To improve health the US must spend more on social services

That the US spends far more, in total and per capita, on health care than any other country is a well-established fact which no one bothers to deny. That this expenditure has not brought us greater health is also established fact, although many still find this hard to believe, or don’t want to believe it. That we do not have the “best health care system in the world”, or even close, or even, actually, a health care system at all, is also demonstrably true. This does not stop a larger percent of the population, and particularly the very privileged sector represented by politicians, from maintaining that untruth.

However, in a provocative op-ed in the New York Times (“To fix health care, help the poor”), Elizabeth H. Bradley and Lauren Taylor argue that it is only when health care is viewed in its most narrow sense that the US spends more than other countries. Their study of 30 countries expenditures, “Health and social services expenditures: associations with health outcomes”[1], “…broadened the scope of traditional health care industry analyses to include spending on social services, like rent subsidies, employment-training programs, unemployment benefits, old-age pensions, family support and other services that can extend and improve life.”

Essentially, their data shows that having services available to people that improve the quality of their lives, or, more important, decrease the negative health impact of the adverse circumstances into which they are born, develop, and live, lessens disease burden and improves health. This then decreases the costs of providing medical care to them. For example, they note, “The Boston Health Care for the Homeless Program tracked the medical expenses of 119 chronically homeless people for several years. In one five-year period, the group accounted for 18,834 emergency room visits estimated to cost $12.7 million.”

Bradley and Taylor indicate that among industrialized countries, the US ranks #10 in total health + social service spending , and is one of only 3 that spend more on health care than on all other social services. This means that, in addition to not getting the preventive or early-intervention health care that they need, Americans are at higher risk of illness and more ill when they come to medical attention. They may not be homeless, although obviously this dramatically increases their risk. People may not have adequate food, not have adequate warmth (see the discussion of “excess winter deaths” in Michael Marmot, the British Medical Association, and the Social Determinants of Health, November 1, 2011), not had a safe environment. They likely had far too little income. Many of them are children, and many of those, and often their parents before them, have had an inadequate education. A large number of the determinants of health are antenatal, and many more are in the early years of life. The other group at high risk of both adverse health outcomes and the poverty-related social deficits that influence them, are the elderly. So what do we see in the US? Threats to cut Medicare, cut Social Security, cut education.

This wouldn’t affect everyone equally, of course. Only the most vulnerable. Or, at least, the more vulnerable. The wealthy, of course, are unlikely to be inadequately housed, inadequately nourished, inadequately educated, and, in a tautology, inadequately employed. Another recent study, from the Organization for Economic Cooperation and Development (OECD), called “Divided we stand: why economic inequality keeps rising”, demonstrates rising inequality in income as indicated by the difference between the income of the top 10% and bottom 10%. “The income gap has risen even in traditionally egalitarian countries, such as Germany, Denmark and Sweden, from 5 to 1 in the 1980s to 6 to 1 today. The gap is 10 to 1 in Italy, Japan, Korea and the United Kingdom, and higher still, at 14 to 1 in Israel, Turkey and the United States. In Chile and Mexico, the incomes of the richest are still more than 25 times those of the poorest, the highest in the OECD, but have finally started dropping. Income inequality is much higher in some major emerging economies outside the OECD area. At 50 to 1, Brazil's income gap remains much higher than in many other countries, although it has been falling significantly over the past decade.”

 

In the report’s “country note” on the US, it observes that “The United States has the fourth-highest inequality level in the OECD, after Chile, Mexico and Turkey. Inequality among working-age people has risen steadily since 1980, in total by 25%. In 2008, the average income of the top 10% of Americans was 114 000 USD, nearly 15 times higher than that of the bottom 10%, who had an average income of 7 800 USD. This is up from 12 to 1 in the mid 1990s, and 10 to 1 in the mid 1980s….Income taxes and cash benefits play a small role in redistributing income in the United States, reducing inequality by less than a fifth – in a typical OECD country, it is a quarter. Only in Korea, Chile and Switzerland is the effect still smaller.” Of course, comparing deciles is deceiving; as the Occupy Wall Street movement emphasizes, the concentration of wealth is in the top 1%, and economist and NY Times columnist Paul Krugman (“We are the 99.9%”, November 24, 2011) and others point out that most of that wealth in the US is in the top 0.1%! The wealthiest 400 families in the US own as much as the bottom 50% of the population.

 

One obvious result of the rising inequality in the US is the increase in the overt control that this wealthy class exerts over the political process, through direct lobbying, political contributions, employment after and between stints of government service, and control of media. The “corporate personhood” decision by the US Supreme Court in Citizens United simply codified and protected this inequality. But income inequality in itself is not sufficient to lead to the destruction of the social safety net that exposes increasing numbers and percents of people to ravages that adversely affect their health. It also requires extreme selfishness and disrespect, so that billionaire people and corporations pay little in tax, and governments are purposely squeezed so that they have neither the will nor the resources to provide services.

 

The findings of Bradley and Taylor are not news to the public health community, of course, which is very familiar with the social determinants of health and the positive impact that investment in basic social supports has on the health outcomes of both populations and individual people. Investment is required to see future benefit, and the investment that we need, and are not making, is in education, is in nutrition, is in housing. It is far more than a shame. It is shameful.  

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[1 Bradley EH, Elkins BR, Herrin J, Elbel B.,Health and social services expenditures: associations with health outcomes, BMJ Qual Saf. 2011 Oct;20(10):826-31. Epub 2011 Mar 29

Veterans Day, the “Bonus Army”, and honoring veterans by actions, not words

We recently celebrated Veteran’s Day, an opportunity to honor the men and women who have served the rest of us, putting their lives on the line, in the wars that our nation has fought. It was a numerologically special day, November 11 this year, being 11/11/11. While I have opposed almost all of the wars fought in my lifetime, as stupid and often motivated by the same greed on the part of the wealthiest that so clearly determines the behavior of our nation, I have only admiration and respect for those who put their lives on the line. The history of the world is often the history of wars, usually one more senseless than the last, and it is the history of the regular people who serve, and are killed, or wounded, or mutilated, or survive apparently intact.

Veteran’s Day began as Armistice Day, with the signing of the peace after WW I, a model for a brutal war that slaughtered millions for no good reason. I live in Kansas City, home of the nation’s WW I Museum, and it is a must-see for anyone who has not studied this first modern war, with millions soldiers dying in trenches; with the first large-scale wartime use of airplanes, with poison gas, with all the other viciousness that people were able to devise. There are some who prefer the use of name “Armistice Day” because it signifies “peace”; I am willing to celebrate our veterans without celebrating, or even condoning, the wars that took the lives of so many of their comrades.

We have not always honored veterans, and we do not do so now. “Honored” in words, sure; honored in deeds, in providing services for them to re-integrate into civilian society and find jobs, even to provide the health care that they need to treat the wounds, physical and mental, that they suffered in battle, not so much. Perhaps the most ignominious and dishonorable treatment of veterans was the attack on the “Bonus Army” of 1932. In 1924, Congress had issued “bonus certificates” to these veterans, but there was a catch – they were not redeemable until 1945. This was not of much help to the men who had “won the war” but were suffering unemployment during the depths of the Great Depression. Over 43,000 people, as many as 20,000 veterans plus members of their families, were camped in Washington DC parks, to demand payment of these bonuses. (It is of interest that President Coolidge had vetoed the bonuses in 1924 with the statement that "patriotism... bought and paid for is not patriotism," before Congress overrode his veto!) Tiring of all these dirty and ragtag families camped on public property (and, of course, the reminder that they brought of the broken promise), on July 28, 1932, President Hoover send the army to break up the encampment and rout them.

That is correct. The President of the United States sent active duty army troops, under the command of General Douglas MacArthur and assisted by Majors Dwight Eisenhower and George Patton, to attack its own veterans.  You didn’t learn this in school? Maybe it wasn’t really that important. Right. It happened. From Wikipedia:

“At 4:45 p.m., commanded by Gen. Douglas MacArthur, the 12th Infantry Regiment, Fort Howard, Maryland, and the 3rd Cavalry Regiment, supported by six battle tanks commanded by Maj. George S. Patton, formed in Pennsylvania Avenue while thousands of civil service employees left work to line the street and watch. The Bonus Marchers, believing the troops were marching in their honor, cheered the troops until Patton ordered the cavalry to charge them—an action which prompted the spectators to yell, "Shame! Shame!"

After the cavalry charged, the infantry, with fixed bayonets and adamsite gas, an arsenical vomiting agent, entered the camps, evicting veterans, families, and camp followers. The veterans fled across the Anacostia River to their largest camp and President Hoover ordered the assault stopped. However Gen. MacArthur, feeling the Bonus March was a Communist attempt to overthrow the U.S. government, ignored the President and ordered a new attack. Fifty-five veterans were injured and 135 arrested….During the military operation, Major Dwight D. Eisenhower, later President of the United States, served as one of MacArthur's junior aides. Believing it wrong for the Army's highest-ranking officer to lead an action against fellow American war veterans, he strongly advised MacArthur against taking any public role: "I told that dumb son-of-a-bitch not to go down there," he said later. "I told him it was no place for the Chief of Staff." Despite his misgivings, Eisenhower later wrote the Army's official incident report which endorsed MacArthur's conduct.”

That’s right. They used poison gas on WW I veterans, many of whom were suffering the effects of gas attacks during the war. Eisenhower, who may look like the “good guy”, was mainly concerned about the seemliness of the army’s Chief of Staff (MacArthur) leading the attack on Anacostia, not the attack itself.

The country was in a Depression. The more than $3 Billion that was owed these veterans was a lot of money for the government during the Depression. Not a good reason to not pay it. Just as it is not a good reason for us to cut back benefits for veterans today, in our own “recession”. In 1930, the Veterans Administration was created, combining several “veterans’ homes” and hospitals. After WW II, when the bonus checks would have come due for the WW I veterans, the GI Bill was passed, granting veterans the opportunity to get needed benefits, including an education delayed by the war. These benefits are regularly eroded by Congressmen who give fine speeches on November 11, but care as much about the actual people who fought our wars as much as Presidents Hoover and Coolidge did. In fact, President Coolidge’s statement about “patriotism” justifying not paying the bonuses would never be uttered by a current-day politician, but the actions of the Congress, which overrode the veto, would not either. We do not have enough money in the US, the story goes. We need to work down the deficit. By taking the money from the most needy, from the poor and the working class and the middle class, including our veterans; certainly not from the wealthiest.

The deficit was created by politicians doing the bidding of the <0.1% of the population who control most of our wealth, cutting their taxes to increase their wealth. And, oh yes, fighting two wars in Iraq and Afghanistan, killing and maiming and creating new veterans who can barely get the help that they need. And, of course, insuring that the 0.1% have every dollar of ours that they lost for us replaced – to them, not us, we pay the bill – and more, is far more important than providing health services and education and jobs for the veterans, or for anyone else.

We would (I think) not send the Army to attack a veterans’ encampment today, but who knows? The people who had fought WW I were honored by our people in those days as heroes even as much or more than our current veterans, and yet our President sent the Army to attack them with cavalry, tanks, and poison gas. Recent history shows us there is no depth of calumny and duplicity to which defenders of the status quo will not go to achieve their ends; remember the military history of #1 hawk Richard Cheney (he had none; he was doing “more important” things during the Vietnam war). Remember the defeat of Senator Max Cleland of Georgia by an opponent who questioned his patriotism and toughness because the Senator had raised questions about the war in Iraq? Sen. Cleland was a decorated Vietnam veteran who had lost both legs and an arm in that war; his opponent had not served.

And, unlike after WW I or WW II, without a draft, with a large group of young people who can find no other jobs, most of us are no longer involved in paying the human price of war. This is the focus of As Fewer Americans Serve, Growing Gap Is Found Between Civilians and Military by Sabrina Tavernise in the NY Times, November 25, 2011. “`What we have is an armed services that’s at war and a public that’s not very engaged’ said Paul Taylor, executive vice president of the Pew Research Center. `Typically when our nation is at war, it’s a front-burner issue for the public. But with these post-9/11 wars, which are now past the 10-year mark, the public has been paying less and less attention.’”

This separation means that, while politicians laud their service on Veterans’ Day, the actual veterans, after serving and suffering from real wounds both physical and mental, are returning to a society that has no jobs,  and is investing less and less in their care. What we need to see is more action on behalf of veterans, and on behalf of the American people. Instead, what we see from too many of our hypocritical Congressmen and “leaders” who sing the praises of our veterans while cutting their benefits, are actions that would make Calvin Coolidge proud.