Summary: Friends around the world watch in disbelief as the US is mired in democratic crisis, hoping we re-normalize soon. The frailties of our political system are on display, challenging its core strengths. This battle is paralleled in the health system, with similar dynamics and perhaps linked futures.
Comment:
By Jim Kahn, M.D., M.P.H.
A European colleague texted me, in response to the news about Roe v. Wade and the divisive implosion of our politics: “I so don’t get your country. Nor do I understand my constant curiosity about it. It’s like watching a video of a car crash – you can’t look away but you cringe throughout!”
I think I know why: the US embodies the best and worst of political systems. This fraught duality is echoed in our health system. Indeed, health reform has the potential to mitigate our political ills.
Here’s my theory:
The best: The US is a beacon of modern democracy – the first (late 18th century), and the global defender (most notably World War II, and most recently in Ukraine). The US has no other fundamental societal identity – it is comprised almost entirely of immigrants to a land of freedom and opportunity. Meantime global democratic forces are weakening (India, China, Russia, Turkey, Hungary, Brazil, Myanmar, Nicaragua, etc), so the US as the last large democracy takes on special meaning. Observers from around the globe root for the continued success of our inspiring democratic example.
Yet: The US is guilty of horrendous systematic oppression of people of color through centuries of enslavement, marginalization, and in recent decades mass incarceration. Women have been subjugated and objectified, by law and culture. Despite formal separation, religious values influence state rhetoric and laws. Beyond our borders, the US has an inexcusable history of abusing its vast global reach. Many of us are deeply embarrassed by these flaws; reversing them is an ongoing struggle.
US history is a cycling battle between two fundamental values: Liberty (free of government control, especially national) vs. Community (government protecting the vulnerable). Since “Community” typically entails spending for the middle and lower classes, “Liberty” is often motivated by protection of wealth. Post-Great Depression and -WWII, “Community” triumphed, with FDR’s New Deal and LBJ’s Great Society, known as the “post-war liberal consensus”. But in 1980 Reagan started decades of deconstruction of social programs and lowering of taxes. Now “Liberty” is ascendent, as in the 1920s and 1850s. Enabling this, our “democracy” is procedurally flawed via the over-representation of small states, such that a minority can wield control. Historic wealth inequality reinforces the “Liberty” trend.
The looming reversal of Roe v. Wade reflects this ascendancy. As previously discussed in HJM, the current conservative Supreme Court reflects how aggressively, undemocratically, and even fraudulently the controlling minority succeeded in creating a court to do its bidding. The vast majority of US adults support retaining a 50-year-old decision protecting the right for women to choose abortion. It doesn’t matter: the packed court represents the minority in power.
Likewise, the dysfunction of our health system – with extravagant costs and excess deaths – represents this ascendancy of a minority. It reflects how aggressively, undemocratically, and even fraudulently the controlling minority – corporate health insurers, providers, and drug manufacturers – succeeded in creating federal legislators and bureaucracy to do its bidding. The vast majority of US adults support having the federal government pay for health care (as long as new taxes are offset by savings in premiums and out-of-pocket costs). It doesn’t matter: the packed federal decision-makers represent the corporate shareholders.
See the parallel?
The US sticks out like a sore thumb on health care. All other wealthy nations and many developing ones implement the principles of solidarity and human rights in health. A universal right to health has been uncontroversial. American exceptionalism in this context is especially mystifying and embarrassing.
There are more similarities: Just like our democracy has core strengths and appalling weaknesses, so does our health system. We excel on research and specialty medical care, but fall far short on financing methods, access, and primary care. We don’t vacillate between competing financing models, instead we combine them in an unwieldy mix that shifts over time.
An appealing link is in the solution: Reforming health care would lay the groundwork for a much-needed political calming and normalization. Single payer is the perfect cross-political policy. The progressives get the “community” they want – caring & equity. The conservatives get the “liberty” they want – shed the morass of divergent public and private insurer requirements we currently endure in favor of a simpler and less burdensome payment system. Estimated daily savings in electronic health record time for doctors: 1-2 hours. Free choice of providers. Straight up competition for patients, based on quality of service. I recognize that selling single payer to conservatives is a heavy lift, because the dreaded government will pay. But dozens of countries demonstrate that for providers and patients, it is loved and taken for granted, even with conservative governments.
Will real health reform treat our democratic malaise? Sharing the joys of universal health care access, with a renewed focus on clinical care instead of financial issues, while controlling costs through stripping away of administrative hassles and corporate profits – that’s bound to lower our democratic hypertension.
It won’t be easy. It’s the change struggle to end our democratic struggle.
To my colleague, I say: “It does look like a car crash, but maybe we’ll regain control just in time.”
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