Every year in the United States of America, 14,000 children die within the first year of their life - each death is preventable. If the deaths of these children were due to an enemy state, the US would declare war in a heartbeat. If terrorists had crept into hospitals in the dead night and stuck a AK-47 into every one of those 14,000 cribs, there would be almost no limit to the degree the government would pursue those organizations. There would be no difference between Democrat or Republican, conservative or liberal. The country would be united in its resolve to stare down the enemy.
Fundamental to any Democracy or Republic is the social contract - a central set of values and agreements that make people ‘a people’. Inherent in the social contract of the United States is the obligation to protect the lives of its citizens from existential threats. Every bullet fired from every military rifle for over two centuries has followed a course set by this logic. The people balance freedom and liberty against the need to protect each other - including those 14,000 children that die each year.
But these 14,000 unnecessary deaths come not from any enemy, but from a broken healthcare system. The United States ranks 34th in infant mortality, with 6.81/1,000 deaths. If the US were to aspire to have the lowest rates in the world, it would need to get that number down to 1.92/1,000 - the current rate for Singapore. The real-world difference between those two numbers are 14,000 infants and devastated families. It doesn’t stop there. According to the Center for Disease Control, heart disease was responsible for the deaths of 599,413 Americans. Cancer claimed 567,628 lives. Diabetes took 68,705 more. Influenza and pneumonia killed 53,692. And this was just in 2010 - similar statistics are available for 2009, 2008, 2007, 2006, 2005, and so on. These deaths are the consequence of an incomplete social contract that stems from the founding of the United States.
The social contract was not meant to be static. Thomas Pain stated that “Every age and generation must be as free to act for itself in all cases as the age and generations which preceded it. The vanity and presumption of governing beyond the grave is the most ridiculous and insolent of all tyrannies.” This is also the central meaning of Thomas Jefferson’s oft-quoted statement that “God forbid we should ever be 20 years without such a rebellion.” Both founders called attention to the ephemeral design of the American social contract - it is meant to be renegotiated each generation to prevent a tyranny of past values. This wisdom is the kernel of democratic governance - there may be founding fathers, but there are no foundational fathers whose rule is forever to be law. Citizens of the United States were meant to embody the values of the founding fathers - not merely reflect them like an old mirror.
The wisdom of this structure can be seen in that other child of the enlightenment, the scientific revolution. The rapid pace of scientific discovery accelerated a generation or two after the founding of the US Republic. Advances in medical technology vastly improved the quality and quantity of life. For example, George Washington died of complications resulting from ‘bloodletting‘ - a treatment that has its origins in the belief that fundamental ‘humors’ govern the health of humans and must be let out when ill. Washington was 67 - a ripe old age for his time. As the life expectancy was 35 for people of the 18th century, Washington enjoyed considerably good fortune.
There was no notion of bacteria or viruses at the time. In fact, the idea that you needed to clean surgical instruments before use would not be successfully demonstrated until Florence Nightingale’s statistical work 100 years later. Science was still very nascent - the most scientifically inclined of the founding generation was perhaps Abigail Adams, who inoculated her children against smallpox using a form of vaccine that would horrify any doctor living today.
An understanding of the relationship between the founding social contract of the US and the relationship of the founders to science (or lack thereof) is essential to understanding the Healthcare debate in the United States.
In 2010, the Patient Protection and Affordable Care Act was signed by President Obama after a lengthy debate in Congress and the country. Healthcare advocates charged that the bill was required to stem the rising cost and limited coverage of healthcare. Opponents argued that its central tenant - that every citizen be required to purchase health insurance, was a major constitutional overstep. It is a distinct possibility that the Supreme Court will agree with the law’s opponents, and their will be a legal basis for doing so. But that will reflect the handicapped and arcane social contract of the United States. Specifically, it will highlight the failure of Americans to renegotiate the social contract and instead celebrate the interpretation of the founding fathers - who didn’t understand the problem with dumping bodies and refuse into public drinking water.
Any government is charged with the responsibility of protecting its citizens. The logic of every American war - right or wrong - has been that engagement on the battlefield will protect American lives. A vast surveillance system has been set up in the post-9/11 world with the purpose of saving American lives. Policeman regularly stop people speeding on the highway because if everyone drives at the speed limit, then lives are saved. These sacrifices of individual liberty have been made because in the American social contract, we accept that some privacy and freedom must be limited to protect citizens. We tend to disagree only in the degree to which this compromise is made. The social contract sees human actors - whether enemy states, terrorists, or speeding teenagers - as the threat to which a state must respond.
Healthcare is different. It isn’t a terrorist or a tyrant the state presumes to protect us from - it is the uncontrolled growth of cells in the pancreas, or a virus too small to see without a microscope. Threats from human actors - willful or accidental - are seen as acceptable subjects for a government to address. The founders would have certainly agreed. But viruses, bacteria, and cancer? Thomas Jefferson, George Washington, and John Adams would have never heard these words, and would not have seen them as threats to the American populace. The critical scientific information they would have needed would not arrive for another century. Unsurprisingly, the word ‘health’ does not appear in either the Declaration of Independence or the Constitution. This is not an omission of intent, but rather of ignorance. An examination of the history of epidemics and civilization can illustrate just how much of an existential threat is posed by disease. The United States is a victim of its early founding before these critical concepts were established.
Japan, a country that had to re-negotiate its social contract following World War II, incorporated health as a government’s obligation to its citizens. All Japanese citizens are guaranteed access to healthcare, and the nation ranks 3rd in infant mortality, having a rate of 3.14/1,000. Granted, Japan is burdened by healthcare expenses, which form an estimated 8.5% of the nation’s Gross Domestic Product (GDP).
However, as the United States has a breathtakingly less efficient system with more bankruptcy, more deaths, and less coverage at the cost of 17.3% of GDP. That is twice as expensive as Japan’s system - despite the fact that in America the costs of healthcare are reported as the primary reason for half of all bankruptcies. In Japan, there are no reports of a single bankruptcy due to healthcare costs. The United States pays a heavy price for a broken system that still fails its citizens at a scale unimaginable in the rest of the civilized world. Despite the high cost of healthcare, 14,000 babies continue to die unnecessarily every year.
The debate regarding the government’s role in healthcare in the United States today reflect a fundamental failure to live up to the ideal of the founding fathers. Conservatives steadily hold fast to an outdated view of government’s responsibilities, treating the founding father’s views of the social contract as written in stone. Liberals are unable to articulate their view of the social contract - arguing instead for benefits and statistics instead of shared values. The Supreme Court’s decision regarding healthcare reform will very likely not address this core problem in the American social contract. It may be that citizens of the United States - certainly those who either die or suffer bankruptcy due to a failed healthcare system - will be victims of a country founded before the advent of science. If America is to fix its healthcare system and be a leader once more in the world, it must recognize that a citizens’s protection extends from enemy states and terrorists to disease as well.
Proponents of a better health care system must frame an argument within the very values of the United States to make a better future. Until then, many thousands will continue to die or face financial ruin.