Positives from the Past Decade?

Steve Chapman, a columnist for the Chicago Tribune, cited my book in a 12/27 column entitled "Remember the good things that happened in America in the past decade."  He used a quotation from The End of the American Century, published in 2009, to compare the end of the present decade to the end of the previous one.

He recognizes the many problems we still face, not least of them due to the "poisonous presidency" of Donald Trump, but points to the many good things that have happened in the ten years since my book was published.  Among these are the continued growth of the U.S. economy; the scaling back of US involvement in Iraq and Afghanistan; the expansion of LGBTQ rights; and the Obama accomplishments on childhood immigrants; health care; and torture.

What most resonates in Chapman's argument, though, is this:

Trump has done immeasurable harm on all sorts of matters. But he has also created a powerful backlash that has manifested itself in annual women’s marches, renewed awareness of the persistence of racism, and public support for modest gun regulations, climate change legislation, immigration reform, the Affordable Care Act — and his impeachment.

Ironically, then, the main contribution of the Trump presidency to this past decade is to generate resistance to the very awfulness of it. This upsurge in political involvement is indeed a positive development, especially if it can persist through the removal of this insidious president.

But this positive growth of political participation is offset by Trump's persistent efforts to undermine democratic institutions and procedures.  He has pushed to restrict the franchise in many states; manipulated and threatened our independent judiciary and legal processes; badgered and threatened his political opponents; eviscerated the governmental institutions that might provide a check on his abuse of power;  and has solicited foreign interference in the U.S. electoral process.  He expresses admiration for foreign dictators as brutal and ruthless as those we have fought against in the past.

 In chapter 5 of my book ("Ailing of American Democracy"), I document the increasing apathy, indifference and political ignorance of the American electorate, and the growing influence of money in politics.  I raise the possibility of the U.S. "becoming like our enemies."  Trump is leading us in that direction.

While I appreciate Chapman's efforts to see the bright side of the last ten years, I think it would be a mistake to underestimate just how much Trump has revived the downward spiral of the U.S. that I documented in The End of the American Century.  Middle class wages have barely budged since the 1970s.  Inequality, already high ten years ago, has rocketed upward since then.  We have not yet solved the problems of expensive health care and violent crime--both unique to the U.S. among developed countries.  Our educational system is among the worst among rich countries.  No president, even George W. Bush, has undermined science as much as the current one, even as the existential threat of climate change becomes more obvious by the day. Global opinion of the U.S. is even lower than it was under Bush, which then was at a postwar nadir.  And no president in history has so deliberately attempted to hollow out our governmental institutions and undermine our democratic principles and processes.

Good Riddance to the American Century

My book “The End of the American Century” appeared in 2009.  There I argued that the combination of domestic decline and global change had put an end to the era of U.S. global dominance, and that American citizens would have to come to terms with a flattening standard of living and reduced global influence.  This was not necessarily a bad thing, either for the United States or for the rest of the world.
     I finished writing the book during 2008, just as Barack Obama was mounting his stunning rise to the presidency.  For the paperbound edition of the book, which appeared just after the election, I added an epilogue called “Reality and Hope in the Obama Era,” where I offered some hope that the new president could temper some of the problems I had raised.  But I also cautioned that America’s problems (for example with education, violence, debt, inequality) were so deep-seated, and the global changes so persistent (e.g. globalization of production, rise of new powers, climate change) that his options would be limited. 

     President Obama, I believe, recognized all of these problems, and tried his best to redress or adapt to them. He rescued an economy in freefall; got us moving on climate change; passed milestone legislation on health care; and restored America’s battered international reputation, winning the Nobel Peace Prize in the process.  He was on track in adapting to the end of the American Century. 

Now we have a President who is intent on returning to that era of American superiority and dominance.  Indeed, Trump rode to power by demagoguing many of the issues of U.S. decline that I had documented in my book: the stagnating incomes of the middle class; the decline of manufacturing; the continuing prevalence of violence; declining trust and confidence in government; the high cost of medical care; and infrastructure decay.   

     Trump knew which buttons to push, but he had no idea how to deal with any of these problems.  He promised to “make America great again” without having any notion of what that might entail.  His vision was to go backwards, not forward.  In a world so rapidly changing, this is no solution at all.  America needs to adapt to change—embrace it, even—and not reject it, as Trump seems to want to do.  His presidency is a dead end. 

     Any progress this country made during the Obama years is quickly being rolled back and reversed in the first months of the Trump presidency.  The most pressing and damaging problems I discussed—debt, inequality, and climate change—are all likely to worsen under a Trump administration. 

     We can not go back to the American Century (which really lasted only about half a century anyway), nor should we.  That era was bred of specific historical, economic and international circumstances.  We are in a different era now, both domestically and internationally.  The U.S. can not and should not dominate the world as we once did.  To think and act otherwise is to court disaster in a globalized and interdependent world.  We should bid adieu to the American Century, and move forward. 

Without Reform, Health Care Costs Will Skyrocket

Rising health care costs will overwhelm the American economy and the American consumer, without an overhaul of the system. This is the conclusion of most health policy analysts, as well as a new study by the Commonwealth Fund, as reported in "The Cost of Doing Nothing" in the New York Times last Sunday.

"Health policy analysts and economists of nearly every ideological persuasion" agree that "the unrelenting rise in medical costs is likely to wreak havoc within the system and beyond it, and pretty much everyone will be affected, directly or indirectly," says the Times.

Karen Davis of the Commonwealth Fund, a nonprofit health care research group, contends that things will hardly stay the same if we do nothing: "in fact, what we will have is a substantial deterioration of what we have."

The Fund analyzed the potential cost savings of past proposals on health care reform, and concluded that all of them would have resulted in a much lighter burden on the economy than we now pay. Health care now absorbs about 18% of GDP in the US--far higher than any other country in the world. (The figure is about half that in other industrialized countries). If the Clinton health care reform had been implemented, according the Fund's analysis, health care would absorb only 14% of GDP. If earlier plans by Carter and Nixon had been, the figure would be about 11%. (See the chart at the NYT site, and above).

The Fund study also estimated that the typical price of health insurance for a family is likely to double in the next decade, from about $13,000 a year, to $24,000. Health insurance premiums as a percentage of median family incomes grew from 11% in 1999 to 18% in 2007, and are expected to grow to 24% by 2020.

These kinds of costs will further erode economic growth in the United States; they will impede U.S. global competitiveness; and they will bankrupt American families and the U.S. government.

The perilous state of the American health care system is one of the key components of the decline of the U.S., both domestically and internationally, and urgently needs correction. One only wishes the members of Congress could put aside narrow self-interest and petty politics, and seriously confront the issue.

For more on the U.S. health care system, see my earlier post "U.S. Health Care Compares Badly to Others" or click on the "Health Care" label on the right side of the page.

U.S. Health Care Compares Badly to Others

In his address to Congress last week, President Obama decried the failures of the American health care system, and pointed out how poorly it fares in comparison to other wealthy countries. Millions of people in this country do not have health insurance and can’t afford necessary medical care. Tens of thousands die each year from lack of such access. We are “the only wealthy nation that allows such hardship for millions of its people,” observed the President.

The sorry and disgraceful state of the American system of health care is documented in The End of the American Century (pp. 48-53), and was also the subject of a post I made on this blog a year ago (US Ranks Low on Health Care). Since then, there is a mounting pile of evidence documenting how badly America fares in health care, on multiple dimensions. This is true both in terms of general overall statistics, like infant mortality, maternal mortality, and average lifespan (reported by organizations like the World Health Organization and the United Nations), but also in more specialized areas, like survival rates for disease, patient access to physicians, and public satisfaction with health care in different countries.

The highly regarded Commonwealth Fund, for example, conducts periodic studies of such issues, comparing the United States to other wealthy countries. One such study on patient access to primary-care physicians found that Americans wait longer to see their doctors than patients in Britain, Germany, Australia, or New Zealand, Holland or France—all countries with strong public-health systems. Almost a quarter of Americans reported waiting six days or more for an appointment, compared to just 14% in the UK and 18% in France, for example.

Another study on “preventable deaths” found the U.S. ranking dead last of the 19 countries in the study. These are deaths that could have been prevented with timely and effective health care--which of course is often unavailable to millions of American citizens. The U.S. ranking on this scale actually declined from 1997 to 2003, from 15th place to 19th place. Number one in the ranking? France.

Yet another study compared five-year survival rates for various diseases in the U.S. Canada, Australia, New Zealand, and England—all of whom spend far less on health care than the U.S. Of the five diseases, on only one of them (breast cancer) did the U.S. have the best five-year survival rates.

The veteran journalist T.R. Reid has just published a new book, The Healing of America, in which he compares health care systems around the world. In a summary of the book in Newsweek ("No Country for Sick Men"), Reid observes that in health care:

“The United States is the odd man out among the world’s advanced, free-market democracies. All the other industrialized democracies guarantee health care for everybody—young or old, sick or well, rich or poor, native or immigrant. The U.S.A., the world’s richest and most powerful nation, is the only advanced country that has never made a commitment to provide medical care to everyone who needs it.”

Consequently, according to Reid,

“about 22,000 of our fellow Americans die each year of treatable diseases because they lack insurance and can’t afford a doctor.”

Many Americans express concern about the “rationing” of health care in a government-supported system. But has Reid observes, the U.S. already rations health care. It is “rationing care by wealth.” While this may seem natural to Americans, he says, “to the rest of the developed world, it looks immoral.”

The immorality of this is particularly callous in its effects on children. A study from the National Center for Health Statistics reports that poor children are 3.6 times more likely to have poor health than children from affluent families. As I point out in my book, “The United States is the only developed country in the world where children suffer poor health and die simply because their parents are poor or unemployed.” (p. 52).

One also hears concern in the current debates about the potential costs of a system of universal health care—legitimate concerns in the face of unprecedented government deficits and debt. But the U.S. already has the most expensive health care system in the world, no matter how you measure it. As a share of GDP (2006), health care constituted over 15% in the U.S., compared to 11% in France, 10% in Canada and 8% in England—all of them with universal coverage for their citizens (OECD). On a per-capita basis, the U.S. also outspends every other country in the world, by a long shot.

Many Americans assume that the largely private medical care in the U.S. is more efficient, less bureaucratic and less costly than the government-run programs in other countries. In fact, administrative costs in the U.S. are higher in for-profit hospitals than in public ones, and overall administrative costs are higher in the U.S. than in countries with government-run programs. Compared to other countries, the U.S. also comes up high on administrative costs in health care. A 2003 study in the New England Journal of Medicine estimates that administrative costs absorbed 31 cents of every health care dollar in the U.S. compared to only 17 cents in Canada, which has a universal health insurance plan paid for by the government.

By all of these statistical measures, the U.S. health care system looks bad. But what it really comes down to is not statistical comparisons but fairness, compassion and justice. And the outcome of health care reform will depend as much on these American values more than anything else. President Obama himself recognized this in his address to Congress, where he appealed to the “large-heartedness” in the American character—“that concern and regard for the plight of others.”

“It, too, is part of the American character -- our ability to stand in other people's shoes; a recognition that we are all in this together, and when fortune turns against one of us, others are there to lend a helping hand; a belief that in this country, hard work and responsibility should be rewarded by some measure of security and fair play; and an acknowledgment that sometimes government has to step in to help deliver on that promise.”

Much of the opposition to health care reform has come from people who are worried about how the changes will affect themselves and their families. Perhaps this self-interest is normal, and part of human nature. But our fate and health as a country is as much dependent on the health and safety of others as it is on our own. Re-establishing a sense of community and common purpose—and of the American tradition of large-heartedness—is an essential ingredient in the prescription for the ailing American health care system--and in restoring the United States as a great power.

Can We Cut Defense Spending to Pay for Health Care and Education?

I received the following email, from a retired medical school professor, raising the question of budget priorities, and whether we might be able to help pay for health care reform and/or education by reductions in the military budget. My response follows the letter:

Professor Mason:

I've been reading your book, "The End of the American Century," these past
several days and am finding it very readable and informative, albeit a bit
depressing. I'm a biomedical scientist by training and trade (and a fellow
academic and resident of Indianapolis; see below), and am much in need of an
uncomplicated, understandable discussion of economic principles. Your book
meets those criteria very well and I appreciate having it available.

Now to my question. Since retiring from the university, I've enjoyed engaging
in online "discussions" of issues political from time to time. Most
recently, during a discussion of how we might pay for health care reform, I
innocently -- and sincerely -- suggested that we might consider closing a
few of our military bases around the world. I've read Chalmers Johnson's
trilogy on the American empire and am quite sympathetic to the view that
we've way overspent on the military. In any case, my opponent dismissed my
suggestion as naïve and irrelevant by citing government figures
(http://www.truthandpolitics.org/military-relative-size.php)showing that military spending--as a percentage of GDP--is a mere 3.7% of GDP and has
actually declined in recent years. His point, of course, which was not
supported by any data, was that domestic social spending far outstrips
military spending. I find this notion preposterous but I'm puzzled by the
data he cited. Should I surmise that the percentage spent on, say,
education, is several times less than 3.7%? Or is this rendering of the data
simply misleading? Can you help me to sort this matter out?

Thanks. I'm sorry to trouble you with this question, but you DID manage to
get me to pick up and read your book...

Regards,

Lynn R. Willis

-----------------------------------
Dear Lynn,

Nice to "meet" you and thanks for reading my book, and for the compliment.

On the question of defense spending, it is true that it is a relatively small share of GDP. But in terms of spending priorities--the question you are addressing--I think the more appropriate comparison is defense spending as a proportion of the budget, not the GDP. In the TruthandPolitics page you mentioned, if you scroll down to Graph 2 (Defense Spending as a Percentage of Discretionary Spending), you will see that defense spending is about half of the entire "discretionary" budget of the U.S. government. So defense constitutes more than all other categories COMBINED, and is far more than that spent for education, welfare, etc. "Discretionary" spending refers to those categories that Congress has some authority over, as opposed to "Mandatory" programs (funds already committed) for Social Security, Medicare, Medicaid, Debt Interest, etc.


You can get a better sense of this if you look at a discretionary spending pie chart, or for a more authoritative and detailed source, look at the actual federal budget summary at:
http://www.whitehouse.gov/omb/assets/fy2010_new_era/Summary_Tables2.pdf

There, you will see (Table S-3) that for 2009, the Defense Department budget is $666 billion, and ALL other programs get only $613 billion. Education (Table S-7), gets a mere $41 billion.

Incidentally, US defense spending also makes up about half of all defense spending in the world, so the U.S. outspends virtually all other countries combined.

So I agree with your point that a small cut in the defense budget could make a huge difference in some of these other programs, including education and health care.

-----------

Other comments welcome!

The Measure of America

The Social Science Research Council and Columbia University Press have published a remarkable and eye-opening book, called The Measure of America: American Human Development Report 2008-2009, which could function as a companion and statistical supplement to The End of the American Century. In analyzing the domestic situation of the U.S., The Measure of America has many of the same themes, and similar (and supporting) evidence as my book. Like my book, it shows that on most measures of societal development, the U.S. has declined over recent decades, and lost ground compared to other countries.

The Measure of America is modeled on the annual Human Development Report published since 1990 by the United Nations Development Programme. That series attempted to get away from the raw economic indicator of Gross Domestic Product, and to determine the level of human development in each country. The “human development index” used by UNDP, an alternative to GDP, was “a composite index measuring average achievement in the three basic dimensions of human development—a long and healthy life, knowledge, and a decent standard of living.” (From the Human Development Report 2006).

The Nobel Prize winning economist Amartya Sen was instrumental in developing the Human Development Report, and wrote the Foreword to The Measure of America. There, he writes that

“we have to judge the success of a society, including its economy, not just in terms of national wealth or the ubiquitous GNP, but in terms of the freedoms and capabilities that people enjoy to live as they would value living” (p. xi).

Sen observes that this approach has been “remarkably neglected in the United States in particular” and notes in this country “a major discrepancy between opulence and achievement.” The U.S. may be on some measures the world’s wealthiest nation, but “its accomplishments in longevity, secure health, fine education and other such basic features of good living are considerably below those of many other—often much poorer—countries.” He also notes, as I do in my book, that the position of the U.S. relative to other countries has been “steadily falling” over the years (p. xii).

The book itself assembles data in clearly presented tables on the three main “building blocks” of the human development index: a long and healthy life; access to knowledge; and a decent standard of living. In all three areas, the U.S. fares poorly in comparison to other countries. Compared to other wealthy countries, for example, the U.S. ranks #24 in life expectancy; #18 in high school graduation rates; and #2 in poverty rates (you don’t want to rank high on that one!).

The data shows the downward trend for the U.S. over time in most of these measures as well. And for the overall index, the U.S. world rank dropped from #2 in 1980 (behind only Switzerland) to #12 in 2005. Countries ahead of us include much of western Europe, Canada, Australia and Japan.

(The American Human Development Project also maintains a useful website at this link.)

These are all trends and themes presented in The End of the American Century, where I also use authoritative data (including many of the same measures used in The Measure of America). They point out how far the U.S. has fallen, and how much work we have to do. The problems of the U.S., both economic and social, predate the disastrous Bush presidency, which simply exacerbated them all. It took more than eight years to dig us into this hole, and will take at least that long to recover. But we have to recognize these problems and understand them before we can begin to solve them.

The Measure of America: American Human Development Report, 2008-2009 (A Columbia / SSRC Book)

Zakaria's Optimism

Fareed Zakaria is everywhere these days, articulating a message similar to mine in The End of the American Century. But I think he underestimates the seriousness of the situation facing the United States.

Zakaria had the lead article last summer in Foreign Affairs’ issue on “Is America in Decline?” His book The Post-American World appeared shortly thereafter, and soon became a best seller. As an editor of Newsweek, his columns appear there regularly, and the October 20th issue of the magazine featured him on the front cover, with the title “The Bright Side” against a cheery yellow background. He even has his own television show, “Fareed Zakaria’s GPS,” where last week he endorsed Barack Obama as the best hope for America’s future.

Zakaria argues that it is not so much that the U.S. is in decline, but that other powers have risen, requiring the U.S. to deal with them with more consultation and compromise. He believes that the U.S. “has the strength and dynamism to continue shaping the world” (Foreign Affairs) and that “the world is moving our way” (The Post-American World). He sees a “silver lining” in the current economic crisis, in that the country will be forced “to confront the bad habits it has developed over the last few decades” (Newsweek).

These bad habits include spending and consuming more than we produce, leading to record levels of household debt, which has grown from $680 billion in 1974 to $14 trillion today. Spiraling consumer debt has been matched by the government. “The whole country has been complicit in a great fraud,” he writes in Newsweek. He quotes the economist Jeffrey Sachs:

“We’ve wanted lots of government, but we haven’t wanted to pay for it.”

He believes the current crisis will force greater fiscal “discipline” by both families and government, recognizing that “this discipline will be painful for a country that has gotten used to having it all.” It will also be good for our country’s foreign policy. Being the only superpower “has made Washington arrogant, lazy and careless.” Perhaps we could get away with this arrogance when we were on top of the world. But things have now changed.

“We cannot keep preaching to the world about democracy and capitalism while our own house is so wildly out of order.”

My book, and this blog, make similar arguments, and I agree with all of this, but especially that last sentence, which appears near the end of Zakaria’s Newsweek essay. However, I think Zakaria understates just “how wildly out of order” our system has become. Record consumer and government debts and a bankrupt financial system and foreign policy, as bad as those are, constitute only parts of the problem. At the same time that we have been madly spending on consumer goods, wars and debt servicing, we have let languish education, health care, infrastructure, science and technology. We have shuffled to the side the hugely expensive fixes required for Social Security and Medicare. Poverty and inequality are higher in this country than a generation ago, and among the highest in the developed world. Even our vaunted democracy, eroded by money and abuse of executive power, is no longer such a beacon for other countries. A major part of my book shows how all these interrelated problems result in a much more serious situation than Zakaria recognizes.

While we seem prepared to spend a trillion dollars bailing out a financial system led by incompetent billionaires, we need at least that much to fix the health care system, not to mention these many other neglected issues. It is difficult to see where the resources will come from to mend our society, once the banks are taken care of. It will require many years to restore the United States, and a change in America’s mindset, as well as its priorities.

Zakaria concludes his essay by suggesting that

“if we can learn the right lessons from this crisis, the United States will once more be playing by its own rules.”

I am not quite sure what “the right lessons” are, or what our “own rules” are. I think the needed lessons may be deeper and broader than he suggests, and that we may even have to change the rules. I am not as optimistic as Zakaria, but even without optimism, one can always hope. And this election week offers much hope.

U.S. Ranks Low on Health Care

Chapter 3 of The End of the American Century, titled "Torn Social Fabric," focuses especially on the relatively poor levels of health care in the U.S., and how badly it fares in comparison to other wealthy countries. As I point out there, this is surprising in many ways "because the United States indeed does have available the best medical care in the world and spends more on health care than any other country." But "because there are so many poor people in the United States and so many people without access to health care, the average level of health and medical care in the United States is among the worst in the developed world" (bold added). In the late 1990s, the World Health Organization ranked the U.S. at 37th in the world in the overall performance of the health system. This was the lowest ranking of any country in the OECD.

New data reported in the New York Times confirms these disturbing trends. The United States now ranks 29th in the world on infant mortality rates which, as the Times points out, is "one of the most important indicators of the health of a nation and the quality of its medical system." The U.S. ranking has declined sharply since 1960, when its ranking was 12th in the world.

This international gap has widened even though the U.S. spends far more on health care than most other wealthy countries, on both a per capita basis and as a percentage of GDP. In 2006, according to the Times, "Americans spent $6714 per capita on health--more than twice the average of other industrialized countries."

Grace Marie Turner, president of the Galen Institute, a conservative research organization, told the Times "infant mortality and our comparison with the rest of the world continue to be an embarrassment to the United States."

The dismal state of health care in the U.S. reflects broader trends of social and economic decline in the U.S.--compared both to our own past and to other countries in the world. It is the major theme of The End of the American Century: that the U.S. has lost ground as other countries have gained; and that we can no longer claim special privilege as the richest, or the most successful, or the most powerful--on almost any dimension.

The poor state of health care, and education, and infrastructure in the U.S. result from inadequate attention and resources to these areas of our domestic health. They pose the second horn of the U.S. dilemma: our economy is collapsing at the very time when we most need resources to rebuild the country at home, and reestablish our reputation abroad.

(See also my 9/23/09 post "U.S. Health Care Compares Badly to Others")