(Image: Lauren Walker / Truthout; Adapted: Thomasjphotos)

Changes are coming to America’s health care system. Not long from now, the Affordable Care Act could be history. President-elect Donald Trump wants to repeal so-called Obamacare, although he is now urging Republicans to repeal and replace it at the same time. But replace it with what?

The political culture of the most powerful nation in the world is such that it vehemently defends the right of people to buy guns but opposes the right to free and decent health care for all its citizens. In all likelihood, the Trump health care plan will be one based on “free market principles.” Under such a plan, as Noam Chomsky notes in the exclusive interview for Truthout that follows, poor people are likely to suffer most. In other words, the scandalous nature of the US health care system is bound to become even more scandalous in the Trump era. Welcome back to the future.

C.J. Polychroniou: Trump and the Republicans are bent on doing away with Obamacare. Doesn’t the 2010 Patient Protection and Affordable Care Act (ACA) represent an improvement over what existed before? And, what would the Republicans replace it with?

Noam Chomsky: I perhaps should say, to begin, that I have always felt a little uncomfortable about the term “Obamacare.” Did anyone call Medicare “Johnsoncare?” Maybe wrongly, but it has seemed to me to have a tinge of Republican-style vulgar disparagement, maybe even of racism. But put that aside…. Yes, the ACA is a definite improvement over what came before — which is not a great compliment. The US health care system has long been an international scandal, with about twice the per capita expenses of other wealthy (OECD) countries and relatively poor outcomes. The ACA did, however, bring improvements, including insurance for tens of millions of people who lacked it, banning of refusal of insurance for people with prior disabilities, and other gains — and also, it appears to have led to a reduction in the increase of health care costs, though that is hard to determine precisely.

The House of Representatives, dominated by Republicans (with a minority of voters), has voted over 50 times in the past six years to repeal or weaken Obamacare, but they have yet to come up with anything like a coherent alternative. That is not too surprising. Since Obama’s election, the Republicans have been pretty much the party of NO. Chances are that they will now adopt a cynical [Paul] Ryan-style evasion, repeal and delay, to pretend to be honoring their fervent pledges while avoiding at least for a time the consequences of a possible major collapse of the health system and ballooning costs. It’s far from certain. It’s conceivable that they might patch together some kind of plan, or that the ultra-right and quite passionate “Freedom Caucus” may insist on instant repeal without a plan, damn the consequence for the budget, or, of course, for people.

One part of the health system that is likely to suffer is Medicaid, probably through block grants to states, which gives the Republican-run states opportunities to gut it. Medicaid only helps poor people who “don’t matter” and don’t vote Republican anyway. So [according to Republican logic], why should the rich pay taxes to maintain it?

Article 25 of the UN Universal Declaration on Human Rights (UDHR) states that the right to health care is indeed a human right. Yet, it is estimated that close to 30 million Americans remain uninsured even with the ACA in place. What are some of the key cultural, economic and political factors that make the US an outlier in the provision of free health care?

First, it is important to remember that the US does not accept the Universal Declaration of Human Rights — though in fact the UDHR was largely the initiative of Eleanor Roosevelt, who chaired the commission that drafted its articles, with quite broad international participation.

The UDHR has three components, which are of equal status: civil-political, socioeconomic and cultural rights. The US formally accepts the first of the three, though it has often violated its provisions. The US pretty much disregards the third. And to the point here, the US has officially and strongly condemned the second component, socioeconomic rights, including Article 25.

Opposition to Article 25 was particularly vehement in the Reagan and Bush 1 years. Paula Dobriansky, deputy assistant secretary of state for human rights and humanitarian affairs in these administrations, dismissed the “myth” that “‘economic and social rights constitute human rights,” as the UDHR declares. She was following the lead of Reagan’s UN Ambassador Jeane Kirkpatrick, who ridiculed the myth as “little more than an empty vessel into which vague hopes and inchoate expectations can be poured.” Kirkpatrick thus joined Soviet Ambassador Andrei Vyshinsky, who agreed that it was a mere “collection of pious phrases.” The concepts of Article 25 are “preposterous” and even a “dangerous incitement,” according to Ambassador Morris Abram, the distinguished civil rights attorney who was US Representative to the UN Commission on Human Rights under Bush I, casting the sole veto of the UN Right to Development, which closely paraphrased Article 25 of the UDHR.The Bush 2 administration maintained the tradition by voting alone to reject a UN resolution on the right to food and the right to the highest attainable standard of physical and mental health (the resolution passed 52-1).

Rejection of Article 25, then, is a matter of principle. And also a matter of practice. In the OECD [Organization for Economic Cooperation and Development] ranking of social justice, the US is in 27th place out of 31, right above Greece, Chile, Mexico and Turkey. This is happening in the richest country in world history, with incomparable advantages. It was quite possibly already the richest region in the world in the 18th century.

In extenuation of the Reagan-Bush-Vyshinsky alliance on this matter, we should recognize that formal support for the UDHR is all too often divorced from practice.

US dismissal of the UDHR in principle and practice extends to other areas. Take labor rights. The US has failed to ratify the first principle of the International Labour Organization Convention, which endorses “Freedom of Association and Protection of the Right to Organise.” An editorial comment in the American Journal of International Law refers to this provision of the International Labour Organization Convention as “the untouchable treaty in American politics.” US rejection is guarded with such fervor, the report continues, that there has never even been any debate about the matter. The rejection of International Labour Organization Conventions contrasts dramatically with the fervor of Washington’s dedication to the highly protectionist elements of the misnamed “free trade agreements,” designed to guarantee monopoly pricing rights for corporations (“intellectual property rights”), on spurious grounds. In general, it would be more accurate to call these “investor rights agreements.”

Comparison of the attitude toward elementary rights of labor and extraordinary rights of private power tells us a good deal about the nature of American society.

Furthermore, US labor history is unusually violent. Hundreds of US workers were being killed by private and state security forces in strike actions, practices unknown in similar countries. In her history of American labor, Patricia Sexton — noting that there are no serious studies — reports an estimate of 700 strikers killed and thousands injured from 1877 to 1968, a figure which, she concludes, may “grossly understate the total casualties.” In comparison, one British striker was killed since 1911.

As struggles for freedom gained victories and violent means became less available, business turned to softer measures, such as the “scientific methods of strike breaking” that have become a leading industry. In much the same way, the overthrow of reformist governments by violence, once routine, has been displaced by “soft coups” such as the recent coup in Brazil, though the former options are still pursued when possible, as in Obama’s support for the Honduran military coup in 2009, in near isolation. Labor remains relatively weak in the US in comparison to similar societies. It is constantly battling even for survival as a significant organized force in the society, under particularly harsh attack since the Reagan years.

All of this is part of the background for the US departure in health care from the norm of the OECD, and even less privileged societies. But there are deeper reasons why the US is an “outlier” in health care and social justice generally. These trace back to unusual features of American history. Unlike other developed state capitalist industrial democracies, the political economy and social structure of the United States developed in a kind of tabula rasa. The expulsion or mass killing of Indigenous nations cleared the ground for the invading settlers, who had enormous resources and ample fertile lands at their disposal, and extraordinary security for reasons of geography and power. That led to the rise of a society of individual farmers, and also, thanks to slavery, substantial control of the product that fueled the industrial revolution: cotton, the foundation of manufacturing, banking, commerce, retail for both the US and Britain, and less directly, other European societies. Also relevant is the fact that the country has actually been at war for 500 years with little respite, a history that has created “the richest, most powerful¸ and ultimately most militarized nation in world history,” as scholar Walter Hixson has documented.

For similar reasons, American society lacked the traditional social stratification and autocratic political structure of Europe, and the various measures of social support that developed unevenly and erratically. There has been ample state intervention in the economy from the outset — dramatically in recent years — but without general support systems.

As a result, US society is, to an unusual extent, business-run, with a highly class-conscious business community dedicated to “the everlasting battle for the minds of men.” The business community is also set on containing or demolishing the “political power of the masses,” which it deems as a serious “hazard to industrialists” (to sample some of the rhetoric of the business press during the New Deal years, when the threat to the overwhelming dominance of business power seemed real).

Here is yet another anomaly about US health care: According to data by the Organization for Economic Cooperation and Development, the US spends far more on health care than most other advanced nations, yet Americans have poor health outcomes and are plagued by chronic illnesses at higher rates than the citizens of other advanced nations. Why is that?

US health care costs are estimated to be about twice the OECD average, with rather poor outcomes by comparative standards. Infant mortality, for example, is higher in the US than in Cuba, Greece and the EU generally, according to CIA figures.

As for reasons, we can return to the more general question of social justice comparisons, but there are special reasons in the health care domain. To an unusual extent, the US health care system is privatized and unregulated. Insurance companies are in the business of making money, not providing health care, and when they undertake the latter, it is likely not to be in the best interests of patients or to be efficient. Administrative costs are far greater in the private component of the health care system than in Medicare, which itself suffers by having to work through the private system.

Comparisons with other countries reveal much more bureaucracy and higher administrative costs in the US privatized system than elsewhere. One study of the US and Canada a decade ago, by medical researcher Steffie Woolhandler and associates, found enormous disparities, and concluded that “Reducing U.S. administrative costs to Canadian levels would save at least $209 billion annually, enough to fund universal coverage.” Another anomalous feature of the US system is the law banning the government from negotiating drug prices, which leads to highly inflated prices in the US as compared with other countries. That effect is magnified considerably by the extreme patent rights accorded to the pharmaceutical industry in “trade agreements,” enabling monopoly profits. In a profit-driven system, there are also incentives for expensive treatments rather than preventive care, as strikingly in Cuba, with remarkably efficient and effective health care.

Why aren’t Americans demanding — not simply expressing a preference for in survey polls — access to a universal health care system?

They are indeed expressing a preference, over a long period. Just to give one telling illustration, in the late Reagan years 70 percent of the adult population thought that health care should be a constitutional guarantee, and 40 percent thought it already was in the Constitution since it is such an obviously legitimate right. Poll results depend on wording and nuance, but they have quite consistently, over the years, shown strong and often large majority support for universal health care — often called “Canadian-style,” not because Canada necessarily has the best system, but because it is close by and observable. The early ACA proposals called for a “public option.” It was supported by almost two-thirds of the population, but was dropped without serious consideration, presumably as part of a compact with financial institutions. The legislative bar to government negotiation of drug prices was opposed by 85 percent, also disregarded — again, presumably, to prevent opposition by the pharmaceutical giants. The preference for universal health care is particularly remarkable in light of the fact that there is almost no support or advocacy in sources that reach the general public and virtually no discussion in the public domain.

The facts about public support for universal health care receive occasional comment, in an interesting way. When running for president in 2004, Democrat John Kerry, The New York Times reported, “took pains .. to say that his plan for expanding access to health insurance would not create a new government program,” because “there is so little political support for government intervention in the health care market in the United States.” At the same time, polls in The Wall Street Journal, Businessweek, The Washington Post and other media found overwhelming public support for government guarantees to everyone of “the best and most advanced health care that technology can supply.”

But that is only public support. The press reported correctly that there was little “political support” and that what the public wants is “politically impossible” — a polite way of saying that the financial and pharmaceutical industries will not tolerate it, and in American democracy, that’s what counts.

Returning to your question, it raises a crucial question about American democracy: why isn’t the population “demanding” what it strongly prefers? Why is it allowing concentrated private capital to undermine necessities of life in the interests of profit and power? The “demands” are hardly utopian. They are commonly satisfied elsewhere, even in sectors of the US system. Furthermore, the demands could readily be implemented even without significant legislative breakthroughs. For example, by steadily reducing the age for entry to Medicare.

The question directs our attention to a profound democratic deficit in an atomized society, lacking the kind of popular associations and organizations that enable the public to participate in a meaningful way in determining the course of political, social and economic affairs. These would crucially include a strong and participatory labor movement and actual political parties growing from public deliberation and participation instead of the elite-run candidate-producing groups that pass for political parties. What remains is a depoliticized society in which a majority of voters (barely half the population even in the super-hyped presidential elections, much less in others) are literally disenfranchised, in that their representatives disregard their preferences while effective decision-making lies largely in the hands of tiny concentrations of wealth and corporate power, as study after study reveals.

The prevailing situation reminds us of the words of America’s leading 20th-century social philosopher, John Dewey, much of whose work focused on democracy and its failures and promise. Dewey deplored the domination by “business for private profit through private control of banking, land, industry, reinforced by command of the press, press agents and other means of publicity and propaganda” and recognized that “Power today resides in control of the means of production, exchange, publicity, transportation and communication. Whoever owns them rules the life of the country,” even if democratic forms remain. Until those institutions are in the hands of the public, he continued, politics will remain “the shadow cast on society by big business.”

This was not a voice from the marginalized far left, but from the mainstream of liberal thought.

Turning finally to your question again, a rather general answer, which applies in its specific way to contemporary western democracies, was provided by David Hume over 250 years ago, in his classic study of the First Principles of Government. Hume found “nothing more surprising than to see the easiness with which the many are governed by the few; and to observe the implicit submission with which men resign their own sentiments and passions to those of their rulers. When we enquire by what means this wonder is brought about, we shall find, that as Force is always on the side of the governed, the governors have nothing to support them but opinion. `Tis therefore, on opinion only that government is founded; and this maxim extends to the most despotic and most military governments, as well as to the most free and most popular.”

Implicit submission is not imposed by laws of nature or political theory. It is a choice, at least in societies such as ours, which enjoys the legacy provided by the struggles of those who came before us. Here power is indeed “on the side of the governed,” if they organize and act to gain and exercise it. That holds for health care and for much else.