1 June 2018 Dear Interested Readers The Introduction to a Highly Recommended ArticleAn interested reader sent me a brief note just before I left New Hampshire headed for Alaska suggesting that I check out the lead article in the June Atlantic. I had meant to follow the advice and read the article, but I was busy with my letter for last week as well as packing for my trip, all while trying to keep up with both the Red Sox and the Celtics. After quickly glancing at the article, I told myself that I would download it on the trip. After last week’s letter went out with a big focus on the Time article by Stephen Brill, I received another note from the the same reader who had initially recommended the The Atlantic Magazine article. She said that she had read the Brill article and was suggesting again that I check out the article in The Atlantic Magazine entitled, "The Birth of a New Aristocracy." In Alaska I have had the time to read the article, and it is a long one, more than 13,000 words, the length of a novella, and now I am eager to tell you about it. As the Interested Reader suggested, it is a great companion piece to the Brill article in Time, but just getting it off the Internet in Alaska was harder than I expected. To my surprise I have found that using the Internet and getting email in Alaska is a logistical challenge. In the hotels and on the ship the Internet has been either non existent or much slower than I have come to expect where I live. It is also expensive. I reviewed the Brill article last week because I felt it had significant implications for healthcare. It felt like Brill gave an accurate description of the opportunities that were available to me when I was leaving college and headed for medical school in the sixties. Times do change. There was not as much “free money” available for my sons in the eighties, nineties and the early two thousands, but by that time we did not need it. I sometimes wondered what the experience of my sons would have been if our family’s resources had been limited and they had needed the help that was so readily available to me. The Atlantic article which was written by Matthew Stewart covers some of the same ground that Brill covered, but it asks the question of whether or not what those of us who enjoyed the benefits of “meritocracy” thought what we earned was really available to everyone who just tried harder. That is what I would like to think, but Stewart is not so sure. The article ventures into a discussion of the hidden inequities that existed even in the sixties for many young people that precluded them from ever getting to demonstrate their “merit.” Those barriers have grown taller and broader since the eighties and have contributed mightily to what we now experience as a divided country. Many of the facts that form the basis for Stewart’s analysis were used by Thomas Shapiro in his book Toxic Inequality to demonstrate how prejudicial use of public policy and federal legislation, which have been topics covered in previous letters to you about the social determinants of health, come up again in Stewart’s analysis. Not only is "The Birth of a New Aristocracy" an indepth look at many of same issues that Shapiro carefully examined from the perspective of the poor but it also adds perspective to Brill’s ideas of meritocracy and emphasizes the lack of universal fairness in the process. Students like me were rewarded for merit but Stweart suggest’s that it is quite unlikely that equally talented students who were not from white middle class families ever got much of a chance. Brill, Stewart, and I along with about 9.9% of the population now share fixed advantages over ninety percent of the population as privileged members of the “meritocracy” which Stewart dramatically labels as the “New Aristocracy.” Shapiro, Brill, and I agree that no matter how you approach the question of economic inequality, be it from the perspective of the “winners” or the “losers,” the reality of a markedly bimodal country is dangerous to the health of everyone. I will try to make this a healthcare discussion. It will not be hard because it is becoming clearer and clearer that anything that affects the creation of public policy eventually impacts healthcare. We have all heard and perhaps read a lot lately about our divided house. We are all “Americans,” but we have increased the voltage in our interactions to the place where we are almost at the level of enemies that we were in 1860 when military battles replaced verbal arguments between political opponents. It is easy to say that “a house divided against itself cannot stand.” My grandmother told me stories told to her by her grandparents of brothers who fought on opposite sides in the Civil War. I know that within my own family and among my circle of friends there are tensions over current issues that threaten to make us enemies rather than brothers and sisters, or neighbors and members of the same church, with different points of view. Yascha Mounk, a Harvard University political scientist, has a new book out, The People vs. Democracy: Why Our Freedom Is In Danger and How To Save It. Mounk’s book paints a disturbing picture and busts some myths about the election. His ideas fit with much of what Stewart has to say. Mounk reports that the average Trump voter was not poor, but was earning about $80,000/year and actually made more money than the average Clinton voter who earned a little more than $75,000 a year. The differences were best explained by location and expectations. People without job security from states that were losing jobs overseas or to automation voted for Trump even though in the moment they were “OK”. Clinton voters made less but in general still were focused on the possibility of improving themselves. Stewart’s analysis speaks to these issues and underlines how living with grim expectations is not so good for your health. I hope that you will find that what follows will fill in the outline that I have suggested. My objective is to pass on much of the analysis that Stewart has offered using a little more than 10% of the words. An even better objective would be to convince you that we can never have a stable healthcare system in our current economic environment no matter how well off 10% of us are, if the other 90% is living with increasing economic uncertainty, if not inequity. Understanding How the Amazing Success of the 9.9% is a Risk to Better Healthcare for EveryoneFriedrich Nietzsche said God Is Dead. Time Magazine declared that Truth is Dead. Now we hear from Matthew Stewart writing in The Atlantic Magazine that “The Aristocracy is Dead.” Perhaps the idea is an extension of Clay Christensen's concept of disruption. For most Americans the idea of an aristocracy was something that we never gave much thought to. For me the idea of an aristocracy was sort of like gravity. I knew it existed. I accepted its validity as a fact of life. I did not give it much thought. I first encountered people who were born into privilege when my family moved back to my father’s home state of South Carolina when I was a junior in high school. I realized then that there were kids in my school whose families had basically called all the shots in business and politics in South Carolina for most of the time since the Civil War. Some families had been in control since colonial days. I really saw aristocracy up close at Harvard Medical School. I quickly realized that some of the students were from families who actually had been in positions of control at medical schools and famous hospitals. It did not take me long to conceptualize the fact that I had been slotted into the class to fulfill some kind of mid sixties diversity formula. I provided regional and academic diversity being from a Southern state university. Stewart begins his article describing his family’s place in an American aristocracy that had mostly faded by the time he came along. The few perks left were to be had in the family vacations that his grandfather was able to provide. His great grandfather had been a “Rough Riider” with Teddy Roosevelt and then was Chairman of Standard Oil of Indiana back in the twenties before getting caught up in some way in the Teapot Dome Scandal. Stewart reports that he was a solid member of the middle class because the family money dried up, and his father was a military man who married a Spanish woman to the horror of his mother with the result being a step down in the social hierarchy. The result was not a disaster as he describes it:
I belonged to a new generation that believed in getting ahead through merit, and we defined merit in a straightforward way: test scores, grades, competitive résumé-stuffing, supremacy in board games and pickup basketball, and, of course, working for our keep. For me that meant taking on chores for the neighbors, punching the clock at a local fast-food restaurant, and collecting scholarships to get through college and graduate school. I came into many advantages by birth, but money was not among them.
I’ve joined a new aristocracy now, even if we still call ourselves meritocratic winners....To be sure, there is a lot to admire about my new group, which I’ll call—for reasons you’ll soon see—the 9.9 percent. We’ve dropped the old dress codes, put our faith in facts, and are (somewhat) more varied in skin tone and ethnicity. People like me, who have waning memories of life in an earlier ruling caste, are the exception, not the rule.
By any sociological or financial measure, it’s good to be us. It’s even better to be our kids. In our health, family life, friendship networks, and level of education, not to mention money, we are crushing the competition below. But we do have a blind spot, and it is located right in the center of the mirror: We seem to be the last to notice just how rapidly we’ve morphed, or what we’ve morphed into.
Stewart presents data that suggests that the expansion of capital and wealth by the richest 0.1 % of Americans has come at the expense of the lowest 90% of Americans who have not had any real improvement in their economic status since the seventies. The 9.9% who lie between the 90% and the top 0.1% are doing just fine and they have now taken over the job of calling the shots that previously belonged to the aristocracy. Stewart then essentially seconds the motion that Brill made when he proclaimed himself to be a part of the generation that succeeded through merit to the detriment of the country.
The meritocratic class has mastered the old trick of consolidating wealth and passing privilege along at the expense of other people’s children. We are not innocent bystanders to the growing concentration of wealth in our time. We are the principal accomplices in a process that is slowly strangling the economy, destabilizing American politics, and eroding democracy. Our delusions of merit now prevent us from recognizing the nature of the problem that our emergence as a class represents. We tend to think that the victims of our success are just the people excluded from the club. But history shows quite clearly that, in the kind of game we’re playing, everybody loses badly in the end.
Stewart describes the 9.9 %:
We’re a well-behaved, flannel-suited crowd of lawyers, doctors, dentists, mid-level investment bankers, M.B.A.s with opaque job titles, and assorted other professionals—the kind of people you might invite to dinner. In fact, we’re so self-effacing, we deny our own existence. We keep insisting that we’re “middle class.”
The wealth threshold for the group is a net worth of $1.2 million. It takes $10 million to knock on the door of the 0.1 %. My guess is that the majority of physicians past mid career are safely over the threshold of the “meritocratic class.” This class is mostly white. Stewart reports that 1.9% of the top “10th” of households are African American, 2.4 % Hispanic, and all other minorities including Asians are 8.8%, “....even though those groups together account for 35 percent of the total population.
Stewart then presents some disturbing statistics:
The Institute for Policy Studies calculated that, setting aside money invested in “durable goods” such as furniture and a family car, the median black family had net wealth of $1,700 in 2013, and the median Latino family had $2,000, compared with $116,800 for the median white family. A 2015 study in Boston found that the wealth of the median white family there was $247,500, while the wealth of the median African American family was $8. That is not a typo. That’s two grande cappuccinos. That and another 300,000 cups of coffee will get you into the 9.9 percent.What is the practical consequence of these statistics in the context of the American ideal that the United States is a place where everybody has a chance to do well and to move up the economic ladder? Stewart provides evidence that debunks this pleasant fiction in the form of an economic concept referred to as the “ intergenerational earnings elasticity,” or IGE, which measures how much of a child’s deviation from average income can be accounted for by the parents’ income. It turns out that if your parents are poor it is more than likely that you will have the same experience or worse. If times get tough as they did in 2008 and continue to be for many people who were employed in manufacturing jobs that moved overseas or were replaced by automation, you are highly likely to not do as well as your parents.
The big advantage of the children of the 9.9% is that they have family resources. Their family probably has a home that has equity and can help finance an education to keep the merit process going or can allow for a false start or two, or perhaps help with a launch into business or a down payment on a home in a town with good schools for the kids. Stewart quotes an economist that points out that intergenerational economic mobility in America now is more like Chile than Japan or Germany. He then shows that this trend leading to less and less intergenerational economic upward mobility is a major cause of our accelerating economic inequality.
Like Brill, Stewart suggests that the winners in the merit game have figured out how to solidify their gains. Ironically the 9.9 has discovered that it is useful to be considered part of the “middle class.” He also points out the importance of social connections to maintain a family’s position in the new meritocracy that are not an option for those trapped below.
Money may be the measure of wealth, but it is far from the only form of it. Family, friends, social networks, personal health, culture, education, and even location are all ways of being rich, too. These nonfinancial forms of wealth, as it turns out, aren’t simply perks of membership in our aristocracy. They define us.
We are the people of good family, good health, good schools, good neighborhoods, and good jobs. We may want to call ourselves the “5Gs” rather than the 9.9 percent.
Stewart becomes somewhat accusatory and begins to offer warnings:
It’s one of the delusions of our meritocratic class, however, to assume that if our actions are individually blameless, then the sum of our actions will be good for society. We may have studied Shakespeare on the way to law school, but we have little sense for the tragic possibilities of life. The fact of the matter is that we have silently and collectively opted for inequality, and this is what inequality does. It turns marriage into a luxury good, and a stable family life into a privilege that the moneyed elite can pass along to their children. How do we think that’s going to work out?
This divergence of families by class is just one part of a process that is creating two distinct forms of life in our society.
This is where Stewart begins to bring in the health related outcomes to the growing inequality that seems to arise in such a benign and meritorious way.
Obesity, diabetes, heart disease, kidney disease, and liver disease are all two to three times more common in individuals who have a family income of less than $35,000 than in those who have a family income greater than $100,000. Among low-educated, middle-aged whites, the death rate in the United States—alone in the developed world—increased in the first decade and a half of the 21st century. Driving the trend is the rapid growth in what the Princeton economists Anne Case and Angus Deaton call “deaths of despair”—suicides and alcohol- and drug-related deaths.
The sociological data are not remotely ambiguous on any aspect of this growing divide. We 9.9 percenters live in safer neighborhoods, go to better schools, have shorter commutes, receive higher-quality health care, and, when circumstances require, serve time in better prisons. We also have more friends—the kind of friends who will introduce us to new clients or line up great internships for our kids.
He then points out once again that the advantages are passed onto the next generation of the 9.9% just like the growing disadvantages are passed on to the to 90%. Some people can’t seem to understand why those “other people” can’t get their act together.
Most important of all, we have learned how to pass all of these advantages down to our children. In America today, the single best predictor of whether an individual will get married, stay married, pursue advanced education, live in a good neighborhood, have an extensive social network, and experience good health is the performance of his or her parents on those same metrics.
We’re leaving the 90 percent and their offspring far behind in a cloud of debts and bad life choices that they somehow can’t stop themselves from making. We tend to overlook the fact that parenting is more expensive and motherhood more hazardous in the United States than in any other developed country, that campaigns against family planning and reproductive rights are an assault on the families of the bottom 90 percent, and that law-and-order politics serves to keep even more of them down. We prefer to interpret their relative poverty as vice: Why can’t they get their act together?
It is a long article with many points that will rub some people the wrong way. He goes into great depth describing the dysfunction of our programs of affirmative action in education. He also takes a shot at the medical profession and essentially suggests that it has been a higher priority to maintain medical compensation than it has been to expand the profession enough to provide for the care of all of our citizens at a sustainable cost.
Why do america’s doctors make twice as much as those of other wealthy countries? Given that the United States has placed dead last five times running in the Commonwealth Fund’s ranking of health-care systems in high-income countries, it’s hard to argue that they are twice as gifted at saving lives. Dean Baker, a senior economist with the Center for Economic and Policy Research, has a more plausible suggestion: “When economists like me look at medicine in America—whether we lean left or right politically—we see something that looks an awful lot like a cartel.” Through their influence on the number of slots at medical schools, the availability of residencies, the licensing of foreign-trained doctors, and the role of nurse practitioners, physicians’ organizations can effectively limit the competition their own members face—and that is exactly what they do.
Stewart contends that the 9.9% not only know how to control wealth, education, and the professions, we also know how to control the output of government to our advantage.
We in the 9.9 percent have mastered the art of getting the government to work for us even while complaining loudly that it’s working for those other people.
Consider, for starters, the greatly exaggerated reports of our tax burdens. On guest panels this past holiday season, apologists for the latest round of upwardly aimed tax cuts offered versions of Mitt Romney’s claim that the 47 percent of Americans who pay no federal income tax in a typical year have “no skin in the game.” Baloney. Sure, the federal individual-income tax, which raised $1.6 trillion last year, remains progressive. But the $1.2 trillion raised by the payroll tax hits all workers—but not investors, such as Romney—and it hits those making lower incomes at a higher rate, thanks to a cap on the amount of income subject to the tax. Then there’s the $2.3 trillion raised by state and local governments, much of it collected through regressive sales and property taxes. The poorest quintile of Americans pays more than twice the rate of state taxes as the top 1 percent does, and about half again what the top 10 percent pays.
Our false protests about paying all the taxes, however, sound like songs of innocence compared with our mastery of the art of having the taxes returned to us...They’re called “tax breaks,” ....Every year, the federal government doles out tax expenditures through deductions for retirement savings (worth $137 billion in 2013); employer-sponsored health plans ($250 billion); mortgage-interest payments ($70 billion); and, sweetest of all, income from watching the value of your home, stock portfolio, and private-equity partnerships grow ($161 billion). In total, federal tax expenditures exceeded $900 billion in 2013. That’s more than the cost of Medicare, more than the cost of Medicaid, more than the cost of all other federal safety-net programs put together. And—such is the beauty of the system—51 percent of those handouts went to the top quintile of earners, and 39 percent to the top decile.
The best thing about this program of reverse taxation, as far as the 9.9 percent are concerned, is that the bottom 90 percent haven’t got a clue. The working classes get riled up when they see someone at the grocery store flipping out their food stamps to buy a T-bone. They have no idea that a nice family on the other side of town is walking away with $100,000 for flipping their house.
I hope that did not sound offensive or hit too close to home. I flinched a little when I read it. Shapiro made many of the same points, as did Matthew Desmond in his Pulitzer Prize winning book Eviction. Like Desmond, Stewart adds to the argument that your ZIP code may be more of a determinant of your life expectancy than your genetic code.
This economic and educational sorting of neighborhoods is often represented as a matter of personal preference, as in red people like to hang with red, and blue with blue. In reality, it’s about the consolidation of wealth in all its forms, starting, of course, with money. Gilded zip codes are located next to giant cash machines: a too-big-to-fail bank, a friendly tech monopoly, and so on. Local governments, which collected a record $523 billion in property taxes in 2016, make sure that much of the money stays close to home.
But proximity to economic power isn’t just a means of hoarding the pennies; it’s a force of natural selection. Gilded zip codes deliver higher life expectancy, more-useful social networks, and lower crime rates. Lengthy commutes, by contrast, cause obesity, neck pain, stress, insomnia, loneliness, and divorce...one study found that a commute of 45 minutes or longer by one spouse increased the chance of divorce by 40 percent.
As the article progresses Stewart has some difficulty hiding his anger.
The source of the trouble, considered more deeply, is that we have traded rights for privileges. We’re willing to strip everyone, including ourselves, of the universal right to a good education, adequate health care, adequate representation in the workplace, genuinely equal opportunities, because we think we can win the game. But who, really, in the end, is going to win this slippery game of escalating privileges?
Stewart points out that the success of the 9.9% has bred resentment within the 90%. The outsized success of the 9.9% has not gone unnoticed by the 90% and the election of Donald Trump may be the most obvious manifestation of that reality. Stewart wonders what other forms of retaliation will arise to threaten the 9.9%. Inequality breeds envy and envy begats resentment and resentment spawns negative responses and creates even wider divisions. The question that faces us who care about the health of the nation is how do we make advances toward the Triple Aim in a climate of resentment. Resentment also produces instability. As Stewart says:
The raging polarization of American political life is not the consequence of bad manners or a lack of mutual understanding. It is just the loud aftermath of escalating inequality…
Unreasonable people also tend to be ungovernable.
Stewart is a student of history and chronicles how the Civil War and the Great Depression were the products of times like these when self interest trumped a sense of community. He goes on to point out that America is not alone in the annals of inequity. We have all seen this movie before even if we have a short memory for the details.
The United States, to be clear, is hardly the most egregious offender in the annals of human inequality. The European nations from which the colonists of North America emigrated had known a degree of inequality and instability that Americans would take more than a century to replicate. Whether in ancient Rome or the Near East, Asia or South America, the plot remains the same. In The Great Leveler, the historian Walter Scheidel makes a disturbingly good case that inequality has reliably ended only in catastrophic violence: wars, revolutions, the collapse of states, or plagues and other disasters. It’s a depressing theory. Now that a third wave of American inequality appears to be cresting, how much do we want to bet that it’s not true?
Stewart spends some time with this history but does find hope in our national story. The 9.9 percenters of the 1770’s were the ones that turned their backs on the English Aristocracy and conceptualized America for everyone’s benefit.
America’s first generation of revolutionaries was mostly 9.9 percenters, and yet they turned their backs on the man at the very top in order to create a government of, by, and for the people. The best revolutions do not start at the bottom; they are the work of the upper-middle class.
These exceptions are rare, to be sure, and yet they are the story of the modern world. In total population, average life expectancy, material wealth, artistic expression, rates of violence, and almost every other measure that matters for the quality of human life, the modern world is a dramatically different place than anything that came before. Historians offer many complicated explanations for this happy turn in human events—the steam engine, microbes, the weather—but a simple answer precedes them all: equality. The history of the modern world is the unfolding of the idea at the vital center of the American Revolution.
Stewart offers the bright moment of America’s beginning as a reason for hope that we can come out of the “tailspin” that Steven Brill thinks is bringing us down. Stewart’s analysis looks a lot like addressing the issues that are the social determinants of health. I added the bolding to point it out for you.
The defining challenge of our time is to renew the promise of American democracy by reversing the calcifying effects of accelerating inequality. As long as inequality rules, reason will be absent from our politics; without reason, none of our other issues can be solved. It’s a world-historical problem. …
The American idea has always been a guide star, not a policy program, much less a reality. The rights of human beings never have been and never could be permanently established in a handful of phrases or old declarations...In our world, now, we need to understand that access to the means of sustaining good health, the opportunity to learn from the wisdom accumulated in our culture, and the expectation that one may do so in a decent home and neighborhood are not privileges to be reserved for the few who have learned to game the system. They are rights that follow from the same source as those that an earlier generation called life, liberty, and the pursuit of happiness.
Stewart sees that there is a lot of work for government to do to get us back on track, but that cannot happen without your involvement, especially if you like me, fall into the 9.9% and are winning big in the moment. As my wife says, “It’s not all about you!” We need to realize that the good life for the 9.9% is in jeopardy if the going keeps getting tougher for the other 90%.
It’s going to take something from each of us, too, and perhaps especially from those who happen to be the momentary winners of this cycle in the game. We need to peel our eyes away from the mirror of our own success and think about what we can do in our everyday lives for the people who aren’t our neighbors. We should be fighting for opportunities for other people’s children as if the future of our own children depended on it. It probably does.Many healthcare professionals are in the 9.9%. We are winners not just because we did everything right. The deck was stacked for us as it is for our children, but things can change, and history says it will, unless we seek to offer something better that will work. I think that is what Don Berwick knew when he suggested a third era of medicine where we don’t focus so much on finance and what we are making, but rather we are focusing on all of our neighbors with a renewed commitment to making sure that everyone gets what they need. Mountains, Glaciers, Fjords, and A Lot of Empty SpaceThey say that Alaska has half the landmass of the lower 48 states. Denali National Park is the size of the state of Massachusetts. Glacier Bay National Park can only be seen by boat and is the size of Connecticut, and there are two national parks in Alaska that are larger than either Denali or Glacier Bay. All that land, and about the same number of people live there are patients at Atrius Health, or live in the state of Vermont. Forty percent of the people live in Anchorage which has about 300,000 people living in an area about the size of Rhode Island. That is nothing when you consider that Sitka, Alaska with a population of 8000 is twice the size of Rhode Island! The numbers and the sizes may seem unreal, but the truth is that “empty” is beautiful. I have had some great walks over the last week. I walked on some wooded trails in Denali National Park on paths through white and black spruce after ten at night in broad daylight. Once on board our cruising ship I walked in circles around the promenade deck as we sailed down fjords looking at glaciers. I have also followed my wife and friends through endless shops and museums in Skaguay. Skaguay, or if you prefer Skagway, went from a population of one family to over 10,000 between 1897 and 1898 as over 100,000 gold crazed men passed through as they began their ill fated 500 mile journey toward the faint possibility of riches in the Yukon. Ironically, President Trump’s grandfather who was an immigrant from Germany made a fortune selling horse meat snacks, a place to sleep, and momentary pleasures to many of those fellows headed toward ultimate disappointment in the Yukon. The picture in toady’s header shows the Margerie Glacier which is one of the gems of Glacier Bay National Park. My other option was a great picture of Denali taken on a clear day from about sixty miles away. The closer you get to the mountain the less you see, even on a clear day. I hope that since there are only fourteen weekends of summer left to enjoy that you will be out and about enjoying nature and the company of friends this weekend. |
