Another mantra I used in the Poverty & Policy series was ‘the test of a nation’s morality is how it treats its most vulnerable citizens,’ though I was far from the first to employ this quite expressive trope.

Surely, the young and old count as vulnerable in any overall population. We often lump them among the worthy poor since their age makes it less likely, though not always impossible, to fend for themselves. Thus, society typically takes a paternalistic attitude toward their well being, or so we believe. We can’t let the young and old suffer, can we?

let us take a quick look at how our health and related care systems deal with these more sympathetic subgroups. In short, not well. Shockingly, we find U.S. maternal and infant mortality rates among the highest, if not the highest, within OECD nations (generally those most like us economically). For example, the infant mortality rate in the U.S. is three times higher than the comparable rate in Japan. One might attribute such disparities to life style choices but that may simply be rationalizing away differential policy regimes.

When you get into the teen populations, we find strikingly high rates of death by suicides and homicides. What are called assault deaths in the U.S. (often via guns) is some 2.7 times higher than the average among OECD countries. Death by violent means now ranks among the highest cause of death among teens. Widespread anomie and hopelessness coupled with the easy availability of weapons and dangerous prescription drugs leads to many early exits from life, some self-imposed and others a consequence of the casual carnage on our streets. Again, policy failures and/or indifference play a role.

A quick detour to the other end of the age spectrum. Here, the policy response is a bit mixed. As far back as the 1960s, we passed Medicare and Medicaid during one of the brief spasms of progressivism in the U.S. Since the early 1980s, we have returned to form, relying more on market forces to provide efficient and equitable care to the elderly. After all, that is the inviolable truth according to neoliberal economic orthodoxy. Our fascination with markets now leads citizens to visit Canada for affordable drugs (if they can) and to take trips to Europe for joint replacements and other procedures available there at reasonable prices. The one contrary blip to the slide toward a conservative medical market in recent decades has been Obama care which caused outrage, anguish, and much screaming among conservatives.

One result of this market-focused approach can be found in how we deal with those elderly needing more intensive care, what we usually term assisted living or enhanced service care. By one account, some 850,000 Americans get such help, and many more need it. But our system of care views this as a profit center for private interests. It has been estimated that half of all facilities providing such care have an ROI (return on investment) of 20 percent or more. Monthly charges range from $5,000 to $10,000.

I have some personal experience here. My spouse had early onset Alzheimers. I could take care of her at home for a number of years but the time came when that proved very difficult, if not impossible. The initial cost of her care was about $5,500 per month, but her needs quickly increased with time. After some three years, the monthly charge was closer to $10,000 monthly. Fortunately, we had Long Term Care insurance (LTC), due to her prescient diligence on this matter. But, in a discussion with the facility CEO, I found that only a small minority of the residents were covered by such care, and not many had the kind of quality insurance we did. The vast majority were paying out of pocket.

We face soaring costs for dealing with our aging citizens. Many can not afford costly institutional care leaving families to patch together home care as best they can. Again, differential policy regimes across countries are apparent. Most other countries act more aggressively to control prices and to expand care opportunities for the high-need elderly. Once again, we stand out among wealthy nations as relying upon the market to handle things.

Here is my bottom line. We do need market forces to ensure a dynamic and vigorous economy. Few doubt that. But unfettered faith in markets is, frankly, unsupportable. The Adam Smith fantasy world of free individuals transacting in transparent and open markets to the collective advantage of all borders on the delusional. The imperfections in the medical market should be obvious to all. Who can negotiate the best deal when they experience a cardiac arrest event? How can the average citizen bargain for best prices when pricing is so convoluted as to defy logic? I have freaking Ph.D and I cannot understand the medical statements I get. Just this week I got a statement (not a bill) for an office visit from last June.

Our over reliance upon market forces to deliver quality health care is a failure. Years ago, I read an illuminating book written by a journalist comparing approaches to health care across nations. The author used his own medical issue to see how he would fare under differing policy regimes. (There are 3 major approaches … national health services, single payor systems, and mandated insurance schemes. The U.S. has all three approaches depending on population in a patchwork system, a medical world that defies all logic.). Hands down, he found the American system to be the most opaque, inefficient, and mismanaged. Of all things, he found France to be the best.

There are many things about the country into which I was born that confuse the hell out of me. Near the top of the list is this. Why do Americans pay so much for a such a substandard product? I ponder this every time I call for a doctor’s appointment in a medical rich community like Madison Wisconsin and am told the next available slot to see the doc is six months out. 🙃