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ISR Issue 57, January–February 2008


Health care in the U.S.

What’s wrong with it, and what to do about it

Part one of a two-part series of book reviews collected by Elizabeth Lalasz

Susan Starr Sered and Rushika Fernandopulle
Uninsured in America: Life and Death in the Land of Opportunity
University of California Press, 2006
295 pages $16

WHEN ANTHROPOLOGIST Susan Starr Sered asked Harvard physician Rushika Fernandopulle how millions of Americans survive without health insurance, Fernandopulle at first gave the standard answers. The uninsured may qualify for Medicaid. They can visit public clinics or rely on a hospital’s charity care.

Statistics, however, showed Sered and Fernandopulle that such explanations don’t hold up. Hospitals write off bills as “charity care” only after aggressive collection attempts fail. People wait months for public clinic appointments. And Medicaid in 2003 covered just over half of people whose income fell below 200 percent of the poverty line ($36,800 for a family of four). It was then that the nationwide journey chronicled in Uninsured in America was launched.

In 2003 and 2004, Sered, in consultation with Fernandopulle, traveled to Texas, Mississippi, Idaho, Illinois, and Massachusetts, using her anthropological training to learn what lack of health insurance means in the lives of individuals and families. In Decatur, Illinois, we meet Dave, laid off from Firestone, and Judy, who lost her job with a regional grocery store chain when Wal-Mart moved in. Unable to afford the multiple deductibles of Dave’s union-sponsored health plan, Dave’s heart condition and Judy’s depression go untreated.

In Philadelphia, Mississippi, Alisha is coming up against her lifetime limit for welfare benefits, yet her most recent job as a home health attendant provides no health insurance. She treats her asthma by borrowing her sister’s inhaler. Outside Boston, Rae, an art teacher, and Martin, a dentist, describe the “Russian roulette” of purchasing insurance for their oldest son, suffering from severe mental illness, while their youngest son, who has had to postpone college, goes without.

With each story, Uninsured in America demonstrates that people are not “scraping by” (the original title for this volume, dropped when the authors realized its inaccuracy). Instead, through a variety of what Sered and Fernandopulle term “portals”—the loss of livable-wage jobs, punitive welfare-to-work requirements, shredded social safety nets combined with scapegoating attacks on immigrants and African Americans—more and more people are in danger of being sucked into a downward spiral ending in death (or homelessness, the fear that haunts this book’s subjects).

The book’s weakness is the authors’ claim that U.S. health care isn’t a class but a caste issue with the uninsured stigmatized as “untouchables.” Intended as an “intellectual jolt” to a presumably complacent readership, the term undercuts the book’s central argument that the crisis is part of the broad disintegration of the “American dream.” Moreover, the term cuts off Sered and Fernandopulle from some struggles through which imperiled rights and programs were won in the first place. For instance, the inspiring late-1980s demonstrations by the group ACT UP against drug company greed and government neglect despite the White House’s vicious demonization of AIDS-HIV sufferers. Uninsured in America does an excellent job of placing the health care crisis within the attacks of neoliberalism, but activists should turn to working-class history for an inkling of the bottom-up movements that are needed now to win health care for all.
By Nancy Welch

Arnold S. Relman, M.D.
A SECOND OPINION: Rescuing America’s Health Care
Public Affairs, 2007
205 pages $ 20

THIS BOOK, by a physician and the former editor of the New England Journal of Medicine, makes a concise, convincing case for why we need to eliminate the for-profit health care industry in the U.S. and replace it with a single-payer system.

As author Dr. Arnold Relman, explains, major reform is the only solution: “I am convinced that within a decade or so, we will begin to see drastic reforms…because the present commercialized system cannot last longer and incremental improvements will be of little avail.”

But to get this place, he concludes that the solution requires broad public understanding of the basic problems. He hopes this book helps take a step in the direction of dispelling the popular misinformation and confusion around what a public health care system would look like.

Relman provides much-needed facts and a comprehensive history to help any reader grasp the trajectory of the U.S. health care crisis. “Total U.S. expenditures,” he states, “are now over $2 trillion per year, or over 16 percent of our gross domestic product.” Relman further cites a prediction “that ‘optimal health spending’ will rise to more than 30 percent of the GDP by the year 2050.…”

This makes clear why big-money interests like the insurance and pharmaceutical companies will fight tooth and nail to maintain the for-profit system. It also makes clear why changing the system will require a long-term battle from below.

A significant portion of A Second Opinion provides a history of how over the last forty years medicine has become more privatized and industrialized. He charts the rise of Health Maintenance Organizations (HMOs), followed by Preferred Provider Organizations (PPOs), finally to plans known as Consumer-Driven Health Care (CDHC), also called “individual mandates”—the scheme that’s already in place in Massachusetts and is proposed by Governor Schwarzenegger in California.

Each new “formation” within the health care industry is about putting more and more of the burden on individuals, rather than on employers or the Washington politicians to provide the coverage necessary to make health care something every human being has access to. A case in point is the most recent contract between General Motors (GM) and the United Autoworkers union (UAW), which offloads health care costs to employees and retirees.

But, as Relman points out, another option does exist. Just compare UAW members here to those in Canada,

In 2005, GM spent $5.3 billion on the health care costs of its 1.1 million workers and retirees and their families, or over $5,000 per year for each GM-insured person. That adds an estimated $1,525 to the average price of every vehicle the company builds in the United States. By comparison, GM spends only $1,385 per year for each insured person in its Canadian plant, which adds only $197 to the average cost of each vehicle assembled there. The difference is due primarily to Canada’s national health system, which pays most of the medical bills of Canadian workers.

Relman lays out clearly what is the only solution—creating a public single-payer system. Such a plan would provide a standard package of benefits, with no private insurance companies. Doctors, nurses, and other health care workers would work within multi-specialty not-for-profit organizations, with their salaries determined through the management of the group.

A Second Opinion makes a quick, yet extremely thorough case for why a change is necessary—and arms readers with the tools to break through the myths about single-payer health care systems.
By Elizabeth Lalasz

Harriet A. Washington
MEDICAL APARTHEID: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present
Harlem Moon, 2008
528 pages $16

WHILE MICHAEL Moore’s Sicko brought the issue of single-payer health care to the fore, one unpleasant detail has usually been neglected in the debate. Harriet A. Washington’s Medical Apartheid exposes a sinister form of inequality—the dark history of medical experimentation on African Americans.

While other works have revealed the story of abuse and exploitation against Blacks in the name of science, notably Allen M. Hornblum’s Acres of Skin and Martha Stephen’s The Treatment, Washington is the first to provide a synthesis of abusive research on Black bodies from slavery to the present. From hospitals to prisons, from medical school anatomy classes to circus freak shows, and from federally to privately sponsored research, Blacks have been unwitting subjects of abusive experimentation at higher rates than any other ethnicity.

Washington’s scholarship reveals bone-chilling tales of crimes against humanity that rival Nazi “Angel of Death” Josef Mengele. For example, James Marion Sims, M.D., is celebrated as “the father of American gynecology” and memorialized with monuments, including a statue in New York’s Central Park. Yet less honorable is the hidden story of how he developed his innovative medical technique of suturing women’s vaginas by practicing on unanesthetized slave women. Slaves provided Sims with the perfect test subjects because they could not refuse his macabre experiments, allowing him to hone his prized skills through a high rate of surgeries made possible only by the slave system. Despite the availability of ether, Sims refused to use it. The shrieks from Sims’ “patients,” with many undergoing multiple painful surgeries, led his assistants to quit, leaving the enslaved women to restrain each other.

With the professionalization of the medical establishment emerging in the mid-nineteenth century, Sims epitomized the first wave of the rising tide of health care for profit. Sims’ new technique brought him royalty-like status in the medical world, as he won medals and fame that made him the toast of Europe. But, according to Washington, his stature came at the price of human suffering that was considered acceptable to many, as long as it was conducted on Black bodies.

Yet Sims is but one figure in the history of racist abuse in the medical establishment. Most famous is the notorious Tuskegee Syphilis Study, from 1932 to 1972. The U.S. Public Health Service (PHS) promised free medical treatment to hundreds of desperately poor and sick male sharecroppers in Alabama inflicted with syphilis. However, rather than treatment, the PHS denied them proper care with the intention of studying the ravages of the disease. Little did the men know that the true purpose of their participation was to provide Black bodies for autopsies. Undergirding the experiment were common racist assumptions in the medical community that Blacks suffered diseases differently than whites due to physiological differences, such as hypersexed bodies and “underdeveloped” brains.

Washington provides new insight into the study by taking on common myths, such as exaggerated claims of Black complicity in the research. She also points out that throughout the decades of research, the experiment was never hidden and was conducted openly with its results, including autopsy reports, published regularly in prestigious journals, revealing the complicity of the rest of the medical establishment.

The Tuskegee nightmare ended due to public pressure that demanded new guidelines to regulate federally sponsored research. But abusive medical studies on African Americans continued. Washington traces the lineage of the Norplant contraceptive, which was marketed and tested on poor Black teenagers in Baltimore public high schools in the early 1990s, to the eugenics movement and the forced sterilizations in the Jim Crow-era South. The device caused side effects that drove women to seek its removal. Medicaid eagerly paid for its insertion but was less receptive in paying the $500 removal fee. The device was later recalled and taken off the market. Also, from 1992 to 1997, Black children in New York City’s Washington Heights were targeted by a Columbia University-sponsored experiment to determine a possible genetic trait for violence. The school prescribed the cardiotoxic drug fenfluramine to Black boys and lured them into a racially biased and scientifically suspect experiment with gift certificates for Toys “R” Us.

However, Washington’s larger thesis that African Americans suffer from iatrophobia, a fear of going to the doctor, due to the long history of abuse and exploitation is over-generalized and incomplete in describing the vast disparity between the health of white and Black America. As the author points out, heart disease claims 50 percent more African Americans than whites, and a Black woman is 2.2 times as likely to die of breast cancer than a white woman. Yet the solution to these problems will require a more radical overhaul of the medical system than the suggestion of maximizing protections through legislation and improving racial integration within the medical establishment. Despite the author’s weak antidote to the problem, Medical Apartheid should be read by everyone serious about fixing the sick and racist system of U.S. health care.
By Martin Smith

Jill Quadagno
ONE NATION UNINSURED: Why the U.S. Has No National Health Insurance
Oxford University Press, 2006
288 pages $16

ONE NATION Uninsured is dense with the meticulous scholarship for which sociologists are known. Dr. Jill Quadagno explains it all for the reader in eight carefully crafted chapters that explain why the United States stands alone in not providing all its citizens with health care.

She starts with how the issue of national health care, or as it was called in the last century—compulsory health insurance—has always been linked to anticommunism and the “red menace” in order to discredit it. Quadagno shows how doctors and the American Medical Association played a decisive role in whipping up red scares as a way to maintain their power, profits, and prestige. During the First World War, universal health coverage was linked to the Germans and the Kaiser (a German Plot), in 1917 with the Bolshevik Revolution in Russia (“medical soviets”). During the McCarthy era, any attempt to make the government responsible for the provision of social services was hysterically denounced as a communist plot. The phrase “socialized medicine” has been used as a pejorative term during every attempt to reform health care. Even now, presidential candidates are quick to say they are not for “socialized medicine.”

In the chapter titled “Organized labor’s health benefits,” she chronicles how the labor movement has historically been divided on the issue of who should be responsible for the provision of health benefits. Samuel Gompers, the leader of the American Federation of Labor (AFL) worked with employers to defeat a bill for national health insurance put forward by the American Association for Labor Legislation—while the United Mine Workers and the International Ladies Garment Workers Union worked to pass the bill. During the heyday of the unionizing drives by the Congress of Industrial Organizations (CIO), health benefits were hard-won at the bargaining table and the trend would continue through the 1940s. This was the beginning of the employment-based health care system that persists to this day and has become so problematic for workers.

Trade unions, however, also took the lead in the fight to win disability insurance and Medicare
—both government-funded programs. Quadagno writes, “The AFL-CIO won Medicare by mobilizing its extensive union network of state federations and local chapters, organizing a grassroots senior citizens’ movement, and supporting Democratic Party members who served on key congressional committees.”

The passage of Medicare in 1965 was a huge victory for the working class and also helped strike a blow against racism and segregation. This history is not well known and we owe the author kudos for including a chapter on “Provider sovereignty and civil rights.” For decades, Southern politicians resisted national health insurance for fear that federal financing would lead to federal oversight and interference with the racist system of Jim Crow, which meant every hospital and clinic was segregated. The implementation of Medicare became a battleground because the program required hospitals to provide health care services without regard to race. Quadagno states, “As federal officials began certifying hospitals for Medicare eligibility on the basis of quality, they also forced the hospitals to prove they were not discriminating.”

This fine book is also an exposé on how government really works, and the powerful influence of the health insurance industry on lawmakers. Quadagno shows how successive administrations, from Roosevelt to Truman to Kennedy, were willing to sacrifice guaranteed health coverage legislation on the altar of political expediency. On the other side, she explains that without a grassroots movement with heavy involvement of labor, no progressive health care legislation has ever been passed—a lesson we need to take note of today.
By Helen Redmond

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