We don't need billionaires, we need a healthy population: It is time to move forward

I recently started reading Ricardo Nuila’s book “The People’s Hospital”, about Ben Taub, the largest public hospital in Houston. This will not be a book review (which can be found in many places, such as the NY Times, Washington Post, and elsewhere); I’ve just started it. What affected me was how, even in the first few pages, Nuila’s description of Ben Taub was so like that of Cook County Hospital (now John Stroger Hospital), the public hospital in Chicago where I did my family medicine residency and later practiced and taught for many years. That should not be surprising; the characteristics of large public hospitals in major cities, and especially the circumstances of the people who come to them for their health care (a major focus of the book, per the reviews) are going to be, sadly, very similar. What was most striking, and depressing, to me was the temporal aspect. Nuila is writing about recent years, including the impact of the COVID pandemic, while my years at Cook County were in the 1970s, 80s, and 90s. And yet so little has changed, especially not for the better.

Yes, medicine has changed. What we can (or, maybe more important, could) do for people is more. When I was a resident at County, CT scanners were uncommon, and didn’t exist at our hospital. If a patient needed a CT scan, it could usually be scheduled for after midnight at the private hospital across the street, if they were accompanied by the resident. Who had been up the entire previous night doing admissions. CT scans, and other imaging, are far easier to obtain now. We now have dozens, perhaps hundreds of more antibiotics, and are able to effectively treat many more infections, although bacterial resistance to them seems to grow faster than the antibiotics themselves, both because of overuse and the special breeding capacity of bacteria in hospitals where antibiotics are so pervasive. We can treat, even  cure, cancers we could not touch in the past, although the cost of chemotherapy drugs – a bonanza for not only the pharmaceutical companies but the hospitals that get paid a huge markup from insurers for administering them – makes them often unavailable to those who are poor and uninsured.

But there have been other things that have not changed. Indeed, have often gotten worse. This is the main focus of Nuila’s book, the social conditions that so many people, especially poor people, live in that have such a major negative impact upon their health. Calling them the “social determinants of health” is largely accurate, although the “socioeconomic determinants of health” would be more so, but it tends to almost make it sound trivial. It is not trivial. The socioeconomic conditions in which people live have a far greater impact upon health than anything except, perhaps, genetics. Certainly more than medical care, which accounts by most estimates for at best 10% of health, although it is where we as a society spend more than 90% of our health-related money. It has far more impact than all those diet/exercise/lifestyle factors, or vitamin/mineral/“natural supplements” that are promoted by those who are true believers as well as those who see this as their way to cash in.

It is shocking and distressing to me that conditions for poor people are not better than they were so long ago, and are in fact worse. The same groups of people who have always been pushed into this category, especially Black and Latino and Native peoples, and indeed poor white people, have been supplemented by immigrants from all over the globe who our society treats just as badly. And even more, supplemented by the NON-poor, working and middle class Americans who often have trouble getting the health care that they need – and deserve – because of limits imposed by insurance companies and health systems, which all operate as if they were for profit.

It is still surprising to me, because although I intellectually know better, much of my instinctive reaction is deep-seated and believes that history moves in a positive direction and things tend to get better. Said so much more articulately by Dr. King, “The arc of the moral universe is long, but it bends toward justice,” it resonates with me as much as I fear it is not so. My own perspective is generational; grandparents who were immigrants and low-income, parents raised in the Depression and in WWII, myself raised after the war thinking we were now middle-class (we were working class); better off than our parents were growing up. It was in that period that CEO salaries relative to average workers were “only” about 30x as much (not the hundreds of times as much as today), unions were stronger, the civil rights movement was gaining ground. See, e.g., this from the Economic Policy Institute from 2019 showing CEO salaries gained 940%  since 1978 while average worker salary was up only 12%!

But now it is much worse. It is moving backwards, except for the wealthiest – and by the wealthiest I mean the really wealthiest. Midwifed by the Republican party (but abetted by the Democrats), especially since the Reagan 1980s, we have become a society in which not just a disproportionate share (which was always), not just most, but virtually everything goes to the wealthiest. This Oxfam report (January 2023) shows that in the last 2 years, the top 1% has accumulated nearly twice as much as everyone else in the world put together!! This is what it is all about. Yes, there is racism, and sexism, and anti-LBGTQ+ ism, and they are terrible and they often make people’s individual lives terrible, and should be fought against ceaselessly. But it is the gangster capitalism (Noam Chomsky’s term) in which there is literally no limit to the greed and the amount of money a few people have, hundreds of times more than they or their descendants could ever spend.

This is the trend in our world and our nation while the people who seek health care at Ben Taub Hospital in Houston or Stroger Hospital in Chicago or their equivalents, not to mention those who live in places where there are not public hospitals, not to mention those from all the parts of the world to whom coming to Houston or Chicago seems like it would be Heaven, get sick and sicker and die. In fact, contrary to the proclamations of right-wing pundits, all of these problems can be solved with money. It should be the money now being amassed by the richest individuals and corporations, including those in health care (providers and insurers and pharmaceutical and device manufacturers) could, and SHOULD, be used to provide medical care, but more important provide the conditions necessary for health. For EVERY person to have adequate and healthful food, to have adequate and warm housing, to have an opportunity for an education as far as their drive will take them, to have a job to feed themselves and their family. There is enough money to do this, and yet it is being socked away in private pockets so deeply it will never be touched.

In 1850, the Frenchman Frederic Bastiat wrote in “La Loi” that "When plunder becomes a way of life for a group of men, they create for themselves, in the course of time, a legal system that authorizes it, and a moral code that glorifies it." They get to do this because we enable them. Directly, our politicians enable them; while Republicans and Democrats keep our attention focused on “culture wars”, both parties (except for the most progressive Democrats) depend upon and enable them. Indirectly, it is the rest of us, who do not demand that the politicians we elect fight for the interests of the people. If the 10,000 or so Americans worth $100M or more disappeared tomorrow, no one would miss them except (presumably) their families and the politicians who have become accustomed to being owned by them. If they averaged just $100M each, that would be $1 TRILLION ($1,000,000,000,000), but of course that is an underestimate since many are worth billions, or tens of billions.

It is well past time to take that, both in taxes and in other changes in public policy, and use it for the people.

Other countries invest in the public's health and welfare. We invest in creating billionaires. ???

It’s not just Donald Trump. It would be nice to think it was, and that, if it was far from perfect, everything was much better in the US before him. Maybe it was; certainly many of the horrible things that he and his administration have done were not done by previous administrations, of either party. These include total denial of climate science (or any science), overt (not subtle) racist appeals, gutting most of the federal agencies responsible for the quality of our life (not to mention survival of our planet) in areas such as health, environmental air and water quality, education The administration has replaced of most of the protections we have had with the most rapacious policies we have seen. Oh, yes, and destruction of our relationships with our allies, and moving ever closer to war with – almost anyone, although his friendship and authoritarian bromances with many of the world’s most autocratic leaders might limit that.

And it’s not just his supporters, as nice as it would be to think that they are just stupid (as long as they do not remain the majority, or the effective majority given the intrinsic inequities of the Electoral College). While the most of them may be stupid and have no understanding of where their own self-interest lies, or are at least more committed to racism than their self-interest, there are a minority of them who are smart (if not wise) and very rich people who have been quite pleased with the direction of (most) of the administration’s policies. That is why they fund it.

And it is not even the Republican Party, as much as that party has, at least for 4 decades, been the party of giveaways to the richest, destruction of the environment, bellicosity which has led to several horrible and pointless wars, appointment of right-wing Supreme Court and lower court justices who manage to convince themselves that they know what the “founders” would have thought 250 years later about issues that they could not imagine, and of course racist approaches to almost everything.

But the most important general trend in the United States over the last 40 years, while it has sometimes been accelerated by Republican administrations, has continued under the Democratic administrations of Carter, Clinton, and Obama. It is the increasing, ever increasing – and incredible, at this juncture -- concentration of wealth in the hands of a few, to a degree that has not existed since the days of the “robber barons” of the late 19^th century. A recent article in the Guardian, ‘The US has the most billionaires in the world – but here's what it doesn't have’ documents what citizens of other industrialized have that we don’t: low-cost, or even free, college education, universal health coverage, guaranteed paid vacation and paid parental leave. And more. And, of course, we also do not have what the article refers to as an “inhospitable climate for billionaires, one in which they actually have to pay taxes commensurate with their income and wealth. Our climate is definitely hospitable for them. And, thus, if you are both a billionaire and a completely selfish immoral person, you should be happy with US policies. If you are neither, or only one, you should not be.

There is obviously no disconnect in between these two things, the hospitable climate for billionaires and the limited programs that benefit our people. In the 1950s, as our economy and that of the rest of the world, rebuilt from World War II (ours rebuilt faster because, after the bombing of Pearl Harbor, there was not actual war fought on our territory), under the Eisenhower administration, employment, wages, and unionization increased. The wealthy were wealthy, but regular people, workers, found unprecedented economic success, buying houses, cars, and sending their children to college. CEOs made about 30 times what the average line worker made – a lot more. Of course, the growth was not equitable; minorities and particularly African-Americans were still marginalized, but even many of them got decent jobs.

 In the 1960s, mainly under the Johnson administration, the federal government developed programs to help Americans at a level not seen since the New Deal of the 1930s. In addition to passing laws like the Civil Rights Act and the Voting Rights Act, it developed programs to aid the neediest in our country, both Medicare and Medicaid, and the “War on Poverty”. That “war’s” programs are often derided, by the right, as a failure, demonstrating the fatuity of “throwing money at problems”, but in fact this narrative is incorrect. While the US did not “end” poverty, it decreased poverty a whole heck of a lot. Expansion of programs such as Aid to Families with Dependent Children (AFDC) and food stamps and the Fair Housing Act kept millions of children in homes, with food. The development of HeadStart made a real difference in early childhood education. As with most social service programs, the failings were almost entirely the result of not doing enough, not spending enough, and not a result of doing and spending too much.

But the money the government was spending needed to come from somewhere. And relatively more equitable taxes was more than the wealthiest wanted to pay. Of course, most people didn’t and don’t want to pay taxes, but the billionaires had a lot more clout to get what they wanted. So they got tax breaks for themselves and their corporations, and huge expenditures for “defense” (the US spends more than the next 10 countries together), really just another way this country subsidizes its corporations, and this became the order of the next four decades. Beyond not taxing the wealthiest, the US has subsidized them.  This is well-described by Paul Krugman in his recent piece “Why Do the Rich Have So Much Power?” (7/1/2020). Every penny spent on helping the neediest, or kept by the average American, is another penny not in the pocket of billionaires who are apparently possessed by the desire to have endlessly more despite the fact that they will not be able, in their lifetimes and those of their descendants, to buy enough mansions, private islands, planes, and yachts to spend it all.

Then comes a major crisis, like the COVID-19 pandemic. It hits everywhere in the world. Not equally, of course, the poor and the old and minority communities and the disenfranchised are hit the hardest. But a great deal of the first wave was in developed countries. Some were hit particularly hard, like Italy and Spain, and then France and Germany. Some responded aggressively and limited the damage, like the Scandinavian countries (except Sweden). But the US has responded abysmally poorly, with the most infections in the world – 25% of all COVID-19 cases in a nation with 4% of the world’s population. And tens of millions of unemployed people. And hungry people. And, increasingly, homeless people. Because we have not only, over the decades, purposely decimated our public health infrastructure, we have purposely inadequate social infrastructure of any type. While, in this pandemic, the people of other developed countries get cash bailouts, and expansion of the social support systems that we never had, the US expanded (for a little while, we don’t want to go too far!) unemployment insurance and gave folks one-time $1200 checks. Thus the NY Times can report that “Europeans get paychecks. Americans scrounge for food” (7/3/2020). And, thus, as reported by Robin Wright in the New Yorker “To the World, We’re Now America the Racist and Pitiful”. They used to envy us; now they pity us.

Some years back, I was amazed to hear the chair of one of the highest-income departments say they couldn’t afford nurses, and could only have medical assistants in their clinic. Since my department was one of the lowest income, and we did have nurses, I initially didn’t understand. But then it came to me.  Our group hired the nurses and medical assistants we needed to run a quality practice, and paid what was left to our physicians. Their department paid their doctors (i.e, themselves) what they thought they deserved, and then looked to see what might be left to pay staff. A different approach. There are a couple of ways, generally speaking, a society can  allocate resources: one is to spend what is necessary to meet the needs of the people, with the remainder going to profit, or savings, or (if this is the goal) to enhance the wealth of the rich. The other is, well, the opposite – give the rich what they want and see what is left over.

In ancient Egypt, we are told, Joseph advised the Pharaoh to stash away reserves of food when times were good in case they were needed in the future. As the 7 years of plenty wore on, there were certainly those who must have said “Enough!” But then came the 7 years of scarcity, and the Egyptians were glad that they had saved. We haven’t, on purpose, because our purpose has been to make the richest richer and preparing for real problems that might befall the rest of us was not really high on the agenda.

We have not been meeting the basic needs of our people in the best of times. Poverty and racism are key social determinants of health, and for too many of us, our pre-existing health was marginal. We do not have affordable, universal health care. And we have cut resources for public health planning and preparing for a crisis, such as that we face today. For most Americans, that is a double hit, and for the poorest and worst off, it is unconscionable. This needs to change, and it needs to start immediately. Equitable taxation, meeting the needs of our people, and planning and preparation for the future.

Or, I guess, we can just keep funneling money to the billionaires.

Venezuela and Medicare for All: Don't forget who benefits!

The mainstream media is not an evil, liberal-to-radical behemoth by any means. It is, however, often a willing, and sometimes self-deluded, ally and shill for the interests of the well-to-do in society, as well as for many questionable government policies. The latter is particularly important in the drumbeat buildups to wars, and is recently apparent in the coverage of Venezuela in journals such as the NY Times. The US government is making the case not only that Venezuelan president Nicholas Maduro is illegitimate because it has decided his election was “unfair” and “tainted”, as well as an evil and violent dictator, but that it will recognize unelected self-declared Juan Guaido as president. The Times has gone so far as to publish a self-congratulatory op-ed by Guaido, and it news coverage is typified by ‘Venezuelans Opposed to Maduro Pour Into Streets for Day of Protests’ and a Sunday Review piece by a Guaido supporter called ‘Venezuela’s Very Normal Revolution’.

I do not doubt that thousands marched against Maduro or that millions oppose him (or probably that millions support him). I certainly am not saying Maduro and his government is good, or that there is not justifiable opposition to his violent repression of opponents. I am not saying that revolutions are bad. I am saying that this one is funded and supported by the US government not because Maduro is bad -- the US has supported and continues to support dozens of brutal dictators around the world. It is because he is not our dictator, not one who supports US policy, and this is critical because Venezuela is the country with the largest oil reserves in the world. As for the NY Times -- as with most leftist governments, the support for the one in Venezuela comes more from the poorest people, while those with access to the NY Times are among the most privileged.

And this is the connection to domestic health policy, and in particular coverage of the Democratic candidates for president’s positions on Medicare for All. The NY Times (and all mainstream media) is of course owned by the very wealthy, and as individuals they see the world as members of the class of which they are part. But, possibly more important, the editors and reporters are middle and often upper-middle class, and they see the world from this perspective, from that of their families, and friends, and neighbors who are – amazingly – also privileged! The people who have access to these editors and reporters are very skewed away from the most needy, or indeed most people (who are not the same as most people in an upper middle class suburb).

In specific, we get essentially uncritical coverage of the statements of billionaires like Michael Bloomberg and Howard Schultz that “Medicare for All” is unaffordable, despite the clear fact that it is the current system that is unaffordable, and that a universal health system is going to cost less. One key part of this lower cost is the elimination of private health insurance companies’ profit, and their incentive to increase it by decreasing the availability of care. Yet the Times article covering Elizabeth Warren’s increasing iffiness on the issue contains phrases like ‘would people lose the choices offered by private insurance?’ That is, your ability to choose (maybe, depending upon what their employer offers) which overpriced-to-unaffordable policy, offered by which rapacious, obscenely-profit-making insurance company, to cover you so that, even after paying the premiums and co-pays and deductibles, you find out that, whoops, it doesn’t really cover what you thought it would or should, and you’re out of luck, and either have to pay out even more money you cannot afford or go without the health care you need. Wasn’t that what the insurance you bought supposed to get you?

Nope, not necessarily, and often not at all. The first goal of private insurance companies is to make a profit. That profit has to be maintained and expanded. The two major ways of doing so are 1) by raising the prices people (and their employers, if they are lucky enough to have employers who pay offer health insurance) pay, in premiums, deductibles, and co-pays, and 2) by denying coverage for care, or paying less for it, which often results in providers not, well, providing it to you. The insurers hire “pharmacy benefit managers” to get them the ‘best’ prices on drugs, often requiring your doctor to keep writing a different brand-name drug-of-the-month (again, see Danielle Ofri, “The Insulin Wars”), with the cost to you always going up.

What would Medicare for All offer? Or, more explicitly, Improved and Expanded Medicare for All, as in the House Bill that was H676 and will get a new number this year? First, everyone would be in the same program. No more shopping around for the least bad deal among the universe of bad insurance. Everyone would get the same benefits. The benefits would include all medically necessary health care: inpatient, outpatient, nursing home, home care, drugs, mental health, dental, eye care. Even hearing aids. Nothing excluded, except perhaps truly cosmetic surgery. Providers could not refuse to accept this insurance because they would have no business. Oh, maybe some doctors and hospitals could make a living caring for Howard Schultz and Michael Bloomberg and Saudi sheikhs who pay in cash, but there aren't very many of them, and so even the supplemental insurance we now buy would be unnecessary. There would be, you see, no deductibles or co-pays. Everything would be 100% covered. It sounds good. It would be good.

And it is not unaffordable. Currently, the government funds over half of health care (Medicare, Medicaid, government employees and retirees at all levels, military), and it is about 60% if you also count the revenue lost because employer contributions to health care premiums (unlike salary) are tax-deductible. The majority of the sickest and most needy (elderly, blind, and disabled) are already in Medicare. Most vulnerable children are in Medicaid or S-CHIP. To make up the additional cost, employers and individuals would continue to pay, but in taxes rather than premiums, co-pays, and deductibles, and for most (maybe not for Schultz and Bloomberg!) it would cost them a lot less. Most estimates of the excess costs in the US health care non-system are in the 30-35% range, for profits and administrative costs in the private sector (Medicare’s are in the 1-3% range). Administrative costs include insurance companies hiring armies of workers to deny claims, while providers have other armies to fight them, and demand more. This is money spent for no health benefit for the population, but it would be a mistake to minimize the extent to which those – insurers and providers and drug and device manufacturers – who are pocketing it would go to keep it coming.

Thus the role of the mainstream media, and the mainstream Democrats – to appeal to the needs (not desires, real needs!) of most of the people for health care and at the same time not threaten the wealthy and profitable sectors that can fund campaigns for or against them. Thus the concerns of “don’t people want to have their private insurance?” and even more ludicrous their choice of insurance company (“I’ve always been an Aetna man! So what if it costs a little more and I get just as little? I’m worth it!”). Thus the nonsensical pieces on how much a single payer Medicare for All program will cost, which ignore the cost of our current arrangement. And, somehow, manage to not address the fact that this current arrangement leaves concern for people’s health to last, and so doesn’t deliver it.

I understand that people are worried about change. But the cost, in dollars and health, of the current system has moved the majority of the population to want something different, something that meets their needs and costs less.  It is available, if we seek to do it, if we can resist the pressures from the industries and billionaires who profit from the current way of doing things.

When we read about the need to overthrow foreign dictators, or hang on to private insurance companies, we always must remember to ask: cui bono?