Deaths Of Despair And The Future Of Capitalism, Case and Deaton - B+

      This book is a study of the rising death rates among middle-aged white Americans caused by suicide, drug overdoses and alcoholic liver failure. Few of these deaths of despair are among those with bachelor's degrees. "When the fruits of success are as large as they are today, so are the penalties for failing the tests of meritocracy." Fully 38% of the population is non-Hispanic whites lacking a college education. Their wages have stagnated for half a century. Their access to health care is inadequate, they marry less and have more children out of wedlock. Globalization is the oft-cited cause, but the problem is uniquely American as the advanced countries of Europe do not share our fate.  At the heart of the matter is the failed healthcare system and a political system geared toward keeping the rich at the top of the pyramid.

        The 20th century saw a major increase in wages, education and longevity. Since 1990, mortality rates have declined in northern Europe and risen amongst the less educated non-Hispanic white mid-life Americans (LEW hereafter). The key milestones were the  1996 FDA approval of Oxycontin and the 2013 introduction of fentanyl.  Mortality rates for male LEW's have increased by a quarter, while dropping 40% for those with a degree. The LEW's also suffer from poor health and regular pain compounding their problems. These are the people who have lost jobs and the sense of self-worth that goes with being engaged in society. "The social and economic upheaval that has swept through their lives is causing increasing numbers of them to take their own lives." Although educated whites drink more often than LEW's, the latter group is more inclined to binge drink, thus causing more liver damage. Physicians' concerns about pain management in the 90's led to the prescribing of painkillers, which were abused by LEW's and thus increased deaths from overdosing.

       "Inequality and death are joint consequences of the forces that are destroying the white working class." And it is the destruction of opportunity and hope that are the root cause of these deaths, as well as the limited access to health care and the  uniquely American lack of a safety net.  The collapse of the industrial base that provided employment for the LEW's has left them with jobs lacking in pride and money. Being an autoworker is more satisfying and remunerative than being a greeter at a Walmart. This inability to be able to afford to marry, the lack of commitment to offspring, and not being involved with religious or social groups all add up to greater despair. 

       Our country's greatest failure is its healthcare system. It is too expensive. It is "a cancer that has metastasized throughout the economy, strangling its ability to deliver what Americans need." We pay 18% of GDP for healthcare, and life expectancy has slid three years in a row for the first time in 100 years. Our physicians are paid twice as much as in Europe, pharmaceuticals cost three times as much and the same medical devices are also three times more expensive. Insurers and hospitals make significant profits.  Hospitals spent $450M on advertising in 2017. Employers hire fewer workers and pay those in their employ less because of the amount they spend on health insurance. The industry spent $567M lobbying in 2018, and $133M in direct gifts to Congressmen. The industry is in essence a shake down supported by Washington.

      Also threatening the LEW's are globalization and automation and unlike other industrialized nations, our inadequate safety net does not protect the displaced. As American companies grow larger, they are able to suppress wages, while focusing on enhancing the pay of their managers and providing outsized returns to shareholders. The balance between labor and capital has swung sharply to the side of capital.

      The authors do not believe that the answer to America's issues is a redistribution of wealth through the tax system. Rather, they suggest attacking each problem directly. They would suppress opioid sales and fund intervention therapies. They suggest emulating any of the world's successful universal health programs with an eye toward cutting profits and decreasing costs. Changing corporate governance by having workers represented on boards and expanding executives' concerns beyond their shareholders to the broader constituencies is encouraged. Raising the minimum wage and/or wage subsidies are preferred over universal basic incomes. Enhanced anti-trust action and a reduction in the length of patents are desirable. And most importantly, a college education should be less expensive to obtain and an apprenticeship system would  be attractive. America has solved problems in its past and can do so again.