Corruption is a Huge Problem and We are Ill-Equipped to Deal With It
We have frequently discussed outright corruption in health care as one of the most important causes of health care dysfunction. Transparency International (TI) defines corruption as
Abuse of entrusted power for private gain
In 2006, TI published a report on health care corruption, which asserted that corruption is widespread throughout the world, serious, and causes severe harm to patients and society.
the scale of corruption is vast in both rich and poor countries.
Corruption might mean the difference between life and death for those in need of urgent care. It is invariably the poor in society who are affected most by corruption because they often cannot afford bribes or private health care. But corruption in the richest parts of the world also has its costs.
The report did not get much attention. Since then, health care corruption has been nearly a taboo topic in the US. When health care corruption is discussed in English speaking developed countries, it is almost always in terms of a problem that affects benighted less developed countries. On Health Care Renewal, we have repeatedly asserted that health care corruption is a big problem in all countries, including the US. But even after Pope Francis decried health care corruption, the topic remained anechoic.
Yet somehow, a substantial minority of US citizens, 43%, seemed to believe that corruption is an important problem in US health care, according to a TI survey published in 2013 (look here). But that survey was largely ignored in the media and health care and medical scholarly literature in the developed world, and when it was discussed, it was again in terms of results in less developed countries. Health Care Renewal was practically the only source of coverage in the US of the survey's results.
So imagine my surprise when Vox published an article on May 17, 2017 entitled "The US is Terrible at Investigating Politicians. Blame the Constitution." The article opened with a discussion of mechanisms in place in some other countries explicitly designed to cope with severe corruption of public officials. The author then noted,
Designing investigations into high-level misconduct is extremely difficult. Every nation has tough choices to make, and none has come up with a perfect solution — though it’s clear that the US system is uniquely bad.
The author noted that the US Constitution provides no clear mechanisms for addressing corruption, and in their absence, at best "we'ver jerry-rigged things instead."
So it is good that there is now some minimal public recognition that we in the US have not developed an effective approach to corruption. The unasked question, of course, is why not. Just becauses our constitution is more than 200 years old is not really an excuse. Constitutions can be amended and laws can be written. I submit that we have been in a long-standing state of denial about the existence of corruption, based perhaps on an erroneous conception of American exceptionalism, and enabled by those who have gotten rich off corruption, and for a long time have been using substantial resources to keep the problem anechoic.
Now we pay the penalty for our perhaps wilfull ignorance.
Impunity Enables Worsening Behavior
We have long railed against the impunity of top leaders in health care. We have gone on ad infinitum about the parade of legal settlements made by large health care organizations after allegations of often egregious misbehavior, including episodes of bribery, fraud, kickbacks, and other crimes. Typically, such settlements allowed the organizations to walk away after paying a monetary penalty that may have appeared big, but was tiny compared to the monay that could have been made from the misbehavior. In particular, almost never does anyone at the organizations who authorized or directed the bad behavior, particularly top executives, suffer any negative consequences at all, even when they may have made huge bonuses because of the revenues such behavior generated. The continuing impunity of top health care leaders only seems to encourage future bad behavior.
So imagine my surprise when Vox published on May 18, 2017, an article entitled, "Trump isn’t a toddler — he’s a product of America’s culture of impunity for the rich."
Its author, Matthew Yglesias, indicted President Trump as a long time beneficiary of impunity, whose behavior was enabled by impunity, and who is thus typical of American corporate leaders.
He’s a man who’s learned over the course of a long and rich life that he is free to operate without consequence. He’s the beneficiary of vast and enormous privilege, not just the ability to enjoy lavish consumption goods but the privilege of impunity that America grants to the wealthy.Imagine my increased surprise when USA Today published on May 17, 2017, and ediorial by Christian Schneider that similarly asserted that Trump has a
Trump’s 'law and order' attorney general wants to throw the book at relatively small-time drug offenders. Trump himself has spent his entire career skating away from lawbreaking with a fine paid here and a political contribution there. He’s an unusual figure, but also very much an exemplar of his era and a product of a decades-long ideological campaign to do as much as possible to empower the wealthy and powerful.
core belief that as long as you're an A-lister, there are no rules worth obeying.
Trump as a Long-Time Beneficiary of Impunity
Trump asserted on the infamous Access Hollywood tape
And when you're a star, they let you do it. You can do anything.
Mr Yglesias documented,
What’s beyond question, however, is that Trump’s expressed view that a rich and famous man like him can get away with anything is both sincere and largely correct. From his empty-box tax scam to money laundering at his casinos to racial discrimination in his apartments to Federal Trade Commission violations for his stock purchases to Securities and Exchange Commission violations for his financial reporting, Trump has spent his entire career breaking various laws, getting caught, and then essentially plowing ahead unharmed. When he was caught engaging in illegal racial discrimination to please a mob boss, he paid a fine. There was no sense that this was a repeated pattern of violating racial discrimination law, and certainly no desire to take a closer look at his various personal and professional connections to the Mafia.Mr Schnider noted
His entire adult life, Trump has been able dodge legal trouble simply by using his bank account as a shield. When Trump Management was sued by the government in 1973 for refusing to rent apartments to people of color, Trump and his father were able to settle without any admission of guilt. When students at Trump University sued him for defrauding them, Trump simply wrote a check for $25 million to make it all go away.
Marriage in the tank? He's got a pre-nup. Casino business going belly-up? He goes to bankruptcy court, walks away, and writes another book praising his own genius.
Trump's Impunity is the Current Vivid Case of a Problem of Historic Proportions
Trump's current actions are, per Mr Yglesias,
entirely emblematic of America’s post-Reagan treatment of business regulation. What a wealthy and powerful person faced with a legal impediment to moneymaking is supposed to do is work with a lawyer to devise clever means of subverting the purpose of the law. If you end up getting caught, the attempted subversion will be construed as a mitigating (it’s a gray area!) rather than aggravating factor. Your punishment will probably be light and will certainly not involve anything more than money. You already have plenty of money, and your plan is to get even more. So why not?
I might quibble that the US problem with corruption and impunity goes back years before President Reagan's administration. However, still
beyond Trump, America is desperately in need of a larger political reckoning as well.
The entire culture of civil fines and settlements without admission of wrongdoing that dominates American business regulation is fundamentally odd. If the rules say you can’t keep your casino afloat with an unapproved loan and you respond to that by getting a shady secret unapproved loan to keep your casino afloat, shouldn’t you be out of the casino game? If compliance with money laundering rules is mandatory and you don’t comply, shouldn’t you be shut down?Any given case obviously presents its nuances, and not every case can be taken to the mattresses. But the settlement racket too easily lets regulators feel like they’re putting points on the board even while criminals continue to roam the streets, having learned the lesson that they’re untouchable. That, fundamentally, is Trump’s problem. Not that he can’t control himself, but that he’s been taught he doesn’t have to.
So to repeat an ending to one of my previous posts on health care corruption.... if we really want to reform health care, in the little time we may have before our health care bubble bursts, we will need to take strong action against health care corruption. Such action will really disturb the insiders within large health care organizations who have gotten rich from their organizations' misbehavior, and thus taking such action will require some courage. Yet such action cannot begin until we acknowledge and freely discuss the problem. The first step against health care corruption is to be able to say or write the words, health care corruption.