Prologue
Twenty-first-century America had become a healthcare country. At almost 18 percent of the entire economy, health was the nation’s largest industry by far—a $3.6 trillion enterprise.
Part I
- Early 1900s, recommendations made for all counties to build hospitals, but lots of resistance, despite poor state of public health
- In Williams County specifically, doctors feared loss of authority and monopoly
- Hospitals funded by benefactors like Carnegies in addition to entrepreneurs, religion orgs, NGOs
- Nationwide resistance to health insurance due to…
- Racism— “blacks were healthier as slaves”
- German assoc with the practice after WWI
- Association with socialism, Bolsheviks → seen as anti-American
- Sustained opposition by JAMA/AMA, who saw it as limitation of power of doctors
- Doctors in places like Williams County often no richer than patients, yet patients could still barely afford care
- Advances in medicine went disproportionately to the rich
- African Americans shut out of medical care in N and S alike
- Very small amount of money in medicine went to public health (most to doctors, hospitals)
- Post Depression, more support for socialist programs, but still not for healthcare
- Ohio → 46/50 in US for health value… rising suicides, obesity, etc. both in the state and country through 1990s
- Idea that loss of work ethic, religion were behind struggling community— people generally didn’t consider structural or systemic factors
- Many ALICE situations (coined by United Way: asset limited, income constrained, employed)
Part II
- Medical economics ≠ regular economics, so hospitals saving money doesn’t pass on lower prices to patients; savings used to pad their own margins
- Device makers, pharma, etc. can charge hospitals whatever they want, because no other options on where to obtain most supplies
- Myth of free market— doesn’t exist in healthcare
- Constant push for consolidation in every aspect of healthcare system (hospitals, manufacturers, doctors, pharma) to get pricing power
- Ex. Ohio hospital systems ProMedica and Mercy both have lots of purchasing power, can manipulate and scheme vs local hospitals
- “Non-profit” hospitals are not actually non-profit… accumulate income, pay CEOs millions, sponsor stadiums
Ronald Reagan was elected president in 1980, ushering in an era of union-busting, financial deregulation, leveraged buyouts, and the financialization of the American economy. What ensued was a precipitous increase in inequality, whether measured by income or by accumulated wealth, and except for short pauses, it kept rising. By 2019, the United States was one of the most unequal countries on earth. Inequality itself was unequal. The gap between whites and blacks grew, and so did the gap between places and education. The well educated flocked to metropolitan areas and worked “knowledge economy” jobs. Rural counties, with few college graduates and a reliance on manufacturing, began to look more and more like poor neighborhoods in urban centers. In fact, many white people in Williams County had a lot more in common with poor black people in places like the Franklinton neighborhood of Columbus than they may have wished to admit.
Decades of research showed that social determinants had an enormous impact on health and longevity—more than medical care itself, which accounted for only about 15 percent of the inequity in mortality.
Part III
Over the previous forty years, fissures radiating from the deepening fault lines of inequality, racism, suspicion, paranoia, and the propaganda of financial self-interest carved their way through America’s landscape until the country and its people had become fragile. Covid-19 just exploited the weaknesses until the crust collapsed, revealing to Americans what had become of their nation. If it hadn’t been Covid-19, it would have been some other catastrophe.
America had a long history of investing in the health of its people, but the public health infrastructure eroded from inattention and financial starvation in the same way other public goods like bridges, water systems, and education eroded, and so the health of Americans eroded, too. For decades, rising levels of obesity, high blood pressure, drug and alcohol abuse, suicide, heart disease, and lack of access to medical care rooted themselves in many millions of Americans. All these were quieter, more insidious epidemics, but they were epidemics just the same. And, as it happened, these conditions—all of them prevalent in Bryan and in Williams County, just as they were across the country—made the people who suffered from them more likely to suffer and die from Covid-19.
America had become an unforgiving nation, a fearful place, hiding behind a pyroclastic flow of guns, flag-waving, and ever-emptier jingoistic bragging. Then Covid-19 arrived. It just showed up, like lightning. There was no way to wrap it up in the comforting notion that the victims were to blame.
The shoddy edifice of American medicine trembled. It had turned itself into just another industry, and like other industries it had grown addicted to the dogma of return on investment, high dollar revenues, and just-in-time supply chains. It had put money into shiny machines, new buildings, and mergers that would boost return on investment—but not into stores of masks, gowns, ventilators, and beds. The refusal to prepare for a crisis they’d been warned about forced hospitals to make mafia-like deals in parking lots to buy masks and to negotiate with shady foreign characters charging extortionate prices for equipment.