What Would a Post-ACA America Look Like?

Around the world, one of the key measures used to chart the economic and political well-being of countries is life expectancy. How long people live serves as something of a proxy for how developed, and how fair, a political and economic system is. And this is why demographers have been so concerned by the declines, albeit slight, in U.S. life expectancy since 2014. It is, apparently, the first time since World War One that overall life expectancy numbers in the country have gone into reverse.

What makes this trend especially baffling is that it is occurring despite rapid-fire advances in medical technology, the absence of large-scale war, and the lack of a single pandemic such as the Spanish Flu, or AIDS at the height of its devastating tear in the 1980s and early 1990s. It is occurring despite the trillions of dollars Americans spend each year on health care, a per person expenditure far in excess of most peer nations – and yet one that is, increasingly, not delivering bang for the buck. And this decline in life expectancy is occurring despite a considerable (though not universal) increase in access to health insurance since 2010, thanks to the Affordable Care Act (ACA).

While germs aren’t responsible for a particularly lethal pandemic at the moment, the United States is in the grip of two deadly despair-fueled health crises: Suicides and drug overdoses are both on the increase. The suicide rate in the country is up almost 30 percent since the turn of the century. In 2017, there were 1.4 million suicide attempts in the U.S. More than 47,000 of them resulted in death. Meanwhile, so many people are now dying because of drug overdoses — 70,000 per year — that they have become the leading cause of death for Americans under the age of 55.

Life expectancy numbers have historically differed sharply along racial lines, with white people overall expected to live 4.3 years longer than Black people on average, and 2.0 years longer than Indigenous people on average, as of 2009. These disparities continue to persist, but the conditions of life in the U.S. are now also starting to eat away at life expectancies for certain subsets of the white population, as well: in 2012, data showed that for white men without a high school diploma, life expectancy since 1990 had declined by three years; for white women without a high school diploma it declined by a staggering five years. In other words, Trump’s most loyal base is suffering huge consequences because of the country’s dysfunctional healthcare delivery system, as well as its addiction and suicide crises.

The U.S. is also in the grip of a third, related, health crisis: inequality. While wealthy Americans have vast resources at their disposals, tens of millions are living ever more insecure lives, bedeviled by constant economic insecurity, the fear of hunger and homelessness, the burden of crushing payday loans or credit card debt. As any doctor will tell you, constant fear of the future generates chronic stress; and stress can, over the long run, contribute to an array of debilitating, and potentially fatal, diseases. So, too, lack of access to affordable, safe housing puts people, especially children, at risk of exposure to the sorts of pollutants that trigger asthma and a host of other serious ailments. The Institutes of Health, for example, has documented numerous links between substandard housing, particularly leaking pipes, mold, and the presence of toxic chemicals and metals, and the onset of asthma, chronic headaches, fever, nausea and other ailments.

In such a moment, any responsible federal administration would be doing everything humanly possible to expand access to health care; to make it easier, rather than more difficult, for people to secure needed drug treatment and mental health services; to make a good faith effort to rein in inequality; to fund more affordable housing programs, and so on.

However, for the past several decades, administrations of both political parties have largely played a passive role as the country’s public housing stock corroded, have made at best half-hearted efforts to reverse the trends of growing inequality, and haven’t invested nearly enough in drug treatment or mental health programs. President Obama’s push to get Congress to pass the Affordable Care Act was a huge exception to this, and did provide millions more with health insurance coverage; yet despite its passage, millions remain either uninsured or desperately under-insured, and access to drug treatment and to mental health services remains spotty at best.

The despair that all of this has spawned is, at least in part, the foundation upon which Trump’s burn-it-all-down faux-populism is based. Candidate-Trump’s insight in 2016 was to grasp that he could manipulate white working class despair, in particular, to his entirely nefarious ends.

Fast forward to today, and, in the face of urgent health crises, Trump is now throwing the weight of the federal government behind legal efforts to find the entire Affordable Care Act unconstitutional. If the lawsuit succeeds, the expansion of Medicaid, the protection of people with pre-existing conditions, the ability of young adults to get insurance on their parents’ plan, the subsidies for the working poor to buy insurance on federal and state exchanges — all these will go out the window. There is no replacement plan to protect these groups, nothing to stand between 20 million-plus Americans and a health coverage void. It’s almost impossible to imagine a more socially irresponsible stance than the one team-Trump has taken here.

But, this shouldn’t be a surprise. Time and again since taking power, Trump has partaken in a sweeping assault on access to health care, and more generally on the health of poor Americans. The administration’s public charge reforms make it all-but-impossible for immigrants without permanent residency, documented and undocumented alike, to access any kind of public health care program. Its push to implement workfare requirements for Medicaid recipients will, if the courts ever uphold the changes, have the effect of banishing huge numbers of impoverished Americans from doctors’ offices. Its attempts to dramatically scale back SNAP will almost certainly result in millions more Americans either going hungry or eating in evermore unhealthy ways simply to get calories on the cheap. The administration’s slashing of public housing and affordable housing budgets puts more people at risk of homelessness or of having to live in unsafe accommodations. Its green light to polluters of every stripe undermines the health of all Americans, but disproportionately poor people and people of color who live near polluting facilities.

We have seen this story play out in the recent past once before, when a massive bureaucratic state ceased to function effectively and, much of its governing apparatus captured by a kleptocracy, stopped being able and willing to provide even the modicums of basic social and health protections to its people. This was when the USSR collapsed in on itself in the 1980s and early 1990s, and the Soviet system disintegrated, replaced by the Russian Federation and a slew of smaller nations. Then, too, addiction soared, despair amongst those who were losers in the new political calculus increased, privatization wiped out jobs, pensions, and for many, access to health care; and life expectancy plummeted. From 1980 to 2000, the number of years men in Russia could be expected to live declined from 62 to 58. The decline for women was less extreme, but also noticeable.

In 1956, the Columbia University sociologist C. Wright Mills published an influential book, The Power Elite, in which he argued that despite their ideological differences, the United States and the Soviet Union had more in common than they liked to admit. Both were in the grip of powerful corporate, bureaucratic, industrial and military complexes; and individual citizens or residents of each system had, as a consequence of this, only vanishingly small levels of autonomy.

Mills was no fan of either system. He saw the cruelty of American racism, and the authoritarianism of the Soviet gulag. Yet he did recognize that as social and political systems both survived in part because they were effective. Putting it crudely, for all that they did wrong they also delivered material goods to a critical mass of their residents. And those goods included access to a certain standard of living, and to basic necessities such as housing, education, food and health care. Enough people were haves than have-nots in each system that they remained somewhat politically stable for decades at a stretch.

As the Soviet Union spiraled into collapse, that guaranteed access also fell apart. While many undeniably good things happened post-1989 — the political system became somewhat freer, the gulag was emptied of prisoners, the stagnant economy was liberalized, Eastern Europe was freed from enforced Communist rule — at the same time, pensioners could suddenly be seen selling onions on the streets of Moscow. Diseases such as tuberculosis began to flourish once more, as the health system disintegrated. And life expectancy imploded.

If C. Wright Mills were alive today, I suspect he’d see anew some similarities between contemporary United States and kleptocratic Russia in the three decades since the Berlin Wall fell. At the most basic of levels, a corrupted American political leadership is failing to meet the needs of ordinary people; is, indeed, in its capricious decision-making becoming a malicious presence. It is making millions of people’s daily lives harder, their access to necessities more of a struggle. And, in now actively attempting to remove already limited health care from tens of millions of people, it is sowing the seeds of a growing crisis.

Removing access to health care is, quite simply, pouring fuel onto a fire. If you think things are bad now around suicide rates, overdose deaths and diseases caused by poor nutrition, pollution and poverty, just imagine how much worse they could get if tens of millions of people are told by the administration and by the courts that their health care is gone.