THE LOOMING HEALTH CARE CRISIS: WHAT DOES IT PORTEND FOR MEDICARE?
DAVE KINGSLEY, PhD
COMMUNITY OF REASON KC
FEBRUARY 25, 2018
Today, I would like to speak to you about health care in the United States – such as it is. I want to make it clear that health care is not just medical care. Medical care is a subsystem of the larger health care system. However, expenditures for delivery of medical services dwarf all other expenditures devoted to our health. Indeed, I am reminded of Gandhi’s answer when he was asked what he thought of Western Civilization. He said, “it would be a nice idea.” The same thing could be said about U.S. health care: it would be a nice idea.
The truth of the matter is that our health care system is in trouble. It is a disturbing, chaotic mess. Untold numbers of people become sick and die each year due to preventable illnesses, and lack of access to medical care.
Indeed, we have a fragmented medical care system to which tens of millions of Americans have no access. And tens of millions more who have access but can’t afford to purchase the insurance or pay the out of pocket costs. And yet, we spend nearly one-fifth of our GDP on treating illnesses. You have probably already heard that we spend double per capita and as a proportion of GDP what other industrialized countries spend, and they all have better health outcomes. Let me repeat, most of that expenditure is devoted to treating illnesses rather than to preventing them in the first place. And if you think it is expensive now, just wait a while.
Heretofore unimaginable technology is being developed and will soon be introduced into the medical delivery system. For instance, gene editing will make it possible to create a specie of pigs with organs transplantable into humans. Sequencing of the human genome has already been utilized for designing cancer treatments. Other forms of bio-technology include mechanical heart pumps, protheses connected to the human central nervous system, and lifesaving technologies hard to imagine.
These innovations have some grave bioethical implications for Medicare that I will cover at a later point in my talk today.
Because I am speaking about Medicare vis a vis the broader health care system, I want to preface my remarks with these fact: Medicare is the only single payer medical system in the U.S.; it is earned by those who receive it; it is only available to us when we cross an arbitrary age line, i.e., 65. The natural history of diseases, whether genetically caused, environmental, or the interaction of genes and environment does not progress in sync with arbitrary ages.
I know that I am speaking to a well-informed audience and that you are aware of many of the issues I will be speaking about today. But to paraphrase George Orwell, “We have sunk to a depth at which the restatement of the obvious is our highest duty.” I know that I will be restating the obvious today but hopefully I will be approaching it somewhat differently than is usual in discourse these days, and, in addition, provide some helpful insights.
For the past few decades, a steady stream of books about health care have been authored for public consumption. I have collected and read most of them. It would be more correct to say that they are about medical care – about the kind of access to care we should have when we are ill. Most of these have come from moderate to conservative Democrats such as Tom Daschle and Howard Dean. They support universal but privatized, corporatized health insurance, which I think is a bad idea but better than nothing. One of the latest and best books about medical care is written by Elizabeth Rosenthal. I recommend it. However, it, like all the others, is about medical care – not health care.
As I mentioned already, none of these books accord much attention to the overall system and how all the parts are related. It is important to examine how we communicate about health care. My colleague, Professor Max Skidmore, recently shared with me an excellent article he wrote in which he explained how communication in our democracy is structured for self-censorship. In the United States, practically no speech is outlawed. However, some ideas are “acceptable” and discussion about them is welcomed into political discourse. While speech about other ideas is not outlawed, it is simply considered unimportant and ignored. Acceptable ideas are stable and predictable – they are the “conventional wisdom” and serve to suppress other ideas.
For instance, I am certain that most people would rather not get cancer – regardless of the progress we have made over the past half century in treating it (I’ll talk more about that later also). Indeed, I think that I can safely say that my fellow Americans, like myself, are all for preventing cancer we might otherwise suffer without that prevention. But in the broader discussion about this multi-faceted disease, not much is said abut the underlying environmental causes and how we need a moonshot program to eliminate them – wipe them out.
Right now, we could begin to eliminate cancers caused by the human papilloma virus by insuring that every teenager is inoculated. But only 43% of teens have received a shot for it. Think about how much less suffering and costs we would experience if we set about to eliminate causes of cancer rather than just treat the diseases.
I want to make it clear that access to good medical care is extremely important. All medical advances that reduce suffering and help people reach their natural life span are wonderful – no matter how much they cost. I am all for the science and medicine on the cutting edge these days.
However, in spite of the nearly $4 trillion dollars that will be spent for medical care this year – often with the most advanced technology imaginable – tens of millions of our fellow Americans become sick, suffer, and/or die due to lack of access to care and exposure to preventable causes that have made them sick or caused them injury. In the case of the uninsured – overwhelmingly people in the lowest socio-economic strata – a disease in any state will often be untreated or treated in an emergency room. This makes no sense whatsoever and I will talk about the resulting problems for Medicare in a bit.
Furthermore, the 65+ demographic is the one group with a universal right to health care – for those of us who cross the arbitrary age line of 65. In additional to being irrational, cruel, and costly, it places the Medicare program and its beneficiaries in a precarious position. It is unjust to deny anyone access to medical care but it is not the fault of the elderly.
Along with Social Security, Medicare is presented by some powerful demagogues as undeserved privileges and unfair to younger generations. Journalists misinform the public about the impact of these programs on the federal budget and consequently on the debt and deficits.
After decades of phenomenal growth in the health care sector of our economy, here is where we have arrived:
- Deteriorating health and reduced life expectancy for half of our population, (2) thirty+ million uninsured fellow Americans, (3) polluted and toxic water, (4) unregulated industries bombarding us with carcinogens, (5) no American has guaranteed access to dental, vision, and hearing care, (6) we have exposure to thousands of toxic waste sights – neglected and ignored by a government that is supposed to protect us.
All of this neglect of our basic health is far more costly left unabated. Later, I will provide my views about how it came to this and would like to hear your views also. But first, I want to discuss and clarify the crisis that is worsening.
You might be thinking that with all the talk about the lack of access to medical care for tens of millions of Americans, we are already in a crisis. You would not be wrong. Indeed, when masses of Americans cannot go to a doctor when they are ill, they become sicker, and eventually die prematurely. This is a catastrophe. But using hurricanes as an analogy, a level four is an exponentially greater catastrophe than a level three.
The health care crisis looming on the horizon will be at a level higher than we are at now. What do I mean by that? First, let’s consider population health. In 2015, Ann Case and Angus Deaton, economists and a husband and wife team on the faculty at Princeton, published a study in which they presented evidence that the death rate of 45 to 55-year-old whites in the United States had been undergoing an increase. This unprecedented reversal of a downward trend in the death rate of any identifiable subgroup of Americans took the mainstream media by storm. It was a sensation. People were shocked, shocked I tell you. What is shocking to me is that people were shocked.
What is also shocking to me is that journalists and politicians have not shown much interest in the perpetual death rate and life expectancy gap between African Americans and whites. Although life expectancy had improved somewhat for African Americans like all other ethnic groups, the research of University of Illinois professor and Jay Olshansky and his colleagues in (2012) indicated that black-white gap in life expectancy was increasing. The largest gap in LE was between the highest educated white males and the lowest educated black males. That gap is 14.2 years. For females it was 10.3 years. I am puzzled by the lack of interest in this phenomenon.
Furthermore, in 2005 Olshansky and his colleagues published an article in the New England Journal of Medicine entitled “A Potential Decline in Life Expectancy in the United States in the 21st Century in which they pointed out that obesity had remained relatively stable in the 1960s and 1970s but had increased 50% per decade throughout the 1980s and 1990s. They wrote: “Being overweight in childhood increases risk among men of death from any cause and death from cardiovascular morbidity among both men and women. The lifetime risk of diabetes among people born in the United States has risen rapidly to 30 to 40 percent – a phenomenon presumably attributable to the obesity ‘epidemic.’”
A few months ago, the National Center for Health Statistics issued a report entitled “Mortality in the United States, 2016.” The authors reported that in 2016, life expectancy at birth was 78.6 years for the total U.S. population – a decrease of .1 year from 78.7 in 2015. For males, LE changed from 76.3 in 2015 to 76.1 in 2016 – a decrease of .2 year. For females, life expectancy remained the same.
One of the problems with the fragmented sources of this type of information, is that it is hard to see the pockets of poor health and connect all the dots. In 2012, Jennifer Montez, A Robert Wood Johnson Foundation Health and Society Scholar at the Harvard Center for Population Studies published research indicating that white women without a high school diploma lost five years of live between 1990 and 2008; their life expectancy was 73.5 years compared with 83.9 years for white women with a college degree.
I do agree with Case and Deaton that education is positively correlated with good health. Subgroups at the higher end of education levels, are healthier. However, education and poverty are also correlated. Indeed, a constellation of factors are associated with the health of Americans in lower socio-economic strata. Among these are exposure to environmental toxins, access to medical care and nutritious food, stress, and a host of other deleterious effects on health.
As I have already mentioned, most of our health care resources are devoted to acute care medicine. Conversely, prevention and preventative medicine have been traditionally underfunded and underappreciated. This imbalance has resulted in a weakened public health infrastructure and a growing population of unhealthy people.
Despite the $100 billion expended by the federal “war on cancer” for the past half century, the vast array of cancers have, with a few exceptions, remained intractable – indeed the incidence of some cancers has increased. Leading edge epidemiological research suggests that half of all cancer is preventable. Too many environmental toxins in our homes, workplace, and other places we enter in our daily lives have been ignored by our government.
The President’s Cancer Panel 2012, stressed the pitifully low amount of federal resources allocated to prevention of cancer. The panel reported that little effort is devoted to research into the effects of the 82,000 chemicals on the market for manufacturing, agriculture, gardening, and myriad other uses. There was, during the Obama administration, legislation passed to update the 1972 Toxic Substances Control Act – the Chemical Safety for the 21st Century Act. Whether this legislation will be adequately implemented is doubtful.
The increase in blood cancers such as leukemia and non-Hodgkin’s lymphoma since the 1970s is horrifying. According to the SEER 9 database non-Hodgkin’s lymphoma, occurring at a rate of 11.1 per 100, 000 in 1975, had increased to 20 per 100,000 by 2014. Between 1975 and 2014, the incidence of leukemia per 100,000 population increased from 12.8 to 13.9. New immunotherapy treatments have recently been approved for these cancers. The cost of the drugs will be priced at close to $400,000.
The rather grim picture I have presented to you thus far will not improve any time soon if we continue to carry forward the trajectory we have been on for the past several decades. What factors account for the irrational path we have been traveling to arrive at the disgraceful and irrational health situation we now have? I now will cover the cultural, economic, and political causes underlying the symptoms of an unacceptable health care system.
Due to modern techniques for growing, processing, and distributing food, a cultural shift in the American diet has taken place over the past several decades. Low fiber and high fat processed foods – often laden with refined sugar/or corn syrup – have become an integral feature in the U.S. diet. Children become conditioned to want fat and sugar through major fast food and processed food industries.
What accounts for the massive increase in U.S. sugar consumption? Conditioning through overwhelming forces over which only the most ardent guardians of their own nutrition can resist. Coca Cola corp. knows that its reputation cannot be besmirched by public knowledge concerning the devastating impact of sugary drinks consumed by children and adults alike. So they distract the public with their well-funded campaign to sell their product as love and caring. They are going to give the world a song. Lately they have been advertising their love for the environment, which has little to do with the environment inside of our bodies damaged by refined sugar.
Most of us as parents have participated in the cultural habit of taking our children to McDonald’s for the happy meal at a franchise complete with a playground, toys, and clowns. What McDonald’s and other purveyors of “fast food” don’t want you to know is that scientists established decades ago that atherosclerosis has its primordial roots in infancy. This was discovered through autopsies of deceased children during the Bogalusa study. You can now find an overwhelming amount of conclusive evidence in the medical literature that children do indeed suffer from early stages of atherosclerosis in infancy. No doubt it usually doesn’t become clinically significant until middle age.
Sugar and saturated fat are addictive and eating habits are formed early in life and difficult to change.
We are experiencing an increasing incidence of childhood cancers. If that happens to your child, McDonalds will provide you with a free stay at a Ronald McDonald house near the treatment center. What McDonalds corp. doesn’t want to talk about is this: Scientists conducting research on the underlying causes of cancer have concluded that along with herbicides, pesticides, and the thousands of chemicals in our food, building products, and other manufactured goods, obesity, lack of fiber and excess of fat in our foods are causal factors in intractably high rates of cancer. For instance, researchers have established the relationship between benzene, formaldehyde, and a host of other chemicals to which we are often exposed with cancers such as leukemia. Diet, cosmetics, and other chemicals are causal factors in breast cancer. There is some evidence that tailpipe emissions such as particulate matter and ozone contribute to lung cancer. Certainly, smoking causes the number one cancer: lung.
Heart disease is the leading cause of premature death and, along with cancer, where the most expensive acute care expenditures are directed. Cardiologists believe that heart disease is one of the most preventable, chronic illnesses facing the U.S. health care system. Just as is the case with cancer, heart disease stems from dietary fats – especially those in red meats – sugar, lack of fiber, and diabetes to mention the main environmental culprits.
Without a doubt, heart disease is the most costly and one of the most preventable diseases in the panoply of scourges besetting the American public. During my research at KU MED on hospital data, I discovered that the five years between ages 65 and 70 is the most costly age group. Various procedures in the treatment of heart disease are the “big ticket” items in this age category. When I explain to people that the big hospital costs are not found in the 80+ (or even 75+) elderly patients – that there is not a linear relationship between age and medical costs – they are incredulous. But, given the natural history of a disease, it makes sense that untreated heart disease will be treated at age 65 or soon thereafter when eligibility for Medicare is reached.
I cannot do justice to the assaults on our health from corporate greed and government neglect. But I think you get my point. Before I talk about the political antecedents to the state of our health care, I would like to share a couple of stories with you.
The first story is about a conversation I had with Dr. Caldwell Esseltyne – one of the most renowned cardiologists in the United States. I asked him about a phenomenon that I had discovered in a large database of hospital discharge data I was using in a PhD Health Policy & Management class I taught at Kansas University Medical Center. The dataset contained 8 million hospital discharges (1/5 of all hospital discharges in any one year). I obtained the dataset each year. I noticed that the most expensive hospital cases were in two age categories: (1) less than age 1, and (2) age 67. Of course, we know that our neonatal intensive care units are doing wonderful work and I am all for it.
The high 67 age group charges were overwhelmingly due to treatment for heart disease. My research also indicated that hospital charges drop on average for age groups over age 70 and drop precipitously past age 80.
Here is what Dr. Esseltyne explained to me: “What you are seeing is the natural history of a disease that most likely reaches a crisis stage in our 60s. We found out during the autopsies on soldiers during the Korean War that atherosclerosis starts in young people. This was a revelation to the U.S. medical profession. Although it generally becomes clinically significant in our 40s and 50s, it has its roots in our youth. Indeed, we have since discovered atherosclerosis in infants during the Bogalusa study in the South.”
Dr. Esseltyne treats heart patients with an extremely strict diet and foregoes the more expensive and invasive treatments. I read his book and learned that he had some marvelous results with his approach. I asked him why his technique hadn’t been more widely adopted. He said, “You don’t get reimbursed for advising patients on diet.”
The second story is about a talk I was giving a couple of years ago in Salina, Kansas on behalf of Physicians for a National Health Program. The talk was sponsored by the League of Women Voters and we had a good turnout. Keen Umbrer, Libertarian candidate for governor in Kansas at that time. In making my case for the PNHP, Medicare for All proposal, I presented a set of slides prepared by Dr. Ed Weisbart and myself. We asked folks to hold their questions until after the talk. Immediately upon the end of my talk, Keen raised his hand and asked where the constitution states that government should provide health care.
I was thrilled to get the question. I had been eagerly anticipating the opportunity to take that one on because I have read the constitution and the relevant case law at issue. Keen was spouting what is a typical libertarian talking point, which all too often goes unchallenged. Indeed, famous libertarian John Mackie, founder of Whole Foods, has made the same comment in talking about the ACA – never mind that Whole Foods employees have a great health insurance program subsidized by the federal government. What I said to Keen was this: the constitution doesn’t say anything medical care but it doesn’t say anything about aircraft carriers either or nuclear waste compacts; nor does it say anything about subsidies for employer provided health insurance like that at Whole Foods.
THE CONSTITUTION DOESN’T GIVE US THE RIGHT TO HEALTH CARE, BUT IT GIVES CONGRESS THE RIGHT TO GIVE IT TO US.
What the constitution does say especially in the preamble and Article 1, Section 8, is that the federal government – the congress – has an obligation to, among other things, provide for the “common defense” and the “general welfare.” That is clear in the constitution and has been so stated in opinions by even the most conservative justices on the Supreme Court.
So why do we allow these people to make absurd claims about the constitution without serious pushback? These Ayn Rand acolytes are extremely misguided and destructive. They are misguided because even a conservative U.S. Supreme Court put an end to their distortions in the 1992 case of New York v. U.S. – the opinion was written by Sandra Day O’Connor and joined by all of the conservative court members, including Scalia and Thomas. Essentially, the court said that the U.S. Congress can do what is “necessary and proper” (Article 1, Section 8) to carry out its obligation to “promote the general welfare and other obligations,” and whatever they did in that regard is the supreme law of the land.
These libertarian arguments are destructive because the U.S. government could and should meet the health care needs of its residents (including undocumented residents). As the court said in New York v. U.S., the framers could not anticipate the type of issues and problems we faced in 1992 or with which we are confronted in 2016.
Corporations are now fully in control of our health care and most other areas of our lives. The Affordable Care Act was indeed a case of private industry dictating health care policy to our government. And let’s be clear, what we have is “corporate medicine.” That is far different than our peer governments in the world.
Until Medicare and Medicaid were legislated into existence in the 1960s, the American Medical Association opposed government provided, universal health care for any group, including the elderly. The AMA had the money and power to block Roosevelt from combining health care with Social Security. He knew that. So he didn’t attempt to include it the SS Act. Truman had a plan but couldn’t overcome AMA opposition.
In 1965, the AMA could no longer muster an anti-Medicare movement strong enough to overcome legislative will to do something about medical care for the elderly. However, hospitals and nursing homes could see the potential in large government expenditures. The AMA also had an epiphany and came to see the benefit for its members. Proprietary hospitals and nursing homes began to spring up around the country.
By the 1980s, innovative treatments and medical devices for heart disease and pharmaceuticals and treatments for cancer were blossoming and Wall Street was paying attention.
Beginning with the presidency of Ronald Reagan, an anti-government ideology was taking root and has grown into a potent force for dismantling not only New Deal and Great Society programs but also enlightened public health programs such as the Clean Water Act, the Occupational Safety and Health Act, and the Toxic Substances Control Act, signed into law by Richard Nixon in the early 1970s.
A right-wing, reactionary mantra of shrinking government was accompanied by a metaphor: “starve the beast.” Deregulation and budget cuts to programs for low income people – the undeserving poor – along with tax cuts for corporations and the upper income strata harmed public health efforts. Grover Norquist, the anti-tax guru on the extreme right, said he wanted to shrink government down to a size that he could “drag it into the bathroom and drown it in the toilet.”
No doubt government has been starved to a great extent. However, in starving the beast, the conservatives with the acquiescence of moderate and conservative politicians, helped create monsters. Money began to pour into politics like never before. Trade associations and their lobbyists along with powerful corporations in increasingly concentrated industries captured government. Public health has not been and is not now their mission.
The questions are: How can this happen? Why did we let it happen? It happened because of a reality that was created for us by organizations comprised of individuals who have a vested interest in creating false narratives. I am talking about extremely wealthy individuals, corporations, and their foundations, think tanks, political parties, and media outlets. I’ll be talking about these narratives – propaganda if you will – at a later point.
I want to bring these stories together and explain from the time of Eisenhower’s warning to now how our health care system came to be what it is. You may say that Eisenhower was speaking about the military industrial complex and ask, “what does that have to do with health care?” Eisenhower’s speech was particularly relevant because he was talking about the permanence and growth an industry the likes of which the country had never seen before: permanent armament manufacturers and a nexus between government, science, universities, and corporations dedicated to profit. He talked about a balance between what would be needed for the “common defense” and what a military-industrial complex would produce for the sake of profit.
What Eisenhower foresaw but didn’t mention specifically was the practically preternatural tendency of capitalist entities to commoditize anything and everything for the sake of expansion and profit. He foresaw the ability of the corporate elite to leverage all other major institution of society in their quest for return on investment. This tendency would, he thought, override the defense needs and undermine our democratic processes.
Let’s fast forward to 1980. Dr. Arnold Relman, a prominent physician and editor of the New England Journal of Medicine paid homage to Eisenhower by giving a speech in which he coined the term “MEDICAL-INDUSTRIAL COMPLEX.” He foresaw the same thing in the health care sector that Eisenhower saw in the so-called “defense sector:” massive hospital/nursing home corporations that were new phenomena in health care, increasing Wall Street interest in the potential for growth and profit. He did, however underestimate the pharmaceutical and medical device manufacturers by suggesting that they had always existed and would remain a rather insignificant factor in the growth of excess and inefficient medical delivery for the sake of profit rather than health.
In over a half century since Eisenhower’s speech and the nearly 40 years since Relman’s warning, the Military, Medical, Financial, Agricultural, media/entertainment and other industrial sectors are no longer relevant as individual entities. We now have an integrated “supra-industrial complex” that has integrated all of the other industrial complexes into one powerful behemoth and juggernaut with the purpose of capturing government, universities, science, and every other sphere of life in the United States. It is like one body with capital flowing through its veins as lifeblood.
The supra-industrial complex will leverage government and its own political, educational, scientific and entertainment creations to gain ever more control over the flow of capital, wealth, and income not only in the $19 trillion U.S. economy but in the entire $100 trillion global economy. They will do it, as they have in the recent past, through legislation, trade agreements, patents, propaganda, and by diminishing the structure of our democracy.
Here is the reality. The health care sector now spends FOUR times more on lobbying and political campaigns than the defense sector. Many of the same hedge funds, capital venture funds, corporations, and wealthy individuals investing in the defense industry have also moved to the medical care and biotechnology industry. The patent laws, trade laws, and anti-trust laws are increasingly stacked in their favor.
During the legislative battle over the ACA, somewhere around 4200 lobbyists – eight for every member of the U.S. Senate & House of Representatives – ascended on Capitol Hill. Indeed, the revolving door between congress and the executive branch and industry has resulted in a merger between our government and the supra-industrial complex. Senator Baucus, the driving force behind the ACA and head of the Senate Finance Committee at the time, had 35 staffers WHO HAD LEFT HIS COMMITTEE and moved to “K-Street lobbying firms.” They will made far better money there.
Consequently, a government sponsored and funded medical care delivery system will also deliver $2 trillion dollars to insurance companies over the next TEN YEARS, $80 billion to pharmaceutical companies, and an unknown amount to medical device manufacturers in the next 10 years. Much of the goods and services delivered by this system will be unaffordable to a large segment of those who qualify for it.
If capital is the lifeblood that keeps the supra-industrial complex going, the U.S. Chamber of Commerce is its nerve center. For instance, we now know that during the political negotiations about the ACA, trade association for the massive health insurance industry – AMERICAN HEALTH INSURANCE PLANS – had teamed up with the U.S. Chamber and set up an $80 million dollar fund, which would be employed to kill the whole to kill the whole deal if it didn’t suit the major insurers.
A small medical device manufacturers’ tax was included in the ACA. It was intended to be one means for funding it. This extremely profitable industry was asked to contribute to the improvement of health in America a little through a 2.5% tax on medical devices. What did they do? They put their massive lobbying arm to work and had the tax killed during the most recent budget session. Elizabeth Warren, the patron saint of the liberals, and Al Franken, another liberal hero, led the fight to have the tax eliminated. Why? In Massachusetts and Minnesota, the medical device industry is powerful and can see to it that they both Senator Franken and Senator Warren are defeated in the next election.
So the medical device manufacturers’ tax is gone. How did Medtronic, the giant medical device manufacturing firm located in Senator Franken’s home state of Minnesota express its appreciation for the untold $billions it has received from Medicare, Medicaid, and taxpayer subsidized private employers insurance? It promptly did what is called and “inversion.” That is, it merged with a minor company in Ireland, moved its headquarters there, and escaped U.S. taxes all together.
But the supra-industrial complex has only one goal: profitability. It doesn’t matter if it is in health care, defense, entertainment, finance, or any other industry. It is global in nature. General Electric is a major medical device manufacturer and so is the German conglomerate Siemens. Everyone knows that these two behemoths do far more than manufacture imaging devices and other equipment for the medical delivery systems across the world.
There is some collateral benefit generated by massive expenditures on biotechnology, research, access to medical care, and such facets of the medical-industrial complex. However, the price paid by the U.S. public is in taxes for excessive pricing of medical care, lack of adequate access to medical care for at least half of our population, and, maybe more importantly, threats to us a specie due to alteration of our genetics for profit.
We got here and stay here because of what I call false, misleading, irresponsible, and, indeed, damaging narratives. Here are the big ones that we need to begin to confront, fight against, and destroy: (1) Government is bad, the market is good, (2) The growing elderly population is a threat to our society, and (3) Poor people are the cause of their own plight and government help will only make matters worse for them.
The idea that government is bad and that responsibility for our health should be turned over to the market is bogus. As James Madison, one of the most influential founders of the constitution, said, “If men were angels, there would be no need for government,” and “what is government anyway but a reflection on human nature.” Nothing in the view of our founders should lead us to believe that the U.S. Constitution denigrates the role of government and that corporations should be glorified. Nothing! It is time for citizens to begin to read the constitution, case law pertaining to it, and the history surrounding it.
We need to stand up to the lavishly funded libertarians ensconced in the propaganda organs of billionaire funded entities such as the Koch funded Cato Institute and Rex Sinqufield’s Show Me Institute. They are spreading misinformation and a massive number of people will die because of it.
The narrative about our elderly population as a threat is nothing less than vicious. It has been promoted by billionaires on Wall Street, right-wing conservatives, and even so-called moderates in the Democratic Party. The term “silver tsunami” is a slur but has been heard in every media outlet from Fox to MSNBC, to NPR and PBS. I even found it to be acceptable in one of our so-called centers on bioethics. The narrative which promotes the idea that the elderly are too costly and sucking up too much of our government expenditures is also bogus. Most of what the elderly receive from the U.S. government is in the form of social insurance for which they have themselves paid – and have paid way too much when it comes to Medicare.
Here are the facts: Social Security is funded solely by the people who receive it. They pay a payroll tax into a trust fund which funds retirement benefits for those who have “earned them.” There are no general revenue funds, i.e. income tax dollars, going into the Social Security Trust Funds. The trust funds cannot borrow money in the form of debt issuance (bonds). If the money flowing in from current and future beneficiaries is not enough to meet obligations, then the payroll tax must be increased, or benefits must be reduced. Approximately, $100 is deducted from each Social Security benefit check to partially fund Medicare Part B (outpatient and physician payments).
According to the latest Medicare Trustees’ report, $678.7 billion was expended in 2016 for Medicare benefits. Over half, $359 billion, or 53% of this was entirely paid for by the elderly who received care under the program. They paid through a payroll tax during their working lives, premiums, copays, and coinsurance. That means that 47% came from general revenue. That 47% would not be necessary if corporations were not allowed to set prices that have nothing to do with the costs of manufacturing and/or delivering services.
Why is that important? It is important because the elderly are blamed for running up budget deficits and the national debt. Let me give you an example:
. Recently, the following misleading and false statements appeared in an “above the fold” NYT article regarding President Trump and his past promises to protect Social Security and Medicare:
On Capitol Hill, some Republicans are hoping Mr. Mulvaney[i] and others will change the president’s mind on far bigger targets and convince him that structural changes to Social Security, Medicare and Medicaid — the biggest drivers of deficits that are projected to rise over the next decade — are needed to control the national debt and to preserve the programs without substantial tax increases.
Social Security, Medicare and Medicaid consumed nearly $1.9 trillion of the government’s $3.9 trillion in spending in 2016, according to the Congressional Budget Office, and with the number of people 65 and over projected to rise by a third over the next decade, Social Security and Medicare spending is projected to increase from a third of all spending in 2017 to 42 percent by 2027. Including Medicaid and military and federal civilian retirement benefits, federal spending on older adults will rise from 37 percent of outlays in 2017 to 45 percent in 2027 if nothing is done to change the programs.[ii]
Journalists usually don’t understand that Social Security, Medicare, and Medicaid are vastly different programs in their legal and structural functions. That is also the case from a budgeting perspective. Lumping them together and declaring that they are all part and parcel of the U.S. budget – or the mythical unified budget – is an indication of a misunderstanding of federal budgeting.
Social Security is not included in the federal budget. The taxes and benefits are determined by legislation. It is a social insurance program for which no budgetary allocation are made. Medicare is also a social insurance program but it is vulnerable to excessive expenditures due to the power of the surpra-complex lobby.
Let’s take Japan versus the U.S. as an example of why the elderly are not the problem: The elderly (65+) population is currently about 15% of the total U.S. population and is expected to peak at 21% in the early 2020s and remain there in perpetuity. Currently the elderly comprise 26% of Japans population and is expected to grow to 36% of population in the next decade. Japan spends 1/3 of what the U.S. spends on health care. And yet everyone goes to the doctor in Japan: 4 times as often as people in the U.S. go. Every Japanese citizen has access to medical care. They are healthier and live longer than we do in the U.S.
The elderly in the U.S. are seen as a tsunami, a catastrophe. In Japan they are valued and respected. The silver tsunami narrative – not to mention the greedy geezer sub-narrative – serve as an excuse for claiming that we cannot afford to take care of younger populations. It is part of the propaganda employed to in the drive to funnel ever more wealth to a small elite.
The final narrative in this speech has to do with placing blame on the poor health for the deplorable health of our citizens: it is said that they are too fat, eat the wrong foods, smoke, drink, commit suicide, take drugs and have an unhealthy lifestyle in general. We hear from academics about obesity, smoking and drinking. But what is ignored is access (or lack thereof) to health care for treatment of disease in early stages – for everything from gum disease, to high blood pressure. We don’t hear about the relationship between stress, despair and hopelessness that comes with under and unemployment and mentally and physically unhealthy environments.
During the late 1990s, anti-government forces were able to convince the congress and president that it would be helpful to the poor to slash their welfare safety net and set them adrift to fend for themselves. The free-market gurus pushed the idea that trade agreements like NAFTA would improve the lot of lower wage workers.
What we ended up with were no or inadequate health care, suppression of wages, lack of adequate housing, poor nutrition, nonexistent child care for most poor parents, and blighted neighborhoods – none of which were conducive to raising the level of health care for the most vulnerable of our fellow Americans of all ages. Indeed, we have seen major deterioration in the health of the bottom half of the economic strata.
In conclusion, I want to connect some dots in this speech. Unrecognized atherosclerosis, environmental toxins, lack of access to preventative medical care, unhealthy food, and a whole host of other factors that could and should be addressed will lead to an incomprehensible amount of suffering and early death.
Nevertheless, for profit corporations and the network of government, university, and scientific entities as they are now constituted will be moving swiftly ahead with extremely costly cures. Only our government – at the national level – can address these health care system issues. Government can, does, and has done a tremendous amount of good on our behalf. However, the supra-industrial complex is preventing this from happening by finding scapegoats such as the elderly; by blaming victims; and by denigrating government.
Without expanding single payer health care to all U.S. residents – poor and rich alike – untreated patients will enter the Medicare system with advanced diseases that will shorten their lives and impact the overall costs of the program. The robust movement to reduce Medicare benefits will be strengthened.
Some daunting bioethical issues will need to be resolved. For instance, what age are we going to say is beyond the limit for organ transplants? Even if another specie can supply the organs, the costs will be astronomical. In the recent past, a group of distinguished bioethicists such as Daniel Callahan, Norman Daniels, and Zeke Emmanuel are proposing that medical care be rationed to the elderly.
Unfortunately, a serious focus on health care is not possible in the cacophony that is considered political discussion on television, Facebook, and Twitter. Hence, we will need to use other media for reaching people affected by the lack of government policy and help them see what is happening.