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Linking Democracy & Health Care for All

July 4, 2023

Summary: Democracy and health intersect and interact. Threats to one are threats to both. On this July 4th, let’s recognize these links, and redouble efforts to strengthen democracy by strengthening our health system … with single payer. Health care for all, not for the few who stand to profit the most.

Threats to Democracy Are Threats to Health
MedPage Today
by Lawrence O. Gostin & Sarah Wetter
June 29, 2023

The U.S. is facing dual crises: a crisis of health and a crisis of democracy. Our nation has been getting sicker. We’re facing the greatest decreases in life expectancy in over a century — with causes extending beyond COVID-19 to include rising drug overdoses, injuries, heart and liver diseases, and suicide. Maternal mortality, often considered a test of a society’s commitment to health and equality, has risen sharply. On all of these measures of health and equity, we are falling behind most all of our peer nations.

Our democracy, too, is unwell, with few guardrails on campaign financing, allowing wealthy individual and corporate donors to have outsized influence on policy and gerrymandering, making political representation simply unrepresentative of the populace.

The health of our nation is inextricably linked to the health of our democracy. Our laws directly affect whether someone has access to health services (e.g., abortion or transgender care) and safe environments (e.g., workplace safety or gun control). In theory, democracy is all about the public’s health, safety, and welfare. Political leaders should have no greater calling. Free and fair elections enable voters to elect leaders who fight to fulfill their health needs; political leaders are incentivized to pay attention to voters’ wellbeing, and are held accountable.

Yet, unlimited and dark money has shifted politicians’ attention away from constituents’ health and toward the interests of big donors. Gerrymandering pushes representation toward the extremes, enabling super-majorities in state legislatures that can pass measures harmful to health (e.g., targeting transgender individuals, forgoing Medicaid expansion, banning abortion, encouraging fossil fuels). And voting rights restrictions often fall on the most vulnerable: the poor and racial minorities. When the voting rights of society’s most vulnerable citizens are curtailed, it makes it all too easy for politicians to ignore them.

The Constitution’s Preamble expresses public wellbeing as the quintessential aim of American governance: “We the People, in Order to form a more perfect Union” and to promote the “general Welfare” do “ordain and establish this Constitution.” The “General Welfare” clause expresses a constitutional value of health, peace, and safety. The Supreme Court was supposed to be the guardian of the common welfare. Yet, it has done the opposite. The justices have given rich donors a virtual free hand to give huge sums of money (often dark money); loosened anti-corruptions restrictions; and allowed extreme gerrymandering and voting rights restrictions.

Medical organizations call voting rights a social determinant of health. The reasons abound: access to voting is consistently associated with better health. Women’s suffrage is associated with decreases in child mortality rates as high as 15%; the Voting Rights Act has been tied to reductions in economic inequality and increased health spending. Voting is linked to reduced risks of cancer death and improved mental health, while voting restrictions correlate with higher likelihood of lacking health insurance.

Comment by: Jim Kahn

On July 4th, we celebrate the founding of US democracy. The revolutionary events of nearly 250 years ago prompted the rise of democracy around the world. This celebration is appropriate, despite – and indeed because of — today’s challenges to democracy at home and abroad. Democracy is under assault, and needs defending.

As Gostin and Wetter persuasively note, the crisis in democracy is echoed by, and intertwined with, a crisis in health. The role of government in advancing the public welfare is undercut by increasing deference to the preferences of corporations and the wealthy. The examples they provide are apt.

But they don’t go far enough. The entire US health system is the antithesis of democracy. A few wealthy individuals and corporations rule the many, by imposing a fragmented insurance system and consolidating the ownership of services. Compromised access to medical care and elevated mortality are accepted as collateral damage from an illusory “free market” in health (which brings no efficiency or welfare maximization) and all-too-real immense financial gains for executives and shareholders. Other wealthy countries democratize health care – everyone has identical coverage, with excellent access to care, and the freedom to choose a provider. Money is saved in the process, and directed to other social needs.

Single payer would foster democracy, freedom, and the general welfare. Let’s issue a “Declaration of Health Care for All”, and revamp our health care into a democracy-conforming and democracy-fostering approach. We will celebrate this revolution for at least the next 250 years.

About the Commentator, Jim Kahn

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Jim (James G.) Kahn, MD, MPH (editor) is an Emeritus Professor of Health Policy, Epidemiology, and Global Health at the University of California, San Francisco. His work focuses on the cost and effectiveness of prevention and treatment interventions in low and middle income countries, and on single payer economics in the U.S. He has studied, advocated, and educated on single payer since the 1994 campaign for Prop 186 in California, including two years as chair of Physicians for a National Health Program California.

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