The New York Times carried a pair of stories over the past week that tells you all you need to know about the present state of America. Alma Ramos is a cook in an Austin, Texas, restaurant who would like the privilege that every civilized nation on earth extends to all its citizens as a matter of right, access to decent health care.
She is one of the 30 million or so wretched of the earth for whom President Barack Obama’s Affordable Care Act was presumably designed (as opposed to the 20 million or so still more wretched for whom it was not).
Ramos, a single mother of three, wanted to get the private health insurance the government now compels her to have, thanks to a twisted reading of the Constitution that, for the first time in American history, demands that she buy a private product on pain of financial penalty.
(Yes, drivers are notionally obliged to have car insurance — many don’t — but driving is not a compulsory activity.)
Ramos’ problem was that she earned too much money to apply for insurance under Medicaid, but, perversely, too little to qualify for the federal subsidy offered by the new health care law: one of the many doughnut holes that lurk, like the black ones of physics, in our so-called social safety net. But that’s what you get in a universe designed by Billy Tauzin.
A storefront enrollment center for Obamacare operating out of Ramos’ neighborhood advised her that she could qualify for the subsidy by earning more money. Gamely, she took on added work, busing tables at night and cooking tamales out of her apartment. Just the ticket for someone trying to raise three children, one only a year old. With three jobs, she eked out the $24,000 annual income she needed.
Ramos is not alone. Four million adults in 24 states fall into the same gap, or shall we say trap, a million of them her fellow Texans. Almost all of these states opted out of the expanded Medicaid program envisioned by the Affordable Care Act, but made optional by a Supreme Court interpretation of the Act’s reach in 2012.
That might seem perverse (who turns down free money?) but not in those parts of the Republic where no sacrifice is too great to compel the poor to work harder.
Enrollment centers such as the one that “counseled” Ramos are, of course, businesses that pay staff to see how much labor can be sweated out of the working poor. Somebody, of course, pays them.
That would be the federal government, which thus subsidizes the very states that reject the Medicaid that would make such advisory services unnecessary, thereby abetting the exploitation of people like Ramos.
Some of the people who come into these centers are self-employed housecleaners. They help their clients calculate how many extra houses they need to clean to get their Medicaid access. This reminded me of an experience of my own. For years, I used a local primary care physician — you know, the people who used to be called doctors.
I liked his service and had no desire to change it. But, one day, he decided he’d had enough of marching to the beat of insurer-mandated medicine. He signed on with a so-called boutique practice, in which his patients paid $1,500 a year to him directly for premium care: quicker access, longer visits, wellness counseling, etc.
He assumed that I would want to continue with him, but I did not.
The problem, as I told one of his staff, was not that I couldn’t afford to pay the extra money but that others couldn’t, and that the effect of this was, wittingly or not, was to get rid of his poorer patients. “Well,” came the reply, “they can always clean more houses.”
Welcome to Texas.
It’s not only the poor, of course, who find themselves caught in the toils of Obamacare. Millions of Americans, having diligently shopped around for the best available deal in the first year of its operation, found themselves faced with sharply increased premiums in the second, and in many cases were forced to pay more to get less. For them, health care reform — and the health care mandate — was compulsory participation in a shell game.
It doesn’t make any difference, in the end, whether you blame Democrats or Republicans or the Supreme Court for a medical system that is an insult to the intelligence and a disgrace to a democracy. The problem is for-profit health care, which in the age of industrialized medicine is an insult not merely to a democracy but to the human race.
For-profit medicine is a relatively recent phenomenon, the sinister product of medical industrialization — hospital chains and Big Pharma — abetted by private insurance networks. Advances in medical technology — or at any rate the increasing cost, complications and specialization of medical treatment — required capital outlays that only large complexes, i.e., hospitals, could provide.
The cost of these “services” (sometimes they are, sometimes they aren’t) became unsustainable for individual consumers, hence requiring an insurance scheme. The logical solution would have been a single-payer system, whether operated directly by the government or through regulated utilities. This was the solution adopted by most other developed countries in the world.
It was the premise of Medicare, whose authors, compelled to confine it to the elderly and the disabled by the furious opposition of the American Medical Association, contemplated its gradual expansion to cover the entire population. This did not happen.
Instead, costs spiraled exponentially, and doctors themselves became the prisoners of the system they helped to build, forced to practice a medicine designed and defined by the unholy trinity — hospitals, drug companies and private insurers — for whom they found themselves working.
The doctors are sorry about that now, and most of them would like nothing better than socialized medicine. Ironically, that’s what we already have, except that it is, as in almost every other function that public subsidy in our happy land supports, socialism for the rich.
Most of the money in the system comes from taxation, without which it could not run for a day. Instead of serving the goal of maximizing public health, however, it maximizes the profits of corporatized medicine instead.
That is why the United States spends more money per capita on so-called health care than any other country on earth, with the worst results, from child mortality to adult life expectancy, of any industrial nation.
In addition to which, you are compelled by the government to buy private insurance of your own. Enjoy your paperwork. Thanks to Obamacare, millions of Americans can now rack their brains hopping from insurer to insurer every 12 months, not to mention dealing with the one you settle on in-between.
Why, you could get sick with frustration and anxiety trying to navigate the system. Which is exactly the idea.
I’ll be briefer with my second story. A New York housing program called 421a (so you won’t have any idea what it means) is supposedly meant to encourage affordable housing by offering tax incentives for developers who provide cheaper units in buildings with a variety of pricings and rentals and tax relief for the residents who live there.
Although the program is applied statewide, its largest target was Manhattan, from which middle and lower-class residents have virtually been driven. In 2013, only 12,748 units of some 150,000 qualifying for property tax breaks of up to 95 percent were low or moderate rentals.
The cost in lost revenues to the state for that year alone was $1.1 billion. In short, New York was subsidizing luxury apartments and penthouses to the sum of nearly a billion dollars per annum. How luxurious?
A six-bedroom, 11,000 square foot apartment on 57th Street with panoramic views on all sides that cost its owner $100.5 million got a $360,000 rebate with a wave of 421a’s magic wand. The tax “burden” on this pad was, in short, about one five-thousandth of its market value. That’s not your average property tax bill; certainly not mine.
But, you might say, how do we expect the rich to get richer without a hand from the rest of us? Good point, and we are so very proud of our billionaires, the Gateses and Buffets and Jobses, that we can hardly praise their great good works enough.
In a follow-up series this week, however, the Times outed a number of New York’s most elite squatters: a Russian banker-politician who was denied entry to Canada because of reputed links to organized crime; a Greek businessman arrested last year in a corruption sweep in his native country; a Chinese contractor who housed his New Jersey workforce in conditions better befitting slave labor, and so on.
Many luxury purchases are made through untraceable shell companies, meaning that our foreign visitors are not here to enjoy the New York skyline but to take advantage of American laws that enable them to move dirty money around with nary a G-man in sight.
Of course, similar arrangements exist elsewhere, in Singapore for example. But where else are assorted crooks, drug kingpins and tax cheats not only invited to look down from their multimillion dollar roosts on the rest of us, but subsidized at our expense in doing so?
There is a great deal more to know, for example about the only country in the world besides Papua New Guinea that can’t afford maternity leave for expectant mothers, or where state legislators debate which lethal cocktail to use in executing prisoners, but Ramos and Vitaly Malkin (the aforesaid Russian banker) give you all the information you need.
No country is perfect, but few let the bad guys win as often and egregiously as the United States of America.
Robert Zaller is a history professor at Drexel University. He can be contacted at [email protected]