The Pervasive Vulnerability of Life in America

Approaching tipping points in a system that fails the citizenry

In the fifteen years since deciding to leave the United States, I’ve had ample time to reflect on the circumstances leading to that decision. There were many reasons then, although the one relating to healthcare was urgent and decisive. The others related to the various ways in which we felt vulnerable in the U.S. and the lack of confidence we had for positive change in the years ahead.

The recent assassination of Brian Thompson, the CEO of UnitedHealthcare, has cast the spotlight on the citizenry’s discontent with health insurance—specifically the right claimed by insurers to override the decisions of medical professionals and to limit care (or coverage for care) based on the judgment of intermediaries (PBMs and medical coders), internally held statistical data, or analyses effected by artificial intelligence. The sense of vulnerability is real and reinforced with every anecdote that has emerged about the horrors experienced by individuals denied coverage, who have endured suffering or even death, or were sent into debt or bankruptcy due to medical expenses. The outcry is a manifestation of how intolerable this kind of vulnerability has become. One purchases insurance to assure a safety net; but when we realise that the safety net protects the insurer rather than the insured, there is debt, suffering, death and outrage.

It was issues of this kind that drove me and my family to make the difficult decision to leave the U.S. in 2009, so this is not a new situation; I’ve commented on this elsewhere. It is, however, a situation that has become worse as greed, symbolised in the popular consciousness by the extraordinary compensation levels of corporate executives, has become more pervasive. Indeed, the sense of vulnerability it creates within society has been continuously amplified and extended to virtually all areas where the personal security of the citizenry is concerned.

That the outburst of rage directed toward one sector affecting personal well-being has been slow in coming also reflects the gradualness of the decline of those mechanisms available to provide social protections.

This essay focuses on identifying the many other issues that contribute to the vulnerability of American citizens. Not all create a life or death situation; in aggregate, however, they have created a collective sense of insecurity and frustration that makes reaching a tipping point over any one issue more likely.

It’s a long list: if you’re looking for a short read scan the headings and read the conclusions. The issues are complex and are simply identified rather than analysed. They also have a few things in common: they are issues that either hardly exist or exist at lesser degrees of intensity in most other countries of the developed world; they all embody some tension between what is systemic (in business, finance, healthcare, etc.) on the one hand, and personal choice and responsibility on the other; and they all affect personal well being.

• Consider the violent tenor of life.
  In the U.S., gun violence is perhaps the most widely debated public-health menace: The provisional CDC figure for deaths from firearms in the U.S for 2023 is 46,728, of which 27,300 (or 58 percent) were suicides. Of all deaths classified as murders, 81 percent were caused by firearms.¹ While individual deaths by gunshot might only be publicised at a local level, mass shootings—particularly at schools—gain national and international attention, heightening the public’s sense of vulnerability even more than the far more frequent individual shooting deaths.
  Public opinion on gun ownership is divided: some feel that gun ownership increases safety, others that it has the opposite effect.² Notably, the common ground on both sides is fear for personal security.

• Consider the issue of student loan debt.
  Some 43 million individuals in the U.S. owe, collectively, $1.74 trillion for educational loans; average debt per individual is approximately $38,175 (second quarter of 2024); new loans now average in aggregate nearly $100 billion annually. While such debt might be reasonably associated with college-age students, changing learning patterns and challenges in meeting repayment obligations mean that this debt is sometimes carried even into retirement age, thereby constraining individuals’ ability to save for a secure income in their senior years (a staggering $400 billion is owed by Americans over age 50).³

• Consider the issue of other forms of debt.
  Mortgage debt? At the end of the second quarter of 2024 there were 51,041,000 outstanding mortgage loans with an aggregate debt of $11.782 trillion; average interest rate was 4.2% with an average monthly payment of $1,849.⁴
  
  Automobile loan debt? About one-third of the U.S. population is currently paying off a loan for an automobile purchase—the are about 100 million outstanding loans. This covers loans for both new and used cars; average interest rates depend on credit scores, but in the second quarter of 2024 the average for new cars was 6.84% and 12.01% for used cars; average monthly payments were $734 and $525, respectively.⁵
  
  Credit card debt? In May 2024 credit card debt in the U.S. had reached $1.27 trillion, or $10,479 per American household. Average interest on credit card debt in 2024 was 22.76%⁶—a figure I’d tend to associate with mob loan sharks of the 1960s.

  
  Medical debt? Medical debt now totals about $220 billion, affecting 14 million Americans who owe at least $1,000 and 3 million owing more than $10,000.⁷
  
  School lunch debt? Children of low-income families may benefit from the National School Lunch Program (NSLP),⁸ but many who do not qualify continue to borrow from schools to pay for meals.⁹ Aggregate school lunch debt nationally is currently reckoned at $176 million per annum, and most school districts report that the number of children in need increases annually. Unpaid debt generally becomes the responsibility of individual school districts, not the major corporations to whom the catering of school meals is frequently contracted. Among developed countries, this category of debt is unique to the United States, so there are no international statistics for comparison.

• Consider the issue of cost of living. Cost of living varies by state within the U.S. In aggregate, however, using the OECD’s ordering by price level index,¹⁰ The U.S. ranks fourth among OECD countries in cost of living, just after Israel, Switzerland, and Iceland.¹¹ In other words, the U.S. has become one of the most expensive countries in the world in which to live.

• Consider personal bankruptcies. While the average number of filings for personal bankruptcies in the U.S. varies from year-to-year. In 2023 the total number was 445,186, an increase of 18 percent over 2022; indications are that the number will continue to grow in 2024.¹² The major cause of such bankruptcies is medical debt: evidence indicates that medical debt is cited in more than 65 percent of all bankruptcy filings.¹³ Other contributing factors include all of the other types of debt referred to above, as well as job loss and natural disasters.

• Consider the issue of homelessness. The is no single statistic that accounts for the number of homeless people or families in the U.S. There is, however, sufficient evidence that homelessness affects about 1.25 million Americans annually. The United States Interagency Council on Homelessness notes that “Housing is a social determinant of health, meaning lack of it has a negative impact on overall health and life expectancy. Tens of thousands of people die every year due to the dangerous conditions of living without housing—conditions that have worsened due to climate change’s rise in extreme weather. People who experience homelessness die nearly 30 years earlier than the average American—and often from easily treatable illnesses.”¹⁴

Let’s also think about personal security in old age. This is a big topic since it applies directly to all working Americans who hope and expect someday to retire, not just the approximately twenty percent of Americans aged 65 or older. It applies to everyone who has ever paid Social Security taxes, opened a simple IRA, or who pays into a retirement savings account—and especially to those who earn too little to save effectively for the future.

• Consider defined benefit pensions versus defined contribution plans. When I was hired in my first “serious” job in 1979, my retirement package consisted of a defined benefit pension¹⁵ programme that was structured to promote staff retention, but which also encouraged retirement at age 65: the pension consisted of an annuity whose value would rise to its maximum value at age 65, and decline thereafter. But a new form of retirement savings was inaugurated in 1978 under section 401(k) of the Revenue Act of 1978, and soon thereafter my employer began to transition its staff retirement programme in the direction of this type of retirement savings. These plans are called “defined contribution plans.”¹⁶ The argument presented to employees was that it would give individuals greater control over how retirement funds were invested, and seminars were offered to introduce staff to basic investment concepts so that they could become, to the extent possible, their own investment managers.
  

  In effect, the money set aside in defined contribution plans provides funds for speculative investment by financial management firms, primarily in capitalist enterprises. Workers therefore live with the vulnerabilities of the investment market, knowing that in retirement their income will depend on the health of the commercial world, the overall stability of the economy, and the continuation of perpetual economic growth. For those of us monitoring our 401(k) or equivalent investments in 2008 and 2009, a lesson in planning for future income was learned: you can’t count on it. You’re vulnerable to “the market” and the ups and downs of the national and global economies.

• Consider Social Security. The topical outrage around health insurance has struck most politicians dumb, but many Republicans are still vocal about seeing an opportunity to reconceive the Social Security programme, by privatising it (making it vulnerable to “the market”), changing the terms for qualifying for payments, or eliminating it altogether. Again, the rhetoric around Social Security is nothing new. We have been reminded continuously of its vulnerability—that the fund will hit a wall in 2035 and be forced to reduce payouts to 75 percent of prior amounts if no action is taken to reinforce it.¹⁷

These are concerns that impact Americans’ income once they reach retirement age. A 2024 survey by Greenwald Research indicates that 79 percent of all Americans believe there is a retirement crisis in America, with a majority fearing financial insecurity after leaving the workplace.¹⁸ With good reason: According to the Congressional Research Service some 46 percent of Americans have no defined contribution plan or IRA,¹⁹ and in 2022 the median retirement savings for the age group 55-65 was just $185,000.²⁰

The list of issues that make U.S. residents vulnerable continues with a few other key elements that affect one’s personal security and sense of vulnerability. These include:

• Job security: In the U.S. employment is generally governed by the doctrine of “employment at will,” whereby either employer or employee may terminate employment at any time, subject to certain constraints (which could include an employment contract or collective bargaining agreement).²¹ The doctrine provides significant empowerment to an employer in managing a workforce, but creates vulnerability for employees for whom employment is linked to both income and, in many cases, health insurance and the building of retirement assets. Because “employment at will” is simply the status quo, the power imbalance between employer and employee is simply taken for granted, even though for many it adds to an ongoing sense of insecurity and vulnerability. (By comparison, in the European Union the “contract of indefinite duration” is the basis of most employment, which provides significant protections to employees, including the right to continued healthcare benefits if a job is terminated.)

• Environmental security: Citizens expect protection from environmental dangers, whether they be created naturally or through social (human) activity. Government action to protect the citizenry lies within the purview of the U.S. Environmental Protection Agency, which the incoming governing administration has proposed for elimination (remember H.R.861 - Matt Gaetz’s 2018 proposal to terminate the EPA?). And the future of the Federal Emergency Management Agency (FEMA) and National Oceanic and Atmospheric Administration (NOAA) is unclear following statements made during the 2024 presidential campaign—even though environmental (and resulting personal) disasters loom ever bigger as the impact climate change intensifies.

• Food security: What confidence should there be in the safety of consumed goods under an incoming administration whose mantra is less regulation? And what about food availability? Consider that in 2022, 54.9 percent of fruit and 29.3 percent of vegetables consumed in the US were imported²²—a large proportion of which originate in countries targeted for punitive U.S. tariffs. And there are deep concerns that the incoming U.S. administration’s stated plans for mass deportations would have widely felt impact on native U.S. food production and therefore on food availability and prices.

• Information security in general: Confidence in information received should be based on verifiable data, whether the data be recorded from observations (including all manner of statistical data about American society), experimentation (consider vaccines, or the case of artificial intelligence), or simulations (such a climate forecasts). But confidence is easily undermined simply through rhetoric, whether it be the false claims of politicians or misinformation disseminated by hostile governments. In the words of Jack Weinstein, “The greatest existential threat to the United States of America is the fracturing of our democracy and the intentional misleading of facts to support political agendas.”²³ Pervasive distrust of information leads one to fall back on some act of faith in the source one chooses to believe, making it ever more difficult to speak truth to the population at large.

• Security of personal information: European privacy laws, and indeed the General Data Protection Regulations (GDPR) of the European Union, are far more comprehensive than US data protection regulations. The framework regulates the roles of all parties that handle personal information, observing seven key principles: lawfulness, fairness, and transparency; purpose limitation; data minimisation; accuracy; storage limitation; integrity and confidentiality; and accountability.²⁴ European nations have been particularly vigilant to the abuses of personal data, given how centralisation of personal data at national scale facilitated the abuses of fascist governments during World War II, and thereafter of Eastern Bloc nations (such as were perpetrated by the Stasi in East Germany) as well. The GDPR, however, also responds to the immense threat posed by the ease of collection and sharing of personal data and information across digital networks and platforms.
  
  The U.S., by contrast, has no comprehensive national privacy policy or enforcement framework. Rather, regulations and enforcement exist at federal and state level, and by consensus within certain industries. Moreover, a major concern that the European GDPR attempts to address—the aggregation of and commerce in personal information without specific user consent—is largely unregulated in the US. Americans may experience the impact of the lack of regulation at various levels, particularly in marketing and advertising. It is such aggregation, however, that potentially enables an easy transition from profiling to enhance online services, to gathering of data to create political profiles—just think of the Facebook–Cambridge Analytica scandal.²⁵ In the hands of authoritarian governments seeking absolute power, such information can also be harvested to identify state “enemies” and lead to their harassment or prosecution.

Some conclusions

The above issues are not all unique to the United States, but what sets the U.S. apart is how extreme the issues of personal safety and well-being are compared to the rest of the developed world. All of these quantifiable issues affect the quality of human lives. In U.S. culture they are incessantly amplified or distorted, often along partisan lines, by a relentless stream of diverse media. They create a drumbeat of blame and anger that compounds society’s sense of vulnerability, even of victimhood, and creates intense political divisions.

What drives this vulnerability, the anger, the fear? Put plainly, it is is the focus on profit that is integral to American capitalism and big business, an economic system too often untethered by ethics or empathy, decreasingly regulated by the governing state, and managed by a thin stratum of society—an oligarchy—that rejects the notion of shared and equitable community values, and therefore investment in the common good of its people.

The apparent divisions and anger across the political spectrum mask a profound irony: surveys indicate that the majority of Americans agree on the need for remedies to many of the issues I’ve identified, including some greater level of gun control, the continuation of programmes such as Social Security, Medicare and Medicaid, and reform of the current approach to costs and availability of healthcare. And these are, arguably, the issues that pose the most direct threats to personal well-being to American citizens and therefore their sense of vulnerability.

So where does this leave us?

The response to the assassination of United Healthcare CEO Brian Thompson could be an indicator that the public at large is approaching a breaking point where at least one of the many stressors of American life is concerned. Calls for changes to policies and practices in the the health insurance industry are ubiquitous, and some minor changes through national legislation have been proposed. But will the recent outcry and anger make profits mean less to business executives and stockholders, causing them to implement humane changes to business practices?²⁶ Unlikely: their strategy will be to manage their corporate communications carefully, wait out the furore and carry on with business as usual. Their shareholders expect nothing less. Will any of the others issues that stress Americans, such as crippling debt, uncertainty about well-being in old age, or gun violence, bring the citizenry to a genuine breaking point?

Even if you think that change is possible—and I’m grateful for the optimists who are willing to fight “the system”—how confident are you that even small steps toward positive change in the issues identified above will endure? Or that they might lead to deeper and more systemic change?

I gave my own answer to those questions fifteen years ago.

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Bernie tells the rest of the story here:

1. John Gramlich, “What the data says about gun deaths in the U.S.,” Pew Research Center Short Reads (26 April 2023) https://www.pewresearch.org/short-reads/2023/04/26/what-the-data-says-about-gun-deaths-in-the-u-s/ (consulted 15 December 2024)

2. Katherine Schaeffer, “Key facts about Americans and guns,” Pew Research Center Short Reads (24 July 2024) https://www.pewresearch.org/short-reads/2024/07/24/key-facts-about-americans-and-guns/ (consulted 17 December 2024)

3. “Portfolio by Age,” Federal Student Loan Portfolio (2024) https://studentaid.gov/data-center/student/portfolio (consulted 15 December 2024).

4. “NMDB Outstanding Residential Mortgage Statistics Summary: United States, All Mortgages as of Quarter 2 of 2024,” National Mortgage Database (NMDB®) Aggregate Statistics Dashboard, https://www.fhfa.gov/data/dashboard/nmdb-aggregate-statistics (consulted 16 December 2024)

5. Ben Luthi, “Average Car Loan Interest Rates by Credit Score,” (14 October 2024), Experian https://www.experian.com/blogs/ask-experian/average-car-loan-interest-rates-by-credit-score/ (consulted 16 December 2024)

6. “Study: U.S. consumers continue to rack up credit card debt,” ABA Banking Journal (8 July 2024) https://bankingjournal.aba.com/2024/07/study-u-s-consumers-continue-to-rack-up-credit-card-debt/ (cnsulted 16 December 2024).

7. Shameek Rakshit, Matthew Rae, Gary Claxton, Krutika Amin, and Cynthia Cox, “The Burden of Medical Debt in the United States,” KFF (12 February 2024) https://www.kff.org/health-costs/issue-brief/the-burden-of-medical-debt-in-the-united-states/ (Consulted 16 December 2024)

8. U.S. Department of Agriculture, Economic Research Service, “National School Lunch Program” (updated 25 November 2024) https://www.ers.usda.gov/topics/food-nutrition-assistance/child-nutrition-programs/national-school-lunch-program/ (consulted 19 December 2024)

9. Hanson, Melanie. “School Lunch Debt Statistics” EducationData.org (23 November 2024)
https://educationdata.org/school-lunch-debt (consulted 19 December 2024). Hanson werites: “Many of those children who owe school meal debt are part of families who earn too much to be considered for free or reduced lunch, but also earn too little to afford regular school meals.”

10. Price level index (PLI) is defined by Eurostat as follows: “The price level index, abbreviated as PLI, expresses the price level of a given country relative to another (or relative to a group of countries like the European Union), by dividing the Purchasing power parities (PPPs) by the current nominal exchange rate.” Statistics Explained: Glossary:Price level index (PLI) https://ec.europa.eu/eurostat/statistics-explained/index.php?title=Glossary:Price_level_index_(PLI) (consulted 16 December 2024)

11. “Price level indices Comparative price level indices are the ratios of purchasing power parities to market exchange rates,” OECD https://www.oecd.org/en/data/indicators/price-level-indices.html (Consulted 16 December 2024)

12. Dan Burns, “US bankruptcies surged 18% in 2023 and seen rising again in 2024 -report,” Reuters (3 January 2024) https://www.reuters.com/markets/us/us-bankruptcies-surged-18-2023-seen-rising-again-2024-report-2024-01-03/ (consulted 19 December 2024)

13. Himmelstein DU, Thorne D, Warren E, Woolhandler S. “Medical bankruptcy in the United States, 2007: results of a national study,” Am J Med. (2009 Aug;122(8):741-6) doi: 10.1016/j.amjmed.2009.04.012. Epub 2009 Jun 6. PMID: 19501347.

14. “Homelessness Data & Trends,” United States Interagency Council on Homelessness ([2022[) https://usich.gov/guidance-reports-data/data-trends (cnosulted 16 December 2024)

15. See the Internal Revenue Service definition, which describes defined benefit pensions as a retirement income programme designed to “provide a fixed, pre-established benefit for employees at retirement.” Defined benefit plan,” Internal Revenue Service https://www.irs.gov/retirement-plans/defined-benefit-plan (consulted 18 December 2024)

16. The U.S. Securities and Exchange Commission describes defined contribution plans os one that “that does not promise a specific payment upon retirement. In these plans, the employee or the employer (or both) contribute to the employee's individual account. The employee bears the investment risks.” See: “Defined Contribution Plan,” The U.S. Securities and Exchange Commission https://www.investor.gov/introduction-investing/investing-basics/glossary/defined-contribution-plan (consulted 18 December 2024)

17. Stephen C. Goss, “The Future Financial Status of the Social Security Program,” Social Security Bulletin, Vol. 70, No. 3 (2010) https://www.ssa.gov/policy/docs/ssb/v70n3/v70n3p111.html (consulted 15 December 2010)

18. Dan Doonan and Kelly Kenneally, |Retirement Insecurity 2024: Americans’ Views of Retirement,” National Institute on Retirement Security: Reports (February 2024) https://www.nirsonline.org/reports/retirementinsecurity2024/ (consulted 17 December 2024)

19. Congressional Research Service, “Ownership of Retirement Accounts in 2022: Amounts in Defined Contribution Plans and Individual Retirement Accounts” (29 July 2024) https://sgp.fas.org/crs/misc/R48143.pdf, p. 1 (consulted 18 December 2024)

20. Moriah Costa, “What's the Median Retirement Savings by Age?” Synchrony (30 July 2024) https://www.synchrony.com/blog/banking/median-retirement-savings-by-age (consulted 18 December 2024)

21. See: “At-will employment,” Wikipedia https://en.wikipedia.org/wiki/At-will_employment (consulted 20 December 2024) ; Charles J. Muhl, “The employment-at-will doctrine: three major exceptions,” Monthly Labor Review, U.S. Bureau of Labor Statistics (January 2001) https://www.bls.gov/opub/mlr/2001/01/art1full.pdf (consulted 20 December 2024)

22. Luis A. Ribera and Landyn K. Young, “Outlook of Fresh Fruits and Vegetables in the United States,” Center for North American Studies Reports, Texas A&M University Reports 2024-01 https://prod2.freshproduce.com/siteassets/files/advocacy/2024.01.outlook-of-fresh-fruits-and-vegetables-in-the-united-states-luis-final.pdf, p. 1 (consulted 15 December 2024)

23. Jack Weinstein, “POV: America’s Greatest National Security Threat: International and domestic disinformation campaigns targeting Americans a greater danger than nuclear capabilities of Russia, China, and North Korea,” BU Today: Voices and Opinion (3 June 2021) https://www.bu.edu/articles/2021/pov-americas-greatest-national-security-threat/ (consulted 15 December 2024).

24. “Quick Guide to the Principles of Data Protection,” Data Protection Commission [Ireland] (November 2019) https://www.dataprotection.ie/sites/default/files/uploads/2019-11/Guidance%20on%20the%20Principles%20of%20Data%20Protection_Oct19.pdf (consulted 17 December 2024)

25. “Facebook–Cambridge Analytica data scandal,” Wikipedia https://en.wikipedia.org/wiki/Facebook%E2%80%93Cambridge_Analytica_data_scandal (consulted 19 December 2024)

26. Paul Krugman offers an interesting analysis pertinent to this question. He writes about health insurance that “It’s a system in which taxpayers bear the cost of major medical care, but this taxpayer money flows through private companies that take a cut, spend a lot on administration, and do their best to deny care to people who need it.” But he also argues that major change, such as transition to a “Medicare for All” system, is unlikely to happen because a large percentage of Americans with private medical insurance have not been touched by denied claims and are satisfied with the system. See: Paul Krugman, “Health Insurance is a Racket,” Krugman Wonks Out (18 December 2024) https://substack.com/inbox/post/153282035 (consulted 18 December 2024)