New APPS

By Gordon Hull

I argued a few days ago that late capitalism, with its fetishization of efficiency, leaves us unprepared for a pandemic because of vulnerabilities in the supply chain. In a recent blogpost, Frank Pasquale adds some healthcare-specific texture to the point, noting how our healthcare system is almost designed to fail in a pandemic. He cites one of his own papers from 2014:

“The reduction in hospital facilities and other resources, although “efficient” in normal times, may prove disastrous if there is an epidemic. For example, one national-preparedness plan for pandemic flu estimated that, in a worst-case scenario, the United States would be short over 600,000 ventilators. “To some experts, the ventilator shortage is the most glaring example of the country’s lack of readiness for a pandemic,” one journalist noted. The lack of “surge capacity” throughout the health care industry is a major infrastructural shortcoming, likely to cause tremendous, avoidable suffering if a pandemic emerges” (179).

The quotes are from… 2006 and 2007, and refer to warnings coming after the SARS epidemic. In other words, we’ve been as unprepared as possible for 14 years, despite a near-miss epidemic and constant warnings from epidemiologists. So Trump is an idiot and an imposter, and his son-in-law supply czar is a feckless idiot who understands nothing about supply, but, as Pasquale underscores, there is another, longer timeline to our pandemic preparation failure.

In Pasquale’s paper, he notes that part of the problem is how we frame healthcare in terms of aggregate costs (and the need to keep costs down), a construction that makes it impossible to notice that some things are over-funded and others under-funded. In particular, not only can mantras of cost-cutting shield wasteful allocations of resources like those to hedge-fund managers from scrutiny, but it can also hide the fact that some aspects of healthcare (let’s see, hmm. Pandemic prevention!) are radically under-funded. Worse, there is absolutely no way to guarantee that money saved here will actually be reallocated to something more socially useful:

“If the health care cost-cutters had a plan for reallocating excess health sector spending to pay for care that is now undercompensated or absent, they would merit the influence they have now achieved. But in reality, money freed up by cost-cutting is much more likely to be retained as profit or claimed by capital and rentiers in some other way” (191)

We see at least three versions of these problems playing out now.

First, healthcare premiums and costsharing are set to spike next year as insurers rebuild cash reserves after the damage done by the Coronavirus and price-in the treatments and vaccines which will hopefully be available. This means that the damage of the pandemic to healthcare for many people will be long-lasting and potentially severe, as healthcare becomes harder to obtain. This is a direct result of insisting on private insurers as a payment system, because it makes beneficial reallocation of resources to cover the COVID costs more difficult.  This is poised to exacerbate the nightmarish and under-inclusive patchwork of insurance schemes that already keep large numbers of people from getting healthcare when they need it.  As Amy Kapczynski and Gregg Gonsalves write, this a legacy of longstanding objections to universal healthcare in the U.S; that is, “because conservatives, insurers, and racists have done their utmost to block what most other industrialized countries have had for decades, we lack anything that properly could be called a health care ‘system.’”  Absent some sort of governmental intervention, it will transfer the costs of COVID to those least able to pay it.

Second, Governor Cuomo has proposed austerity measures in New York’s Medicaid budget for next year, a position he’s not backing off of, despite his daily recitation of system capacity problems made worse by Medicaid cuts like the ones his own administration has been enacting for years.  He also is refusing to back off caps on tax rates. There is a reason Cynthia Nixon primaried Cuomo from the left!  Of course, Cuomo is Pericles compared to Trump, but it is a debased world where we have to make such comparisons at all, which mainly underscore that he (and Biden, who loudly opposes Medicare for All) are at best fantasy projections of what a post-neoliberal healthcare system might look like, not individuals who would work to achieve such a system, despite all the evidence at hand that we urgently need one, preferably starting a few years ago.

Finally, as the previous two suggest, costs within the healthcare system cannot be measured without reference to the exogenous social factors that interact with them.  This is a (hopefully) familiar point; I mention it here because specific evidence to support it is arriving in realtime.  Here those include class. Kapczynski and Gonsalves offer a synoptic view:

“We have known since the work of Rudolf Virchow, who studied typhus in Upper Silesia in the mid-nineteenth century, and Friedrich Engels, who studied the conditions of the English working class, that we create conditions that make people sick, and that those who lack economic, social, and political power typically bear the greatest burden of disease. But more recent work on the impact of inequality on health reveals another truth: inequality is itself associated with poorer health outcomes, including lower life expectancies across nations”

In other words, the entirety of our neoliberal order is part of not preparing for the pandemic.  Kapczynski and Gonsalves note that epidemics “can collapse social classes, even if—as with all forms of collapse—the people at the bottom get the worst of it.”  It’s clear enough that the ability to stay at home during the pandemic is based on class, and (as I argued in the last post), the decision that some of the most vulnerable members of society are simultaneously “essential” and expendable is a political one, not a medical one.  I’ve mentioned the utility of geolocation data in tracking social distancing a few times before (here, here and here); a new article in the New York Times uses that data to quantify what you might have suspected: the poor are far less able to stay home.   Not only will they bear the brunt of the inequalities and problems in the healthcare system going forward, and of the austerity measures imposed as a result of COVID, but they provably are bearing more of the costs in dealing with it.