or not).

President Trump apparently feels conflicted; he promised the repeal of ACA, and the Congress wants to do that. He also knows that any plan that comes out that does this will be called “Trumpcare”, just as the ACA was called “Obamacare”. Enough Republican senators are concerned that the House’s AHCA will make it too hard for too many people to afford insurance that they might vote against it, so “Mr. Trump was left to strike a balance between siding with House Republicans while also distancing himself from the details, with top aides conceding that the legislation needed modifications before it could pass the full Congress,” (”G.O.P. Senators Suggest Changes for Health Care Bill Offered by House” NY Times, March 14).

For the rest of us, it is an impending disaster.

The urban-rural divide and the health of people in both settings

I recently wrote about the impact of the massive vote for Donald Trump by “white working class” voters and how it will have repercussions for their health, as well as that of others, if the policies advocated by the Republican majority (as exemplified by Secretary of HHS nominee Rep. Tom Price) are implemented. And there is little doubt that they will be implemented, but slowly, so people are less aware of what is being done to them. As Medicare is increasingly privatized, as vouchers that cannot cover the cost of health insurance for those with chronic disease are implemented, “Medicare for all” will increasingly seem a poor idea. And people’s health will suffer. I wrote about the cynicism of the AMA and the AAMC in endorsing Mr. Price; they are doing more than “kissing the ring”, as a colleague suggested. They are lauding the fact that one of “theirs”, a doctor, will be in this role, not an insurance executive. But if anyone had a doubt about whether having an “MD” at the end of your name guarantees a concern for people’s health, Mr. Price is the poster child for “not so”.

The other big divide demonstrated by the election is urban-rural, and this one is also real. A majority of the people in the US are jammed into small geographic areas, urban islands. Maps that portray “red states” and “blue states” seem to be an ocean of red because of physical size; think New Jersey  (population about 9 million, with 8700 square miles, more than 1000 people/sq mi) vs. Montana (just over 1 million, in 147,000 square miles, less than 7 people/sq mi). The contrast is even greater if we look at counties; most of the population of even “blue” states is concentrated in a few urban counties, although, conversely, there are many “blue” seas and islands in “red” states, cities like Houston, Dallas, San Antonio, St. Louis, Kansas City, etc. The media has recently been awash in articles about the way that our Electoral College system advantages rural areas; because of the 2-Senate-seat-per-state rule, a Wyoming voter has 5 times the clout of a Californian. See, for example, Steven Johnson’s “Why blue states are the real Tea Party” in the NY Times, December 4, 2016. He points out that at the time of the writing of the Constitution, the urban northern states were in debt while the southern states were solvent – largely through the magic of the free labor of slavery. Now cities are the engines of our economy; they are where ambitious and educated young people go, leaving rural areas increasing older and poorer (as well as whiter).

But we need to remember that there is tremendous need in rural America, as there is in the inner city. Rural areas are poor, and underserved both medically and in terms of social services (as well as, of course, in the other things you’d expect – access to groceries, for example). Those rural areas that are located in “red” states are even worse off, because those states spend far less on health care and social services in the first place so that their more isolated communities are in the worst shape. And yet, as Johnson points out, they get far more federal aid for tax dollar contributed: New Jersey receives $0.61 on the dollar while Wyoming gets $1.11. The Trump campaign, and the Republican Party, strongly appealed to voters in these areas, but Trump and his proposed cabinet all live and work in cities; they are not rural billionaires. Tom Price is a suburban doctor; he does not deliver care to the rural poor, as do Rural Health Clinics.

So there is tremendous need in rural communities, but their political clout, which is both unfair and anti-democratic, is not being used to actually help the people there, but rather to limit positive policies in urban areas. The North Carolina “bathroom law”, to force people to use the restrooms of the gender of their birth, was a reaction to the city of Charlotte (a blue “lake”) making it legal for people to use the restroom of their current gender. The most well-publicized efforts currently are threats by Trump and his people to forbid cities from declaring themselves “sanctuaries” for immigrants (see NY Times debate on whether sanctuary cities have a right to defy Trump, December 1, 2016; “yes” by Cesar Vargas and “no” by Jan C. Ting). These cities are trying to exert their local control over such important issues, while states (generally supported by rural populations that do not actually have to deal with these problems) try to restrict their ability to do so. These hypocrites are against government regulation when it comes to their rights to carry guns or graze their cattle on public land (things they want to do), but are all for it when it comes to things important to others, like deciding who can marry, where one can go to the bathroom, whether people can get an abortion or even contraception. “Those who deny freedom to others,” said Abraham Lincoln, “deserve it not for themselves”, which I first learned as a young stamp collector; it appears at the 4 cent American Credo stamp.

If the selective interpretation of what “freedom” means is not enough, if rampant discrimination and bigotry is not enough, there are other, health related, concerns that go with this divide. For example, federal funds for HIV care go to the area where patients are from. However, a large percentage of gay HIV patients leave those areas for the cities where they are more accepted. Thus the cost of providing that care is borne by the cities, while the money flows to the rural areas where services are not available – and often the victims themselves are not welcome.

A recent article published in Science Direct by Jason Beckfield and Clare Bambra, “Shorter lives in stingier states: Social policy shortcomings help explain the US mortality disadvantage” demonstrates that the lack of social services in the US leads to shorter lives than in other Organization for Economic Cooperation and Development (OECD) countries, i.e., the rich countries. The “highlights” of their study are that:

• The US combines a laggard welfare state with shorter life expectancy compared to the OECD.
• Fixed-effects models show associations between life expectancy and social policy generosity.
• US life expectancy would be 3.77 years longer if the US welfare state were just average

In this article “state” refers to nation-states, comparing the US to other OECD countries, but similar differences can be seen among the US states, again depending upon their social services, including public health and access to health care. This is supported by a new study from the Commonwealth Fund which finds that “adults in the U.S. are more likely than those in the 10 other countries to go without needed health care because of costs”. A third of U.S. adults “went without recommended care, did not see a doctor when sick, or failed to fill a prescription because of costs”, as compared to as few as 7-8% in other countries. They were also the “most likely to report material hardship. Fifteen percent said they worried about having enough money for nutritious food and 16 percent struggled to afford their rent or mortgage.”

This is not good for our country, not good for our health, and not good for our lives. And as far as we can see, the new administration’s plans are not to fix it but to make it worse.