CORONAVIRUS: BARRING THE FORESEEABLE

This morning, as I was making breakfast, I tuned into the middle of a Morning Edition interview on NPR with Jason Isbell, someone I had never heard of.  He’s a successful country and western musician from Muscle Shoals, Alabama; a four-time Grammy winner; and a recovering alcoholic.  He talked about the closing of small, independent music venues all over the U.S. and the hardship and heartache that brings to performers and club owners alike.  But there was something he said that confirmed what I've been thinking about.  Isbell predicted, “This pandemic is going to be really hard on addicts everywhere.” I found that particularly relevant to two recent news items.  

The first is the jobs report.  Last week, roughly three million Americans filed for unemployment benefits, bringing the eight-week total to over 36.5 million claims and, as the Washington Post put it, “erasing years of economic gains and threatening lasting devastation to the country that rivals even the Great Depression.”  That’s a big percentage of the workforce out of a job, around 15%, but as with pandemic infection and mortality rates, the numbers are not evenly distributed.  According to The New York Times, 

In an analysis of the latest unemployment-claims report, the U.S. Chamber of Commerce found that in 11 states, more than a quarter of those in the work force in February were now unemployed. And a survey by the Federal Reserve found that in households making less than $40,000 a year, nearly 40 percent of those who were working in February lost their jobs in March or the beginning of April.

Because health care is typically tied to employment in the U.S., that means that 36.5 million Americans are now not only looking for work, they’re also looking for health insurance in the middle of a pandemic.   Some of the unemployed are—in theory—eligible for alternative coverage under Medicaid (if they’re poor enough and live in a state that expanded coverage), COBRA (if they can afford it), or on the Obamacare insurance exchanges (if the U.S. Supreme Court doesn’t side with the Trump Administration and declare the law unconstitutional).  But based on a study by the Kaiser Family Foundation out last month, about 6.5 million are likely to remain uninsured until they find another job that offers health benefits.  The other 30 million may or may not actually find a health care solution, because health insurance is very complicated and signing up is really hard.

The second news item is a decision by the Trump Administration reported on May 6 by Politico:  

President Donald Trump on Wednesday said his administration will urge the Supreme Court to overturn Obamacare, maintaining its all-out legal assault on the health care law amid a pandemic that will drive millions of more Americans to depend on its coverage.

The administration appears to be doubling down on its legal strategy, even after Attorney General William Barr this week warned top Trump officials about the political ramifications of undermining the health care safety net during the coronavirus emergency.

Comforting to know that Barr caved to what is actually the President's re-election strategy rather than fulfill his duty to apply the law to the facts, without regard to politics.  But that’s completely in line with his answer this week when asked how he thought history would judge his decision to drop all criminal charges against Michael Flynn, Trump’s first national security advisor, who pleaded guilty in open court to lying to the FBI--twice.  Barr’s answer?  “History is written by the winners, so it largely depends on who’s writing the history.” Nice respect for the rule of law, Billy Bob, replied over 2,000 former U.S. Attorneys, who called for his resignation.  Fat chance.

But it’s not Barr’s disrespect for, and politicization of, the law that got me thinking about how his leadership of the Justice Department will affect who gets and doesn’t get health insurance during this pandemic and how that will cause the increase in addiction Isbell foresees.  It was his speech at the Notre Dame School of Law last year, which I wrote about last October.  That speech popped up again this January in a New Yorker profile of Barr at The New Yorker:  

Last October, Attorney General William Barr appeared at Notre Dame Law School to make a case for ideological warfare. Before an assembly of students and faculty, Barr claimed that the “organized destruction” of religion was under way in the United States. “Secularists, and their allies among the ‘progressives,’ have marshaled all the force of mass communications, popular culture, the entertainment industry, and academia in an unremitting assault on religion and traditional values,” he said. Barr, a conservative Catholic, blamed the spread of “secularism and moral relativism” for a rise in “virtually every measure of social pathology”—from the “wreckage of the family” to “record levels of depression and mental illness, dispirited young people, soaring suicide rates, increasing numbers of angry and alienated young males, an increase in senseless violence, and a deadly drug epidemic.”

Let me repeat that:  Barr claims the assault on religion and traditional values is responsible for “record levels of depression and mental illness, dispirited young people, soaring suicide rates, increasing numbers of angry and alienated young males, an increase in senseless violence, and a deadly drug epidemic.”

That is, quite simply, a load of crap.  And, typical of Barr, his false claim serves to distract from the real causes of what are called “deaths of despair.”  A new book by Princeton University economists Anne Case and her husband Angus Deaton, Deaths of Despair and the Future of Capitalism (Princeton), investigated the connection between two societal trends in the U.S.:  one, the increase in the number of people who suffer from chronic pain, and two, the disconnect between health and wealth on the one hand and happiness on the other. 

Dr. Atul Gawande, a surgeon and public health researcher, reviewed the book at

Deaths of Despair (well worth a closer read) and recounts the research methodology:

They combed through survey data together and found that communities with higher rates of chronic pain also had higher rates of suicide. What’s more, rates of both had risen markedly for middle-aged, non-Hispanic white Americans—but not for black or Hispanic Americans. And the data grew only more curious and concerning the further they looked. As Case and Deaton… dug deeper into national vital statistics and compared rates of suicide with those of other causes of mortality, “To our astonishment, it was not only suicide that was rising among middle-aged whites; it was all deaths,” they write.

This was nearly unfathomable. Outside of wars or pandemics, death rates for large populations across the world have been consistently falling for decades. Yet working-age white men and women without college degrees were dying from suicide, drug overdoses, and alcohol-related liver disease at such rates that, for three consecutive years, life expectancy for the U.S. population as a whole had fallen.

Case and Deaton decided to find out why the American dream had turned into a nightmare for white, working class, non-college educated Americans.  By looking at the data, they were able to eliminate the usual suspects and isolate the real culprits.  It’s not the rise of secularism or moral relativism and the decline of religion, as Bill Barr wants you to believe.  It’s the unfairness of the American economy and its healthcare system.  This is what Case and Deaton found.

It’s not an oversupply of opioids.  About 1 million Americans use heroin or synthetic opioids like fentanyl daily.  Most users are functional and many eventually kick their habits.  Among those who don’t, opioid deaths are unevenly distributed.  White college-educated Americans account for only about nine percent of overdose deaths; the percentage of blacks and Hispanics is even smaller.  The vast majority of overdose deaths occur among white working class users.  Further, although opioid deaths flattened temporarily in 2018, the increase in suicides and alcohol-related deaths continued to rise.

It’s not obesity.  Obesity increases chronic illness and joint pain and tracks regional and demographic patterns that line up with deaths of despair.  But Case and Deaton report seeing the same mortality trends—deaths linked to suicide, domestic violence, alcoholism, and substance abuse --among the underweight, normal weight, overweight, and obese.

It’s not poverty.  Despite a fall in poverty rates beginning in the 1990s, white working class death rates have not declined for the past 30 years.  Interestingly, overdose deaths are most common in high-poverty Appalachia and along the low-poverty Eastern Seaboard.  

It’s not income inequality.  Case and Deaton found that patterns of inequality don’t match the patterns of mortality by race or region.  For example, California and New York have among the highest inequality levels in the country and the lowest mortality rates.

It’s not cultural, either.  Conservatives tend to give cultural explanations for these deaths of despair, as Barr does in his Notre Dame address and J. D. Vance does in Hillbilly Elegy.  They claim people are lazy and shirk responsibility, choosing of their own volition alcohol, drugs, and welfare and disability checks over a commitment to hard work, family, and community.  But as Gawande convincingly argues in his review of Deaths of Despair: 

Yet, if the main problem were that a large group of people were withdrawing from the workforce by choice, wages should have risen in parallel. Employers should have been pulling out the stops to lure people back to work. But they haven’t. Wages have stayed flat for years.

So what does explain the rise in deaths of despair among white, non-college-educated Americans?  Two things, both related and working in tandem:  Wage stagnation (including a total loss of wages through loss of a job) and the complicated and costly American health care system.  

As for wage stagnation, Case and Deaton found that the communities with higher rates of unemployment or underemployment are also the communities with higher rates of death by suicide, drug overdoses, and alcohol-related liver disease.  In fact, per capita economic growth; i.e., wages, has declined since the end of World War II, when growth averaged between 2 and 3%.  Then it dropped below 2% in the 1990s; now it’s below 1.5%.  But wage declines, like deaths of despair, haven’t been experienced equally.  Earnings of college graduates have soared.  Anti-discrimination laws have improved earnings and job prospects for black and Hispanic Americans.  Expectations matter.  While their earnings and job prospects still lag behind those of the white working class, the economic lives of blacks and Hispanics have improved, and these fulfilled or exceeded expectations likely account for the fact that deaths of despair have left the black and Hispanic community relatively untouched. 

 

But expectations have not improved for whites without a college education.  On the contrary, they have been betrayed.  Among working class white men, median wages have declined since 1979.  The work non-college-educated Americans of both sexes find is less stable, the hours more uncertain, and the duration shorter.  They tend to work in the gig economy, temporary contracting, or day labor, work which is less likely to come with health insurance.  Gawande explains:

Among advanced economies, this deterioration in pay and job stability is unique to the United States. In the past four decades, Americans without bachelor’s degrees—the majority of the working-age population—have seen themselves become ever less valued in our economy. Their effort and experience provide smaller rewards than before, and they encounter longer periods between employment. It should come as no surprise that fewer continue to seek employment, and that more succumb to despair.

Case and Deaton also lay the blame for deaths of despair at the door of a complicated and costly American healthcare system that is “peculiarly reliant on employer-provided insurance.”  Gawande explains how employers pay a kind of perverse tax on hiring lower-skilled workers:

According to the Kaiser Family Foundation, in 2019 the average family policy cost twenty-one thousand dollars, of which employers typically paid seventy per cent. “For a well-paid employee earning a salary of $150,000, the average family policy adds less than 10 percent to the cost of employing the worker,” Case and Deaton write. “For a low-wage worker on half the median wage, it is 60 percent.” Even as workers’ wages have stagnated or declined, then, the cost to their employers has risen sharply. One recent study shows that, between 1970 and 2016, the earnings that laborers received fell twenty-one per cent. But their total compensation, taken to include the cost of their benefits (in particular, health care), rose sixty-eight per cent. Increases in health-care costs have devoured take-home pay for those below the median income. At the same time, the system practically begs employers to reduce the number of less skilled workers they hire, by outsourcing or automating their positions. In Case and Deaton’s analysis, this makes American health care itself a prime cause of our rising death rates.

Ignoring the twin sources of deaths of despair—the economy and the healthcare system-- in the context of the massive increase in unemployment triggered by the pandemic risks the spread of those deaths of despair beyond white Americans without college degrees to the unemployed workforce at large.  That will lead to unprecedented, geographically, and demographically widespread despair throughout the U.S. replicating everywhere lines for food banks like the one in Florida above.  Some of that despair will manifest as anger toward immigrants and perceived “inferiors,” but most of it will be experienced as a sense of hopelessness and helplessness, and those feelings will be drowned in alcohol and smoothed over with drugs.  Again per Gawande:

When it comes to people whose lives aren’t going well, American culture is a harsh judge: if you can’t find enough work, if your wages are too low, if you can’t be counted on to support a family, if you don’t have a promising future, then there must be something wrong with you. When people discover that they can numb negative feelings with alcohol or drugs, only to find that addiction has made them even more powerless, it seems to confirm that they are to blame.

The problem isn’t, as Barr would like us to believe, that people aren’t the way they used to be, or that secularization and moral relativism have destroyed American society.  The problem is that the economy and the structure of work itself are not the way they used to be, and that these systemic flaws are destroying American society.  These are the flaws responsible for deaths of despair.  And I fear that after the pandemic, the economy and the structure of work will bear even less resemblance to “the time before.” 

So when people like Barr try to convince me that it is the Democrats, Harvard, The New York Times, and Hollywood who are responsible for the “wreckage of the family, record levels of depression and mental illness, dispirited young people, soaring suicide rates, increasing numbers of angry and alienated young males, an increase in senseless violence, and a deadly drug epidemic,” I do what Emma Gonzales from Marjorie Stoneman Douglas High School in Parkland, FL did, “I call bull shit!”  

Mr. Barr will not distract me with some First Amendment bogus argument that uses faith as a political cover-up of an economic problem.  He will not "Barr" me from seeing the foreseeable.  Nope.  Not falling for it.  It’s the economy, stupid!  And if you don’t believe me, listen to what Jason Isbell said on Twitter to a fan in November 2017.  When asked,

"Why do we have to inject politics in every aspect of our life?  Can't we just enjoy the music and the football games?" Isbell responded, "Until you are the one being treated unfairly, that's easy to say."

Tell it like it is, Jason.  Straight outta Muscle Shoals.

Keep it real!  Wear your mask!

Marilyn