Posts Tagged ‘United States’


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The dystopia of the American healthcare system certainly invites a utopian response—a ruthless criticism as well as a vision of an alternative.

As I showed last week, the left-wing response involves a critique of the conditions and consequences of the capitalist organization of U.S. healthcare and the fashioning of a radical alternative. Single-payer, which uses tax revenues to finance the purchase of adequate healthcare services for everyone, is one possibility. On top of that, it is necessary to expand the diversity of healthcare providers, which would include more democratic, cooperative or worker-owned healthcare enterprises.

That’s how activists, educators, and policymakers informed by heterodox economics can begin to rethink the U.S. healthcare system. What about mainstream economics?

Given the persistent attacks on and attempts to replace Obamacare by Republican legislators—against a “government takeover” of healthcare in the name of “free markets”—one would expect mainstream economists to provide a theoretical justification based on their usual utopianism—of an efficient allocation of scarce resources in an economy characterized by private property and individual decisions in unregulated markets.

However, as it turns out, they can’t. And that’s all because of Kenneth Arrow.

Consider, for example, the 2017 New York Times column by Greg Mankiw.

In Econ 101, students learn that market economies allocate scarce resources based on the forces of supply and demand. In most markets, producers decide how much to offer for sale as they try to maximize profit, and consumers decide how much to buy as they try to achieve the best standard of living they can. Prices adjust to bring supply and demand into balance. Things often work out well, with little role left for government. Hence, Adam Smith’s vaunted “invisible hand.”

Yet the magic of the free market sometimes fails us when it comes to health care.

Mankiw, who is known to celebrate free markets in everything, is forced to allow for an exception when it comes to healthcare. (Fellow mainstream economist John Cochrane, in a sharp riposte, argued that “For once, I think Greg got it wrong.”)


The reason is because, back in 1963, future Nobel Laureate Arrow published “Uncertainty and the Welfare Economics of Medical Care.” Mankiw’s column (and the longer treatment for his textbook [pdf]) is basically a restatement of the issues raised by Arrow over a half century ago.

According to Arrow, healthcare is characterized by a set of “special features,” all of which stem from the “prevalence of uncertainty.” These include the following:

  • an irregular, unpredictable demand for medical care
  • an element of trust in the relationship between patient and provider
  • considerable uncertainty as to the quality of the healthcare provided as well as asymmetry of knowledge concerning that quality
  • a restricted supply (e.g., because of licensing)
  • a combination of price discrimination (e.g., between the insured and uninsured) and price-fixing

In consequence, the healthcare industry cannot be expected to operate along the lines of, or to deliver the same results as, the canonical neoclassical model of perfect competition.

Thus, Arrow concludes,

It is the general social consensus, clearly, that the laissez-faire solution for medicine is intolerable. . .

The logic and limitations of ideal competitive behavior under uncertainty force us to recognize the incomplete description of reality supplied by the impersonal price system.

Neither Arrow nor Mankiw suggests what the alternative is. But it’s clear that, from the perspective of mainstream economics, healthcare cannot be shoehorned into the neoclassical model of perfect competition they use to analyze all other commodities and markets. What we can say is their theory of the economics of healthcare leaves open the possibility of considerable extra-market intervention and regulation.

Healthcare is where the utopianism of neoclassical economics fails.

But then we can ask, where does that utopianism not fail? Why should it hold any better when it comes to other capitalist commodities, such as labor power, money, and land? And, if it does not, then neither the modes of analysis nor the policy conclusions that are central to mainstream economics retain any validity.

In my opinion, that’s why the issue of utopia and healthcare is so important.


This is the first in a series of blog posts on the utopian dimensions of healthcare.

I’ve written quite a bit about the U.S. healthcare dystopia over the years—including a seven-part series back in 2016.* But I haven’t yet addressed the utopian dimensions of healthcare reform.

The appearance of the new issue of Jacobin Magazine, titled “The Health of Nations,”  is a good occasion to start that discussion. Adam Gaffney starts with much the same question that provoked my own series of blog posts: “if American health care used to be so much worse, why is it in crisis now?”

In part because, despite such wide-ranging reform, the system’s injustices remain unresolved, pervasive, and deadly.

The figures tell the story. Even without Republican rollbacks, twenty-eight million have no insurance, and, according to the Commonwealth Fund, some forty-one million are underinsured. A substantial portion of the nation—predominantly those of low and middle income and disproportionately people of color—cannot afford to see doctors, pay for medicine, or go to the emergency room.

Families who bought silver plans on the Obamacare marketplace still have $8,292 deductibles, but less than half of American households can cover even a $4,000 deductible. Patients take twice-a-day medications only once, skip doses, or fail to ll their prescriptions to save on co-payments. And of course, people die — tens of thousands of people a year—because they lack coverage.

But the crisis in American health care isn’t simply that the ACA didn’t go far enough: it’s that there’s no ACA 2.0 available to finish the job. Real progress has been made, but the incremental reforms left us with a deeply inhumane system.

The problem, as Gaffney sees it, is that

the Right is on the prowl, offering a slew of tired, malicious nostrums about personal responsibility, while liberal reformers have mostly run out of ammunition. But the Left has not, and single payer is now the only potent policy weapon still on the table.

I agree that the Right is attempting to dismantle many of the supports and safeguards, however limited, that are already in place. And liberals simply have nothing new to offer. But, beyond that, should the the utopian horizon for healthcare reform, at least from the Left’s perspective, be limited to Medicare-for-all?

The case Gaffney makes is quite persuasive:

Almost everyone—sick and well, insured and uninsured—has something to gain from this system. Single payer’s universalism is its strength, and the reason we can win it. But the Medicare-for-all movement is both a means and an end: it will clearly make for a happier and healthier nation, but it can also can become a unifying issue within a larger egalitarian political project at a moment of political crisis.

The universalism, I concur, is its strength—much like Social Security, which represents a collective bond whereby current generations of workers contribute to supporting previous generations who are now retired. Single-payer is the use of tax revenues, levied on individuals and corporations, to finance the purchase of adequate healthcare services for everyone. And, yes, it certainly can serve as a key issue within a larger egalitarian project.

But the Medicare-for-all proposal only gets at how healthcare is financed, not how it is produced or provided. It substitutes single-payer for private insurance and individual payments (for copayments and deductibles, and absurdly high expenditures for those without insurance). But it still leaves the mostly profit-driven system of U.S. healthcare services (along with hospitalization, pharmaceutical drugs, nursing homes, rehabilitation facilities, and so on) in private hands.

It therefore doesn’t include a critique of how healthcare is currently provided—by doctors, nurses, technicians, and other healthcare professionals and aides who are forced to have the freedom to work for large profit-making conglomerates—or any kind of proposal to expand the diversity of healthcare providers—whether at the local, regional, and national level, which would include more democratic, cooperative or worker-owned healthcare enterprises.

That’s a utopian horizon—covering both the financing and provision of healthcare—worth articulating and fighting for.


*The series started with the problem that, compared to other countries, Americans pay more but get less for their healthcare continued with an analysis of what workers are forced to pay to get access to the healthcare system, the role of healthcare insurance, pharmaceutical companies, hospitals, the double squeeze of declining real incomes and higher healthcare payments, and finally the case for universal, affordable, high-quality healthcare.


Chris Rock may be right. Still, Americans are well aware that economic inequality in their country is obscene, even though they often underestimate the growing gap between the poor and the rich.

But it’s Frank Rich, who conducted the interview with the American comedian, who made the more perceptive observation:

For all the current conversation about income inequality, class is still sort of the elephant in the room.

All the experts agree—from Thomas Piketty and the other members of the World Inequality Lab team to John C. Weicher of the conservative Hudson Institute—that inequality in the United States, especially the unequal distribution of wealth, has been worsening for decades now. Both before and after the crash of 2007-08. And there’s no sign that things are going to get better anytime soon, unless radical changes are made.

But, as it turns out, even the experts underestimate the degree of inequality in the United States. The usual numbers that are produced and disseminated indicate that, in 2014 (the last year for which data are available), the top 1 percent of Americans owned one third (35 percent) of total household wealth while the bottom 90 percent had less than half (45.3 percent) of the wealth.

According to my calculations, illustrated in the chart at the top of the post, the situation in the United States is much worse. In 2014, the top 1 percent (red line) owned almost two thirds of the financial or business wealth, while the bottom 90 percent (blue line) had only six percent. That represents an enormous change from the already-unequal situation in 1978, when the shares were much closer (28.6 percent for the top 1 percent and 23.2 percent for the bottom 90 percent).

Why the large difference between my numbers and theirs? It all depends on how wealth is defined. Both the World Inequality Lab and the Federal Reserve (in the Survey of Consumer Finances) include housing and retirement pensions in household wealth—and those two categories comprise most of the so-called wealth of most Americans. They just don’t own much in the way of financial or business wealth. They live in their houses and they retire based on contributions from their wages and salaries over the course of their work lives. They produce but don’t take home any of the surplus; therefore, they just don’t have the ability to amass any real wealth.

For the small group at the top, things are quite different. They do get a cut of the surplus, which they use, not only to purchase housing and put aside in their pensions, but to accumulate real wealth, for themselves and their families. If we take out housing and pensions and calculate just the shares of financial or business wealth—and, thus, equities, fixed-income claims, and business assets—the degree of inequality is much, much worse.

Yes, rich people in the United States are very rich—even more than either regular Americans or the experts believe.

But that’s not the real elephant in the room. The big issue that everyone is aware of, but nobody wants to talk about, is class. And that’s the reason there should be, if not riots, at least a sustained political movement to transform the existing economic and social structures in the United States.


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Tom Toles Editorial Cartoon - tt_c_c180219.tif

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