Toward a Just Healthcare System in the United States: The Problem of Cost

 How Has Capitalism Run Amuck in Healthcare?

The shooting of Brian Thompson has focused our country’s attention yet again on the injustices of our healthcare system.  We are seeing a revival of proposals for Medicare for All as a way to provide a more just healthcare system, but if we are going to do that, we are going to have to find a way to control the high cost of healthcare in the United States. Otherwise, Medicare for All will break us financially.

The high cost of healthcare in our country is an example of what last week’s post called “capitalism run amuck,” but that statement is too general to be useful as a guide for action. In order to fix our healthcare system, we will need something much more specific. How has capitalism run amuck in healthcare, and what can we do about it? Several years ago, I wrote a blog post on this topic, and rather than repeat what I wrote then, I refer you to “Why Does Healthcare Cost So Much in the United States?” Here is another view.

These sources deal with systemic problems, not with instances - like that reported in today's New York Times - where greed induces companies to act in ways that are obviously immoral. Greed and immoral behavior have existed throughout human history. They are not unique to capitalism, and we should not focus on them as the causes of our healthcare system's problems. Instead, we should focus on structural features of our system that cause it to be expensive and unjust even when everyone acts in good faith. My blog post referred to above lists a number of such features in our healthcare system.

Thinking About Solutions

How can we solve the problem of the ever-increasing cost of healthcare? How can we create a system that provides care for all of us at a cost we can afford to pay?  I will not attempt to offer a detailed prescription for a solution, although a modified and improved Medicare for All could provide one answer to the question. However, I can suggest some principles that can form the basis of a solution.

First, we must accept the need for non-market methods to control costs. That is, we cannot rely on market competition to control costs in our healthcare system. We will not be able to provide care for all citizens without using non-market methods to control costs. Every country with a successful system of universal healthcare has had to use non-market methods for controlling costs, and there is no reason to believe that we can be an exception. 

Medicare's cost control mechanism is very imperfect. Medicare can set the price it will pay for any specific service, but its fee-for-service model offers no protection against the proliferation of unnecessary services or against the continual invention of new "services." 

Second, our system must encourage hospitals and doctors to strive for high quality care rather than for maximum revenue and market share.  Some incentives of this kind are already included in the Affordable Care Act. For example, a hospital may be penalized if it has too high a readmission rate. However, much more will need to be done.

Third, we need a system that encourages people to make good use of primary care. Good primary care reduces the need for emergency care and for hospitalization, which are the most expensive parts of our healthcare system.  Some encouragement for people to use primary care is already included in the Affordable Care Act. For example, the act requires that certain kinds of screening tests – like colonoscopies - be offered free to patients.  We might also reduce costs by requiring primary care physicians to act as gatekeepers to the rest of the healthcare system as is done today in the United Kingdom.

Fourth, we need a system that encourages people to live in ways that promote health.  Much of the cost of healthcare in the United States is due to the cost of caring for people with chronic conditions like diabetes or obesity, and the frequency of such conditions can be reduced by encouraging people to adopt healthy lifestyles.  Ways to do this are not hard to find. For example, Medicare could pay for membership at a gym on the theory that regular exercise will make people less likely to need expensive medical care.

Finally, the system must provide patients and doctors with accurate information about prices in order to enable them to make decisions based on costs. Often, a medical condition may be treated effectively in various ways that have widely differing costs. 

If we can find ways to control the cost of healthcare, we will be able to provide healthcare for all of our people. As we work toward that goal, we must not forget that our resources are not infinite. Other countries have found ways to control costs, and we can do it, too.

What is the Issue?

Two Recent Events 

A month ago, Donald Trump was elected to be the next president of the United States, and a few days ago, Brian Thompson, the CEO of United Healthcare was shot to death. The two events do not appear to be related, but they are symptoms of the parlous state of American Democracy. Mr. Thompson’s killer has been seen on social media as a kind of folk hero, and the shooting as a legitimate protest against the inhumanity of health insurance companies. Mr. Trump ran for president successfully as a kind of voice of the common people against an oppressive elite. Thus, both events are symptoms of a political and economic system that millions of Americans feel is rigged against them, and they are not wrong.

A Rigged System

We live in a system in which an outlandish share of the wealth and the income is held by a tiny minority of wealthy people. In one of the world’s richest countries, millions of hardworking people struggle to pay their rent or feed their children. We live in a country with some of the most advanced medical care in the world but where unexpected illness is the number one cause of personal bankruptcy. The injustice of our system is plainly visible to everyone, and deaths of despair have become ever more frequent in recent years.

Capitalism and Democracy

In his book, The Crisis of Democratic Capitalism, Martin Wolf argues that liberal, representative democracy and market capitalism depend on each other but that their mutually supportive relationship is fragile. It depends in each country on a tacit bargain that capitalism will deliver an acceptable level of living to all of the country’s citizens. Otherwise, they will see that the system is rigged against them, and they may turn to authoritarian, anti-democratic leaders who promise to remedy their distress. Thus, a capitalist system that fails to live up to the tacit bargain that makes it compatible with democracy will inevitably render that democracy unstable. That is the situation in which we find ourselves today.

Wolf suggests that the elements of an acceptable level of living include:

• Prosperity
• Opportunity
• Security
• Dignity

Our system produces a high level of national prosperity, but it falls short on the other three elements for millions of our people, and so, unsurprisingly, the system has become unstable.

The Propaganda of the Deed

This is not to say that either the election of Trump or the shooting of Thompson is a rational, response to the injustices of our society. It has always been clear that Trump’s “populism” is fake, and his recent cabinet appointments have made the fakery even clearer. Similarly, the shooting of Thompson will probably not have much affect on our health insurance system. The shooting of Thompson looks very much like “the propaganda of the deed” of the anarchists of the late 19^th and early 20^th century. It is an act of political desperation by a person who believes that all of the usual approaches to political change are blocked.

The election of Trump is the fruit of a political culture in which lying by our politicians and our government have eroded our sense of truth and morality. Today, many people believe that no politicians or institutions of government are trustworthy. Trump does not lie more than the rest, but at least his lies seem sympathetic to millions of voters. We need change - they believe - and that is what he promises. So, why not take a chance? If our system is rigged against people like us, maybe we should tear it down and try something else.

That is exactly the situation that Wolf describes in his book. Capitalism run amuck has broken the bargain that says that it must produce a decent standard of living for all of the people, and so, it has become incompatible with representative democracy. If we want to preserve our democracy, we will have to rein in our capitalism. 

We Must Frame the Issues in Economic and Sociological Terms

If we want to rein in our capitalism, we will have to think about the issues involved in economic and social-structural terms rather than psychological ones. We cannot deal with issues of this scale in terms of the psychologies of specific persons. The question to be answered is not why particular individuals voted for Trump or what specifically drove Luigi Mangione to shoot Brian Thompson. The question is what is it about our society and our economy that causes millions of people to vote for a man like Trump and that drives a young man to risk his life in an act of propaganda of the deed?

The Fight to Maintain the Constitutional Power of the Senate

A New Issue to Split the Republican Party 

Not long ago, I published a post in which I argued that theissue of the deportation of undocumented immigrants would cause a split in the Republican Party. Sunday’s NY Times included an article that described yet another issue that may split the party. The issue is the power and independence of the Senate. Trump wants the Senate to rubber-stamp his cabinet appointments without exercising the body’s constitutional power to “advise and consent.” This is one of the Senate’s most important powers, and senators who care about the Senate as an institution will work to preserve its power. They will work to make sure that the Senate does a thorough job of vetting Trump’s cabinet appointments.  Those senators have considerable power as we saw when Matt Gaetz withdrew his name from consideration when it became clear that the Senate would not approve him without a fight.

Support the Institutional Power of the Senate

The fight to maintain the power of the Senate is not unrelated to the fight against mass deportations because Trump has chosen people who are committed to his policy of mass deportations, and he wants the Senate to rubber-stamp them. In this situation, we can resist mass deportations by encouraging our senators to support the institutional independence of the Senate, and we can also resist deportations by working locally to build support for the senators who want to preserve the power of the Senate to advise and consent. We can begin by contacting our senators to encourage them to support and fight for the independence of the Senate, and we can work locally to encourage others to do the same.

Oppose Mass Deportation Directly

We can also work locally to encourage local leaders and others to contact their congressional representatives to express opposition to mass deportation. The opposition may be based on humanitarian concerns, but it may also be based on a purely economic argument. Mass deportation will cause many local businesses to lose their work forces or their customers, and that will damage the communities where the businesses are located. The cost of the deportations will be paid using taxes paid by the residents of the communities that are damaged. Why should we allow our government to use our tax money to damage our communities?

So, if you believe in preserving the constitutionally mandated power of the Senate to review a president’s appointments, you should contact your Senators to let them know that you support them in their fight. You should also encourage your friends and neighbors to do the same thing. In the meantime, we can all work to spread understanding of the harm that mass deportations will do to our communities.

We Are Blind to Class Oppression

A Blind Spot 

An article that appeared in the NY Times on December 18 shows a lack of awareness of issues of class that many of us share. The author of the article is a high school junior, and she bemoans the fact that the day after the election, her female friends were crying while the boys were playing Minecraft. She tells us that she and her friends are scared of the dangers that women will face in a country where Trump has been elected. She says,

I am scared that the Trump administration will take away or restrict birth control and Plan B — the same way they did abortion. I am scared that the boys I know will see in a triumphant, boastful Mr. Trump the epitome of a manly man and model themselves after him. I was 8 years old the first time he was elected. Now I am 16. I am still unable to vote, but I am so much more aware of what I have to lose.

Her fear is understandable and realistic, but she – like many Democrats - misses the fact that, if she continues her education, she will probably be ok under Trump because she will be on the upper side of our education-based class system. Like other well-to-do women, she will be able to obtain an abortion if she needs one because she will be able to travel to a place where abortions are legal. The suffering that Trump creates will be borne by working-class women and their families.

The Oppression of Working-Class Women

Working class women are some of the most oppressed people in our society, but the author does not see that. She is so concerned about gender as such that she does not notice that women are not all equally oppressed. All women suffer from gender-based oppression, but working-class women also suffer from class-based oppression. In an earlier post on this blog, I said,

… Fani Willis, the district attorney of Fulton County in Georgia, is a … woman, and as such she has surely encountered obstacles in her career. Her movement up the career ladder has undoubtedly been slowed by men’s resistance to promoting women. As an attorney, she has had to overcome the common tendency to take women … less seriously than … men. Like all professional women, she has had to put up with the sexual harassment that pervades women’s professional lives. Very likely, she earns less than a man in a similar position

On the other hand, she does not have to worry about being evicted from her house because she cannot pay the rent. She does not have to see her children get sick because she cannot afford routine, preventive care for them. She does not live in a “food desert.” Millions of … women suffer in these ways, but she does not because she belongs to the patrimonial middle class.

A Shared Blind Spot

Many of us share the author’s blindness to class oppression, and our failure to see class differences has had important political consequences for the Democratic Party as we saw in the recent elections. We have framed issues in ways that defined white men as the oppressors and defined women and people of color as the oppressed. We have ignored the fact that while our country is run by a small group composed mostly of white men, most white men do not belong to that small group. Most white men are also among the oppressed. They may be less oppressed than working-class women or people of color, but focusing on that difference only serves the interest of the real oppressors. 

Moreover, the ruling group is not exclusively male. It includes some women. Betsey DeVos, Pam Bondi, and Amy Coney Barrett are real people, and so are Karen Lynch and Mary Barra. They are part of our ruling class, and they represent its interests. To put it bluntly, the people who work on the assembly line at GM's DHAM plant are not in a position to oppress Mary Barra.

Our Blindness Has Consequences

Our blindness to issues of class has cost us votes among working-class members of racial minorities as well. Working-class Latinos and Blacks have voted in large numbers for a president who openly disparages minorities. They have done so because they hope that he will be better than Biden at managing the economy. They worry about putting food on the table much more than about saving democracy, and we must recognize the legitimacy of their concerns if we want to regain their votes.

If we want to regain the votes of working-class people of all races, we will have to learn to frame our issues in ways that do not ignore class oppression.

Local Framing of Economic Issues

Framing Big Issues in Local Terms

Last week’s post talked about the coming split in the Republican Party over two big, economic issues: tariffs and the deportation of undocumented immigrants. The post said that the split will create opportunities for Democrats, and in this post, I want to suggest ways to take advantage of those opportunities by framing issues in ways that will appeal to conservative, rural and small-town voters. The specific framing will depend on the conditions and ways of thinking in each community. People in a community have specific, local concerns and specific ways of expressing them, and effective framing should refer to the local concerns and make use to the local ways of expressing them. However, there are some general principles.

How Tariffs Can Harm a Community

First, effective framing of economic issues is not about social justice. It is about self-interest. So, if we are talking about tariffs, the focus should be on the harm that they are likely to do to a local community and its businesses. That means that in order to create effective framing, we will need to learn a lot about the communities that we want to affect.

Does a community produce agricultural or industrial products for export? If so, what are those products, and what countries are they exported to? What other countries produce the same products and  compete for the same markets? How might the community’s exports be hurt if the countries that are customers were to impose tariffs on the community’s exports? If the community’s businesses were hurt, how would that affect other aspects of its economy? How would it affect its tax base?

How Deporting Immigrants Can Harm a Community

If we are talking about the deportation of undocumented immigrants, we should also talk about the harm that losing them would do to a local community. Who are the community’s employers? Do they hire immigrants? What would happen to the employers if they lost those employees? Could the employers' businesses survive? Could they pay wages high enough to attract other employees? What about other community businesses? Are the immigrants customers of local businesses like grocery stores? If they left, what would happen to those businesses? What about the local housing market? How would the loss of immigrant residents affect the owners of rental properties? What would happen to the value of those properties?

What about the school system? Does it have many students who are immigrants or children of immigrants? If those students had to leave, how would that affect the budget of the local school district? Would the district lose some of the state aid it receives?  What about the local tax base? The immigrants pay sales taxes. How would the loss of that revenue affect the community’s budget?

We Need to Do Our Homework

These are some of the questions that can be asked. The answers should be framed in local terms. They should refer local businesses that might be hurt or to local public projects that might have to be canceled. Finding the answers will entail local research, but we do not have to start from scratch. Local people with interests at stake will be good sources of information. So, we have to go back with new questions to the people we have talked to.

The Coming Crisis of the Republican Party: An Opportunity For Democrats

Republicans Face the Prospect of Enacting the Things that Trump Promised

Now that Trump has been elected, Republicans are going to have to face the reality of his policies, and the result may well destroy their party.  Even if the party survives, the divisions within it will create opportunities for Democrats. 

The coming division within the Republican Party is rooted in the fact that the party is an uneasy coalition between the traditional, business Republicans and Trump’s radical rightists. The business Republicans fund the party, and the radical rightists provide millions of votes. The alliance has worked reasonably well because the business Republicans have controlled the party’s real, policy agenda, while Trump’s radical rightist agenda provided electoral propaganda. When elements of the radical rightist agenda have actually been implemented, the political results have not been so great for the Republicans.

The Abortion Issue: a Preview

Look, for example, at the abortion issue. As long as Roe v. Wade was in force, the issue worked well for the Republicans, but then Trump fulfilled his promise to appoint judges who would overturn Roe v. Wade, and they did overturn it. The result was to activate millions of women in support of their right to choose whether or not to have abortions. In 2022, the Republicans lost congressional elections, and yesterday, several states where Trump won enacted laws to protect a woman’s right to choose. Republicans split over the issue, but the party did not break up because the business Republicans don't care about the abortion issue. Companies can make money whether or not a woman’s right to choose is protected. 

This Time is Different: Tariffs

This time, Trump campaigned on issues that the business Republicans care about deeply, especially in the deeply Republican states of the Midwest and the Great Plains. One of those issues is tariffs. Trump promised to enact high tariffs on imported products. If he enacts the tariffs, the countries that lose exports to the United States will surely retaliate by putting tariffs on American goods including agricultural products. 

Farmers in places like Iowa, Missouri, Texas or South Dakota know that, and they will not want to lose the profits that come from the export trade, which accounts for about 20% of American agricultural production. So, the farmers along with big, agricultural companies like Cargill or Archer Daniels Midland will oppose the tariffs, and the result will be a deep split in the Republican Party. The tariffs may never be enacted because of Republican opposition. If they are enacted, they will damage the economies of many, Republican states and perhaps drive some big financial supporters of the Republican Party out of business. Whether or not the tariffs are enacted, the Republican Party will be split.

This Time is Different: Deporting Immigrants

The idea of deporting undocumented immigrants will be similarly controversial within the Republican Party. Grocery stores, restaurants, gas stations and automobile dealers in communities that supported Trump will not want to lose a large share of their customers. Dairy farms, slaughterhouses, factories, hotels and construction companies will not want to lose a large part of their work force. (In my state of Wisconsin, most of the large dairy farms would go out of business without their undocumented workers.)

So, a policy of deporting millions of undocumented people will be strongly opposed by influential Republicans in Republican states. If Trump tries to implement the policy (and many think that he will), the party will lose the support of many of its important financial backers. If he does not try to implement the policy, the party will lose the support of an important part of its base. Either way, there will be a crisis in the Republican Party. Meanwhile, Liz Cheney and her allies will be waiting in the wings to take advantage of the crisis when it comes. They will push to take back control of the party, and we will see the effects of their effort in the election of 2026.

Opportunities for Democrats

The split in the Republican Party will create opportunities for Democrats, and local party leaders will be best able to see what they are. However, to take advantage of them, we Democrats will have to think carefully about how we frame the issues, and I will talk more about that in next week's post.

Immigration and Social Justice

Immigration Raises Issues of Social Justice

In a post two weeks ago, I said that a loyal American must favor immigration because it has been and continues to be the basis of our national wealth and power.  Having said that, I think that we must recognize that using immigrants to grow our economy also creates significant social injustice. Immigration has costs, and they are born mainly by working-class people including both the immigrants themselves and native-born, working-class Americans, especially those with less than high-school educations who compete directly with immigrants for jobs. 

The Social Injustices of Immigration Are Important Politically

The social injustices brought about by immigration are important politically as well as morally. The Democratic Party has lost many working-class votes because the party has failed to take working-class concerns about immigration seriously. The MAGA wing of the Republican Party has attracted working-class votes by claiming to be the voice of "real Americans." Immigration is one of the areas where the Democratic Party is most vulnerable. Instead of admitting that immigration can harm some Americans, we have branded people who are anti-immigration as racists. We should not be surprised to learn that we have not attracted many votes that way.

If we are to promote immigration because it is good for our country as a whole, we will have to frame it in a way that recognizes that, while it is good for the country as a whole, it is not always good for everyone. Some people may be harmed by immigration, and we must mitigate that harm. We must also recognize the potential for harm in our framing of the issue of immigration. The framing must address potential harm to two groups of people: immigrants and native-born Americans.

Social Justice for Immigrants

If we are going to rely on immigrants for the growth of our economy, we must include in our framing a path to citizenship for them. Our economy’s need for immigrant workers has attracted a far larger number of people than our legal system can handle. The result is that we now have more than ten million undocumented immigrants living in our country. Some Republican politicians talk loudly about deporting them, but we all know that is unlikely because our economy depends on them. In my home state of Wisconsin, the large dairy farmers who are among the Republican party’s important supporters would go out of business without their undocumented workers.

However, the undocumented status of the workers makes them vulnerable to exploitation by employers. They are paid low wages, and they work under very unsafe conditions. They are afraid to complain because they are afraid of being deported. They are unable to get drivers’ licenses, but in our automobile-dependent society, they must still drive. So, they are vulnerable to harassment by local police.

Some people say that immigrants should enter the United States only in legal ways, but it must be obvious to everyone that our legal system cannot support the level of immigration that our economy demands. Some people ask why the immigrants cannot come in legally as our grandparents and great-grandparents did. The answer is that at the time of the wave of immigration in the early twentieth century, we did not have laws restricting the number of immigrants. Anyone who came was accepted legally. At Ellis Island and other places, the immigrants were sometimes rejected because they carried communicable diseases like tuberculosis but never for lack of proper visas.

It is wrong for us to build an economy on the backs of immigrants while not giving them the right to live in our country and to be treated as native-born workers are treated. It is unjust, and it is un-American. It is un-American because inconsistent with the belief that we are all created equal. We must reform our immigration laws to be consistent with social justice and with our economy's demand for labor, and in addition, we must include a path to citizenship in our framing of the issue. 

Social Justice for Native-Born Workers

While immigration benefits our country as a whole, it has a cost which is born by native-born workers who suffer from competition with immigrants who are willing to work for low wages under unsafe conditions. Workers without high school diplomas are especially vulnerable. The availability of immigrant workers keeps wages low for native-born workers who must compete with the immigrants. The fact that immigrant workers are vulnerable to exploitation weakens the bargaining power of unions and makes jobs unsafe for all workers. Reforms to our immigration system to legalize the status of undocumented workers will help all workers by taking away employers’ opportunities to hire workers who will work for less than native-born workers. In our framing of the issue of immigration, we must talk about preventing native-born workers from suffering.

In addition, we must make sure that our native-born workers are not left behind. To do that, we must provide opportunities for unemployed and underemployed workers to retrain. This means that we should provide free or very cheap post-secondary education and that we should pay generous unemployment benefits and childcare benefits to workers who take advantage of opportunities to retrain. We have a precedent for this in the GI Bill. After WWII, returning veterans were able to obtain education and training at almost no cost, and that contributed to their ability to rise economically during the post-war economic boom. Inequality declined during that period, which saw the height of the American Dream.

Providing free or very cheap post-secondary education also means increasing the tax-support for it. Over the last fifty years, we have shifted the cost of post-secondary education from the taxpayers to the students, and the effect has been to increase inequality because working-class people must take on crippling levels of debt to obtain post-secondary education. This was not always true. In the nineteen fifties, post-secondary education was extremely cheap for the students as I can attest. I attended the University of California from 1958 to 1962, and at that time, the tuition was free, and the fees were $140 per semester. Our framing of the immigration issue must stress the connection between growing our economy on the one hand and providing opportunities for our people on the other.

Social Justice in the Framing of the Immigration Issue

If our framing of the immigration issue is to be effective in appealing to working-class voters, we should stress the idea that immigration is one part of an effort to make our economy work for all Americans. Economic growth can enable us to fund the initiatives to make our country more just. We should stress our commitment to increasing opportunities for all Americans, and we should link our ability to do that to our ability to grow our economy.