Defund Health Care!

In the wake of the protests related to George Floyd's death, there have been many calls to "defund police."  Those words come as a shock to many people, some of whom can't imagine even reducing police budgets, much less abolishing entire police departments, as a few advocates do indeed call for.

If we're talking about institutions that are supposed to protect us but too often cause us harm, maybe we should be talking about defunding health care as well.

Credit: Kyra Ching

America loves the police.  They're like mom and apple pie; not supporting them is essentially seen as being unpatriotic.  Until recent events, it's been political suicide to try to attack police budgets.  It's much easier for politicians to urge more police, with more hardware, even military grade, while searching for budget cuts that will attract less attention.

It remains to be seen whether the current climate will actually lead to action, but there are faint signs of change.  The mayor of Los Angeles has promised to cut $150 million from its police budget, the New York City mayor vowed to cut some of its $6b police budget, and the Minneapolis City Council voted to "begin the process of ending the Minneapolis Police Department," perhaps spurred by seeing the mayor do a "walk of shame" of jeers from protesters when he would not agree to even defunding it.

Let's look at the problem.  According to a Washington Post analysis, U.S. police fatally shoot about 1,000 people per year (and, bear in mind, George Floyd wasn't shot).  Police-related deaths are far higher, in absolute numbers or per capita, than other developed countries, as are arrests, use-of-force, and imprisonments.  All of this falls disproportionately on people of color, especially African-American men.

Not coincidentally, over the past forty years our spending on "law & order" has grown steadily, while our spending on social welfare programs has stagnated; they've gone from being roughly equal shares of national income to law & order being twice as much.  Even worse, there is no clear correlation between all that spending and crime rates.  As I've discussed previously, most of our arrests are not for violent crimes but for drug offenses as part of our "War on Drugs," even though our use of drugs isn't dissimilar to other countries while our treatment of drug users is.

We've cut social service programs and forced police to pick up the resulting problems, like drug addiction and homelessness.   As has been debated for years, we've turned our police into warriors instead of guardians.

If you haven't watched it yet, John Oliver nails the problems yet again:

On average, minorities have far less income and wealth, attend lower performing schools, are less likely to graduate from college, have lower rates of home or business ownership, and serve in fewer technical/managerial/executive roles.  We can't police ourselves out of the hole we've dug for many of our fellow citizens.  The question isn't why we have crime but, indeed, why don't we have more?

So, what does this have to do with health care?

We have the world's most expensive healthcare system, but one whose spending doesn't buy us better health or even longer lives.  A substantial portion of that spending is wasted at best and inappropriate or even dangerous at worst.  We have way too many medical errors, and those errors lead to a shocking number of injuries and deaths.

If you want to know why we should be angry at our healthcare system, read Elisabeth Rosenthal's An American Sickness, Cathryn Jakobson Ramin's Crooked, Beth Macy's Dopesick, or Jeanne Lenzer's The Danger Within Us, to name just a few recent exposes.

More of us suffer from our healthcare system than from the police system, with African-Americans having perhaps again the most to complain about, so, yes, why not call to defund health care? 

We can do better.

Ironically, the pandemic has effectively defunded large parts of our healthcare system.  For the first time anyone can remember, healthcare spending dropped.  Healthcare jobs, usually one of the major sources of new jobs, have been lost.  People are delaying care at astonishing levels.  Even ER visits for true emergencies, like heart attacks or suicide attempts, are way down.

With some exceptions, like increased use of telehealth, we're just not doing this defunding in any way that necessarily either improves our health or the healthcare system post-pandemic.

Credit: CDC

Start with public health.  If the COVID-19 pandemic has taught us anything, it is that we do not have a robust public health system, at any level.  We spend trillions of dollars on advanced medical care, but pinch pennies on public health, a pound foolish investment if there ever was one.  That has led to not only our slow, mistaken-ridden response, but also to the wide gap in African-American fatality rates from it, which are largely driven by the underlying health disparities, which themselves are both public health and socio-economic failures.

Focus next on social determinants of health (SDOH).  SDOH contributes much more to our health than medical care does, and investments in it produce outsized returns.  Better housing, a cleaner environment, better education, more income equality will result in a healthier population (and probably lower crime).

Then focus on primary care, which should be central to our healthcare system.  Over the past few decades, we've been funding institutions and sub-specialists more than primary care, and the pandemic has made that worse.  That is akin to the warrior versus guardian distinction for police.

Then, and only then, take a hard look at who we're paying for what care, with what outcomes.  There won't be enough money for everything our healthcare system is doing now, and that's OK; the goal is to need less care.

We're not going to get rid of the police.  As much as we rightfully decry some police practices, when it's your life or your property that is threatened, you're thankful for the police.  The issue is not whether to have police but what we should expect them to do and how to do that, and what we can do to reduce the need for them.

Same with healthcare.  When your loved one gets COVID-19, or has a heart attack, you want those ICUs and sub-specialties.  When the pharmaceutical companies develop vaccines for COVID-19, you'll be thankful for them too.  The issue is not whether to have a healthcare system but in how to make it less about medical care and more about health.

We should take this opportunity to defund healthcare, but do it thoughtfully.