The Body Economic (18 page)

Conversely, while Europe was bailing out the banks that drove markets to the worst crash since the Great Depression, it imposed penalties on the Greek citizens who had little control over their government's accounting frauds or economic strategy. The economist James Galbraith called the treatment of the Greek people a form of “collective punishment.” This level of punishment was unprecedented in Europe. Even Germany after World War II had benefited from large-scale investment as part of the Marshall Plan to reconstruct its broken economy.
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Unsurprisingly, the Greek people are furious and desperate. One of the most dramatic riots in the country, in October 2012, was sparked by the arrival of Chancellor Merkel. Six thousand police were mobilized for her protection, firing pepper spray and stun grenades at protesters who threw stones, burned Nazi flags, chanted “No to the Fourth Reich!” and hoisted banners reading “Merkel out, Greece is not your colony,” “This is not a European Union, it's slavery,” and “They've turned our lives into hell.” The irony of Germany's insistence on austerity in Greece even though Germany itself had been “bailed out” by the US and the rest of Europe after World War II was not lost on the Greeks.
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Beyond the economic damage, the harms wrought by austerity policies also destroyed Greece's social cohesion (a factor vital to Iceland's health stability). The Greek political scene witnessed a return of radical far-right parties, just as the politics of austerity did in post-Depression Europe. The neo-Nazi Golden Dawn Party stepped in to plug the hole in safety nets left by the troika. On the streets of Athens, they began serving hot meals to the hungry, at least to people who could show a Greek national identity card. Racist attacks have risen, as troops of Golden Dawn members prowl the streets to “purge” immigrants. The purges have now expanded to include gays and lesbians. The circumstances are eerily reminiscent of the Depression-era politics that paved the way for fascism and World War II in Europe. Blaming foreigners for the crisis became so popular that Golden Dawn claimed twenty-one seats in the 300-seat parliament in the May 2012 election.

Unquestionably, Greeks are not merely the victims of foreign mistakes. Many lived beyond their means, evaded taxes, and cooked their books. But the Greek government's response to the recession turned a bad economic situation into a public health disaster. Whereas Iceland's health looks more like that of the US in the New Deal, Greece's health has begun to resemble that of Russia in the aftermath of Shock Therapy and mass privatization.

And so it was that on the morning of April 4, 2012, Dimitris Christoulas, age seventy-seven, whom we met at the beginning of this book, killed himself in front of the Greek Parliament. He had paid into his pension for years, running his pharmacy. But ironically, he could no longer afford medicines for himself. His pension was cut, and his retirement benefits slashed. He saw no other way out.

For want of a nail the shoe was lost.

For want of a shoe the horse was lost.

For want of a horse the rider was lost.

For want of a rider the message was lost.

For want of a message the battle was lost.

For want of a battle the kingdom was lost.

And all for the want of a horse shoe nail.

(Proverbial rhyme)

Diane was forty-seven years old when a splinter ruined her life.
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She had been a teacher at a charter school in California. Because of $8.1 billion in education budget cuts the state enacted in 2009, she lost her job. Without her job, Diane lost her health insurance, so she had to purchase an individual coverage plan and pay the monthly premiums out of pocket. Diane signed up to the best plan she could afford, but that came with a high deductible: typically she would have to pay $5,000 before her insurance company covered any significant medical bills, making her think twice about whether she really had the money to seek medical help.
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One afternoon, about a year after she lost her job and signed up for this high-deductible health insurance plan, Diane was walking on the floor-boards of her old apartment and got a large splinter in her foot. Because Diane has diabetes, her minor wound became a large gash, then an ulcer that wouldn't heal.

Diane felt that she couldn't afford to pay the fee for a doctor's office visit, nor for prescription antibiotics. So she tried to treat her leg herself—hoping that the redness creeping up her leg would go away if she strictly followed instructions she had found online: hot baths, soap, scrubbing, and over-the-counter antibiotic creams.

After a few weeks, Diana started to feel feverish and sweaty. Then she passed out. Luckily, a neighbor heard the shatter of glass when Diane's head broke the coffee table. The neighbor called 911, and the police broke down Diane's door and called an ambulance.

That's when Sanjay met Diane—in the intensive care unit of the local hospital. Her leg was so badly infected it had to be amputated—something that could have been avoided if the infection had been treated earlier. Worse still, the infection had spread to her bloodstream. It was so overwhelming that it was causing her to become septic—causing her blood pressure to drop below 80 over 40. To stop it from dipping any lower and leading to a potentially fatal cardiac arrest, Sanjay inserted a catheter through her jugular vein and into the right side of her heart, so he could pump intravenous fluids into her system and give her medicines that increased her blood pressure. Her kidneys were failing because of the infection, so a dialysis port had to be sewn into her groin. But the dialysis machine created its own problems. Diane suffered a stroke when the dialysis caused a second precipitous drop in her blood pressure.

Diane now lives in a nursing home. At the age of forty-seven, she is unable to speak or walk or move the right side of her body. Like hundreds of uninsured or underinsured patients, she delayed medical care because of fear of the cost. But ironically, her one hospitalization cost over $300,000. Her stroke left her disabled, and she will cost the state of California tens of thousands of dollars a year for the rest of her life. She requires twenty-four-hour nursing care to turn her in bed, clean her when she soils herself, and spoon her food into the left side of her mouth so she won't choke on it.

Diane's story is an extreme, tragic example of an everyday occurrence in the United States: the deferral of essential medical care among Americans who simply can't afford it.

Her case is particularly tragic because if she had encountered that splinter a few years later, Diane might have been covered under the new healthcare law, the Patient Protection and Affordable Care Act (PPACA), passed by Congress and signed into law by President Barack Obama on March 23, 2010. Before the law, about 20 percent of Americans with high-deductible healthcare insurance plans like Diane skipped preventive doctor's visits because of the cost. The new legislation helps ensure that everyone has affordable healthcare coverage, even if they are unemployed. While it is impossible
to say with certainty that Diane's tragedy could have been avoided, had she been covered by an affordable plan, she probably wouldn't have let cost come between her and her doctor. That meant she would have been able to go out and seek work again in an economy slowly recovering from the Great Recession.

While the United States under President Obama began taking urgently needed steps to help prevent the Great Recession from leading to more avoidable tragedies like Diane's, the UK's National Health Service (NHS) began doing the opposite. Initially its universal healthcare system had been a great protector of its people—and no one lost healthcare access due to the economic crash. But now, under the politics of austerity, the UK Tory government is trying to mimic the US model by introducing competition, markets, and private contractors into the NHS. To understand what these privatizing reforms are likely to mean for the UK, it's first necessary to trace why the US healthcare system was in such dire straits during the recession.

Before the Great Recession, the US healthcare system failed to provide coverage for many of its people. Although two-thirds of Americans received health insurance through their employer, the rest—those whose employers wouldn't cover them, part-time workers, and the self-employed—were on their own, if they couldn't qualify for federal insurance programs. These Americans had to buy health insurance on the private market, but many could not afford the high monthly payments (premiums) and high deductibles. What's more, before the passage of the PPACA, insurance companies were able to restrict coverage on the basis of pre-existing health conditions, like diabetes or high blood pressure—so many who could afford private insurance were nevertheless not fully covered. All in all the US system left about 40 million Americans—almost 13 percent of the population—without health insurance.

The Great Recession turned this bad healthcare situation into a full-blown crisis. When Americans lost their jobs in the recession, another 6 million people lost their health insurance. Losing healthcare coverage is extremely dangerous. A 2009 study found that people who lacked medical insurance were 40 percent more likely to die prematurely than those who had it. During the Great Recession, before the PPACA came into effect, there were approximately 35,000 avoidable deaths due to the lack of healthcare insurance.
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Americans who lost insurance through their jobs had few options during the recession. Some tried to seek insurance on the private market, but about
a third of them were refused coverage for a variety of reasons, including preexisting medical conditions. Others simply couldn't afford the cost of a private healthcare insurance plan, which could be up to $25,000 per year for a two-person family. The recession exaggerated these costs further. Across America, on the pretext that the recession made it harder to operate, insurance companies were increasing their premiums—the monthly amounts people paid in to their insurance plans. Anthem Blue Cross in California, a subsidiary of WellPoint, raised its premiums by as much as 39 percent. The American Medical Association, the largest association of doctors in the country, officially condemned this practice (commonly known as purging), but they could do nothing to stop it.
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Some people were eligible for public insurance (if they earned under about $23,050 house hold income for a family of four). These people could qualify for Medicaid, the US government health insurance program for the very poor. But as enrollment in the program jumped 8.3 percent every year since 2009, some politicians and officeholders, mostly Republican, grew increasingly vocal about “out-of-control” government spending on Medicaid.
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All over the US, state officials began finding ways to cut Medicaid budgets. They introduced higher deductibles and co-payments (out-of-pocket fees) for prescriptions and doctor's visits, cut benefits, levied new taxes on care providers, and instituted hiring freezes, furloughs, layoffs, and salary cuts to Medicaid workers. Since the peak of the recession in 2009, forty states have cut their Medicaid budgets in at least one fiscal year. Twenty-nine of these states subsequently cut their budgets a second time, and fifteen states did so a third time.
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While it is too early to determine the full extent of the long-term impact of these cuts, there are already signs that people's health is suffering. Among the Americans who switched to high-deductible plans to save money, many began forgoing medical care as Diane had done. Families on health insurance plans with high deductibles were 14 percent less likely to see a doctor when they needed to, compared with those who stayed on lower deductibles.
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Much of the care that people stopped paying for was preventive in nature. For example, about 500,000 fewer Americans who had health insurance undertook colonoscopy screening for colorectal cancer during the recession. A survey conducted between March and April 2009 found that of those Americans
who had a chronic illness, two-fifths did not fill a routine prescription to keep their illnesses under control because of cost pressures.
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Just as in Greece, recession and austerity in the US resulted in people having to wait longer to see doctors and access necessary treatment. Emergency rooms in the United States were already operating at or over capacity before the recession. Patients increasingly used emergency rooms more than outpatient clinics as they ended up in situations like Diane's—avoiding preventive care when they could no longer afford it. Doctors described being “overwhelmed” or “close to the breaking point.” For patients, overcrowded emergency rooms meant longer waiting times, inattention to real emergencies, and lower overall quality of care.
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In short, the US healthcare system failed to protect its people during the Great Recession. Americans were doing without needed care that they could no longer afford—and sometimes, like Diane, they suffered tragic health consequences.

But there was one group that benefited. Profits of health insurance companies soared during the Great Recession. In 2009 the top five US health insurance companies reported $12.2 billion in profits, a staggering increase of 56 percent over the figures for 2008. In 2009, a year that saw 2.9 million people lose coverage, insurance companies' profits rose by 56 percent. And again, during the first nine months of 2010, profits increased by an average of 41 percent, breaking all-time industry records despite the recession. These windfall profits came at the expense of patients. As insurance companies were purging people from their ranks, they were paying out less for patient care, making more money in the process. While it was once thought that high enrollment was the key to successful insurance, WellPoint's CEO Angela Braly rephrased the new objective in 2008: “We will not sacrifice profitability for membership.”
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