Saturday, June 15, 2019
Rising US “deaths of despair” driven by health care costs, lack of access to care
By Kate Randall
14 June 2019
A new report reveals that most
US states are losing ground on key measures related to life expectancy, which
has declined in each of the last three years. The Commonwealth Fund’s “2019
Scorecard on State Health System Performance” shows that “deaths of despair”—premature
deaths from suicide, alcohol abuse and drug overdoses—continue to rise in
nearly every state. The report further shows that these deaths are tied to
rising healthcare costs that are placing an increasing financial burden on
families across the country.
The Commonwealth Fund’s
Scorecard assessed “deaths of despair” in all 50 states and the District of
Columbia, as well as ranked states on 47 measures of access to health care,
quality of care, health care usage, health outcomes and income-based health
care disparities. The report found that Medicaid expansion under the Affordable
Care Act has been a central factor leading to meaningful gains in access to
health care.
The reasons behind the
decision of a person to take his or her own life, to take drugs resulting in a
fatal overdose, or to drink alcohol in excess leading to health problems and
death, are complex. But this new study shows that one of the major underlying
causes of such tragedies is social inequality, in particular lack of access to
health care and the associated financial struggles.
The opioid crisis, suicide and
alcohol-related deaths
While the study finds that
deaths from suicide and alcohol and drug abuse are a national crisis, it notes
that states and regions are affected in different ways. Opioid use disorder has
fueled a rise in drug overdose deaths with tragic outcomes for families across
the country. The emergence of highly lethal synthetic opioids, such as
fentanyl, in the illicit drug supply has contributed to this national crisis.
The opioid epidemic has hit
states in New England, the Mid-Atlantic and several Southeastern states
particularly hard. West Virginia, Ohio, Pennsylvania, the District of Columbia,
Kentucky, Delaware and New Hampshire have the highest death rates from drug
overdoses.
In Pennsylvania, Maryland and
Ohio, death rates from drug overdose were at least five times higher than from
alcohol abuse and about three times higher than suicide rates. In Montana,
Nebraska, the Dakotas, Oregon and Wyoming, death rates from suicide and alcohol
were greater than those from drugs.
West Virginia has been the
state hardest hit by the opioid crisis, with 58.7 deaths per 100,000 residents—a
staggering two-and-a-half times the national average. This was 25 percent more
than the state with the next highest rate of opioid deaths, Ohio, which had
46.3 deaths per 100,000 residents. Opioid-related deaths in West Virginia
increased fivefold in 12 years—rising from 10.5 deaths per 100,000 in
2005 to 57.8 in 2017.
The rate of death from drug
overdose more than doubled across the US between 2005 and 2017. These deaths
surged by 10 percent just between 2016 and 2017.
Suicide rates nationally have
risen by nearly 30 percent since 2005. Parallel to the sharp rise in the death
rate from drug overdose, the national suicide death rate rose more sharply between
2016 and 2017 than during any other one-year period in recent history.
Similarly, the alcohol-related death rate rose by about 2 percent per year
between 2005 and 2012 but increased by about 4 percent per year between 2013
and 2017.
Health insurance, access to
care, cost
The Commonwealth Fund notes
that the reductions in the uninsured population following the Affordable Care
Act’s (ACA) expansion of health coverage in 2014 have now stalled or even begun
to erode in some states.
The ACA, commonly known as
Obamacare, while expanding some access to health care coverage, has never
challenged the domination of the for-profit health care industry. It required
that individuals without insurance from their employer or a government program
purchase insurance from a private insurance company.
Nearly all states saw
substantial reductions in uninsured rates between 2013 and 2017 with the
opening of the ACA’s insurance marketplaces, with fewer people citing cost as a
barrier to receiving health care.
As the ACA was written,
Medicaid, the health insurance program for the poor jointly administered by the
federal government and the states, was to be expanded to cover all US citizens
and legal residents with incomes up to 133 percent of the poverty line. However,
the US Supreme Court ruled in 2012 that it was up to the states whether or not
to expand their Medicaid programs.
Almost all those states that
expanded Medicaid under the ACA saw a reduction in rates of uninsured through
2015. However, after 2015 any progress in reducing the rates of uninsured had
stalled in most states. From 2016 to 2017, more than half of states were simply
treading water. Sixteen states saw a rise of 1 percent in the uninsured rate,
including both those that did and did not expand Medicaid.
States that adopted Medicaid
expansion have seen lower rates of the uninsured. As of January 1, 2017, Massachusetts
had the lowest rate of uninsured, at 4 percent. The states with the highest
rates of uninsured—Mississippi, Florida, Georgia, Oklahoma and Texas—were among
the 19 states that had not expanded Medicaid as of January 1, 2017. In Texas,
24 percent—nearly a quarter of all residents—were uninsured.
Uninsured rates were
particularly high in states with large African-American and Hispanic
populations. In Florida, George and Texas, about 20 percent of black adults
were uninsured in 2017, compared to the US average of about 14 percent. In
Texas, more than a third of Hispanic adults were uninsured in 2017. Undoubtedly
contributing to the uninsured among Hispanics is the denial of Medicaid and
access to the ACA marketplace for undocumented immigrants.
Health care costs
In addition to the lack of
health insurance, the high cost of coverage for those who are insured is
contributing to the crisis in accessing health care. The report notes that as
of the end of 2018, 30 million adults remained uninsured and an estimated 44
million people had insurance but were considered “underinsured” due to the high
out-of-pocket costs for health care in relation to their income.
People with individual-market
plans under the ACA were insured at the highest rates. However, the cost of
private, employer-sponsored health care plans is rising, exposing workers and
their families to increasingly higher deductibles and out-of-pocket costs. In
most states, the amount that employees contribute to their employer coverage is
rising faster than median income.
A key contributing factor to
the uninsured and underinsured rates is the overall rate of growth in US health
care costs compared to the slow growth in US median income. Workers face rising
costs as insurers increase deductibles and other cost-sharing for enrollees. As
workers in both ACA and employee plans are covered by the insurance industry,
these private companies raise costs for the insured to boost their bottom
lines.
The Commonwealth Fund’s report
explodes the myth that people’s use of health care services is the primary
driver of cost and premium growth. The report notes that there is growing
evidence that the prices paid by private insurers to health care providers,
particularly hospitals, are responsible for this growth.
The report notes, according to
the Health Care Cost Institute, that “between 2013 and 2017 prices for
inpatient services paid by private insurers climbed by 16 percent while
utilization fell by 5 percent. The analysis found similar patterns for
outpatient and professional services as well as prescription drugs.”
In other words, while workers
and their families are struggling to obtain decent health care and to pay for
it, the entire system of health care delivery in America is geared toward
enriching the hospitals, pharmaceuticals and insurance companies. Those
succumbing to “deaths of despair” are the victims of a health care system and a
society that values capitalist profit over the health and very lives of its
citizens.
The Left’s Failure to Envision a World Without Capitalism
Bernie Sanders' speech on
democratic socialism underscored the limits of a growing movement's
imagination.
By CONOR
LYNCH
June 12, 2019
There is a common saying on
the left, usually attributed to the Marxist critic Fredric Jameson, that
“it is easier to imagine the end of the world than it is to imagine the end of
capitalism.” The late writer Mark Fisher once described this
as “capitalist realism,” or the “widespread sense that not only is capitalism
the only viable political and economic system, but also that it is now
impossible even to imagine a coherent alternative to it.”
This sense has prevailed since
the collapse of communism three decades ago, which led to a triumphalism
throughout the capitalist world right up until the 2008 financial crisis and
ensuing global recession, which triggered different anti-capitalist movements.
But in the ten years since then, a true political and economic alternative has
yet to materialize.
Though many now believe that
capitalism should end, this doesn’t make it any more likely—not even
if Senator Bernie Sanders becomes president.
The Vermont senator made that
clear with a speech on Wednesday whose very title proves the limits
of his revolution: “How Democratic Socialism Is the Only Way to Defeat
Oligarchy.” He did not denounce capitalism itself, but “unfettered capitalism”
specifically, and even used “socialism” as a sort of epithet.
“Let us never forget the
unbelievable hypocrisy of Wall Street, the high priests of unfettered
capitalism,” he said. “In 2008, after their greed, recklessness, and illegal
behavior created the worst financial disaster since the Great Depression—with
millions of Americans losing their jobs, losing their homes, losing their life
savings—Wall Street’s religious adherence to unfettered capitalism suddenly
came to an end.
Overnight, Wall Street became
big government socialists and begged for the largest federal bailout in
American history.”
Sanders’ hesitance to go any
further may come as a disappointment to many on the far left today, but it’s
not surprising given recent history. One of the first major signs of a socialist
resurgence was the outbreak of Occupy Wall Street back in 2011. Though
decentralized and leaderless, it was perhaps the biggest anti-capitalist
movement since “the end of history” was declared 20
years earlier. While the movement spread globally and the “occupations” lasted
for months, it didn’t produce any coherent vision of what was to replace
capitalism. At the time, Slovenian philosopher Slavoj Žižek commented that
the Occupy movement recalled Herman Melville’s famous short story about the law
clerk Bartleby: “The message of Occupy Wall Street is ‘I would prefer not to
play the existing [capitalist] game.’... Beyond this they don’t have an
answer.”
A few years after Occupy,
Thomas Piketty published his book Capital in the Twenty-First Century,
which became one of the best-selling academic works of all time and prompted an
international debate about inequality. Though centrist and right-wing
critics labeled Piketty a “modern Marx,” the French economist
was hardly calling for an end to capitalism or promoting some grand theory of
capital. With an impressive slew of data, Piketty confirmed what those on the
left had long known: that extreme inequality and the concentration of wealth is
a natural outcome of capitalism. Unlike Marx, however, Piketty didn’t even
attempt to imagine a radical alternative to the system of capitalism.
(His prescription was
ultimately a global wealth tax, which manages to be both underwhelming and unrealistic.)
A year after Capital was
published in English, Sanders launched his 2016 presidential run, which became
another important display of the growing anti-capitalist mood that had spread
since the financial crisis. Sanders openly identified as a “democratic
socialist”—a radical gesture in itself—and provided an alternative to the
“progressive neoliberalism” that had come to dominate the Democratic Party
since the nineties. (I borrow this term from Nancy Fraser to describe an alliance between
emancipatory movements such as feminism and anti-racism with “neoliberal forces
aiming to financialize the capitalist economy,” who, according to Fraser, use
the “charisma of their progressive allies to spread a veneer of emancipation
over their own regressive project of massive upward redistribution.”)
Though Sanders reintroduced
class politics to the debate and inspired a generation of young people to
embrace the socialist label, he was ultimately offering an upgraded version of
New Deal liberalism rather than a true socialist alternative to capitalism. The
fact that his most “radical” policy—public universal healthcare—has been the
status quo in European countries like the United Kingdom since the
mid-twentieth century was telling enough. As many commentators noted at the
time, Sanders was less a democratic socialist in the tradition of Eugene Debs
than he was a social democrat in the tradition of Franklin Roosevelt.
Sanders is now embracing that
comparison. His speech on Wednesday was an effective love letter to FDR (with
no mention of Debs). He called for the Democratic Party to take up the
“unfinished business of the New Deal,” and proposed a twenty-first-century version
of the FDR’s “economic bill of rights.” Though the senator continues to call
himself a democratic socialist, his vague definition of socialism is still
closer to the social democracy that FDR ushered in. According to Sanders,
democratic socialism is the belief that “economic rights are human rights,”
which means the right to a living wage, quality healthcare, education,
affordable housing, and a secure retirement; it means “requiring and achieving
political and economic freedom in every community in this country,” he said.
These are all worthy and important goals, but only right-wing critics would
honestly call this socialism.
In the three years since
Sanders lost his primary bid, more and more Americans share his view, loosely
speaking. According to a survey released by Axios just this week, four in ten
respondents would prefer to live in a socialist country over a capitalist one,
and 55 percent of women between 18 and 54 reject capitalism. That would seem to
work in Sanders’s favor, but the size of the primary field has not. He does not
have a sole establishment candidate to contrast himself with, and moreover, many
of his competitors have embraced much of his agenda—albeit without the
confrontational class-politics that defined his first campaign.
Sanders is still the only
candidate who is remotely anti-capitalist, and the only candidate who calls
himself a socialist. But his policies aren’t quite as unique as they were in
2016. Though no doubt “radical” in the American setting, Sanders’ economic
agenda would be considered center-left in the rest of the developed world, and
in practical terms there’s not much separating him from Senator Elizabeth
Warren, who has insisted that she is “capitalist to [her] bones.”
There’s a degree of nostalgia
for mid-twentieth century social democracy among today’s leading leftists, who
long for the days when income taxes were high, unions were strong, and
reformist policies found a middle ground between the extremes of “socialism”
and “capitalism.”
Commonly referred to as the
“golden age” of capitalism, the postwar era saw a reduction in inequality,
growth in wages and living standards, and increased social mobility. This was
all made possible—in part—by the policies implemented by New Dealers in America
and Social Democrats in Western Europe.
There is a real problem with
trying to emulate the social democratic policies of the twentieth century
today, however, and it’s not clear whether the middle-of-the-road approach is
still viable in the twenty-first century. We live in a far more globalized
world than we did 75 years ago.
Capital is more flexible and
mobile than ever before and the rapid economic growth experienced during the
postwar era is unlikely to be repeated, which makes national welfare states
harder to sustain. In Capital, Piketty provided ample evidence that the
trends during the mid-twentieth century were historically anomalous, and that
today’s extreme inequality is a return to the norm.
“A concentration of
circumstances (wartime destruction, progressive tax policies made possible by
the shocks of 1914-1945, and exceptional growth during the three decades
following the end of World War II),” he wrote, “created a historically
unprecedented situation which lasted for nearly a century. All signs are,
however, that it is about to end.” He added, “Broadly speaking, it was the wars
of the twentieth century that wiped away the past to create the illusion that
capitalism had been structurally transformed.”
Social democratic policies
were originally designed to “save capitalism from itself.” Like Marx, John
Maynard Keynes recognized the inherent instability of capitalism, but unlike
the German revolutionary, he believed the system’s contradictions could be
limited and its tensions mediated through state intervention—in other words,
that the system was reformable. When Keynes was alive, it was still possible to
imagine the end of capitalism (indeed, it was impossible not to), and
the British economist devoted his life’s work to preserving the system. Today,
even if you aren’t “capitalist to your bones” and believe that capitalism is
“irredeemable,” as Representative Alexandria Ocasio-Cortez does, it’s
nearly impossible to imagine the end of capitalism (or at least a viable
alternative replacing it). It’s even difficult to imagine a return to the
capitalism of the mid-twentieth century.
Sanders is an anti-capitalist
at heart—otherwise he wouldn’t call himself a socialist—but we continue to live
in an age where it is easier to imagine the end of the world than the end of
capitalism (and with climate change and other ecological disasters threatening
humanity, it doesn’t take H. G. Wells to imagine the end of the world these
days). The question for today’s left seems to be whether the ultimate goal is
to reform or to replace capitalism—and if the latter is indeed the goal, then
what will a post-capitalist world actually look like? If Sanders wants to set
himself apart from a candidate like Warren, he can start by giving these
questions serious thought, and go beyond a simple critique of what he calls
“unfettered capitalism.”
Friday, June 14, 2019
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