The Body Economic
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38. One former Labour MP in the UK went so far as to argue, “Just as Germany destroyed Europe once in World War II, it is now bent on doing so for a second time.” See “Athens Police Fire Tear Gas in Crackdown Clashes at Anti-Merkel Protest,” RT, Oct 8, 2012. Available at: http://rt.com/news/greece-protests-germany-merkel-946/
PART III: RESILIENCE
Chapter 6: To Care or Not to Care
1. Name changed for confidentiality.
2. J. Steinhauer, “California budget Deal Closes $26 Billion Gap,” New York Times, July 25, 2009. Available at: http://www.nytimes.com/2009/07/25/us/25calif.html?hp IRS, Administrative, Procedural and Miscellaneous. http://www.irs.gov/pub/irs-drop/rp-09–29.pdf
Routine care was often covered, but not all Americans were aware of what was covered and what was not. See C. Fleming. “New Health Affairs: High-Deductible Health Plan Enrollees Avoid Preventive Care Unnecessarily.” Health Affairs Blog, Dec 3, 2012. Available at: http://healthaffairs.org/blog/2012/12/03/new-health-affairs-high-deductible-health-plan-enrollees-avoid-preventive-care-unnecessarily/
3. A. Wilper, et al. 2009. “Health Insurance and Mortality in US Adults,” American Journal of Public Health v99(12): 2289–95.
4. Ibid. People who are uninsured are just one emergency room visit away from bankruptcy. During the recession about one-quarter of uninsured persons used their entire savings to pay medical bills. About three out of every four Americans are now struggling to cope with medical bills or healthcare-related debt, which is more than those with mortgage-payment difficulties. New Hampshire Medicaid Enrollment Forecast, SFY 2011–2013 Update. Available at: http://www.dhhs.nh.gov/ombp/documents/forecast.pdf. K. Carollo, 2010. American Medical Association condemns insurance “purging.” Available at: http://abcnews.go.com/Health/HealthCare/american-medical-association-condemns-insurance-purging/story?id=10920504
5. Prior to the Affordable Care Act in order to qualify for Medicaid the applicant had to be poor and a) a family with children who met certain eligibility requirements (e.g. disabled), b) elderly, disabled or blind, c) with child less than six years old or pregnant mother, d) with school-age children ages six to eighteen.
6. Kaiser Commission of Medicaid and the Uninsured, State Fiscal Conditions and Medicaid Program Changes, FY 2012–2013, Nov 28, 2012. Available at: http://www.kff.org/medicaid/7580.cfm; Erica Williams, Michael Leachman, and Nicholas Johnson, “State budget Cuts in the New Fiscal Year Are Unnecessarily Harmful—Cuts Are Hitting Hard at Education, Health Care, and State Economies,” Center for budget and Policy Priorities, updated July 28, 2011. Available at: http://www.cbpp.org/cms/index.cfm?fa=view&id=3550
7. A. Haviland, et al. “High-Deductible Health Plans Cut Spending but Also Reduce Preventive Care.” RAND Health Fact Sheet, 2011. Available at: http://www.rand.org/pubs/research_briefs/RB9588.html; M. Buntin, et al. 2011. “Healthcare Spending and Preventive Care in High-Deductible and Consumer-Directed Health Plans,” The American Journal of Managed Care v17(3): 222–30.
8. The Commonwealth Fund, “Help on the Horizon,” March 2011. Available at: http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2011/Mar/1486_Collins_help_on_the_horizon_2010_biennial_ survey_report_FINAL_v2.pdf; S. Dorn, et al. 2012. “Impact of the 2008–2009 Economic Recession on Screening Colonoscopy Utilization Among the Insured,” Clinical Gastroenterology and Hepatology v10(3): 278–84. Available at: http://www.sciencedirect.com/science/article/pii/S154235651101278X; J. D. Piette, et al. 2011. “Medication Cost Problems Among Chronically Ill Adults in the US: Did the Financial Crisis Make a Bad Situation Even Worse?” Patient Preference and Adherence v5:187.
9. Since 2008, more than 49,000 state and local public health department jobs have been cut. “Kaiser Commission on Medicaid and the Uninsured. Emergency Departments Under Growing Pressures,” 2009. Available at: http://www.kff.org/uninsured/upload/7960.pdf
10. Emily Walker, “Health Insurers Post Record Profits,” ABC News, Feb 12, 2010. Available at: http://abcnews.go.com/Health/HealthCare/health-insurers-post-record-profits/story?id=9818699
See, for example, Emily Berry, “Health Plans Say They’ll Risk Losing Members to Protect Profit Margins,” American Medical News, May 19, 2008. Available at: http://www.ama-assn.org/amednews/2008/05/19/bil10519.htm
FIGURE 6.1 For-Profit Insurers—Profits for the First Nine Months of 2010
Source: Third quarter earnings reports compiled by the office of Congressman Pete Stark
11. Kenneth J. Arrow, “Uncertainty and the Welfare Economics of Medical Care,” The American Economic Review, Dec 1963; P. Krugman, “Why Markets Can’t Cure Healthcare,” New York Times, 2009. Available at: http://krugman.blogs.nytimes.com/2009/07/25/why-markets-cant-cure-healthcare/
12. J. Hart. 1971. “The Inverse Care Law,” The Lancet v297(7696): 405–12. As the paper notes, “this inverse care law operates more completely where medical care is most exposed to market forces, and less so where such exposure is reduced.”
13. Contrary to conventional wisdom, Americans don’t visit the doctor as much, or use more expensive technologies, either—for example, they get fewer MRIs per person than Japan and fewer expensive hip surgeries than much of Europe, but are simply being charged more for the same MRI. The nursing home population is also smaller, proportionally. Institute of Medicine. “U.S. Health in International Perspective: Shorter Lives, Poorer Health,” 2013. Available at: http://www.iom.edu/Reports/2013/US-Health-in-International-Perspective-Shorter-Lives-Poorer-Health.aspx. The reasons for high US healthcare spending are reviewed in a report by the Commonwealth Fund, available at: http://www.commonwealthfund.org/Publications/Issue-Briefs/2012/May/High-Healthcare-Spending.aspx. For the data on drug research and development spending, see Families USA. “Profiting from Pain: Where Prescription Drug Dollars Go,” 2009. Available at: http://www.policyarchive.org/handle/10207/6305
14. Institute of Medicine, “U.S. Health In International Perspective: Shorter Lives, Poorer Health,” 2013. Available at: “http://www.iom.edu/Reports/2013/US-Health-in-International-Perspective-Shorter-Lives-Poorer-Health.aspx. The United States now ranks last in male life expectancy among developed countries (even after taking into account its exceptionally high death rate from firearms).
15. A. Lusardi, D. Schneider, P. Tufano, “The Economic Crisis and Medical Care Usage,” Dartmouth College. Available at: http://www.dartmouth.edu/~alusardi/Papers/healthcare_031610.pdf
16. Many factors contributed to the rise in the NHS. It was implemented as part of a suite of major reforms that launched the British welfare state in the postwar period. See D. Stuckler, A. Feigl, S. Basu, M. McKee, “The Political Economy of Universal Health Coverage. First Global Symposium on Health Systems Research,” Nov 2009. Available at: http://www.pacifichealthsummit.org/downloads/UHC/the%20political%20economy%20of%20uhc.PDF
17. Jeremy Laurance, “NHS Watchdog Is Winning the Price War with Drug Companies,” The In de pen dent, Dec 21, 2009. Available at: http://www.independent.co.uk/life-style/health-and-families/health-news/nhs-watchdog-is-winning-the-price-war-with-drug-companies-1846352.html. See NHS core principles, 2013. Available at: http://www.nhs.uk/NHSEngland/thenhs/about/Pages/nhscoreprinciples.aspx
18. The Commonwealth Fund and the OECD had previously labeled the NHS the most efficient, effective, and responsive system in the world; the Tory government is now turning it into an unresponsive market-based healthcare system like that in the US.
19. Sunny Hundal, “Revealed: The Pamphlet Underpinning Tory Plans to Privatise the NHS,” Liberal Conspiracy, June 3, 2011. Available at: http://liberalconspiracy.org/2011/06/03/revealed-the-pamphlet-underpinning-tory-plans-to-privatise-the-nhs/
Andy McSmith, “Letwin: ‘NHS Will Not Exist Under Tories’,” The In de pen dent, June 6, 2004. Available at: http://www.independent.co.uk/life-style/health-and-families/health-news/letwin-nhs-will-not-exist-under-tories-6168295.html. Austerity went a step further: “For unto every one that hath shall be given, and he shall h
ave abundance: but from him that hath not shall be taken away even that which he hath.”
20. The big difference in costs were coming from private healthcare, which added 1.6 percent in the UK, 2.6 percent in France, 2.7 percent in Germany, and 9.1 percent in the US. The Commonwealth Fund 2010 International Health Policy Survey. See also Rita O’Brien, “Kent, Keep Our NHS Public.” Available at: http://www.keepournhspublic.com/pdf/howdoestheNHScompare.pdf
21. The British Medical Association held its first emergency meeting in two decades, calling on the government to withdraw the bill.
Helen Duffett, “Nick Clegg’s Speech on NHS Reform,” Liberal Democratic Voice, May 26, 2011. Available at: http://www.libdemvoice.org/nick-cleggs-speech-on-nhs-reform-24260.html
22. Tom Jennings, “Action to Turn Round Health Centre Wins Praise,” Oxford Times, Jan 16, 2013. Available at: http://www.oxfordtimes.co.uk/news/yourtown/witney/10162757.print/
23. “Further Privatisation Is Inevitable Under the Proposed NHS Reforms,” British Medical Journal, May 17, 12012. Available at: http://www.bmj.com/content/342/bmj.d2996
24. Randeep Ramsh, “Public Satisfaction with NHS Slumped During Reforms Debate, Thinktank Finds,” The Guardian, June 11, 2012. Available at: http://www.guardian.co.uk/society/2012/jun/12/public-satisfaction-nhs-thinktank. These patterns were consistent with research of a natural experiment in Italy’s National Health Service, which found that those regions undergoing greater privatization of healthcare delivery had worse healthcare performance. C. Quercioli, G. Messina, S. Basu, M. McKee, N. Nante, D. Stuckler. 2013. “The Effect of Health Care Delivery Privatization on Avoidable Mortality: Longitudinal Cross-Regional Results from Italy, 1993–2003,” Journal of Epidemiology & Community Health v67(2): 132–38.
25. “A&E Waits Highest for a De cade,” BBC News, Feb 13, 2012. Available at: http://www.bbc.co.uk/news/health-21444444
26. “NHS Shakeup Spells ‘Unprecedented Chaos,’ Warns Lancet Editor,” The Guardian, March 24, 2012. Available at: http://www.guardian.co.uk/society/2012/mar/24/nhs-shakeup-chaos-lancet
27. Under current EU competition law, the NHS would be fully opened up to compulsory competitive markets, and private corporations are to be eligible to receive the same government subsidies as publicly funded services.
28. F. Ponsar, K. Tayler-Smith, M. Philips, S. Gerard, M. Van Herp, T. Reid, R. Zachariah, “No Cash, No Care: How User Fees Endanger Health—Lessons Learnt Regarding Financial Barriers to Healthcare Services in Burundi, Sierra Leone, Democratic Republic of Congo, Chad, Haiti and Mali,” International Health, 2011. Available at: http://fieldresearch.msf.org/msf/bitstream/10144/203642/1/Ponsar%20No%20cash,%20No%20care.pdf
29. D. Stuckler, A. Feigl, S. Basu, M. McKee. “The Political Economy of Universal Health Coverage.” First Global Symposium on Heath Systems Research, 2009. Available at: http://www.pacifichealthsummit.org/downloads/UHC/the%20political%20economy%20of%20uhc.PDF
Chapter 7: Returning to Work
1. B. Wedeman, “Death and Taxes in Italy,” CNN, Sept 9, 2010. Available at: http://edition.cnn.com/2012/09/10/business/italy-economy-suicide/index.html; A. Vogt, “Widows of Italian Suicide Victims Make Protest March Against Economic Strife.” The Guardian, 2012. Available at: http://www.guardian.co.uk/world/2012/may/04/widows-italian-businessmen-march
2. “May Day: Italy’s ‘White Widows’ Give Private Pain a Public Face.” Available at: http://thefreelancedesk.com/?p=543; A. Vogt, “Italian Women Whose Husbands Killed Themselves in Recession Stage March,” The Guardian, April 30, 2012. Available at: http://www.guardian.co.uk/world/2012/apr/30/italian-women-husbands-recession-march
3. K. N. Fountoulakis, et al., “Economic Crisis-Related Increased Suicidality in Greece and Italy: A Premature Overinterpretation,” Journal of Epidemiology and Community Health, March 12, 2012. Available at: http://jech.bmj.com/content/early/2012/12/03/jech-2012-201902.full.pdf+html; to which we responded in R. De Vogli, M. Marmot, D. Stuckler. 2012. “Strong Evidence That the Economic Crisis Caused a Rise in Suicides in Europe: The Need for Social Protection.” Journal of Epidemiology and Community Health. Available at: http://jech.bmj.com/content/early/2013/01/14/jech-2012-202112
4. “In Debt or Jobless, Many Italians Choose Suicide,” NBC News, May 9, 2012. Available at: http://worldblog.nbcnews.com/_news/2012/05/09/11621840-in-debt-or-jobless-many-italians-choose-suicide?lite
5. Looking at data disaggregated by state from the US Centers for Disease Control and Prevention, we found that increases in state suicide rates corresponded in timing and size to the changes in each state’s unemployment rate.
6. Source for Figure 7.1: Authors’. Adapted from R. De Vogli, M. Marmot, D. Stuckler. 2012. “Excess Suicides and Attempted Suicides in Italy Attributable to the Great Recession,” Journal of Epidemiology & Community Health. doi: 10.1136/jech-2012-201607.
7. G. Lewis and A. Sloggett. 1998. “Suicide, Deprivation, and Unemployment; Record Linkage Study,” British Medical Journal v317:1283. Available at: http://www.bmj.com/content/317/7168/1283
8. Source for Figure 7.2: Adapted from A. Reeves, D. Stuckler, M. McKee, D. Gunnell, S. Chang, S. Basu. November 2012. “Increase in State Suicide Rates in the USA During Economic Recession,” The Lancet v380(9856): 1813–14.
9. The leading advocate of this theory was Professor Hugh Gravelle, who argued that people were not sick because they were unemployed, but unemployed because they were sick. Professor Mel Bartley, a social epidemiologist, criticized Gravelle’s logic in the BMJ: Where, Bartley asked, was the sudden massive epidemic that preceded the rise in unemployment by 3 million people? He noted, “we really cannot plausibly argue that an increase in the incidence of mental ill health or alcoholism could cause an increase in unemployment at the level of a national population.”
K. Moser, P. Goldblatt, A. Fox, et al. 1987. “Unemployment and Mortality: Comparison of the 1971 and 1981 Longitudinal Study Census Samples,” British Medical Journal v294:86–90.
For suicide risk, see Lewis and Sloggett, “Suicide, Deprivation, and Unemployment; Record Linkage Study”; T. Blakely, S. C. D. Collings, J. Atkinson, “Unemployment and Suicide: Evidence for a Causal Association?” Journal of Epidemiology & Community Health v57(8): 594–600.
Montgomery and colleagues found that unemployment predated symptoms of depression and anxiety. See S. Montgomery, D. Cook, M. Bartley, et al. 1999. “Unemployment Pre-dates Symptoms of Depression and Anxiety Resulting in Medical Consultation in Young Men,” Int J Epidemiol v28:95–100.
10. In 1994 Professor Mel Bartley later explained in the Journal of Epidemiology and Community Health: “It is no longer seriously argued that there is no such relationship [between unemployment and illness]. Lower levels of psychological well-being are found in all studies which compared unemployed people, at all ages and in both sexes. More persuasively, these differences in mental health have been shown to emerge after entry into the labor market in young people showing no such differences while still at school. Mental health improves when young people find jobs.” Available at: http://jech.bmj.com/content/48/4/333.full.pdf. Women report higher rates of depression, but men are about three times as likely as women to experience suicide. The reasons are multiple, but are in part because women are more likely to seek help.
R. Davis, “Antidepressant Use Rises as Recession Feeds Wave of Worry,” The Guardian, June 11, 2010. Available at: http://www.guardian.co.uk/society/2010/jun/11/antidepressant-prescriptions-rise-nhs-recession
11. “Workers Turn to Antidepressants as Recession Takes Its Toll,” Mind, May 17, 2010. Available at: http://www.mind.org.uk/news/3372_workers_turn_to_antidepressants_as_recession_takes_its_toll
The Telegraph reported an even larger rise of 7 million prescriptions during the recession. See Martin Evans, “Recession Linked to Huge Rise in Use of Antidepressants,” Telegraph, April 7, 2011. Available at: http://www.telegraph.co.uk/health/8434106/Recession-linked-to-huge-rise-in-use-of-antidepressants.html
12. Unemployment was
also correlated with rising prescriptions for pain medicines and stomach ulcers. F. Jespersen and M. Tirrell, “Stress-Medication Sales Hold Up as Economy Gives Heartburn to U.S. Jobless,” Bloomberg, Dec 27, 2011. Available at: http://www.bloomberg.com/news/2011-12-27/stress-medications-holding-up-through-economic-doldrums-study-suggests.html
13. Consistent with existing research, our further evidence found that fear of unemployment—economic insecurity—could be as harmful to mental health as actual job loss.
14. We found this applied not only to the individual but also whether any member of the family had recently lost work. M. Gili, M. Roca, S. Basu, M. McKee, D. Stuckler. 2012. “The Mental Health Risks of Economic Crisis in Spain: Evidence from Primary Care Centres, 2006 and 2010,” European Journal of Public Health v23(1): 103–8. Available at: http://eurpub.oxfordjournals.org/content/23/1/103. We also found eviction was a major risk factor for mental health diagnoses.
15. The OECD defines ALMPs as follows: “First, they make receipt of benefits conditional on the benefit recipient demonstrating active job search and/or a willingness to take steps to improve employability. Second, they provide a range of pre-employment services and advice to help the individuals in question find work or get ready for work.” For a distribution of passive versus active labor market policies, see J. P. Martin, “What Works Among Active Labour Market Policies: Evidence from OECD Countries’ Experiences.” Available at: http://www.rba.gov.au/publications/confs/1998/martin.pdf
16. J. Vuori and J. Silvonen, et al. 2002. “The Tyohon Job Search Program in Finland: Benefits for the Unemployed with Risk of Depression or Discouragement,” J Occup Health Psychol v7(1): 5–19; J. Vuori and J Silvonen. 2005. “The Benefits of a Preventive Job Search Program on Re-employment and Mental Health at 2- year Follow-up,” Journal of Occupational and Organization al Psychology v78(1): 43–52. The specific Työhön program included the following components: The program paired a job-search trainer with newly unemployed people. The trainer worked five half-day sessions to help place unemployed people into the job search databases, and improve their skills—interviewing techniques, how to find jobs through social networks, how to assemble resumes and job applications—to overcome common setbacks and prevent the slump of chronic unemployment. The ALMPs also featured encouragement to take even part-time work or help gain job-training to switch to other types of work. Financial support was also a component of ALMP programs, but funds were provided only to those who participated in the part of the program that also helped them get back to work. Those participating in the program also found better-quality jobs, with the greatest benefits observed among those who had lost jobs within the past few years. Similar evidence that ALMPs helped prevent depression came from studies in the United States.