He came as a penniless youth of fifteen from Syria, put himself through college and Washington University (St. Louis) medical school and settled in Elk City, Oklahoma. In 1929, Dr. Michael Shadid opened the first cooperatively owned hospital in America, which served the impoverished farmers and their families. Dr. Shadid pioneered prepaid group medicine and, against the ferocious opposition of medical societies, spread the doctrine of cooperative medicine allover the United States and Canada. Twenty-five hundred farmers owned their own hospital in Elk City providing medical and health care, both preventative and curative. Their prepayment was a fraction of what they would pay under the usual fee- for-service medicine. Following this inspired, politically astute physician came the prepaid group practice of medicine at Puget Sound and Kaiser Permanente on the West Coast. Imagine controlling your own health care! Fee-for-service held on for most of the century until, in the 1970s, the federal government started promoting Health Maintenance Organizations (HMOs) on a large scale.
The dream began turning into a nightmare as smaller nonprofit HMOs were replaced by ever-larger for-profit HMOs, hospital chains, and the perennial health insurance company giants. Today, our country is under the yoke of corporate medicine dominating the Washington landscape. It ties the hands and judgment of physicians and nurses, secures and often defrauds the government of huge amounts of taxpayer dollars and, in contrast to nonprofits, delivers poorer, more rationed, more expensive, less accessible, choiceless health care. Obscenely compensated executives contrive to undermine Medicare with your own tax dollars. The picture is not pretty and costs are spinning out of control. A Dartmouth study estimates that almost a third of the health care sub-economy of $1.6 trillion this year goes to either duplicate or useless care or makes matters worse!
You've probably read, or viewed on television, the many exposes of this industry, its denial of care, its overbilling, its rip-off of Uncle Sam, its large monetary settlements with the Justice Department. The benefits go mostly to the CEOs worth hundreds of millions of dollars each, according to the data provided by the California Nurses Association. HMO overhead and profits as a percent of premium ranged from 14 percent for Pacificare to 33 percent for Cigna in 1999. With big money, ruthless organization, and lobbying, they prevail over superior non-profit health care services that are nonprofit. The latter do not have organized consumer-patient groups to seek and bargain for the best arrangements. Instead, large employer groups, which could be more aggressive and in some recent instances have asserted themselves, routinely deliver groups of employees to these HMOs that have managed through mergers to reduce the level of competition in geographical areas.
One third of all Americans are either uninsured or underinsured. This is the case despite our country spending much more money per capita on health care as does Canada, France, Switzerland, and Sweden, whose universal systems cover everybody in their countries and produce better health outcomes. We're paying as taxpayers, workers, and consumers and still tens of millions of people have no health insurance. That number has been increasing year after year.
The unwritten rule beneath the monetized minds of the HMOs, for-profit hospitals, and the drug companies is "Pay or Die." And die the poor do. The Institute of Medicine of the National Academies estimates that about 18,000 Americans die every year because they cannot afford to pay for diagnosis, treatment, or cures. That is 1,500 people a month! What about the preventable sickness, the pain, the family disruption? Add to this human toll the medical malpractice, the medical mistakes, the over-prescription of drugs and their adverse effects, the assembly-line pace of pressured physicians and understaffed nurses, the drug company bribes and kickbacks to many physicians, and it spells mayhem -- a silent form of preventable violence, far greater than many more publicized trauma and disease totals in other sectors.
Years ago, I suggested to a group of psychologists that they expand their research into the mental health or outright insanity of organizations, both corporate and government. They could find fertile ground studying the drug companies for kleptomania, General Motors for endless resistance to being toilet-trained out of its gaseous emissions, the HMOs for attention-deficit disorder. They laughed, but I was serious. Were humans to behave this way, they would be viewed as manifestly deviant.
Jamie Court, whose book Making a Killing: HMOs and the Threat to Your Health, was not just about data, and the aggregate statistics. He documented the travails of many real people -- the consequences of profiteering run amuck. There was five-month-old Chad Aitken who was given vaccine shots that caused a reaction. When his mother called their HMO for assistance, she was told, incorrectly, that her insurance had lapsed and was refused care. Chad died. David Goodrich was diagnosed with stomach cancer but was unable to get HMO approval for recommended treatment. He finally started therapy with his physicians anyway. By then it was too late. He died leaving his wife Teresa, a kindergarten teacher, with $750,000 in medical bills. No wonder nearly half of all personal bankruptcies in this country involve illness or medical debts.
Suffering the Consequences
One of Jamie Court's many poignant cases comes. from the Olsen family. Two-year-old Steven Olsen fell on a twig that punctured his cheek and sinus. A few days later, he developed a fever and his parents took him twice to the urgent care physician. They were told not to be concerned. Steven was lethargic. On the third visit, the little boy was admitted to the HMO-approved hospital where Mrs. Kathy Olsen asked the medical staff to do a CT scan. Since the hospital's contract with the HMO specified that money spent on patients like Steven come out of hospital funds or the monthly per-patient fee paid them from their HMO, there was a tendency to ration care. They told the Olsens that a scan was unnecessary. Three days later, Steven fell into a coma due to a brain abscess that could have been detected easily by a scan. Steven became blind and has cerebral palsy. He and his parents face a lifetime of expensive tests and treatments along with around-the-clock care, pain, anguish, and immense costs.
When I met Steven and his parents -- who were waiting to see their Senator Diane Feinstein (D-California) but had to settle for a staffer -- I recalled that HMOs were originally promoted as being keen on prevention. Maybe that belief was premised on a nonprofit HMO. Perverse incentives and awful consequences come from the rampant profit motives of today's commercial HMOs. These HMOs rake off tens of billions of dollars from consumers and taxpayers, yet deliver no health care themselves. These corporations just regulate more and more doctors and nurses and pay for more and more politicians to let them continue their harmful practices. They are indeed a profitable bureaucracy piling up expenses, restricting medical judgments and corporatizing the practice of medicine, just as if their profits are the first and foremost priority. While the American Medical Association was living in the past by rejecting a universal health insurance system, they discovered that in the 1990s more and more of their members fell into a spider's web of private corporate government -- HMO style -- and lost their professional independence. In reaction, thousands of interns, residents, and other physicians, to defend themselves, are doing the formerly unthinkable -- organizing or joining unions.
Physicians are moving toward support of a single-payer, universally accessible and affordable health care system. Polls show the public is already there, even with the massive daily propaganda by the corporations to slander the concept, which is really only a fuller version of Medicare with built-in protections from commercial looting. A very recent survey of physicians in Massachusetts shows about two-thirds favor a single-payer system that preserves choice of doctor and hospital, unlike the current HMO restrictiveness.
Over eleven thousand doctors have already signed on to the Physicians for a National Health Program (NHP) which was drafted by a broad panel of experienced practitioners and professors of medicine. In their book Bleeding the Patient -- The Consequences of Corporate Health Care, describing both the necessity and the practicality of the NHP, Drs. David Himmelstein, Steffie Woolhandler, and Ida Hellander write,
Non-profit national health insurance can expand coverage, improve care, and limit costs by slashing health care bureaucracy and outrageous profits. Our resources for care -- hospitals, clinics, high-tech machinery -- are already plentiful, your personnel ready and willing and our current spending levels are sufficient.... Overall, the average American would pay no more for health care under the NHP than they do at present.
The difference is that the coverage would be universal, comprehensive and without co- payments, deductibles, and the other maddening fine print of exclusions and denial of remedies for the patients. Health outcomes would be better also, as the authors demonstrate: "The experience of many nations -- that spend less and get more health care -- proves that national health insurance works." These are nations where workers are paid as much or more than in the United States -- as in Sweden, Switzerland, and Germany.
Only in America
Visitors from these and other countries like France, Italy, and Holland can scarcely believe how American workers (who work longer hours than they do) have to endure what they in their countries take for granted.
In the world's richest country, three-quarters of the millions of uninsured are children or working adults. Long-term health care is not available to their elderly relatives unless they pay directly or demonstrate that they have no assets. Despite the economic boom of the 1990s, eight million more Americans were uninsured at the end of the decade. Workers have to accept paying a higher share of their premiums through co-payments and deductibles -- a major issue in union-management negotiations. The elderly are forced to increase their out-of-pocket costs. Americans go into bankruptcy because they cannot pay their medical bills. Thousands of Americans die every year because they cannot afford health care. Large numbers of other people delay prenatal care or do not see a doctor after discovering a breast lump or chest pain because they cannot pay for the service. Seriously ill patients ask to die because they do not want to burden their families with more bills. Other uninsured citizens are forced to choose between medical care, drugs or food, rent or heat. European visitors shake their heads in disbelief. They give another meaning to the phrase "Only in America." The system is not working.
We really don't have to take this anymore. Already, half of health care in this country is now paid for by taxpayers (Medicare; Medicaid; federal, state, and municipal employee plans; etc.), as well as a large portion of the medical research and support of medical schools and teaching hospitals. Take the $1.6 trillion (and mounting) that will be spent every year (nearly $6,000 per person already, on the average) and shift it to health care -- preventative and treatment -- for the people and away from the canyons of corporate greed and looting of taxpayers, replete with costly bureaucracies, billing fraud and denials of care.
Here is what the NHP would comprise. Every person receives a health care card assuring payment for all needed care. There would be complete free choice of doctor and hospital. Physicians and hospitals would remain independent and nonprofit and negotiate fees and budgets with NHP. There would be far less billing fraud and paperwork (in Canada patients rarely see a bill) for health care providers, patients, and their beleaguered families. There would be far less bureaucratic interference in day-to-day clinical practice. We would learn both from the successes and the mistakes of other nations with universal coverage. I would add that patients would be able to join their own fully staffed consumer watchdog associations through simple voluntary dues check-offs. No longer would the health care system have profit incentives that ignore working with patients for safe workplaces and environments, good diets, exercise, and cessation of addictions. The NHP is both health care, prevention, and a payments system.
My guess is that if the various national groups (unions, church groups, civic organizations) that support the NHP would deploy 1,000 full-time, experienced organizers in the needed congressional districts and states, together with their own additional mobilizations, the present 25 percent of the Congress now in favor of universal health care would grow to a majority in months, not years. Organization and coordination are all that NHP lacks because the general public registers majority support already. Think about it: An oligarchy, with a corporate-dominated government demands the future expenditure of trillions of dollars against projected stateless terrorism. But, it refuses, decade after decade, to put in place a health care and health care payment system to save hundreds of thousands of American lives and prevent larger numbers of injuries and diseases certain to occur year after year. This behavior is not sane. It fits the clinical definition of insanity by deliberately leaving fellow Americans defenseless, having to pay or die, pay or get sicker, pay or stay disabled. No fire department or neighbor would refuse to put out a house fire if the owner was delinquent on her property taxes.
Let's make this point another way. Put yourself in the place of your members of Congress. The Centers for Disease Control (CDC), a federal agency, has been warning of a coming pandemic from East Asia that could be as devastating as the 1919 influenza epidemic that took almost a million American lives. Infectious disease specialists at the CDC say such a pandemic is overdue. Each year a flu strain is announced and a vaccine is prepared. Often the strain has a Chinese name because the same sequence repeats itself again and again. Ducks or chickens get the flu, give it to the pigs on farms in China. Then it passes to farmers and the virus is off and running to North America and around the world. CDC has about five full-time infectious disease specialists stationed in China to work on early alerts, lab testing, and other indicators with the Chinese authorities. CDC knows that there are not enough specialists there or here, not enough facilities there or here, not enough research and vaccine production capabilities there or here. We are not ready, put simply, for a viral attack that could take more American lives than did World War II. So you are sitting in a congressional chair. You hear that David Kay has returned to Washington, D.C., empty handed after managing 1,500 U.S. inspectors for Saddam's weapons of mass destruction on a budget of $500 million. The entire budget of the CDC is $7.2 billion. Kay was on a mission to vindicate George W. Bush's political reputation and failed. But neither Congress nor George W. Bush appear ready to grapple with saving untold American lives by forestalling the human devastation from a pandemic. Is this sane?
But, then, even in the realm of stateless terrorism, sanity is in short supply. During the early 1970s, during the hijacks of commercial passenger aircraft to Cuba, our aviation safety group began urging the FAA, the airlines, and the aircraft manufacturers to harden cockpit doors and strengthen their latches. Some foreign airlines have done so. Three decades passed and all three of these decision makers could not be bothered. Year after year, they ignored the advice of airline security specialists. It was too expensive, or not necessary. As airline regulator, the permissive FAA has long had what close observers call a "tombstone" mentality. That is, the FAA, at best, acts after crashes point to a problem long known, but ignored. Well, the families of 9/11 victims have learned about the FAA's tombstone mentality the hard way. Finally, on a leisurely schedule, the airlines are now equipping their planes with cockpit doors that would keep hijackers from turning the aircrafts into giant, lethal, fuel-loaded missiles. Were these airline organizations in government and business acting sanely? Can anyone say these are unrealistic priorities? Storekeepers shutter their shops in high crime neighborhoods.
The concentration of greed and power breeds institutional insanity as a matter of course and misdirection. It is driving America backward into the future.
Military vs. Civilian Investment
I wonder how Seymour Melman feels these days. For over half a century, this Columbia University professor of industrial engineering has been meticulously connecting the massive overspending and waste in our military budget With. the de-industrializing of the. United States and the draining of public investment in public works -- repairing the crucial physical capital of America. He sees the permanent war economy weakening the civilian economy and draining the scientific and engineering talent it needs. This results in the loss, he believes, of millions of good paying jobs.
Melman cites the "Report Card for America's Infrastructure" that was issued in 2002 by the American Society of Civil Engineers (asce.org/reportcard). One and a third trillion dollars, the Engineers say, is needed just for repair of twelve categories of public works. These include schools, drinking water systems, solid waste, sewage systems, airports, dams, navigable waterways, public transit, bridges, and roads. Melman's knowledge of U.S. industry is legendary. The federal government's military spending crowds out civil manufacturing whose products repair and modernize America's infrastructure, he states. Unsurprisingly, not one U.S. company submitted a bid in 2002 for supplying a new fleet of subway cars for New York City -- a contract worth $3 to $4 billion.
Other studies have shown that a billion dollars in civilian investment creates considerably more jobs than a billion dollars in a military weapons system. Melman questions why thirteen years after the fall of the Soviet Union, this military budget continues to expand the massive redundancy and costliness of weapons systems such as the next wave of fighter planes, missiles, submarines, and aircraft carriers. He sees our domestic economic needs being strip-mined right down to libraries, fire and police departments, sanitation departments, schools, health care, and services for elderly people.
In a more detailed manner than President Eisenhower's famous comparison of the cost of weaponry to civilian needs, Melman shows what we could have by way of domestic public investment if we tame our military expenditures. Jobs in public works in our country are usually good paying jobs in local communities improving public services. Such jobs cannot be outsourced to China. The manufacturing base to supply these public works projects would be expanded with a similar expansion in employment. Melman does not subscribe to the thesis that we can have a prosperous economy without a strong manufacturing foundation and its multiplier effects. He characterized our present economic system not as capitalism but as state capitalism fusing big business with big government.
As an aside, now in his mid-eighties, Melman does his own research and has just written a new book. When I asked him who researched his finding that in the fall 2002 L.L. Bean catalog, 92 out of the 100 products offered were imported, he replied, "I did."
Now, if there is ever a consensus about any jobs programs, investing in public works or infrastructure wins the prize. In communities around the country, support comes from the construction industry; trade unions and workers; the local mayors; the banks; insurance companies; sellers of fuel, food, and real estate; and local chambers of commerce. One could go on and on. Yet, apart from highway funds" the allocations are woefully small. Just ask our only struggling passenger train system -- AMTRAK -- which can scarcely get the $1.5 billion it needs for capital improvements and operating needs each year. In contrast, the missile defense system took $9.1 billion this year and over $140 billion since Reagan's folly got underway. Moreover, according to Professor Theodore Postel and other scientists, the system is unworkable because, among other reasons, it is very easy to decoy.
The Growing Gap
So, if just about everyone back home favors such repair and modernization, why isn't it happening? The easy answer is that the military industrial complex is much more organized and entrenched in Washington, D.C. Right off, a major public works program faces the charge that our country would be plunged into a deficit it cannot afford. That is the usual argument. Well, George W. Bush inherited a surplus. What did he and his supporters in Congress do? They pushed through, over an anemic Democratic Party opposition, two large tax cuts, mostly for the wealthy, that will cost far more than the American Society of Civil Engineers' estimate of $1.3 trillion, upgraded in 2003 to $1.6 trillion. Blocking such tax cuts could have led to community rehabilitations. Now, there is a massive deficit, as far as the forecast can predict from tax cuts, justified by President Bush as a way to expand the economy. These tax savings are not going to public investment infrastructure. Nor do rich people who already have far more than they spend rush into the market to spend their newly received mega-tax savings. Last year, Bernard Rapoport, founder of the American Income Life Insurance Company, called me and said: "Ralph, what am I going to do with another $150,000 a year? I've got more money than I can spend. Bush is talking economic nonsense."
Making connections between how the super-rich and corporations rig the tax system in their favor requires dedication -- how they make sure that the IRS has neither the mandate nor budget to audit their schemes needs a further effort of enquiry. We must learn how their lobbyists and PACs go beyond the ways they've already legalized to shift the tax burden to lesser-endowed humans whose children inherit the deficits and interest payments. With this effort and knowledge, we can turn this Great American Rip-Off into a Great American Political Issue before elections.
One sensible and surprising institution involves very rich people like Warren Buffett, George Soros, Paul Volcker, and William Gates Sr. Responsible Wealth has over 1,000 rich members opposed to the repeal of the estate tax-a refreshing transcendence of their own economic interest. Gates is so passionate about the reasons and morality behind the estate tax that, in addition to lobbying Congress, he co-authored with Chuck Collins the book Wealth and Our Commonwealth: Why America Should Tax Accumulated Fortunes.
The bookstores have many fine investigative books on tax loopholes, tax breaks, tax shelters, tax havens, and the scurrilous greed of tax escapes, whether super-rich or large companies. Among the best recently are The Cheating of America by Charles Lewis and Bill Allison and Perfectly Legal by David Cay Johnston. These books help us understand what is going on. Understanding the complex web of connections is essential. Otherwise, people will not see what they are losing where they live, work, and play in the cruel trade- off between consummate greed and public need.
Enter John O. Fox, who after thirty-six years as a Washington tax lawyer quit and moved to western Massachusetts (an exciting civic region). There he has pioneered, teaching undergraduates at Mt. Holyoke College, a course on U.S. tax policy. Fox is on a mission. His new book is titled 10 Tax Questions the Candidates Don't Want You to Ask. Among them are: "Would you limit the home mortgage interest deduction so that it subsidized the purpose of one basic home, and would you redirect some of the tax savings to help qualified renters purchase a basic home? Would you stop giving tax breaks for much higher pension contributions for highly paid employees (managers) than for rank-and-file employees? Should Congress prohibit pension plans from depriving employees of their pensions after they have been employed for at least three years?"
John O. Fox, despite his many years in the grim world of corporate tax law, is idealistic. Given the insipid, stagnant, sloganized, debateless campaign culture, how can reporters, much less voters, get a foot in the door of the bubble that encloses the candidates and their microphones? What does he think that we live in -- the Lincoln-Douglas era when debates continued for hours before large standing audiences?
Let us start evaluating our institutions -- local, state, national, and international -- by the same yardsticks that we judge people. Depersonalization runs rampant and thereby runs away from familiar frameworks of accountabilities. Let's stop the institutional insanity!