America’s Growing Lack of Trust in Medicine

In this exclusive video, Eric Reinhart, MD, PhD, a political anthropologist, psychoanalyst, and medical resident at Northwestern University in Chicago, discusses the national trend of decreasing trust in public health systems and how privatized healthcare causes “horrific” public health.

The following is a transcript of his remarks:

In my view, the biggest obstacle to health in the U.S. today is the lack of trust that the public holds for medical care, for public health systems, and, ultimately, for the government. This distrust that is so widespread that we saw surface during the pandemic, that we see in anti-vaccine campaigns, for example, is in many cases quite legitimate. We have not built systems that earn the public’s trust.

Many people in the U.S. know healthcare best through personal bankruptcy — this is the leading cause of personal bankruptcy in the U.S. — or through their medical bills; unexpected bills. These are not the kinds of interactions that produce a basis for trust.

Another reason that the public does not in general trust public health, medical science, and the government is because over the last 40 years, our public systems that would generate that trust through interpersonal relationships, through supportive care, have really been disassembled.

One of the justifications that people now give for this — and this is both Democrats, Republicans, people who identify as left-leaning liberals and people who are very staunch conservatives — is that the private sector is more efficient. That this is, in fact, a good system.

The reason that the private sector can be said to be more efficient in many instances is because they exploit their workers. If you work for the U.S. Postal Service, for example, or you work for — I have lots of qualms with them, but they have pretty good labor practices — police departments, you have good pensions, you have good labor protections, you have good compensation.

If you go to one of the nonprofits that I’ve worked around as an anthropologist for over a decade on the south and west sides of Chicago, these are, in general, poverty jobs. The workers who are there are disposable; they’re treated as if [they are] disposable. They’re paid minimum wage; they have no protections; there’s lots of sexual assault that happens in these places. These are not good places to work.

So if you get a million dollar grant and you can employ a whole bunch of people versus you get a million dollar grant as a public entity — you can employ a fraction of the number of people because the labor conditions you have to provide are much better.

Then we’re going to talk about efficiency, but what are we really talking about in terms of efficiency? Are we just talking about the number of contact points? Are we talking about the quality of the services provided? We need to reframe that whole discussion. But it’s very important to confront, the fact that a lot of the so-called efficiency of the private sector is really just about exploitation.

Right now, we’re in a position where as a consequence, in my view, of the privatization of social services, which are so important for health — these are the major determinants of health: 10% to 20% of the determinants of human health are estimated to be related to medical interventions; 80% to 90% are matters of environmental quality, but also basic social services. This is the core of public health. We don’t have a public system to produce that.

What this has done is it’s given members of communities contact points with care systems that are fractured and do not relate to government, so that when you have a nonprofit that you might have a good relationship with, and you have services you’re receiving from them, et cetera, that does not translate into the generation of trust into broader public systems. So you are disincentivized from believing that government matters, from participating in elections, from voting to fund the reconstruction of public systems. You don’t have a reason to trust and you’ve been hearing for 40-50 years that “big government is bad, big government is inefficient.” The consequence of this at a population level is horrific public health.

This is an ideological determinant of public health, in my view. We have to, I think, confront this and think about what is the possibility for producing a society that genuinely values rights and backs it not with rhetoric, but with material investments. We’re not going to be doing that through the liberal humanitarian charitable enterprise. It makes people feel good, but it doesn’t produce population-level health. You can see this through international comparisons.

In my view, reversing the privatization of public health in the U.S. is one of the most important things we can do. There’s another reason it’s very important, which is that if you talk about public health in the U.S. right now, and you talk about direct-service delivery, most people think about clinical services: seeing a nurse, seeing a doctor, going to a clinic, going to a hospital. Is the public sector going to be doing that? Then they talk about public health and they mean something like biosurveillance, measuring the number of cases of COVID or something like that.

What’s left out in this middle section is the kind of direct care-services that are non-medical care services: community care workers that can address social isolation and can assist people who are elderly and need help just getting around and getting to the grocery store; people who are disabled and need everyday assistance, people who have a hard time negotiating welfare bureaucracy in order to get income; in order to get housing, which is so important for health.

The biggest returns we could get for public health in the U.S. lies not in further investment in clinical services — which we should have absolute universal healthcare, we already spend $4.3 trillion per year in the U.S., [which is] two to three times as much as peer nations per capita and we have horrific health outcomes. The reason is because we’re missing this middle layer of direct service provision that is so important for health and is not intrinsically medical.

So we need to demedicalize our concept of care at the same moment that we recover from the private sector the responsibility to provide these services to people as a public obligation, as a matter of rights.

If you’re a healthcare worker in the U.S. right now, you probably work in the private sector, either for a for-profit healthcare institution or a nonprofit healthcare institution. I work at a nonprofit academic healthcare institution right now. These institutions are tax-exempt in general, and they’re tax-exempt because of the claim that they’re providing charity care, so they should be protected from any kind of drain on their resources, which is going to serve the community. That’s why they exist.

If you spend any time inside these institutions, you know that that’s not in fact true. That’s a nice line, but it doesn’t bear out in the policies of the institution, nor does it bear out in their bottom line financials.

There was a really important analysis that came out in Health Affairs this last month that looked at the increase in operating profit and cash reserves at nonprofit hospitals in the U.S., hospitals like the one that I work at, and whether there was a corresponding increase in charity care. There was, in fact, no corresponding increase in charity care, as millions of people do not have access to healthcare in the U.S. But what there was is a huge ballooning of cash reserves that these institutions are just sitting on. Many hospitals have billions of dollars in cash just sitting there for them to use as an investment whenever they feel like it. They have operating profits that are in many cases, $300, $600, $800 million per year.

These are nonprofit entities. They don’t pay public taxes. If they were paying taxes, then we wouldn’t have to say “Please reinvest in communities. Try to address the root causes of health. The communities around your gentrifying academic medical center suffer a lot of housing insecurity. They don’t have good quality jobs, even though they’re often working in your hospitals because you’re exploiting them in their custodial service positions, in their cafeteria positions, et cetera.”

Instead of appealing to these institutions to just be better citizens, if we taxed them, we could use those resources to do those things through the government. We could say that these communities deserve rights to housing, they deserve rights to good quality jobs, they deserve rights to basic income, if they have disabilities and cannot work, they deserve rights to healthcare. But without public revenue, you can’t do that.

One thing that I think workers inside these institutions can do is to organize collectively, whether through unions or through other forms, and to put pressure on these institutions to confront the fact that they are operating like a for-profit industry and they’re doing it under the guise of charity.

We need to push them to invest those cash reserves in communities. There was a very good article by Usha McFarling in STAT News a month or two ago about Rush, the medical center here in Chicago, producing itself as an anchor institution for the communities around it. They asked communities: “What do you most need?” And they [community members] didn’t say, “We need more medical appointments.” They said “We need housing, we need food co-ops, we need all of these basic things of everyday life.”

So Rush has committed, with several other entities in the Chicago area, several hundred million dollars collectively to produce themselves as an anchor institution for disinvested communities around them.

This is still a private model, it’s still a charitable enterprise. This is not ideal, but it’s a hell of a lot better than the norm that we have at most academic medical centers and other nonprofit entities around the U.S.

We shouldn’t be as workers just tolerating the fact that our CEOs are making millions and millions of dollars and assembling billions of dollars in cash reserves while we are denying in our emergency departments and in our clinics people access to care that they absolutely need.

It should go beyond just ensuring that we are using these huge financial resources of the nonprofit healthcare sector to ensure care. It should also be about addressing the root causes of disease. This is what that Rush program, for example, is doing.

This is the kind of stuff that, as workers inside these institutions, we collectively have power to do, but we have to organize together to make it possible. You can’t simply be a lone wolf who goes and shouts at the CEO. That’s not going to change anything. But we can do it through unions and through other forms of organization.

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