Health care - what Republicans don't understand

[fpb]

David Emmet Cockrum, an Air Force brat brought up on a succession of air bases on a diet of superhero comics, is one of the four or five men who have the best claim to have created the most successful superhero franchise after Superman. Cockrum is the man who designed the X-men. Stan Lee and Jack Kirby designed the original team; of the two, for reasons I set out elsewhere, I think that Kirby must have been the leading spirit. Len Wein created the new members of the team - including Wolverine, Nightcrawler, Storm and Colossus; and the wayward and ultimately self-destructive talent of Chris Claremont, his successor, gave them form and shape and character. But David Cockrum was responsible for their look and design, and it was that look and design that went around the world on billions of keyrings, lunchboxes and baseball caps.

Well, never mind that. Never mind that he is party responsible for profits worth, at a conservative estimate, several hundred million dollars. Never mind that he is the part builder of a mythology that will outlive all its creators (Nightcrawler was especially his creation, and he dedicated many excellent pages to this character); never mind that he was an able and successful artist whose work has given pleasure to millions. Never mind all that, and let us come to just this: this man worked all his life, earned an honest living - much less than he deserved, but honestly earned from beginning to end, and that his wife worked together with him through their whole careers (she was his colourist). What I am saying is this: that when this good, hard-working American, of military stock, whose life had given a positive contribution to his country and the world, was struck down by a murderous combination of diabetes and pneumonia, he had to spend his last days begging in public for money. It was his good luck that he had many friends and admirers, especially in comics, who quickly got together $40,000 for desperately needed medicines and care (plus an unspecified contribution from Marvel Comics for his part in creating the X-Men). It was his good luck. But then, it was his bad luck, from that point of view, to have been born American.

I only just read of his death (which took place two years ago), and I made up my mind that, whatever happened, this time I could not keep my views to myself. First, of course, there is the personal and artistic feeling. That a man like Cockrum - admittedly, not the top artist in his generation, but a seriously good one nevertheless, and one whose legacy will live - should suffer this sort of indignity in his dying days, just makes me sick. In my country, such a man would probably have received an official pension under the so-called Bacchelli law, a specifically Italian provision (named after the famous writer for whom it was first written) to honour and support people who had honoured the country but had fallen on hard times. This comes from a specifically Italian feeling that our country owes as much to her artists, her scientists, her intellectuals and her philosophers as to any politician, industrialist or military leader; although I like to think that every nation honours her artists, if they are aware of them.

But this, after all, is more than personal. It is not even about an artist it is about a citizen reduced in his last days - without any evidence of improvidence or vice - to begging for money, begging for his life in public. Nothing about David Cockrum's hard-working life suggests that he had done anything to deserve this. And apart from him, how often does this happen? How many thousands, tens of thousands, hundreds of thousands, perhaps, of begging websites are there on the net, begging for someone from America who has worked, paid tax and contributed to private health care schemes for decades - only to be thrown off them just when they need them most, when some lingering and expensive disease is eating them alive from within, and it has become simply too expensive for a private health business to pay for their care? I know that such things happen, because even I, poor as I am, have put in my penny in some such funds.

Americans brag of the multitudinousness of their private charity. They claim that American individuals and American corporations give much more than European individuals and charities. But then we do not expect our old and our sick to be desperate for help just as they are least able to help themselves; to have to go and beg in public just when they most need their dignity and their respect. These things have long been banished from our lands. And the height of demonic irony is that the very people who are working to keep from America the evils of "socialized medicine" always quote the very moments in which the British Health Service turns out to be most like their own - letting unhappy old and sick citizens to die in the cold, or forcing them to beg for money for their cure - as if this somehow condemned the principle of national health care and proved anything in their own favour! Truly, as the poet said, there is no wonder in the world so strange as Man.

In fact, this is part of a much deeper American misunderstanding about Europe. Europeans, for instance, are routinely appalled at the low amount of Americans who turn up to vote. In most European countries, the vote is regarded as a public duty, as much as paying tax. And mention of paying tax rouses another echo: while Americans are more law-abiding than most Europeans (even staid Germany had some incredible revelations recently from banks in Liechtenstein), they have a lot less respect for taxation as an institution. They never pay a penny without grumbling about "the State taking my money" - as if that money were, somehow, their own creation, to which nobody but themselves had any legitimate claim. And the same population treats the vote not as a citizen's duty, but as a kind of favour they do to politicians, and which they can give or withhold at their will. Is this not the same difference? Does it not make a structure? The American does not regard either his vote or his taxation as due, owed, part of his citizenship, his belonging to a unit. Until recently, you could have pointed to a third element: the draft, a founding element in all continental European states, but intrusive and barely tolerated in America, and for that matter in Britain.

The American citizen does not feel that he has anything fundamental that he shares with all the citizens of his country. He does not feel that he is, in the philosopher's words, a tribal animal - zoon politikon - naturally and inevitably a part of a community. He does not feel that the community has certain and inevitable claims upon him; much less that, as the wisest of the Greeks used to say, the nation has a more radical and unanswerable claim on us than our own parents. The vote is something he can give or withhold; the taxation, something he does under protest; fighting in the army has to be volunteer (and I argued elsewhere that this is actually contrary to the letter and spirit of the Constitution). Generations of Americans were taught Perikles' great speech in Thucydides, without understading the force of that remark: "Among us democratic Athenians, and among us alone, a man who does not take an interest in public matters is regarded, not as a harmless fellow, but as good for nothing". We understand it. Among us, to be concerned with public matters, to have an opinion on politics, to vote on it when called upon, is a fundamental duty of citizenship. In Europe, an 80% turn-out for an election is considered disastrously low. In America, the system nearly broke down under the pressure of a 60% in 2004.

That being the case, the difference is obvious. We do not give as much in private benefactions, because we do not need to. We have long made up our mind that such things as health are public concerns, not private ones. And we frankly do not understand the selfish sophistry that argues that the State is entitled to protect the citizen's life from foreign invaders (armed forces) and domestic banditry (police, judiciary, prisons), but not from the equally damaging and murderous physical counterparts, disease, plague, contagion. We understand that such things cost; and on that ground, we accept the inevitability of taxation. But we accept it on a deeper level: for to pay for our collective organization, as to take part in its management with our vote, and to be responsible for its defence in our conscript armies, is simply a part of our citizenship. All these things have been weakened in various ways of late, which I do not find a good development, but the principle still holds. The State and the citizen are bound by mutual obligations of service, and also - as long as the citizen is a free man - by the citizen's duty to criticize and work to correct evetything they see as wrong in the State, indeed in the community. And from that viewpoint, if a European sees a law-abiding, hard-working citizen reduced to penury and beggary by failures in our healthcare system, we will know that it is not just our desire but our duty to work to make sure that such a thing does not happen again.

The arguments for a national health care system are infinite, and here I only set out one that particularly angered me. The arguments against it can be summed out in one burst of outdated, and indeed fairly ridiculous, Victorian rhetoric: "I am the master of my fate, I am the Captain of my soul". No you are not. Your fate does not belong to you; and as for your soul, no Christian with the slightest bit of sense ever conceived anything so wholly ridiculous. The posture of the man who owes nothing to anyone but himself is something that three seconds of unblinkered thought would blow to smithereens; yet policy is still made from it. And on the pretence of being the masters of one's fate and the captains of one's soul, sick and dying citizens are made to go out and beg for their lives at the point in time where they could hope some return for everything they had contributed to the community down their lives.

Comments

[dustthouart.livejournal.com]

I'll be leaving for class shortly, but I do want to make one comment, regarding something that has occurred to me. Prescription medications are extremely expensive in the US and reasonable to inexpensive everywhere else, as far as I know. (I know they're cheaper in Mexico, Canada and Taiwan.) Exact same brand and dose may cost a fraction of what it is in the US. In the US, I used insurance and paid a copay of $10 every time I refilled my prescription; in Taiwan, I paid less than $10 out of pocket for the whole thing. (Taiwan has nationalized healthcare, but as a foreign student I had to pay out of pocket, and it was always cheaper than I would have paid WITH INSURANCE in the US.)

Many people speculate as to why this is. I think it's because the enormous costs of medical research have to be recouped somewhere, and at the moment, it's the US that gets stuck with it. Where healthcare is nationalized, the government regulates how much profit can be made. For now, the drug companies have tolerated it because they can still do the obscene price gouging on Americans.

When America develops a national health care system (I say when, because I believe it will happen sooner or later), it will be very good for Americans, but very bad for the rest of the world. Our prices will go down, and the rest will go up. Hopefully it will settle into a fair and happy medium. However things could go awry; for example, if every country in the world puts a cap onto profits, the incentive for research becomes philanthropic rather than profit-driven, and I think the human desire for profit is strong than desire to benefit his fellow man.

Gotta go now. :)

[mentalguy.livejournal.com]

I don't know about prescription drugs, per se, but the high cost of medical care in the US in general owes much to the extreme heights to which malpractice insurance premiums have risen there.

[starshipcat.livejournal.com]

The MDeity effect is at least partly responsible for this. Once we start treating doctors like gods, we start expecting godlike performance from them -- and when they fail to deliver, we don't accept that they are just human beings, but instead blame them for not producing a miracle.

Then there is the whole thing of using the courts as slot machine, hoping to get the lawsuit payout so big you'll never have to work again, but that's a whole nother rant for another time.

[elskuligr.livejournal.com]

I think you may be confusing two methods through which governments may make health care affordable.

One method is -- probably what Taiwan's doing according to your post -- controlling the prices of medicine, which does help making them affordable, but means it's harder for a company to get their money back on their investment. Another similar way is to limit drastically the amount of time a copyright holds in such matter, and allowing cheaper copies of the medicine to be made earlier. Still a third way of making prices lower is to subsidize them, though in that case the company producing the medicine would make just as much money. (and of course, prices will be lower in countries where the cost of life in general is lower: i.e. medicine is bound to be cheaper in Togo than in Japan, just like food or clothes are bound to be cheaper as well)

The other method is having a national universal health insurance: basically all the people earning money pay taxes for health care in proportion to what they earn and when someone is ill, his treatment is paid for by the state. In that situation, medicine prices have no reason to be lower than elsewhere: the difference is not in the cost but in who pays for it. Instead of the individual, it's the community. It's the type of system existing in most of Europe, though each State has its own specific system.

Combinations of the two methods are of course possible, but what I'm trying to say is that forcing companies to lower their prices is only one way of making medicine affordable for all, but not the most efficient or the most widespread and it certainly has nothing to do with having a national health care service or not.

In one case you reduce the cost of medicine, in the other you spread the cost of each individual's treatment on all the community according to the well-known principle: from each according to their means, to each according to their needs.

NB: anyway not all pharmaceutical research is made in the states and even if it is a sizeable market, it certainly would not be enough to compensate low profits in the whole rest of the world, if the situation was as you describe. It is after all only one country, albeit a big one. It is true however that profits made in all the "rich" countries may compensate for the fact some poorer states have had to force prices of medicine down, particularly when one disease was a major national catastrophy such as AIDS in some South African countries (can't remember which state took that decision regarding the price of medicines).

[mentalguy.livejournal.com]

Although Americans are subject to a certain perverse individualism, I think the American position can be better understood if you realize that it is not so much a disinterest in the community as a profound lack of faith in the willingness or ability of American government to serve the interests of the community, and additionally a lack of faith in the two-party-dominated electoral system to produce a candidate who display sincere interest in changing that.

In particular, it is difficult to convince Americans that contributing tax money to new social programs would actually benefit the community, when the existing programs have been administered by government officials with an utterly jaw-dropping level of fiscal irresponsibility.

[stigandnasty919.livejournal.com]

Isn't one of the main reasons why American Health Care is so much more expensive in the USA that in much of the rest of the world is that it is a business? Designed to make money. In Canada and Europe you can cut the cost by whatever the cumulative profit margin is for drug distribution, lab work, medical insurance and hospitals. The total cost is borne by the tax payer and no profit is expected.

I'm not sure if costs for the rest of the world would go up for drugs. I don't think they currently differ much at source, however instead of there being a distribution margin added to the top of the cost, as in the USA, there is a subsidy from taxation, provided in Canada and in the UK. And I think, but stand to be corrected, that the time for which patents for drugs are protected is shorter in the rest of the world than in the USA.

I do think that there is a danger that if the US moved to a social medicine system, that the engine of research, the profits derived from the medical industry, would stall and we would see fewer medical breakthroughs.

[elskuligr.livejournal.com]

"I do think that there is a danger that if the US moved to a social medicine system, that the engine of research, the profits derived from the medical industry, would stall and we would see fewer medical breakthroughs."

On the contrary: medicine would be paid for by the state, so more people would have access to it, so the companies would be able to sell more instead of limiting their market to people who can afford it with their own means.

Of course if a "social medicine system" meant control of the industry by the state, as in some form of communist economy, you would be right, but that's not what a national health system is about.

[stigandnasty919.livejournal.com]

In most european countries and, I believe, in Canada, Cuba etc. the national health systems are controlled by the state. The Health Services are not industries, but services. Canada and the UK and the rest of europe

I hope you are right, that Americans would be prepared to pay for a national health service that maintained profits to fund research, but i'm not sure that any leader proposing the necessary tax hikes could get himself elected.

I think the main issue for America is that under the present system the taxpayers can't, or won't, pay for universal health care but the structural changes to cut costs would be unacceptable as they would impact directly on the huge number of personal shareholders in medical insurance companies and other areas of the health industry. Even more difficult is the impact the structural change would have on some of the biggest shareholders, pension funds.

Hard choices will have to be made. And from the outside looking in I think they ought to be.

I suppose my basic political view is that "No one left behind" ought to be the motto of every nation when it comes to education, health and retirement.

[fpb.livejournal.com]

You evidently are not aware that, while European countries spend between eight and nine per cent of GDP on healthcare, of which about 80% is state expenditure, American health expenditure costs between thirteen and fourteen per cent - of which 45% is still state expenditure. Work it out. A properly managed switchover would reduce private expenditure and lead to a barely noticeable tax increase.

[stigandnasty919.livejournal.com]

No Fabio I do appreciate the figures. I was speaking of an either/or situation.

You either raise taxes to pay for universal health care under the existing private system, (too expensive to be viable) or you restructure the health system along the lines you mention. A measure which would be very unpopular due to the impact on the share prices of various health industries including Insurance and the equivalent of our hospital trusts.

The fact that Health is the one 'industry' in the US which is more or less recession proof makes it a favourite stock to hold, especially at the moment. It will be a brave politician who will risk the wrath of the small shareholder and those who are members of share-based pension plans.

This is made more serious by the fact that the people who miss out on health care are also those least likely to vote, while small shareholders seem to be very politically aware.

I'm not putting this forward to disagree with your comments on the american health situation, simply to offer an explanation as to why politicians are fearful to do anything about it.

[fpb.livejournal.com]

Obama certainly does. His speech only spoke about regulating the insurance industry so it would not drop long-term sick clients. This would increase the costs all around and do nothing whatsoever for the ten-plus per cent of the total population who have no health cover at all. As for McCain, he is a Republican. I expect nothing from him.

Nonetheless, change must come. The current situation in America is simply untenable, and, in spite of the enormousness of private health, state and federal public programs are still ballooning out of control. My guess is that it will take a future conservative president, becoming convinced by the facts - like Peel became convinced that the Corn Laws were untenable, or Nixon that the US could not afford to have no relations with Communist China - to drive real, substantial change. As it is, the United States of America are wasting a tremendous amount of money, sapping both public accounts and the welfare of individual families, for no good reason, and at the same time disgracefully encouraging that atmosphere of sneering incomprehension that drives Europe and the rest of the world away from them.

[elskuligr.livejournal.com]

sorry, we must have misunderstood each other: when you mentionned the profits of research, I only thought of the development of new medicines by pharmaceutical companies, not of the services provided by doctors, hospitals, etc and it is obvious to me that such private companies can thrive and develop many new products in a country where the health service (not the pharmaceutical industry) is public and free.

As for the pros and cons of public research vs. private research, I think they're pretty much the same no matter the area of research: private means profit-driven means more money readily available and more incentive to find results quickly and so it is more effective in some areas. On the other hand, public research means that long-term projects with much potential but no immediate profit, and research on less profitable (but important for public health) products get attention as well.
Both are necessary, I think.

As for the fact the Americans don't welcome new taxes, that's obviously quite true: the whole conception of the State and its role and relation to individuals is at stake here, so I wouldn't await significant changes with bated breath. I really hope that the USA are going to make sure all its citizens get decent health insurance, but I'm not particularly optimistic.

[fpb.livejournal.com]

Incidentally, except for the doctrinaire follies of Canada and of course Cuba - of which I do not approve - the existence of a health system does not prevent a great deal of private healthcare from going on anyway. The idea is, or should be, to prevent citizens from dying like abandoned dogs, not to force every strand of health care to pass through the hands of the State. In many health care systems, such as (I believe) those of France or Japan, the State is simply the main client of a largely independent hospital and medical industry.

[mentalguy.livejournal.com]

That raises an interesting point for me: in my experience, the Canadian model is what most Americans seem to imagine when they think of socialized anything, whether they are in favor of it or are against it. Most have no clue how things are done in countries like France or Japan.

[fpb.livejournal.com]

I am not wholly clear about the various organizations of health in various countries. Japan I looked up, and France I know something about. The British Health Service is state-owned (and the biggest employer in the country), but involves a great deal of private features (for instance, all the GPs are private contractors rather than State employees) and allows private practice alongside the public structure. There is at least one huge private health provider, BUPA, with its own hospitals and doctors. What I can say for certain is that in all European countries, wholly private medicine - as opposed to private features in the national health services - accounts for between a fourth and a fifth of health spending.

[elegant-bonfire.livejournal.com]

With regards to Canada--as I live in a border state I see some of this first hand. I'm close to some major cutting-edge medical establishiments; I live within 2-3 hrs of Beaumont Hospital, UofM Medical Center, and another big hospital in Detroit whose name escapes me now. A fair percentage of the patients in some of them are Canadians, who can afford to pay up front for whatever procedure they are on a waiting list for back in Canada.

And I don't know the whole story about the comics artist, but if he were unemployed and homeless, I'd have thought Medicaid would have picked up the medical cost--I've always understood the truly poor and homeless are the ones served by Medicaid. (Medicare is for senior citizens.) The people in the US who fall through the gaps are the underemployed--fast food workers and the like, who don't make enough money to pay for insurance, but whose job doesn't include it either.

[fpb.livejournal.com]

He was not unemployed and homeless, and had the support of his wife. It was just the classic American story of the insurance running out. And I assure you that the thought turns the stomach of any European. The idea that you should beg or die because you cannot afford to pay for your doctor is something we have outlawed for decades, and we do not miss it.

[elegant-bonfire.livejournal.com]

I have to admit I'm confused. If he was working, was it for a company that didn't have insurance, or did they drop him because of pre-existing conditions? (Which is supposed to be illegal, but I'm not naive enough to think it doesn't still happen.) Or was it a case of running up a huge deductible, which I can certainly understand, as my own insurance has a $2000 deductible and 8% co-pay in the event of hospitalization.

[fpb.livejournal.com]

Comic book artists are freelancers.

Anyway, this is missing the forest for some of the smaller knots in the lower reaches of one tree. The point is that nobody outside America understand the reasoning whereby the State has the duty to protect the citizen against violence from people, but not against ill-health and accidents.

[elegant-bonfire.livejournal.com]

You know, the fact that I didn't see this story as hugely out of the ordinary probably makes your point better than anything else.....

[mentalguy.livejournal.com]

I'm not even considering relative expense or research investment.

I'll take the obvious example of the US Social Security system, which even under the best circumstances would be under strain from declining birth rates, but is at this point almost entirely propped up by IOUs because politicians have re-allocated its funds to their own pet projects.

The issue I was concerned with was that, based on the prevailing pattern of government use of funds for social programs, Americans have little reason to believe that if a public health care program were established, that those public health care funds would actually get spent on public health care.

[cheyinka]

Right - I joked about voting for Cthulhu in my journal recently, because the whole process feels to me like "election year theater". Any number of candidates pretend to promise things, we make ritual marks on paper or signify our participation in other ways, two candidates get picked as potential winners, we go through the ritual again, and then one candidate gets the office in question.


I'm comfortable paying taxes on the fuel I put into my car, because I see it as supporting the upkeep of the roads I drive on, and I expect that the various governments that I live under will build and maintain roads connecting different parts of the country / state / city. But when I heard that a very ill friend of mine had finally gotten on Medicaid, it didn't fulfill any expectations I had - it went contrary to my expectations and I was surprised and pleased.

I guess I meet the profile of an American who doesn't really know what socialized-anything would look like, like you said downthread - I think of "socialized medicine" and I think "the government making something that barely works stop working even that much", not a system more or less like the one I'm used to except with the government stepping in to pay if someone legitimately can't afford to do so.

[cheyinka]

When I was in high school I had half a year of "civics class", which was pretty pathetic (and miserable to endure - I had classmates who would literally howl to prevent anyone from asking or answering questions in class!). The only two lessons I retained about voting was that women weren't always allowed to do so (and it was wonderful that women could vote now) and that one person's vote didn't matter, but we had to all pretend that everyone's vote mattered, otherwise nobody would vote and the government would simply cease to exist. As far as taxation went, well, government was inefficient and politicians were greedy but it was important to pay taxes anyway.

If my experience was anything like representative, I think it explains at least some of the American attitude towards taxes and voting.

[fpb.livejournal.com]

We do not expect taxation to be spent efficiently, and we do not imagine that one vote out of forty million (in Italy) or even two hundred thousand (in Luxemburg) will make a huge difference. The point is rather that voting is a feature of the connection of the citizen with the State; it validates the authority of the State, by basing it on explicit popular support, and conversely it shows that the citizen has a definite claim on the State. Which, in turn, means that the citizen has a right to take any politial initiative (within the law) that seems right to him or her. One person never makes a difference, but many times one person makes a party, a movement, or a people.

That being said, it sounds as if you had a teacher with serious personal disappointments.

Re: The low voter turnout

[elegant-bonfire.livejournal.com]

I know a few years ago, there were a lot of people who never registered to vote as they didn't want to serve on a jury. (The county used the voter registration rolls to call jurors.)

Now, however, jury duty is pulled from the Secretary of State's records, as they issue driver's licenses, and state ID cards for the eensy minority of non-driving people here. So there's no excuse.

Re: The low voter turnout

[fpb.livejournal.com]

I did not think of jury duty, but yes, I would look on it in the same light - as a citizen's duty. (In Italy it is actually quite recent: jurors, called "popular judges", were only introduced in the courts with the Constitution of 1948.)

Re: The low voter turnout

[elegant-bonfire.livejournal.com]

I would serve on a jury if I were called. Some people don't want to do it as their job doesn't give them jury duty pay (mine does).

Bit of trivia: The cop slang for a situation where an officer may have to shoot someone who's threatening them--"I'd rather be tried by twelve than carried by six."

Re: The low voter turnout

[fpb.livejournal.com]

I also heard a six-shooter called a "jury of six".

Re: The low voter turnout

[elegant-bonfire.livejournal.com]

Heh. I've also seen bumper stickers here that say "protected by Smith and Wesson Co."

[mindstalk.livejournal.com]

Nice post.
Regarding voting: most of Europe has some version of proportional representation by now, don't they? That might explain some of it: in much of the US, the marginal difference an individual voter makes seems non-existent. If I'm a Democrat in Hawaii, and I've never voted, there's no point to my starting voting; the state is majority Democratic. Not much point to voting as a new Republican, either. But with PR, a new vote has a small but real marginal addition to the power of its party.

jury duty: a duty, but one potentially rather disruptive to a life, at a random time, for a potentially arbitrarily long time, and for $5 a day. The Athenian jury doubled as a dole; ours isn't sufficient for that.

Regarding types of health systems, an interesting article on path dependence, and why almost no one has as socialized a system as Britain.