While I recover from a nasty case of food poisoning, I thought in honor of the SCOTUS decision, it would be worth re-running this piece from 2009. For all that this is not the national health care system the US needs, it is, in the end, a small step in the right direction.
A while back, at a talk I gave, a small scale farmer asked me why my family didn’t farm full time. I observed that one of the reasons we don’t is simply that we have young children and we feel that we have a need for benefits. He pointed out that my state, New York, has a program to provide health insurance for the children of the uninsured, and that we could rely upon that. My own observation was (beyond the fact that I prefer not to burden state safety nets if we can avoid it and the insurance provided is vastly inferior to the one we have now) that I do not expect that program to continue if the recession goes on. Thus, we would not give up my husband’s existing benefits to switch to a state program that I suspect will at some point be cut in the vast rush of states to cut social service programs to balance their budgets. While I suspect that my husband’s university may also eventually cut benefits, I’d still say the odds were a little better for hanging on to health insurance via his job.
And, of course, we can see that other states are leading the way here – most notably California, which (in 2009) planned to resolve its budget crisis not by legalizing pot or releasing non-violent drug offenders, by stripping benefits from children, the disabled and the elderly. But California isn’t alone – children’s health care is threatened or there are pushes to curtail it in nine other states, and I suspect it is only a matter of time before more states make the push to cut health care programs for children and the working poor.
Now with luck, the state budget cuts won’t matter all that much – if we can pull together a functional and meaningful national health care system. The problem is that that’s a bigger “if” than it may seem. Besides the endless debate about what type of national health care system to provide, there’s the very real possibility that our enormous deficits and bailouts may have made it truly impossible for us to have a system that looks like the one we have at present, and is sustainable. Even if we can implement national health care, the question becomes whether we can sustain it over the long term, as our demographic situation shifts towards an older and sicker population, and our national economic, ecological and energy system puts us closer to crisis. So far, as far as I can tell, most of the proposed programs for national health care do comparatively little to regulate costs, and assume levels of growth that we simply may not see.
In _Depletion and Abundance_ I included a chapter on health care – on the ways that could keep national lifespans up and spend much, much less than we do now – half as much or even less than that. It involves a great deal of system triage and difficulty, but it is possible – and IMHO, in the end, as long as we imagine that the goal of national health insurance is not keeping infant mortality low and lifespans high, but the serving of people accustomed to a large range of drugs and interventions with as may drugs and interventions as possible, we are facing trouble.
And yet, we need national health care desperately – we already have a tiered class system in the US where those who are poor and lack health insurance get sicker, die younger and suffer more. We already have a lifespan pathetic in the developed world – we are 44th, and lifespans are declining in many poor counties in the US. That decline in lifespans represents a profound change – for almost a century, medical advances have lengthened lifespans – reversals are sign of something seriously wrong. Moreover, we know that in difficult times lifespans can drop dramatically – we need only to look to Russia during its economic collapse.
We need national health care because otherwise we will see that class division, and the differences in lifespans and infant mortalities between rich and poor grow and grow. We need it because our current system is too costly and devours too many resources in every sense. We need it because it is a basic issue of justice, and because having the crappiest medical care system in the developed world is not an honor.
We need it because we already bear the costs of medical care for the uninsured in our society, both directly and indirectly – we all pay for the poor mother who takes their daughter to the ER in the middle of the night for an ear infection that could have been handled with a ten minute office visit. We already pay for the people who age into Medicare with uncontrolled diabetes and high blood pressure, whose medical costs are double what they would have been if they’d had basic preventative care. We already pay – the question is whether we pay honestly and directly, or inhumanely and dishonestly.
We need national health care for another reason as well, one that is not often spoken of. We need it because we need sustainable food systems. National health insurance is the key to ensuring that we can have the Nation of Farmers we so desperately need to be. One of the major things preventing people from farming, one of the things driving small farmers off their land, is the cost of medical care.
Nationally, a survey showed that farmers pay twice as much out of pocket for health care as the average American. Most farmers large enough have to buy their health care coverage as individuals, driving up the cost, and because of the risks of farming, their premiums are higher than average. Others have no insurance, and have to put their insurance on credit cards, or pay with their savings. The average US farmer is nearly 60 years old, and many have pre-existing conditions that come with age – either forcing insurance costs out of reach, or driving them up. No wonder so many of today’s farmers, when polled, say they wouldn’t want their children to follow in their footsteps – but that leaves us with the very real question of where the population that grows our food will come from.
Among younger small farmers getting started, I’ve watched many of them struggle with the insurance conundrum – they start out young and healthy, and often are willing to forgo health insurance because they truly and honestly want to do something good. But farming pays poorly, and the first serious injury can be a disaster – and working outside all day, you get hurt sometimes. Or perhaps they have a baby – even those able to take on a homebirth find that the cost of having a child is a few thousand dollars or more out of on a small household income. Those who must have a hospital birth or more interventions can find themselves rapidly indebted. Soon, finding a job with health care coverage starts to look awfully good – and there goes the farm, or it goes down to a part-time venture.
Farmers who experience a major injury or illness risk losing their land to bankruptcy. While losing your home is always traumatic, there’s a big difference between losing the house you love but that mostly provides shelter and a good school district, and losing the land you use to make your living. Up to 10% of all agricultural bankruptcies are linked to illness and injuries - mostly among the uninsured. Once the land is lost, it is gone – most farmers once out of agriculture, are out for good.
Without a national health care system, we can become a nation of hobby farmers and victory gardeners, but that won’t resolve the grain production problem, and it won’t feed our cities. A lot can be done by home scale agriculture, and I am an ardent proponent of each of us doing what we can – but we need professional, full time farmers as well. Without insurance, the lure of any other work that covers the child’s asthma medication or the husband’s heart pills will always drive farmers away from agriculture. What parents wants their child to go into a profession that leads in so many ways to heartbreak and loss at so many levels – including the fact that one medical crisis is the end?
We have spent trillions of dollars bailing out the banks and stimulating our ways out of various economic problems. Now whether you are a fan of big central government or not (and I’m not for many purposes), I think there can be little debate between honest people on the left and the right that the money would have been better spent serving the needs of people in need than bailing out the banks. And we simply cannot allow our venal foolishness in subsidizing the rich to allow us to forget that we can and should take care of the basic needs of the population.
It is certain that there will be costs and losses in whatever system arises – in _Depletion and Abundance_ I strive to acknowledge that we cannot do all the things we do at present, and that will hurt some people. That said, however, enormous cuts could be made in the costs we incur at critical times in our lives – for example, 1/3 of all medical interventions take place in the last 3 years of life. Some of that is inevitable – someone who gets cancer, has major interventions, but then dies two years later will fall in that category. But an enormous number of those interventions operate simply to draw out the process of death and add to suffering – my great-aunt, visibly dying, was pressured into having open heart surgery a few months before she died, simply because no one would say “you are dying, it is time to talk about relieving your pain.” My husband’s grandmother was pressured into giving her dying husband medications to prevent a heart attack that caused him great discomfort - at a point where a heart attack was the most benign and merciful sort of death possible.
Even if we were simply to radically cut back our interventions at the time of death and birth – for birth too is radically overmedicalized – and shift our emphasis not to treating disease, but to preventing it, we could afford health care that would keep lives long and infant mortality low, that would minimize suffering and allow us to keep our farmers farming and every other useful person engaged in subsistence and cottage industry business going, doing what we desperately need – increasing the self-sufficiency of our nations, states and communities.
Few of us think of the debate on health care in terms of food security and our agriculture – but we are on the cusp of a great shift in our food system, mostly driven by demographics. As noted before, the average age of US farmers is approaching 60, and there are not enough young farmers to follow them. If we do not make it possible to go into farming a profession – if we make it only the province of the young, the healthy, the childless, we risk facing a national food crisis. The reality is that all of us have a real investment in our country’s continuing to produce sufficient food, and the right kind of food – and that investment requires that it be possible to produce that food without sacrificing your health.
I do not doubt that we will struggle to afford the kind of national health care system being discussed right now. I do not doubt that we will find ourselves at some kind of impasse at some point in the political process. I do not doubt that our spiraling debts and unfunded mandates will stress our ability to provide health insurance – but we should not believe that this means we cannot achieve health care for the masses that meets most of our basic needs. And that we must do so, not only because it is right, but because we must eat.