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Society never advances. It recedes as fast on one side as it gains on the other. It undergoes continual changes; it is barbarous, it is civilized, it is christianized, it is rich, it is scientific; but this change is not amelioration. For every thing that is given, something is taken. Society acquires new arts, and loses old instincts. What a contrast between the well-clad, reading, writing, thinking American, with a watch, a pencil, and a bill of exchange in his pocket, and the naked New Zealander, whose property is a club, a spear, a mat, and an undivided twentieth of a shed to sleep under! But compare the health of the two men, and you shall see that the white man has lost his aboriginal strength. If the traveller tell us truly, strike the savage with a broad axe, and in a day or two the flesh shall unite and heal as if you struck the blow into soft pitch, and the same blow shall send the white to his grave. The civilized man has built a coach, but has lost the use of his feet. He is supported on crutches, but lacks so much support of muscle. He has a fine Geneva watch, but he fails of the skill to tell the hour by the sun. A Greenwich nautical almanac he has, and so being sure of the information when he wants it, the man in the street does not know a star in the sky. The solstice he does not observe; the equinox he knows as little; and the whole bright calendar of the year is without a dial in his mind. His note-books impair his memory; his libraries overload his wit; the insurance-office increases the number of accidents; and it may be a question whether machinery does not encumber; whether we have not lost by refinement some energy, by a Christianity entrenched in establishments and forms, some vigor of wild virtue. For every Stoic was a Stoic; but in Christendom where is the Christian?

The United States spends more than twice as much per capita on health care as other rich capitalist countries —around $9,400 compared to around $3,600—and for that money its citizens can expect lives that are three years shorter. The United States spends more per capita on health care than any other country in the world, but 39 countries have longer life expectancies. [...] Under the current US system, rich, insured patients visit doctors more than they need, running up costs, while poor patients cannot afford even simple, inexpensive treatments and die younger than they should. Doctors spend time that could be used to save lives or treat illness by providing unnecessary, meaningless care. What a tragic waste of physician care.

Notably, Tennessee is known as a “Right to Work” state, which, despite having the ring of a guaranteed job, is a phrase that refers to laws that ensure workers are not required to pay union fees as a condition of their employment. The “Right to Work” movement was initiated in Southern states as a way of weakening union control and, in doing so, luring factory jobs from the Rust Belt. Studies have shown that workers in “Right to Work” states tend to have lower wages, inferior health insurance, and inferior pension programs when compared to workers in states that do not have “Right to Work” laws.75

Ironically, many of the institutions that run the economy, such as medicine, education, law and even psychology are largely dependent upon failing health. If you add up the amounts of money exchanged in the control, anticipation and reaction to failing health (insurance, pharmaceutical research and products, reactive or compensatory medicine, related legal issues, consultation and therapy for those who are unwilling to improve their physical health and claim or believe the problem is elsewhere, etc.), you end up with an enormous chunk. To keep that moving, we need people to be sick. Then we have the extreme social emphasis placed on the pursuit and maintenance of a lifestyle based on making money at any cost, often at the sacrifice of health, sanity and well-being.

The best available apples-to-apples comparison of inflation-adjusted earnings shows what the typical fully employed man earned back in the 1970s and what that same fully employed man earns today. The picture isn’t pretty. As the GDP has doubled and almost doubled again, as corporations have piled up record profits, as the country has gotten wealthier, and as the number of billionaires has exploded, the average man working full-time today earns about what the average man earned back in 1970. Nearly half a century has gone by, and the guy right in the middle of the pack is making about what his granddad did. The second punch that’s landed on families is expenses. If costs had stayed the same over the past few decades, families would be okay—or, at least, they would be in about the same position as they were thirty-five years ago. Not advancing but not falling behind, either. But that didn’t happen. Total costs are up, way up. True, families have cut back on some kinds of expenses. Today, the average family spends less on food (including eating out), less on clothing, less on appliances, and less on furniture than a comparable family did back in 1971. In other words, families have been pretty careful about their day-to-day spending, but it hasn’t saved them. The problem is that the other expenses—the big, fixed expenses—have shot through the roof and blown apart the family budget. Adjusted for inflation, families today spend more on transportation, more on housing, and more on health insurance. And for all those families with small children and no one at home during the day, the cost of childcare has doubled, doubled again, and doubled once more. Families have pinched pennies on groceries and clothing, but these big, recurring expenses have blown them right over a financial cliff.

In March 2002, the National Academy of Sciences, a private, nonprofit society of scholars, released a high-profile report documenting the unequivocal existence of racial bias in medical care, which many thought would mark a real turning point. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care was so brutal and damning that it would seem impossible to turn away. The report, authored by a committee of mostly white medical educators, nurses, behavioral scientists, economists, health lawyers, sociologists, and policy experts, took an exhaustive plunge into more than 480 previous studies. Because of the knee-jerk tendency to assume that health disparities were the end result of differences in class, not race, they were careful to compare subjects with similar income and insurance coverage. The report found rampant, widespread racial bias, including that people of color were less likely to be given appropriate heart medications or to undergo bypass surgery or receive kidney dialysis or transplants. Several studies revealed significant racial differences in who receives appropriate cancer diagnostic tests and treatments, and people of color were also less likely to receive the most sophisticated treatments for HIV/AIDS. These inequities, the report concluded, contribute to higher death rates overall for Black people and other people of color and lower survival rates compared with whites suffering from comparable illnesses of similar severity.

If you are stuck in circumstances in which it takes Herculean efforts to get through the day— doing low-income work, obeying an authoritarian boss, buying clothes for the children, dealing with school issues, paying the rent or mortgage, fixing the car, negotiating with a spouse, paying taxes, and caring for older parents— it is not easy to pay close attention to larger political issues. Indeed you may wish that these issues would take care of themselves. It is not a huge jump from such a wish to become attracted to a public philosophy, spouted regularly at your job and on the media, that economic life would regulate itself automatically if only the state did not repeatedly intervene in it in clumsy ways. Now underfunded practices such as the license bureau, state welfare, public health insurance, public schools, public retirement plans, and the like begin to appear as awkward, bureaucratic organizations that could be replaced or eliminated if only the rational market were allowed to take care of things impersonally and quietly, as it were. Certainly such bureaucracies are indeed often clumsy. But more people are now attracted to compare that clumsiness to the myth of how an impersonal market would perform if it took on even more assignments and if state regulation of it were reduced even further. So a lot of “independents” and “moderates” may become predisposed to the myth of the rational market in part because the pressures of daily life encourage them to seek comfort in ideological formations that promise automatic rationality.

A recent survey of private US health care facilities estimated that the support staff of hospital physicians spends nineteen hours a week interacting with insurance providers in prior authorizations, while clerical staff spend thirty-six hours a week filing claims. The cost of interactions between private health care providers and private insurance providers was estimated to be $68,000 per physician per year, totaling a whopping $31 billion per year—equivalent to the GDP of the Dominican Republic in 2005.22 The interaction costs in 1999 for the entire health care system, including private and public, were estimated on the low end to be $31 billion and on the high end to be $294 billion—which is comparable to the present day GDP of Singapore or Chile.

For interested consumers, there are many health pricing tools. For starters, I recommend The Wall Street Journal’s “Medicare Unmasked” tools,2 although they may be behind a paywall. The Health Care Cost Institute3 is a health-insurer funded effort to compare the cost of various procedures around the country.4 ProPublica, a non-profit news site, is one of several consumer sites that has used the CMS databases to build tools that are not exactly beloved by health care providers, including Dollars for Docs5 and Surgeon Scorecard.6

Netherlands, which has a restrictive immigration policy compared to the United States. Most European nations, including the Netherlands, after all, have universal health insurance coverage, which makes drug treatment and psychiatric treatment more available, and the Dutch government subsidizes more housing. Finally, the Netherlands’ big success was with heroin, which has effective pharmacological substitutes, methadone and Suboxone, not with meth, which lacks anything similar. But there may be fewer obstacles than appear. The Netherlands has a private health-care insurance system similar to that of the United States and covered the people who needed health care in ways similar to Medicaid and the Affordable Care Act, which significantly expanded access to drug treatment, including medically assisted treatment, in the United States.4 San Francisco subsidizes a significant quantity of housing, as we have seen. While California is larger than the Netherlands, the population of Amsterdam (872,000) is nearly identical to San Francisco’s (882,000).5 And while California’s population and geographic area are larger and more difficult to manage than those of the Netherlands, California also has significantly greater wealth and resources, constituting in 2019 the fifth-largest economy in the world.6 And the approach to breaking up open drug scenes, treating addiction, and providing psychiatric care is fundamentally the same whether in five European cities, Philadelphia, New York, or Phoenix.

Consider, for example, the landmark 2004 study that followed several hundred patients treated with one of three popular antidepressants: Zoloft, Paxil, or Prozac. Among those who took the drugs as prescribed, only 23% were depression-free after six months of treatment. (As you might expect, patients who failed to take their meds did even worse.) And all three medications yielded roughly the same dismal results. A fluke result, perhaps? It’s actually pretty typical. The recovery rate with antidepressants in similar studies usually falls somewhere between 20% and 35%. Clinical researchers at forty-one treatment sites across the country have just completed the largest real-world study of antidepressants ever conducted, and the results fit the same overall pattern. This multimillion dollar project, sponsored by the National Institutes of Mental Health, followed about three thousand depressed patients who initially took the drug citalopram (marketed under the trade name Celexa) for about twelve weeks. By the end of that short-term treatment period, only 28% of study patients had fully recovered. The study’s 28% response rate might even be an overestimate of the medication’s true effectiveness, because patients received higher drug doses and had more frequent doctor’s visits than people do in everyday clinical practice. (In real life, insurance companies sharply restrict the frequency of “med check” follow-up appointments). Remarkably, the study’s authors—a veritable All-Star team of clinical researchers—noted that the observed 28% recovery rate was about what they had expected to see based on comparable studies. That’s right: They weren’t surprised to find that the majority of study patients failed to recover on an antidepressant. In the study’s published write-up, the researchers also raised a provocative question: What percentage of their patients might have recovered if they had received a sugar pill—a placebo—instead of the medication? Could it possibly have been as high as 28%?

Here’s an example from the test Marty and his students developed to distinguish optimists from pessimists: Imagine: You can’t get all the work done that others expect of you. Now imagine one major cause for this event. What leaps to mind? After you read that hypothetical scenario, you write down your response, and then, after you’re offered more scenarios, your responses are rated for how temporary (versus permanent) and how specific (versus pervasive) they are. If you’re a pessimist, you might say, I screw up everything. Or: I’m a loser. These explanations are all permanent; there’s not much you can do to change them. They’re also pervasive; they’re likely to influence lots of life situations, not just your job performance. Permanent and pervasive explanations for adversity turn minor complications into major catastrophes. They make it seem logical to give up. If, on the other hand, you’re an optimist, you might say, I mismanaged my time. Or: I didn’t work efficiently because of distractions. These explanations are all temporary and specific; their “fixability” motivates you to start clearing them away as problems. Using this test, Marty confirmed that, compared to optimists, pessimists are more likely to suffer from depression and anxiety. What’s more, optimists fare better in domains not directly related to mental health. For instance, optimistic undergraduates tend to earn higher grades and are less likely to drop out of school. Optimistic young adults stay healthier throughout middle age and, ultimately, live longer than pessimists. Optimists are more satisfied with their marriages. A one-year field study of MetLife insurance agents found that optimists are twice as likely to stay in their jobs, and that they sell about 25 percent more insurance than their pessimistic colleagues. Likewise, studies of salespeople in telecommunications, real estate, office products, car sales, banking, and other industries have shown that optimists outsell pessimists by 20 to 40 percent.

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People employ what economists call “rational ignorance.” That is, we all spend our time learning about things we can actually do something about, not political issues that we can’t really affect. That’s why most of us can’t name our representative in Congress. And why most of us have no clue about how much of the federal budget goes to Medicare, foreign aid, or any other program. As an Alabama businessman told a Washington Post pollster, “Politics doesn’t interest me. I don’t follow it. … Always had to make a living.” Ellen Goodman, a sensitive, good-government liberal columnist, complained about a friend who had spent months researching new cars, and of her own efforts study the sugar, fiber, fat, and price of various cereals. “Would my car-buying friend use the hours he spent comparing fuel-injection systems to compare national health plans?” Goodman asked. “Maybe not. Will the moments I spend studying cereals be devoted to studying the greenhouse effect on grain? Maybe not.” Certainly not —and why should they? Goodman and her friend will get the cars and the cereal they want, but what good would it do to study national health plans? After a great deal of research on medicine, economics, and bureaucracy, her friend may decide which health-care plan he prefers. He then turns to studying the presidential candidates, only to discover that they offer only vague indications of which health-care plan they would implement. But after diligent investigation, our well-informed voter chooses a candidate. Unfortunately, the voter doesn’t like that candidate’s stand on anything else — the package-deal problem — but he decides to vote on the issue of health care. He has a one-in-a-hundred-million chance of influencing the outcome of the presidential election, after which, if his candidate is successful, he faces a Congress with different ideas, and in any case, it turns out the candidate was dissembling in the first place. Instinctively realizing all this, most voters don’t spend much time studying public policy. Give that same man three health insurance plans that he can choose from, though, and chances are that he will spend time studying them. Finally, as noted above, the candidates are likely to be kidding themselves or the voters anyway. One could argue that in most of the presidential elections since 1968, the American people have tried to vote for smaller government, but in that time the federal budget has risen from $178 billion to $4 trillion. George Bush made one promise that every voter noticed in the 1988 campaign: “Read my lips, no new taxes.” Then he raised them. If we are the government, why do we get so many policies we don’t want?

People employ what economists call “rational ignorance.” That is, we all spend our time learning about things we can actually do something about, not political issues that we can’t really affect. That’s why most of us can’t name our representative in Congress. And why most of us have no clue about how much of the federal budget goes to Medicare, foreign aid, or any other program. As an Alabama businessman told a Washington Post pollster, “Politics doesn’t interest me. I don’t follow it. … Always had to make a living.” Ellen Goodman, a sensitive, good-government liberal columnist, complained about a friend who had spent months researching new cars, and of her own efforts study the sugar, fiber, fat, and price of various cereals. “Would my car-buying friend use the hours he spent comparing fuel-injection systems to compare national health plans?” Goodman asked. “Maybe not. Will the moments I spend studying cereals be devoted to studying the greenhouse effect on grain? Maybe not.” Certainly not —and why should they? Goodman and her friend will get the cars and the cereal they want, but what good would it do to study national health plans? After a great deal of research on medicine, economics, and bureaucracy, her friend may decide which health-care plan he prefers. He then turns to studying the presidential candidates, only to discover that they offer only vague indications of which health-care plan they would implement. But after diligent investigation, our well-informed voter chooses a candidate. Unfortunately, the voter doesn’t like that candidate’s stand on anything else — the package-deal problem — but he decides to vote on the issue of health care. He has a one-in-a-hundred-million chance of influencing the outcome of the presidential election, after which, if his candidate is successful, he faces a Congress with different ideas, and in any case, it turns out the candidate was dissembling in the first place. Instinctively realizing all this, most voters don’t spend much time studying public policy. Give that same man three health insurance plans that he can choose from, though, and chances are that he will spend time studying them. Finally, as noted above, the candidates are likely to be kidding themselves or the voters anyway. One could argue that in most of the presidential elections since 1968, the American people have tried to vote for smaller government, but in that time the federal budget has risen from $178 billion to $4 trillion.

...the United States is the sickest of the rich. ... The United States spends more than twice as much per capita on health care as other capitalist countries on Level 4--around $9,400 compared to around $3,600--and for that money its citizens can expect lives that are three years shorter. the United States spends more per capita on health care than any other country in the world, but 39 countries have longer life expectancies. ...US citizens should be asking why they cannot achieve the same levels of health, for the same cost, as other capitalist countries that have similar resources. The answer is not difficult, by the way: it is the absence of the basic public health insurance that citizens of most other countries on Level 4 take for granted.

It is a fact of life that people love to complain, particularly about how terrible the modern world is compared with the past. They are nearly always wrong. On just about any dimension you can think of—warfare, crime, income, education, transportation, worker safety, health—the twenty-first century is far more hospitable to the average human than any earlier time.

Popular accounts portray Europe as either an economic phoenix or a basket case. The phoenix view observes that output per hour worked has risen from barely 50 percent of U.S. levels after World War II and two-thirds of those levels in 1970 to nearly 95 percent today and that labor productivity so measured is actually running above U.S. levels in a substantial number of Western European countries. Since the turn of the twenty-first century, the euro zone has created more new jobs than either the United States or the United Kingdom. Its exports have grown faster than those of the United States. It provides more of its citizens with health insurance, efficient public transportation, and protection from violent crime. The basket-case view observes that the growth of aggregate output and output per hour have slowed relative to the United States since the mid-1990s. Between 1999, when EMU began, and 2005, euro-zone growth averaged just 1.8 percent, less than two-thirds the 3.1 percent recorded by the United States. Productivity growth has trended downward since the early 1990s, owing to labor-, product-, and capital-market rigidities, inadequate R&D spending, and high tax rates - in contrast to the United States, where productivity growth has been rising. The growth of the working-age population has fallen to zero and is projected to turn significantly negative in coming years. High old-age dependency ratios imply large increases in the share of national income devoted to health care, lower savings rates, potentially heavier fiscal burdens, and an aversion to risk taking. All these are reasons to worry about Europe's competitiveness and economic performance. One way of reconciling these views is to distinguish the distant from the recent past and the past from the future. Comparing the European economy at the midpoint and the end of the twentieth century, there is no disputing the phoenix view. Economic performance over this half century was a shining success both absolutely and relative to the United States. More recently, however, Europe has tended to lag. Although this does nothing to put the past in a less positive light, it creates doubts about the future. One way of understanding these changing fortunes is in terms of the transition from extensive to intensive growth. Europe could grow quickly for a quarter century after World War II and continue doing well relative to the United States for some additional years because the institutions it inherited and developed after World War II were well suited for importing technology, maintaining high levels of investment, and transferring large amounts of labor from agriculture to industry. Eventually, however, the scope for further growth on this basis was exhausted. Once the challenge was to develop new technologies, and once growth came to depend more on entrepreneurial initiative than on brute-force capital accumulation, the low rates of R&D spending, high taxes, conservative finance, and emphasis on vocational education delivered by those same institutions became more of a handicap than a spur to growth. Consistent with this view is the fact that Europe's economic difficulties seem to have coincided with the ICT revolution and the opportunities it affords to economies with a comparative advantage in pioneering innovation, as well as with globalization and growing competition from developing countries such as China that are moving into the production of the quality manufacturing goods that have been a traditional European stronghold. The question is what to do about it. Is it necessary for Europe to remake its institutions along American lines? Or is there still a future for the European model?

Automated tools for allocating care have major problems as well. In a well-publicized 2019 study60, public health scholar Ziad Obermeyer and his collaborators evaluated a prediction system used by hospitals, physician groups (including health maintenance organizations or HMOs), and health insurance groups to identify patients who may have complex health needs and provide more resources for care management. The algorithm they assessed had been applied to about 200 million people in the United States, nearly two-thirds of the population. Obermeyer and his team found that the algorithm dramatically underestimated the care needed for Black individuals, compared to white individuals. The team found that this was largely due to the lack of access to health care for Black people: the algorithm used previous expenditures to predict future expenditures on health care, rather than actual health care needs. Black people in the dataset were, on balance, sicker than white people, but were less likely to seek treatment (likely due to cost, availability, and potential discrimination).

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