Life under capitalism: Early deaths a ‘silver lining’ for corporations

Participating in Monday evening’s demonstration at the Trump Tower in Manhattan, I couldn’t help thinking of the connections between a Bloomberg article proclaiming that people dying earlier contains a “silver lining” because corporations will save pension costs and the ongoing savagery of the Trump administration.

Not simply the naked symbiosis between the Trump administration and white supremacists, neo-Nazis and assorted far-right cranks — all too sadly on display in Charlottesville, Virginia, last weekend — but the alliance of corporate titans, Republican Party leaders and President Trump himself. The rush by even conservative congressional Republicans to condemn the tweeter-in-chief for his refusal to condemn his so-called “alt-right” allies for two days should not distract us from the Trump administration’s all-out assault on regulations, civil rights laws, health care and the environment. (Let’s please retire the useless term “alt-right” and call them what they are: white supremacists, fascists and fascist wannabes.)

The health care system of the United States is already by far the world’s most expensive while delivering among the worst results. So of course the solution to this, in Republican eyes, is to make it worse. That effort has, so far, failed, thanks to massive grassroots activism. But plenty else is being rammed through under the radar through executive decrees — which is why we shouldn’t hold our breath waiting for Congress to impeach President Trump. He’s much too useful to Republicans and corporate executives. Should that change, of course, all bets are off, but short a Democratic tidal wave in 2018 Republican members of Congress turning on the president anytime soon isn’t likely.

On the march against Trump in New York City August 14 (photo by Mark Apollo/Hashtag Occupy Media)

So what does this have to do with an article published by Bloomberg? The headline on this particular article says it all: “Americans Are Dying Younger, Saving Corporations Billions,” complete with a subhead declaring “lower pension costs” a “silver lining.” As not only a proud member of the corporate media, but one specializing in delivering news to financiers and industrialists, extolling a benefit to corporate bottom lines and ignoring the, ahem, human cost of said benefit is only to be expected. The article is not at all atypical of the business press, even if this one is a little more obvious than usual.

But, as a friend who is an activist with a Marxist party but who once ran a chemical industry consultancy by day (if only his clients knew his politics!) once taught me, the business section is where they hide the news. So the point here isn’t the attitude of Bloomberg toward working people (no more hostile and sometimes less so than your average business publication) but the attitude of corporate titans toward employees. The article states:

“In 2015, the American death rate—the age-adjusted share of Americans dying—rose slightly for the first time since 1999. And over the last two years, at least 12 large companies, from Verizon to General Motors, have said recent slips in mortality improvement have led them to reduce their estimates for how much they could owe retirees by upward of a combined $9.7 billion, according to a Bloomberg analysis of company filings.”

Austerity costs human lives

Gains in U.S. death rates had been improving until 2009, Bloomberg reports, citing a Society of Actuaries analysis, but those rates then flattened before reversing in 2015. This isn’t necessarily unique to the U.S. — the Institute and Faculty of Actuaries in the United Kingdom last month reported that U.S., Canadian and British seniors have ceased seeing longevity improvements, suggesting the impact of austerity since the 2008 economic collapse is a primary culprit. The Actuaries report said:

“The rising mortality rates among US working age demonstrates that the historical fall in mortality rates cannot be taken for granted. The pace of life expectancy gains of older ages has slowed down, with some age groups showing signs of increasing death rates. These signs should be taken as warnings that worsened health care, behaviour and environment can reverse decades of success in health and longevity. Actuaries need to have a better understanding of the drivers of longevity to consider how to incorporate recent experience into forecasts of future longevity.”

As welcome as a new quantification of the toll of austerity is, such a notion is far from new, nor is it simply the latest variant of capitalism, neoliberalism, that is at work here. The increased deprivation of capitalism caused a half-million U.S. deaths from 1999 to 2015. Specifically, nearly half a million excess deaths have occurred since 1999 among middle-aged White non-Hispanic United Statesians, according to a paper published in 2015 by two Princeton University researchers, Anne Case and Angus Deaton.

A shuttered hospital (photo by Jim Henderson)

From 1978 to 1998, the mortality rate for U.S. Whites aged 45 to 54 fell by 2 percent per year on average, matching the average rate of decline in five comparison countries (Australia, Britain, Canada, France and Germany). But although, from 1999, other industrial countries continued to see a decline in mortality rates for the middle-aged, the U.S. White non-Hispanic mortality rose by half a percent a year, an increase that is unique, Drs. Case and Deaton reported. African-American death rates have not similarly risen although remain considerably higher than those for Whites.

The authors do not speculate on the reason for White deaths to increase in contrast to the trend of minority groups, but we might reasonably conclude that People of Color have had deprivation and economic difficulty imposed on them in greater numbers and more intensely, and thus are experiencing less of a change in historic circumstances than are Whites. The economic downturn that the world has lived through since 2008 certainly hasn’t bypassed People of Color — far from it — but the decline has not spared Whites, a group not as hardened to lower living standards thanks to their privileges.

Privatization costs human lives

Privatization and intensified reliance on “the market” has already been demonstrated to worsen health outcomes. A 2009 study published by The Lancet concluded that the mass privatization in the former Soviet bloc resulted in one million deaths. Mass privatization caused the average number of deaths to increase by 13 percent from the 1992 onset of shock therapy. An Oxford University press release summarized these findings:

“David Stuckler, from Oxford’s Department of Sociology, said: ‘Our study helps explain the striking differences in mortality in the post-communist world. Countries which pursued rapid privatisation, or ‘shock therapy’, had much greater rises in deaths than countries which followed a more gradual path. Not only did rapid privatisation lead to mass unemployment but also wiped out the social safety nets, which were critical for helping people survive during this turbulent period.’ ”

During Soviet times, we were assured by Western commentators that high levels of alcoholism were a sign of despair in Russia, yet alcohol per-capita consumption rates in 2007 were three times that of 1990.

When a health care system is designed to deliver corporate profits rather than health care — and this is precisely what privatized health systems do — such are the results. Throwing more than 20 million people off the roles of health insurance, as all Republican Party plans would have done, could only have exacerbated poor health outcomes. But doing so is consistent with Republican plans to shred what remains of the U.S. social safety net, sure to lead to further early deaths. As the more reliable instruments of the will of corporate plutocrats (Democrats having to sometimes make concessions to their voting base), Republicans see Donald Trump in the White House as a gift.

The purported disapproval enunciated by the likes of Senator Jeff Flake are a sad joke — the Arizona Republican has reliably voted for all Trump appointees and legislation. What really “embarrasses” members of Congress are the president’s vulgarity and ham-fisted obviousness. He simply refuses to use code words that way that ordinary Republicans have learned to do. Stop being so obvious! But in reality President Trump is the logical product of 37 years of Republican pandering — half a century if we go back to Richard Nixon’s “Southern strategy.”

We can certainly argue over what constitutes fascism, and whether President Trump is properly called a fascist or that he is simply a Republican who is more willing to show the fist behind capitalist rule albeit someone who carries the seeds for a potential fascist movement. The latter is more than scary enough. But as the casual talk of a “silver lining” for shortened life spans illustrates, human life is expendable in the pursuit of profits under capitalism. And as long as the Trump administration is useful to this pursuit, occasional protests from corporate executives will remain no more than hollow gestures.

The cost of not having single payer: $1.4 trillion per year

You could not devise a worse health care system than that of the United States if you tried. By far the most expensive, with among the worst results.

Perhaps saying “among” the worst results is being too kind. That is an accurate statement if we are simply measuring metrics such as mortality rates and other medical outcomes. But if we consider that tens of millions of United Statesians go without health insurance while none do in any advanced capitalist country (or most any other) — and that tens of thousands annually die because of that lack — then we must reasonably assess the U.S. health care system as the worst.

This is the high cost of private profit in health care. How much? The United States spends more than $1.4 trillion per year than it would otherwise if it had a single-payer system. Such is what happens when a service is left in the hands of the private sector, and allowed to be bent toward profit rather than human need.

To calculate that figure, I took the average per capita health care spending of the three largest EU countries — France, Germany and the United Kingdom — and the neighbor of the U.S., Canada, and compared that average to U.S. per capita spending. The composite average for Britain, Canada, France and Germany for the years 2011 to 2016 is $4,392 per capita per year, converted to U.S. dollars adjusted to create purchasing power parity as reported by the Organisation for Economic Cooperation and Development (OECD). Per capital health care spending in the U.S. for 2011 to 2016 averaged $8,924 — more than twice as much! Taking that difference and multiplying by 317 million, the average U.S. population for the five-year period, and the total annual excess comes to $1.44 trillion.

That excess has been steadily increasing. Doing these same calculations for earlier periods found that for the period of 2001 to 2010, the annual average of excess spending was $1.15 trillion. The annual average for the period of 1990 to 2000 was $685 billion.

For 2016, the OECD reports that only nine of the 35 countries surveyed spent more than half of what the U.S. spent on health care, and the second highest spender, Switzerland, spent $2,000 less per capita than did the United States.

Can this astounding amount of spending be accounted for by more health care? Nope. The average length of a hospital stay in U.S. in 2014 was 5.5 days, seventh shortest of 35 countries surveyed by the OECD. The average hospital stay in each of the four core comparison countries (Britain, Canada, France and Germany) was longer — a composite average of 7.6 days.

Paying more for less

So it really comes down to inferior results. The U.S. does well in combating cancer, but poorly in almost every other category of health care measurement. And people in the U.S. pay dearly for the privilege of health care, if they are lucky enough to have access to it. The cost of health insurance continues to rise, and the amount a patient must pay out of pocket before insurance kicks in (the “deductible” in U.S. lingo) is also steadily rising as employers push more of the cost of health insurance on to their employees.

Phillip Longman, discussing this issue for Popular Resistance, wrote:

“Indeed, the inflating cost of health care is the overwhelming reason why most Americans haven’t received a raise in years, and why employers increasingly make use of contract workers rather than taking on new employees that would receive benefits. This year, the total annual cost of health care for a typical family of four covered by a typical employer-sponsored plan surpassed $25,000, according to the actuarial research firm Milliman. Such a family will typically pay more than $11,000 of this cost directly out of its own pockets, through payroll deductions, copayments, and deductibles. They will also pay much more indirectly in foregone wages and other forms of compensation, and quite possibly more yet in the form of unemployment, as employers seek to escape their share of the mounting cost of providing health care for their employees.”

And because health care is dependent on maintaining a full-time job, bosses have more leverage over their employees, who will lose their insurance should they quit their job. Women with lower-paying work or staying at home to raise a family are also put at greater risk as health insurance for themselves and children are tied to their husband’s job, making it more difficult to leave a bad marriage. This dynamic could also apply to any one person in a non-traditional family or within a gay or lesbian household.

Thus it comes as little surprise that the United States is one of two countries in the world that do not provide paid maternity leave for women workers. Hope to get it at work? Good luck with that — only 9 percent of companies offered fully paid maternity-leave benefits to workers in 2014, down from 16 percent in 2008. By contrast, at least two-thirds of countries have mandatory maternity pay for at least 14 weeks, according to an International Labour Organization report.

You might not have it so good, but that is the price to be paid for high profits. An analysis by Forbes magazine found that health technology had the highest profit margin of any of 19 broadly defined industrial sectors, at 20.9 percent, topping even finance, the second highest. Three of the biggest companies — Pfizer, Merck & Co. and Johnson & Johnson — had profit margins of 25 percent or higher. When a separate study broke down profit margins by smaller, more specific industry categories, health care-related industries were three of the six most profitable. Generic pharmaceuticals topped the list, with a margin of 30 percent. Major pharmaceuticals and biotechnology were also among the top six.

Keeping people sick as a business model

The piles of money vacuumed into pharmaceutical pockets do not sit entirely idle. Big Pharma lavishes vast sums on doctors, state Medicaid officials and regulators to promote their products. Studies have shown that doctors who have received payments from pharmaceutical companies are more likely to prescribe those companies’ medications. But pharmaceutical companies go far beyond wining and dining doctors, or paying them speaking fees. They organize “patient advocacy” groups that pretend to be grassroots organizations. An investigative health reporter, Martha Rosenberg, writes that these front groups fly in “patients” to hearings to ask for expensive drugs to be fast-tracked for approval.

Expensive drugs that have to be taken for years, or even a lifetime, create a business model that “actually wants people sick,” Ms. Rosenberg writes. She says:

“ ‘Mental illness’ is a category deliberately ‘grown’ by Pharma with aggressive and unethical million-dollar campaigns. These campaigns, often unbranded to look like a public service, convince people with real life challenges they are ‘depressed’ or ‘bipolar’ and that their children have ADHD. Despite the Pharma marketing, the New England Journal of Medicine recently reported that the rate of severe mental illness among children and adolescents has actually dropped dramatically in the past generation.”

All this adds up to a 2011 study in the journal Health Policy that ranked the U.S. last in preventing early deaths. Attributing this result to “the lack of universal coverage and high costs of care,” the Commonwealth Fund noted:

“The United States placed last among 16 high-income, industrialized nations when it comes to deaths that could potentially have been prevented by timely access to effective health care. … [O]ther nations lowered their preventable death rates an average of 31 percent between 1997–98 and 2006–07, while the U.S. rate declined by only 20 percent, from 120 to 96 per 100,000. At the end of the decade, the preventable mortality rate in the U.S. was almost twice that in France, which had the lowest rate—55 per 100,000.”

An OECD report found that life expectancy in the U.S. is two years less than the average of OECD countries, a gap that is growing. That statistic isn’t improving at either end of life, as U.S. infant mortality rates are considerably higher than in peer countries. A report prepared by the Peterson Center on Healthcare and the Kaiser Family Foundation explicated this poor performance:

“The U.S. has been slower to improve its infant mortality rate than comparable countries, which we define as countries whose gross domestic products (GDP) and per capita GDP were above average in at least one of the past 10 years. While the infant mortality rate in the U.S. improved by about 13 percent from 2000-2013, the comparable country average improved about 26 percent, according to data from the Organization for Economic Cooperation and Development.

U.S. infant mortality rates appear to be about 42 percent higher than the comparable country average. Looking into specific measures of infant mortality, it also appears that the U.S. has about 66 percent more neonatal deaths (deaths which occur less than 28 days after birth) than the comparable country average. From 2000 to 2013, neonatal deaths decreased by 13 percent in the U.S. and by 23 percent in comparable OECD countries.”

What’s good for big business is good for big business

With such dismal results, why does such a furious campaign continue to insist on privatized health care? Ideology, of course. Ideology no different than that propagated to insist that government is always bad and private enterprise always better. But government doesn’t have to earn a profit; private enterprise expects to and will pack its bags if it doesn’t. Just as privatization invariably results in higher costs and often poorer quality than when the service was provided by a government agency as a public good, health care is provided far more efficiently when in public hands.

Noting that “high administrative costs and lower quality have also characterized for-profit HMOs” (health maintenance organizations funded by insurance premiums that supervise health care), a Journal of the Canadian Medical Association article provides the following figures for the percentage of revenue that is diverted to overhead:

  • For-profit HMOs: 19 percent
  • Non-profit plans: 13 percent
  • U.S. Medicare program: 3 percent
  • Canadian Medicare: 1 percent

Ideology drives the Trump administration and the Republican-controlled Congress to have no problem with adding more than 20 million people to the ranks of the uninsured by attempting to reverse the weak-tea, incremental improvement of Barack Obama’s Affordable Care Act. This is not different from Donald Trump’s chimeric $1 trillion infrastructure program, which is a scam that commits his administration to zero dollars while showering corporations with massive subsidies that would supposedly magically induce private infrastructure investment.

That extra $1.4 trillion paid for health care in the United States is the result of a system designed to deliver corporate profits rather than health care. It’s the “magic of the market” at work. It just isn’t magic for you. In a concise explanation on the Real-World Economics Review Blog, Peter Radford explains:

“Markets, you see, are wonderlands that always and inevitably lead to efficient outcomes. And it is no good any starry eyed liberal tinkering with those outcomes. They are magically correct. By correct we mean that they cannot be improved upon. Economists have this vice like attachment to certain core beliefs. One of those is that, if left unfettered, markets will zero in on an allocation of stuff that can never be improved, especially by meddlesome governments.

The way you get to this particular promised land is by letting the great forces of supply and demand batter away at individual preferences and budgets until all the trading and so on ends with no one able to make another trade without such a trade making someone else worse off. It sounds wonderful. Now to make this all work we have to believe in magic. We have to suspend our intelligence and imagine a world where everyone knows exactly what everyone else is doing, where no one cheats, where everyone is marvelously rational, where they don’t suddenly change their minds, where they can calculate at the speed of light, absorb vast amounts of data, and always — yes always — arrive at precisely that combination of stuff they wanted. Within the constraints of their budget of course.”

Sarcastic, yes, but that is a summation of what passes for economic orthodoxy nowadays. Markets always magically result in fair and just results for all, and any actions by government automatically damage this miraculous machine. And therefore health care should be left in the hands of corporations with as little regulation as possible. And therefore the U.S. is a country in which 22,000 people die and 700,000 go bankrupt per year as a result of inadequate, or no, health insurance in the United States. That’s one of the prices of capitalism.

Dump the kid and get back to work

The presidential campaign season is well underway in the United States, and never in human history will more money be spent to say less. And only 16 more months to go.

A perennial favorite of the worst electoral system money can buy is the race among the candidates to be the most in favor of motherhood and apple pie. Not actually do something to make it easier to balance personal life and work, of course, but to send endless platitudes into the void. To put this in context, here is the complete list of all the countries in the world that do not provide paid maternity leave for women workers:

  • Papua New Guinea
  • United States of America

The International Labour Organization reports that 183 countries and territories on which it has information provide cash benefits to women on maternity leave; the two listed above do not. The ILO report, “Maternity and paternity at work: Law and practice across the world,” found that although not all countries reach its standard of at least two-thirds of pay for at least 14 weeks, almost half of the world’s countries do, including 25 of the 29 developed countries in which ILO researchers were able to make an assessment. [page 19] (Canada, Iceland and Slovakia are the others.)

Stockholm (photo by Sharon Hahn Darlin)

Stockholm (photo by Sharon Hahn Darlin)

The geographic region with the best results is Eastern Europe/Central Asia, where 88 percent of countries exceeded the ILO maternity-leave standards and every one at least equaled the standard. [page 18] This result isn’t surprising, as these countries were mostly part of the Soviet bloc. Women on maternity leave in the Soviet Union received full pay up to 112 days, partial pay up to 18 months, and unpaid leave from 18 to 36 months, according to a Max Planck Institute for Demographic Research paper. Maternity-leave benefits achieved during the communist era in countries such as Poland, the Czech Republic, Slovakia and Hungary have largely been retained.

That doesn’t mean all was well; women workers in the Soviet Union from the 1960s on earned about 70 percent of what men did, and industries with the highest concentrations of women tended to be those with the lowest pay. Then again, that is not much worse than today in the United States, where women earn 78 percent of what men earn. Canadian women earn about 74 percent of what Canadian men take home.

Leave for both parents

Of course, there is more to family-friendly work policies than conditions of maternity leave. Only about half of the world’s countries provide paternity leave. Although the ILO has not established a standard for paternity leave, the organization encourages it. The “Maternity and paternity at work” report says:

“Research suggests that fathers’ leave, men’s take-up of family responsibilities and child development are related. Fathers who take leave, especially those taking two weeks or more immediately after childbirth, are more likely to be involved with their young children. This is likely to have positive effects for gender equality in the home, which is the foundation of gender equality at work.” [page 52]

One way of encouraging gender equality is to provide for parental leave, where either parent can take it, or in the case of countries such as Sweden and Norway, some of the parental leave must be taken by the father. The ILO’s report says:

“As countries move toward greater gender equality in their legislation and policies, most countries are setting out parental leave as a shared entitlement, where either the mother or the father has the right to take parental leave and the parents determine the allocation of leave themselves. Countries adopting this approach include Albania, Cuba, Estonia, Finland, New Zealand, Uzbekistan and many others. …

“Sweden was the first country to grant men and women equal access to paid parental leave in 1974. Few men took parental leave, however, so, in 1995, Sweden introduced a non-transferable ‘daddy’s month’ and extended this leave to two months in 2002, with pay at 80 percent of income. Norway also has a non-transferable leave period of 14 weeks to encourage men’s take-up of childcare responsibilities. Germany and Portugal too provide non-transferable allocations of paid parental leave for fathers.” [page 62]

More help in difficult times

In contrast, in the United States, parental leave is a privilege attached to your job, just as with health care (where health care is far more expensive than every other developed country. Only 9 percent of companies in the U.S. offer paid maternity-leave benefits, down from 16 percent in 2008. Lest we pin this reduction on the ongoing economic crisis in which the world has been mired since 2008, the ILO report found that several European countries, along with others such as Chile and El Salvador, actually increased the levels of government support to families, and in 2010 Australia introduced paid universal parental leave for the first time. [page 28]

Those countries that already provided generous benefits haven’t reduced them. Sweden provides 480 days of paid parental leave, prenatal care through free or subsidized courses, and allows parents pushing infants and toddlers in prams and buggies to ride for free on public buses. Norway provides 49 weeks of paid parental leave at 100 percent of income or 59 weeks at 80 percent of income.

The only legal requirement in the U.S. is the 12 weeks of unpaid leave provided under the Family and Medical Leave Act — if you can’t afford to be without a wage, too bad. A Senate bill with 19 sponsors, the Family and Medical Insurance Leave Act, has been introduced that would provide up to two-thirds of pay for 12 weeks, capped at $4,000 per month, paid for by contributions by employers and employees. By contrast, most countries that provide paid parental leave do so through government benefits.

No Republicans have offered to co-sponsor this bill, and not one of the 17 candidates vying for the Republican Party nomination is in favor. The Family and Medical Leave Act was bitterly opposed by George H.W. Bush when he was president, who vetoed it twice, and his son, current Republican establishment favorite Jeb Bush, shows no more inclination to align actions with rhetoric. When governor of Florida, Jeb Bush’s big initiative was to privatize the foster-care system, which handed big profits to corporations, and which took “a pretty well-functioning system and blew it to bits,” according to one case worker.

When “the market” is allowed to decide social questions, it shouldn’t be a surprise that corporate profits, not human needs, are the priorities.

TPP promises health care for profits, not patients

Health care will take a large step toward becoming a privilege for those who can afford it rather than a human right under the Trans-Pacific Partnership. Government programs to hold down the cost of medications are targeted for elimination in the TPP, which, if adopted, would grant pharmaceutical companies new powers over health care.

This has implications around the globe, as such rules could become precedents for the Transatlantic Trade and Investment Partnership and Trade In Services Agreement, two other deals being negotiated in secret.

The U.S. Congress’ difficulties in passing “fast-track” authority has thrown a roadblock in the path of the Trans-Pacific Partnership, but by no means has this most audacious corporate power grab been defeated. The latest leak of TPP text, the annex on pharmaceutical products and medical devices published by WikiLeaks earlier this month, makes clear that the U.S. pharmaceutical industry is taking aim at health care systems that put accessibility above corporate profiteering.

Craters of the Moon Geothermal Area, New Zealand (photo by Pseudopanax)

Craters of the Moon Geothermal Area, New Zealand (photo by Pseudopanax)

People in other countries should be extremely wary of any attempt to make their health care systems more like that of the United States. The U.S. health care system is designed to produce profits for pharmaceutical, insurance and other health care industry corporations, not to provide health care. Because of this, health care in the U.S. is by far the world’s most expensive while delivering mediocre results. How expensive? During the decade of 2001 to 2010, U.S. health care spending was $1.15 trillion higher per year than it would have been otherwise.

As always with the TPP, bland-sounding text written in stilted, bureaucratic language contains more danger than initially meets the eye. New Zealand’s Pharmaceutical Management Agency, which makes thousands of medicines, medical devices and related products available at subsidized costs, is a particular target of TPP and the U.S. pharmaceutical lobby because it is an example that drug companies do not wish to be emulated elsewhere. Agencies of other governments will also be under threat.

U.S. government targets New Zealand subsidies

A “Special 301 Report” issued in April 2015 by the U.S. government under the name of U.S. Trade Representative Michael Froman specifically names no less than 17 countries in which it seeks to undo health-system protections. Taking direct aim at New Zealand, the report said:

“With respect to New Zealand, U.S. industry has expressed serious concerns about the policies and operation of New Zealand’s Pharmaceutical Management Agency (PhARMAC), including, among other things, the lack of transparency, fairness, and predictability of the PhARMAC pricing and reimbursement regime, as well as the negative aspects of the overall climate for innovative medicines in New Zealand.” [page 25]

Note that the wishes of “U.S. industry” are presented as the only possible point of view. This is consistent with the fact that 605 corporate lobbyists have access to the TPP text as “advisers,” while the public is shut out. The real issue is that the New Zealand agency holds down the price of medicines, cutting down the industry’s exorbitant profit-gouging. A 2011 submission to the U.S. government by corporate lobby group Pharmaceutical Research and Manufacturers of America, called the New Zealand agency an “egregious example” because of its “focus on driving down costs.”

Professor Jane Kelsey of New Zealand’s University of Auckland, who has closely followed TPP issues for years, leaves little doubt that New Zealanders will pay more for medications if TPP comes into force. In an analysis of the leaked health care annex text, she writes:

“This leaked text shows the [TPP] will severely erode Pharmac’s ability to continue to deliver affordable medicines and medical devices as it has for the past two decades. That will mean fewer medicines are subsidised, or people will pay more as co-payments, or more of the health budget will go to pay for medicines instead of other activities, or the health budget will have to expand beyond the cap. Whatever the outcome, the big global pharmaceutical companies will win, and the poorest and most vulnerable New Zealanders will lose.” [page 2]

But other countries are in the cross hairs

The Pharmaceutical Management Agency estimates it has created savings of more than NZ$5 billion since 2000. The language of the TPP health care annex specifically targets “national health care programs” that make pricing decisions and not direct government procurement of medicines and medical devices. Professor Kelsey sees a nationalist agenda behind this specific wording, writing:

“ ‘National’ is presumably chosen to preclude such programmes that are run by states and provinces, which are politically sensitive in the US and Canada. In effect, the US has excluded almost all its own programmes, while targeting New Zealand, as it did with the [Australia-U.S. Free Trade Agreement].” [page 3]

But U.S. Medicare and Canadian provincial programs will certainly be targets as well. Medicare is prohibited under U.S. law from from negotiating prescription prices with drug makers, and the same language that would undermine New Zealand’s program would block any attempt to allow Medicare, or any other agency, from instituting a similar pricing program. Per-capita spending on drugs is far higher in the U.S. than elsewhere, in part thanks to this prohibition, which would become irreversible under the TPP.

The advocacy group National Committee to Preserve Social Security and Medicare notes:

“The fact that Medicare is forbidden in the law that created Medicare Part D to negotiate lower prices is no accident. The drug lobby worked hard to ensure Medicare wouldn’t be allowed to cut into the profits which would flow to big Pharma thanks to millions of new customers delivered to them by Part D.”

“Part D” is a program that shifted millions of people from Medicaid, which pays much less for drugs, to Medicare, a boon to pharmaceutical companies.

The TPP health care annex also contains language that the annex’s provisions are exempted from the “investor-state dispute mechanism,” the secret tribunals in which corporate lawyers sit as judges when corporations sue governments under so-called “free trade” agreements. The annex’s text is misleading, however. Language elsewhere in the TPP that requires “fair and equitable treatment” of foreign “investors” would still enable challenges to New Zealand’s program or any other. Thus, governments could be sued using provisions other than the annex, Professor Kelsey writes:

“The biggest risk is the obligation to provide ‘fair and equitable treatment’, which investors may claim includes a legitimate expectation that governments will comply with their obligations in making regulatory and administrative decisions. They could launch a claim for many millions of dollars compensation, including expected future profits, if they believed New Zealand’s process in general, or in specific cases, violated their expectations under the Transparency Annex and adversely affected the value or profitability of their investment.” [page 6]

Who gets to “consult”?

Deborah Gleeson, a lecturer at La Trobe University in Australia, points out another danger. A “consultation” mechanism that requires governments to consider corporate objections in pricing decisions could be used to apply pressure to make changes to benefit pharmaceutical and medical-device corporations. She writes:

“The inclusion of the Healthcare Transparency Annex in the TPP serves no useful public interest purpose. It sets a terrible precedent for using regional trade deals to tamper with other countries’ health systems and could circumscribe the options available to developing countries seeking to introduce pharmaceutical coverage programs in future.” [page 2]

As elsewhere in the TPP, the U.S. government is taking the most hard-line approach, and has been opposing efforts to exempt the poorest countries from attacks on health care subsidies. Judit Rius Sanjuan of Médecins Sans Frontières/Doctors Without Borders said:

“If the US proposal is accepted, the poorest countries would be forced to limit access to affordable medicines long before their public health needs are under control. The fact remains that no country, rich or poor, should accept limitations on its sovereign ability to ensure medicine is accessible and affordable for all those who need it.”

It’s not as if pharmaceutical companies are not already hugely profitable. They like to whine that they have high research and development costs, and while that is true, the prices they charge are well beyond reasonable expenses. They enjoy one of the highest, if not the highest, profit margin of any industry — nearly 20 percent for 2013. The world’s 10 largest pharmaceutical corporations racked up a composite US$90 billion in profits for 2013, according to a BBC analysis. As to their expenses, these 10 firms spent far more on sales and marketing than they did on research and development.

“Free trade” agreements have very little to do with trade. The Trans-Pacific Partnership, and the similar Transatlantic Trade and Investment Partnership and the Trade In Services Agreement, are nothing more than initiatives to cement corporate control over all aspects of society, in which governments lock themselves into binding agreements that elevate corporate profits above all other human considerations. Don’t get sick.

The toll of privatization and the ideology of “there is no alternative”

No ideology lasts forever, and nothing of human creation lasts forever. Margaret Thatcher embodied the idea of stasis in thought and structure with her infamous statement that “there is no alternative,” which was given further form in her second most notorious utterance, “there is no such thing as society.”

There is no stasis, and five years and counting of economic crisis has chipped away at the idea that there is no alternative to present-day capitalism. It has perhaps also begun to undermine the former prime minister’s second quote, a stark encapsulation of the underlying ideology of everyone for themselves — that pitiless competition is the primary way that human beings relate to one another. Humans surely can be competitive. But they are at least as capable of cooperating, as the reactions to any natural disaster demonstrate.

Time plays its part as well. The bogeys of one generation fail to have the same effect on the next; now that two decades have passed since the disintegration of the Soviet Union, a powerful bogey is becoming less of a talisman for capitalists and the politicians who love them. Thus it is not surprising that polls show that young people are more open to socialism than their parents — the concrete realities of the debt-saturated, limited vistas that today’s economy offers them can not fail to grab their attention.

An often-cited April 2011 survey by the Pew Research Center found that the opinions of respondents in the United States ages 18 to 29 had virtually identical opinions of capitalism and socialism — both were viewed as favorable by 43 percent, while the unfavorable responses differed by one percentage point. An interesting aspect of this poll, much less noticed, is that among respondents who described themselves as Democrats, regardless of age, 44 percent had a positive response to the word “socialism” while 43 percent had a negative response. (Republicans and those who not identify with either major party responded strongly negatively.)

Opinions seem to be evolving, as a later poll, conducted in November 2012 by the conservative Gallup organization, found that 53 percent of “Democrats/Democratic leaners” were favorable to socialism (and 55 percent were favorable to capitalism). Perhaps most interestingly, 23 percent of “Republicans/Republican leaners” were favorable to socialism. Although three times as many of the Republican/Republican-leaning respondents answered positively to the word “capitalism,” nonetheless such a response would have been unimaginable a few years ago. Minds do seem on the move.

The toll from “shock therapy” is, well, shocking

If we are to believe “there is no alternative,” the result should be, if not paradise, then at least rapid improvement in countries in which capitalism was re-instated two decades ago, such as in Russia. But, alas, that has not been so.

Take, for example, a 2009 study published by The Lancet, one of the world’s leading medical journals and hardly a bastion of socialist boosterism. The study, conducted by a team of professors from institutions like Oxford and Cambridge universities, concluded that the mass privatization in the former Soviet bloc — a critical aspect of economic programs often referred to as “shock therapy” — resulted in one million deaths. If you haven’t heard of this study, that is not surprising as it received almost no attention in the corporate media after its issuance.

An Oxford University press release announcing the publication of the study (“The public health effect of economic crises and alternative policy responses in Europe: an empirical analysis”) said:

“The Oxford-led study measured the relationship between death rates and the pace and scale of privatisation in 25 countries in the former Soviet Union and Eastern Europe, dating back to the early 1990s. They found that mass privatisation came at a human cost: with an average surge in the number of deaths of 13 per cent or the equivalent of about one million lives.”

The study used World Health Organization mortality statistics corrected for a series of factors, including population aging, past mortality and employment trends, and country-specific differences in health-care infrastructure. The study found a definitive link between increased mortality and shock therapy:

“David Stuckler, from Oxford’s Department of Sociology, said: ‘Our study helps explain the striking differences in mortality in the post-communist world. Countries which pursued rapid privatisation, or ‘shock therapy’, had much greater rises in deaths than countries which followed a more gradual path. Not only did rapid privatisation lead to mass unemployment but also wiped out the social safety nets, which were critical for helping people survive during this turbulent period.’ ”

The whip was applied earlier than critics assert

Naturally, this sort of ideologically inconvenient research did not lack counter-studies. The Lancet, in January 2010, published “Did mass privatisation really increase post-communist mortality?,” which, this set of authors admit, was motived by an unwillingness to accept the study led by Professor Stuckler. The authors of the counter-study, led by Christopher J. Gerry, made, inter alia, the following complaints:

“[T]he data show that the health trends driving the association noted by Stuckler and colleagues pre-date the introduction of mass privatisation programmes in the post-communist world. … [T]he Russian privatisation programme, announced in December, 1992, and completed in June, 1994, cannot plausibly be claimed to have affected mortality rates at all in 1992 and at most weakly in 1993.”

Unfortunately for this argument, privatization began well before December 1992. Elements of capitalism were introduced into the economy of the Soviet Union as early as 1987, following the uneven adoption of Mikhail Gorbachev’s Law on State Enterprises, the net result of which was to impose wage cuts and other measures of market discipline on workers but not on managements or bureaucracies. A series of liberalization measures in the following years, including a 1990 law that institutionalized privatization, caused more job insecurity and increased shortages, unraveled the dense network of threads that bound together the Soviet system and cut the social safety net.

Moreover, shock therapy was implemented on the second day following the end of the Soviet Union — January 2, 1992 — with complete liberation of prices (except for energy), the concomitant ending of all subsidies of consumer products and for industry, and allowing the ruble to float against international currencies instead of having a fixed exchange rate. This was a strategy to reduce demand significantly, a devastating hardship considering that most products were in short supply already, and it would also lead to hyper-inflation, wiping out savings.

Privatizations and takeovers had already begun; that the government’s formal program, in which enterprises would be sold off at minuscule fractions of their value, did not start until months later is no argument that shock therapy was not already well under way.

The counter-study authors led by Professor Gerry goes so far as to conclude:

“If anything, there may be some evidence of a positive link between market reforms and health outcomes.”

Poverty, alcoholism and sexism as health indicators

The preceding statement seems to be based more on ideology than facts. By the end of 1998, Russia’s economy had contracted by an astonishing 45 percent. The World Bank — a powerful institution of the advanced capitalist countries — estimated that 74 million Russians were living poverty by then, as opposed to two million in 1989. Russia’s murder rate become one of the world’s highest. During Soviet times, we were assured by Western commentators that high levels of alcoholism were a sign of despair, yet alcohol per-capita consumption rates in 2007 were three times that of 1990. The toll on health from these factors can’t be separated from “market reforms.”

The breakdown of a society under the sudden onslaught of unbridled capitalism, neoliberal style, is exemplified in a study by University of Rhode Island Professor Donna M. Hughes, “Supplying Women for the Sex Industry: Trafficking from the Russian Federation,” in which she demonstrated how unemployment, skyrocketing levels of violence at the hands of male partners, the elimination of the Soviet-era social safety net, the pervasiveness of organized crime, and ubiquitous television and other mass media images glamorizing prostitution and the consumption of the rich of the West resulted in hundreds of thousands of Russian women trafficked into prostitution. Professor Hughes also noted the dramatic social shifts unleashed:

“A much reported 1997 survey of 15-year-old schoolgirls found that 70 percent of schoolgirls said they wanted to be prostitutes. Ten years before, 70 percent said they wanted to be cosmonauts, doctors, or teachers. Some people have claimed this finding is an indication of the decline in moral standards or the social acceptability of prostitution. This finding is more likely an indication of how the media has glamorized and romanticized prostitution.” [page 14]

The point here isn’t to suggest that the Soviet Union was some sort of paradise. It was far from that. But it is necessary to challenge assumptions, particularly when when those assumptions rest on ideological foundations. How could the larger social disintegration documented in Professor Hughes’ study, and other indications, not be indicative of a decline in health and well-being?

If market forces improve health outcomes as Professor Gerry believes, then we need only compare the country in which market forces drive health care more than anywhere else, the United States, with other countries. In an average year, 22,000 people die and 700,000 go bankrupt as a result of inadequate, or no, health insurance, while the U.S. is well below average in life expectancy and infant mortality in comparison to other developed countries. And the U.S. spends, by far, the most money on health care of any country.

When “market forces” are allowed to govern health care, then the result is that the system will be geared toward maximizing corporate profit, not providing health care. When society — social bonds — break down, we are reduced to a scramble for survival.

Surely there is an alternative. Crises are overcome with cooperation, not competition. Future alternatives won’t be anything like the Soviet Union, but the number of people newly open to socialism is a sign of the open-mindedness, and strong societies, the world needs.

The high cost of private profit in health care

The United States spends huge amounts of money on health care. But it is only in comparison to other countries that the magnitude of health care spending becomes clear. Because the U.S. health care system is designed for private profit rather than public health, the U.S. spends an extra $1.15 trillion per year beyond what it would otherwise.

If that total astounds you, you are not alone. When I first began making calculations to determine excess spending in health care, the figures were so large that I had difficultly believing them and performed the calculations over again. The result was the same.

The excess spending on health care is not only growing, it is growing much faster than the rate of inflation, in concert with overall health care spending. For instance, the annual average of excess spending for the period of 1990 to 2000 was $685 billion. For the period of 2001 to 2010, the annual average ballooned to $1.15 trillion.

And despite all that extra spending, U.S. residents have poor health results in many key indicators, in comparison to the world’s other advanced capitalist countries. Still more amazing, 51 million people in the U.S. are without health insurance, while all other peer countries have universal care. This is the system that millions of U.S. citizens believe is the best in the world thanks to the world’s most developed public relations and misinformation industries.

The rest of the world is quite in disagreement, to the point that even the harsh austerity-minded Conservative prime minister of the United Kingdom, David Cameron, has repeatedly had to deny (whether or not sincerely I will leave to others) any intention to emulate the U.S. system as he attempts to impose changes on the country’s National Health Service.

U.S. health care is by far the world’s highest

Let’s do a bit of digging under the surface of numbers. First off, an explanation of where the $1.15 trillion in annual excess spending comes from. I calculated the number by first obtaining total health care spending per capita* of the three largest economies within the European Union (France, Germany and the United Kingdom) and of Canada, the neighbor of the United States. I then averaged the numbers for the years 2001 to 2010 (the latest for which full statistics are available) as compiled by the Organisation for Economic Co-operation and Development (OECD), the club of the world’s advanced capitalist countries and the largest developing countries.

The composite average of Canada, France, Germany and the U.K. for 2001 to 2010 is US$3,479 per capita per year. That number is less than half of the U.S., which had by far the world’s highest health care spending at $7,325 per capita per year. The differential was then multiplied by 300 million, the approximate U.S. population during the past decade. If you prefer a different measure, the U.S. spent 17.4 percent of its 2009 gross domestic product on health care expenditures, again the world’s largest by a wide margin. The average of the 34 countries of the OECD is 9.6 percent.

And if that is not enough, here is one more astounding comparison: Not only are out-of-pocket expenses by U.S. health care consumers higher than in any of the four comparison countries (no surprise there) but per capita government spending in the U.S. is higher than in any of the four comparison countries. Those four have varying versions of what U.S. right-wing ideologues venomously denounce as “socialized medicine” — health care systems either run or closely regulated and supervised by a federal government paid for through taxation — and yet each government nonetheless spends less than does the U.S. government on a per capita basis.

Despite the massive transfer of money to private insurance companies by employers and employees, on a per-capita basis government health care spending by itself in the U.S. is higher than total health care spending in Canada.**

The authors of the paper “Why is health spending in the United States so high?” (a supplement to an OECD statistical report) attempted to draw conclusions from a mass of data on health care expenditures:

“It does not have many physicians relative to its population; it does not have a lot of doctor consultations; it does not have a lot of hospital beds, or hospitals stays, when compared with other countries, and when people go to hospital, they do not stay for long. All these data on health care activities suggest that U.S. health spending should be low compared with other countries.”

The reason that spending is anything but low is because of the high prices extracted throughout the system. The costs of a range of medical procedures or surgeries are much higher in the U.S. than elsewhere, as are pharmaceutical prices. The authors write:

“Overall, the evidence suggests that prices for health services and goods are substantially higher in the United States than elsewhere. This is an important cause of higher health spending in the United States.”

The OECD is an organization that is representative of the world’s most powerful capitalist countries, so the report does not inquire into underlying causes or in any way challenge the economic system that leads to such results; it merely reports facts and figures. Those facts and figures, however, give us a useful starting point. The wasteful spending on health care are subsidies for pharmaceutical manufacturers, hospital-chain operators, insurance companies, managed-care companies and medical-products manufacturers. Money flows to those corporate entities directly from your pocket and indirectly from you via government spending.

Each U.S. citizen’s annual share of wasteful, excess spending on health care — excess spending that goes into the coffers of some of the country’s largest corporations among the many industry profiteers — amounts to $3,846. Business leaders, their lavishly funded think tanks and pressure groups, and the public-office officials who represent them continually assert that private enterprise is always more efficient. It would seem that the efficiency lies in extracting money and wealth.

Government more efficient because goal isn’t private profit

Noting that “high administrative costs and lower quality have also characterized for-profit HMOs” (health maintenance organizations funded by insurance premiums that supervise health care), a Journal of the Canadian Medical Association article provides the following figures for the percentage of revenue that is diverted to overhead:**

  • For-profit HMOs: 19 percent
  • Non-profit plans: 13 percent
  • U.S. Medicare program: 3 percent
  • Canadian Medicare: 1 percent

In contrast to the rhetoric so often employed, government is far more efficient at delivering health care than the private sector. (This is also true in retirement plans, where the U.S. Social Security program’s overhead is much lower than mutual-fund managers or other financial-industry enterprises.) An important reason is that the government does not skim off massive amounts of money for bloated executive pay nor does it need to generate large profits to enrich financiers.

Such large expenditures also flow from a lack of competition. Few people in the U.S. have a choice of insurance provider, which is dictated by their employer, and insurance companies and HMOs frequently limit choice of doctors, and often deny coverage so as to maximize profits. A company that has stock traded on exchanges is legally required to maximize profits above any other consideration; it is no different because health care happens to be the product.

A few summers ago, I found myself in a debate with a Canadian woman who was critical of her country’s health care system. I acknowledged that Canadian health care is not perfect, but then gave the example of a friend who had recently died in his 50s of a heart attack because his insurer decreed that he did not require medication for his weak heart and he could not afford it on his own. Does that happen in Canada?, I asked. She replied with silence.

As in any other mature industry, most market share has consolidated into a few hands, a condition that is known as an “oligarchy.” Although competition in younger or more fractured industries does result in price reductions, when an industry is reduced to a small number of dominant corporations, price competition is usually a casualty.

Health care constitutes several industries — insurance, pharmaceuticals, hospitals and medical equipment, among others — and each adds to the cost. Giant pots of government money are involved, always a lucrative source of private enrichment. And insurers have people over a barrel because health insurance comes through their employer, who make deals with a single insurer, take it or leave it.

Health care provision also has unique attributes that further inflate costs. In “The high costs of for-profit care,” by Steffie Woolhandler and David U. Himmelstein (the Journal of the Canadian Medical Association article quoted above), the authors write:

“Why do for-profit firms that offer inferior products at inflated prices survive in the market? Several prerequisites for the competitive free market described in textbooks are absent in health care. First, it is absurd to think that frail elderly and seriously ill patients, who consume most health care, can act as informed consumers (i.e., comparison-shop, reduce demand when suppliers raise prices or accurately appraise quality). …

“Second, the “product” of health care is notoriously difficult to evaluate, even for sophisticated buyers like government. … By labeling minor chest discomfort “angina” rather than “chest pain,” a U.S. hospital can garner both higher Medicare payments and a factitiously improved track record for angina treatment. It is easier and more profitable to exploit such loopholes than to improve efficiency or quality.

“Even for honest firms, the careful selection of lucrative patients and services is the key to success, whereas meeting community needs often threatens profitability. … [For-profit] hospitals duplicate services available at nearby not-for-profit general hospitals, but the newcomers avoid money-losing programs such as geriatric care and emergency departments (a common entry point for uninsured patients). The profits accrue to the investors, the losses to the not-for-profit hospitals, and the total costs to society rise through the unnecessary duplication of expensive facilities.”

U.S. fares very poorly in a comparison of national systems

In the spirit of comparison-shopping, here is a brief examination of the five countries under discussion, the United States and the four comparison countries.

  • German health care system: Everybody is covered. Workers pay eight percent of their gross income into a “sickness fund,” a nonprofit insurance company; employers pay the same amount. These contributions account for almost all money in the system. Workers choose among 240 sickness funds. There are no deductibles. Everything, including drugs, is free for children younger than eighteen. The government regulates all insurance companies closely.
  • French health care system: Everybody is covered. Workers pay 21 percent of their income into a combined retirement and national health care system; employers pay about half that amount. Payroll and income taxes largely fund health care. There are no waiting lists for elective surgery or to see a specialist. Doctors’ fees are negotiated with medical unions, while hospital fees are regulated. Patients with one of 30 long-term and expensive illnesses pay nothing for care.
  • British health care system: Everybody is covered. The National Health Service is funded by income taxes, employs physicians and nurses, and owns most of the hospitals and clinics. The service also pays directly for all health care expenses, with prescriptions and dentistry being the two exceptions. There are sometimes long waiting lists, which are commonly attributed to there being no restrictions on services, particularly hospitalization.
  • Canadian health care system: Everybody is covered. The federal government sets standards; provincial and territorial governments administer the system. Medically necessary hospital, physician and diagnostic services are free, although most dental care and prescription drugs are not covered. Services are primarily through private providers. Long waiting times for specialists are a problem, with reduced government payments cited as an underlying cause.
  • U.S. health care system: 51 million are not covered. Coverage is through an employer (of which the employee pays a portion), or through own purchase of private insurance, but most can’t afford to do so. Insurance companies frequently dictate what, or if, services will be provided. Coverage generally requires out-of-pocket expenses and includes a “deductible” before payments begin. Patient bankruptcies due to inability to pay bills are common.

Another weakness of the U.S. health care system is that is based on the concept of a “family wage” instead of a “social wage.” That is both cause and effect — unlike other countries where health care is a right, in the U.S. health care is a privilege, and the large disparities in the ability to obtain it reflects the canyon-like inequality there and also aggravates social inequities. Not only because health care is tied to an employer, giving a boss more power over employees, but because a family’s health care coverage is tied to the person who has the job that provides it — usually the man in a traditional family. But it could be any one person in a non-traditional family or within a gay or lesbian household.

Universal health care systems are gains of movements

Feminist pioneer and theorist Kathie Sarachild of the influential group Redstockings, in a July 4 interview on the Joy of Resistance: Multi-cultural Feminist Radio program, summarized this concept. She said:

“The family wage is another way of saying this old idea that men should support the family. [U.S.] society is built on the idea that men should get higher pay than women because men would support the family and women would stay home and take care of the children. … Even though there were always women who worked, they received less pay than men did because of this family-wage concept. …

“A lot of [the European social wage] came out of socialist and communist theory. … The labor movement and the feminist movement in [Europe] have been able to win a social-wage system, which pays to raise the next generation [through universal health care and paid leave when a child is born instead of being dependent on an employer to pay a ‘family wage’ to the man].”

Nationalized health care becomes part of a basket of social benefits, including more vacation time, life-long education and elder care that liberates working people from dependence on an employer. A shorter work week would also bring benefits, Ms. Sarachild said:

“If the work week were shorter … there would be more jobs. There’d be less unemployment because the work week is shorter so there are more paid jobs. There would be more time at home for the father and mother to be with the child. …. [With the introduction of a] social wage, the unfair family wage would not be necessary. … [Women] are not as dependent on the man, and both of you are not so dependent on the employer.”

The lower wages of women in the “family wage” system boost corporate profits on the backs of women, Joy of Resistance host Fran Luck points out, and many women are forced to stay in bad relationships because they would lose their health care.

For men and women, the price of private profit is enormously high: 22,000 people die and 700,000 go bankrupt per year as a result of inadequate, or no, health insurance in the United States.*** The U.S. ranks among the bottom five of the 34 OECD countries in per capita doctor consultations, hospital beds and average length of stay in hospitals,**** and is well below average in life expectancy and infant mortality.

The country’s people pay more than $1.15 trillion per year on top of what they should pay to swell corporate profits and executive and Wall Street wallets — in return, we receive worse coverage. That is the price of capitalism.

* OCED figures. Spending per capita in U.S. dollars adjusted to create purchasing power parity.
** Steffie Woolhandler and David U. Himmelstein, “The high costs of for-profit care,” Journal of the Canadian Medical Association, June 8, 2004, pages 1814, 1815.
*** T.R. Reid, “No Country For Sick Men,” Newsweek, Sept. 21, 2009, pages 43-44.
**** “Why is health spending in the United States so high?,” OECD report, page 5.