Intro: This is Citations Needed with Nima Shirazi and Adam Johnson.
Nima Shirazi: Welcome to Citations Needed, a podcast on the media, power, PR, and the history of bullshit. I am Nima Shirazi.
Adam Johnson: I’m Adam Johnson.
Nima: This is our season seven premiere of Citations Needed. We are thrilled to be back after our brief summer break. Thank you so much, everyone, for listening. We are excited to get down to this new season of Citations Needed. As always, I should mention of course, you can follow the show on Twitter @citationspod, Facebook Citations Needed and if you are not already a supporter of our show, we urge you to become one. It is the way that we keep our show going. It is the way that we keep it sustainable. It keeps all the episodes free for all listeners while also providing news briefs and other goodies to our subscribers. You can do that through Patreon.com/citationsneededpodcast. Adam, welcome to season seven.
Adam: Thank you. Thank you for having me on season seven. I’m glad to be here. Oh wait, I’m not a guest.
Nima: You’re back.
Adam: Yeah, no, I’m excited.
Nima: The team got together, Adam, and we decided to have you back. [Laughs] We offered you a new contract.
Adam: Yeah, people don’t know this but after each season, we all turn in our resignation letters and he has to hire us back.
Nima: It’s all up to Julianne and Florence.
Adam: Exactly. [Laughs] Yes, media is the shitty gift that keeps on giving. So there’s a ton more in store for season seven. We’re very excited to get started. So let’s do that right now.
Nima: That’s right. Buckle up and welcome back.
“COVAX and World Bank to Accelerate Vaccine Access for Developing Countries,” a World Bank press release trumpets. “How AI Is Making Healthcare More Affordable And Accessible,” Forbes announces. “How technology is helping improve financial inclusion around the world,” CNBC reports.
Adam: It’s a linguistic frame that appears regularly in media, PR, and policymaking. Those who can’t afford top tier forms of basic necessities like housing or physical or mental healthcare, we’re told, can have “access” to less expensive, lower quality versions. Enter bottom rung, ACA marketplace plans, less effective COVID vaccines, homeless people living in train containers, scammy cryptocurrency apps, and clunky chatbot “therapist.” After all, it’s better than the alternative, which is having no healthcare, housing, or income at all.
Nima: But why must having nothing at all be the only alternative? Why isn’t it possible to ensure high quality essentials for everybody? And how does media’s repackaging of substandard necessities as “increasing access” and fostering “inclusion” serve to make the barbarism of austerity politics seem somehow palatable, maybe even benevolent?
Adam: On today’s episode, we’ll examine the trope of framing subpar material essentials as forms of “inclusion” for the poor or “increasing access” to important life-saving and sustaining needs, exploring how media simply accepts rather than challenges this manufactured austerity that allows this cruel stratification in the first place.
Nima: Later on the show, we’ll be speaking with Beatrice Adler-Bolton, writer, artist and co-host of the Death Panel podcast, which covers the political economy of health. She’s the co-author with her podcast co-host Artie Vierkant, of the book Health Communism: A Surplus Manifesto, which was published by Verso Books in 2022.
Beatrice Adler-Bolton: The recent focus on, in particular, generative AI as a solution to healthcare inaccessibility has been really discussed so much recently in the media through this lens that’s totally smothered in like a techno-capitalist utopianism. But it’s also much more, I mean, I hate this word and framing, but it’s much more “consumer-focused” than ever before in the worst way. In the last few years, we’ve seen somewhere between 10,000 and 20,000 new mental healthcare apps that have been launched. It’s truly staggering.
Adam: So this idea of increasing access as a media trope, I wrote an article about it for my Substack back in April 2023. The headline is “Throwing the Poor Crumbs Isn’t ‘Increasing Access’” in which we discussed many iterations of the themes we’ll be discussing on today’s show. So you can read that if you’d like. It’ll be in the show notes. But this is a similar idea. I’m very much influenced by a concept that was coined by Keeanga-Yamahtta Taylor, which is this idea of what she calls “predatory inclusion,” a term she coined in her 2019 book Race for Profit: How Banks and the Real Estate Industry Undermined Black Homeownership, which you should definitely read if you haven’t. She sums up the process whereby bankers, real estate brokers work in tandem with the government to support housing policies that “fortified racial inequalities and made billions of dollars for the private sector” under the auspices of being inclusive.
Nima: Right, so it’s a way that like the US Department of Housing and Urban Development known as HUD or the Federal Housing Administration, FHA used mainly in the 60s and 70s although the book really does cover up until the present, this idea of how like these federal housing agencies weaponize their policies, that while moving away from explicitly discriminatory practices like redlining, turned instead to these predatory ones that seemed inclusive in their design. So rather than excluding Black communities, from housing policies like in redlining, these targeted Black communities, to bring them into real estate schemes that wound up making massive real estate industry profits and did very little to redress residential segregation or other kinds of housing inequities and actually exacerbated a lot of them.
Adam: Yeah, so the broader logic of throwing the poor crumbs and claiming that you’re doing them a favor because it’s better than nothing, right? This is a recurring theme you’ll recognize in this episode. It’s been around for centuries. Notable examples were the first objections to the abolition and curtailing of child labor in the mid-19th century. According to journalist Julia Baird, then-Prime Minister in the 1830s, when Britain was discussing limitations on child labor, which were extremely modest, by the way, basically saying anyone under the age of 14 can’t work more than 10 hours a day, then Prime Minister Lord Melbourne for whom the Melbourne Australia is named after, he opposed these measures. And in doing so he argued that “children should be able to work instead of starve,” which basically means that these are the only two options, either child labor or people starve.
Nima: That’s the binary that we’re working with. [Laughs]
Adam: Which was a very common argument for either slow walking or outright opposing child labor laws in both the UK and the United States. And the New York Times editorial in 1914, argued against Teddy Roosevelt, who they call the colonel in this editorial.
Nima: [Laughs] He’s literally just referred to as “the Colonel,” and you’re supposed to understand who that is.
Adam: This is after he had left office, but he was revving up for another election run, which he ended up not doing. He came out in support of a federal child labor law and the New York Times Editorial Board wrote this:
The Colonel was reported yesterday as saying that when the Constitution was written there was no child labor. So far as this country is concerned that was true, because there were no factories, no tenements, no sweatshops. The Constitution did not produce them, and if the Constitution were amended or abolished they would still exist. They are not the product of modern heartlessness, but are byproducts of a factory system, without which modern populations could not feed nor clothe themselves. That is no excuse for overworking children, and the Colonel carries everybody with him in wishing it reduced and regulated. But he shows small acquaintance with the industrial history, when he assails his contemporaries as child drivers. When it was discovered how the application of power to machinery could enlarge human satisfactions the machinery was built low in order that children could work at it. That sounds shocking, but the fact is that such children workers came from the poorhouses, there being no means of support for either themselves or their parents. In the factories there were abuses which have disappeared. The children were flogged, and fettered, and sometimes committed suicide. Life was truly hard then, and yet the factory towns were better places to live in than the country towns where there was no work.
And so, this is a similar idea to what Lauren Melbourne had said, basically, it’s either they’re either going to starve, but we need to have child labor. This was also a very popular argument made to fast forward a little bit and we’ll go back to the past. This was a very common argument made for Nicholas Kristof. So Nicholas Kristof wrote the following article, September of 2000: “Two Cheers for Sweatshops.” June of 2002: “Let Them Sweat” by Nicholas Kristof. June of 2006: “In Praise of the Maligned Sweatshop.” Gotta stand up for the little guy there.
Nima: That’s right.
Adam: And in January of 2009: “Where Sweatshops Are a Dream?”
Nima: Yeah, his general argument, obviously, is not that sweatshops are the best things in the world but depending on what you’re comparing them to, they’re pretty damn great, and we should understand their utility. In his article “Two Cheers for Sweatshops,” which he wrote in the year 2000. This is how he summed up his argument:
Of course, it may sound silly to say that sweatshops offer a route to prosperity, when wages in the poorest countries are sometimes less than $1 a day. Still, for an impoverished Indonesian or Bangladeshi woman with a handful of kids who would otherwise drop out of school and risk dying of mundane diseases like diarrhea, $1 or $2 a day can be a life-transforming wage. This was made abundantly clear in Cambodia, when we met a 40-year-old woman named Nhem Yen, who told us why she moved to an area with particularly lethal malaria. ‘’We needed to eat,’’ she said. ‘’And here there is wood, so we thought we could cut it and sell it.’ But then Nhem Yen’s daughter and son-in-law both died of malaria, leaving her with two grandchildren and five children of her own. With just one mosquito net, she had to choose which children would sleep protected and which would sleep exposed. In Cambodia, a large mosquito net costs $5. If there had been a sweatshop in the area, however harsh or dangerous, Nhem Yen would have leapt at the chance to work in it, to earn enough to buy a net big enough to cover all her children.
Adam: Yeah, this was a common argument in all pro-sweatshop discourse, pro-globalization in the ‘90s, 2000s. People kind of went out of favor in, like, 2013, 2014. This has actually even a line used in The West Wing, which is that like, sweatshops are good cause the other option is that you have to make money by being sexually trafficked, that children are either going to work in sweatshops. The idea that there’s a third option is simply not entertained. That’s pie-in-the-sky, far-left ideology. And what’s important to note is that the logic that Nicholas Kristof is using is exactly the same logic as people who defended child labor and the 1820s up to the 1920s, 1930s when it kind of fell out of favor, which is that they’re either going to starve or they need to work.
Nima: Right. There are just naturally people who are the dregs of society who have to get by the way that they have to get by.
Adam: Whether they be in Cambodia or on the streets of Dickensian London, right? They’re sort of naturally poor. And those who wanted to push for child labor because they always said, oh, if they’re not in the factories, they’re going to be delinquents, right? They’re going to be committing crime. This was the most popular argument. And they would say, oh, wait, there’s a third option. There’s actually one editorial from 1924, when they first proposed the Child Labor Act, which now I think we need to actually pass now over almost 100 years later, because of the growth in child labor laws. They would say, No, there’s like a third option, they can go to school, like we can mandate they go to school, and we can pay their parents enough to where they don’t have to work.
Nima: Right. You don’t have to, like, have the children employed so that they can pay for food for their family? How about we change the way our society operates? And then
Adam: In the ‘90s, and 2000s, which isn’t to say that sweatshops have gone away but when these arguments are being advanced, people say, well, how about instead of just having a race to the bottom of seeing which country can have the lowest labor standards, you have some kind of global labor floor, right? Instead of just asserting it’s a system, how natural that the options are either, you know, juvenile prison or the sweatshop. There’s a third option, which is a theme again, we’ll be repeating ad nauseam in this episode. And this idea that you’re increasing access to money, or increasing children’s access to money by letting them work in sweatshops or letting sweatshops exist in the hopes you’re increasing their access to money, again, assumes a degree of austerity and zero sumness that is not natural or organic, but is indeed political.
Nima: Note how Kristoff doesn’t say that in high malaria-affected areas, government should provide adequate mosquito nets, right? Like it’s all about how are poor people going to earn enough to buy an expensive, necessary life-saving product without interrogating the fact that like, well, if this is such a threat, maybe we change what we understand as access, right? And it’s not access to money through terrible, grueling working conditions, to then give that money to a company to buy a life-saving mosquito net. Rather, what if we cut out that whole middle part? And just make sure that, I don’t know, people, let’s say have malaria vaccines and also mosquito nets. That is never really contemplated. So framing this false dichotomy as merely “increasing access” is not a concept that has been linguistically with us for centuries. Rather, it seems to have begun in earnest about 50 years ago in the 1970s at the dawn of neoliberal policymaking. Really used as a PR tool for industry and politicians, some early instances of the access framing that we’re focusing on applied to healthcare or rather, health insurance, which itself often prevents the care part of healthcare. The health insurance industry has relied on this access framing for a long time. One such example comes from a UPI newswire article on October 24, 1975, which was syndicated in newspapers around the country. It goes like this:
In an effort to counter the doctor drain from rural America, a private health-care foundation plans to set up 25 modern small-town medical practices designed to attract bright young physicians to similar communities. The Robert Wood Johnson Foundation of Princeton, New Jersey is committing $14 million to the innovative project. ‘The program represents a search for new approaches to the problem of health-care access in rural America,’ said Dr. David Rogers, president of the foundation.
Adam: Now the Robert Wood Johnson Foundation is named after Robert Wood Johnson of Johnson and Johnson fame. No relation. Now, an ad from the hospital management company, American Medicorp, Incorporated published in the Los Angeles Times, Boston Globe, and Chicago Tribune in November of 1976 made use of this access framing, swiftly dismissing the concept of quality care for all: “How much for healthcare?” “Every American should have access to basic health-care services and no American family should be destroyed financially by catastrophic illness. We support this emerging recognition of healthcare is a fundamental right. But how much can a nation afford?” Over the years talk of “access” would permeate news coverage appearing with respect to other commoditize essential needs like housing.
Here’s an example from the Associated Press in August of 1990:
Independent-Republican gubernatorial candidate Doug Kelley proposed a series of measures Friday aimed at improving circumstances for families in Minnesota. Among Kelly’s proposals are exploring a housing voucher system, which might be able to offer improved access to housing, and to ensure the availability of low cost housing goes to those who truly need it.
Notice the quote “those who truly need it,” an implication that the system is being abused and must be means tested.
Nima: Well, right. So all of these uses of ‘access,’ like talking about healthcare, talking about bringing more doctors to rural areas, talking about housing, it all sounds like vaguely good, right? Like these are good things. You want more doctors in rural areas, you want better healthcare services across the country, you want people to be able to have a roof over their heads. But this framing of access, it doesn’t say that everyone needs a house or needs a home. It doesn’t say that, it says that they need access to be able to get one, which creates this market-based middle section.
Adam: Well, it’s a way you avoid rights-based language. Because the idea of positive rights or the idea that you’re entitled to things like housing, healthcare, clean water, the idea that you’re entitled to a job, the idea that you’re entitled to transportation, reliable transportation, you don’t want to say rights so you say access, which like we’re going to increase access, which reinforces the framing that the existing status quo is good and healthy. You know, you’re sort of broad, you’re sort of democratizing the private sector.
Nima: Here’s another example from the Asbury Park Press, from February 25, 1994. The headline reads “Two builders’ programs help inmates, homeless.” A part of the article reads like this:
Through the program known as HEART, homeless people are trained in construction skills, acting as apprentices for association builders. They are trained in frame carpentry, plumbing, electricity, building, and apartment maintenance, and landscaping. They are given access to transitional housing and social services programs.
Now, HEART and the other program discussed in the article were both run by the Home Builders’ Institute, the philanthropic arm of the Home Builders’ Association, which is a real-estate developers’ lobbyist group. Now notably, the article’s author was on the real estate beat and thus, not expected to really ask any political questions in his article like whether a foundation associated with a developer’s trade group that opposes rent control is sincerely interested in improving homeless people’s standards of living. Or maybe they might have an ulterior motive, but because this was released as a real-estate piece, it didn’t really interrogate those things.
Adam: Yeah, it’s very popular among trade groups that do charity stuff, right, whether it be health insurance companies or for-profit healthcare that does charity around healthcare, real estate developers to do charity around “increasing access” to housing. It’s a very kind of 2004 Republican National Committee-like faux, like, it’s one of these sort of great, meaningless concepts. This was popular in healthcare in the last, you know, 20 years or so, 25 years or so. And it was very popular around the Affordable Care Act that was passed in March of 2010 that would offer partial subsidies to “moderate-income people” as The New York Times phrased it at the time to buy health insurance. As the Bismarck Tribune noted in March of 2010, “The Patient Protection and Affordable Care Act increases access to coverage for people without health insurance.” And that this access language continues to the present day, it’s very popular to avoid the idea of healthcare as a right. Increasing access makes it look like some grand project or, you know, 50, 100, 200 years that we’re gonna sort of go from 67% access to 71% access and that that’s somehow good. And by the way, of course, access to something is not the same thing as having a right to it. I have access to a Porsche if I want to walk in and buy one, I cannot buy one. I cannot afford access without affordability. Access without something being a right, of course, doesn’t really mean much. The 2016 Democratic Party platform, for instance, traffics in this language, writing, “Democrats will never falter in our generations-long fight to guarantee healthcare as a fundamental right for every American. As part of that guarantee, Americans should be able to access public coverage through a public option, and those over 55 should be able to opt in to Medicare.” Both Joe Biden and Hillary Clinton ran on a public option. The second Biden was elected, he basically stopped mentioning it.
Nima: Notice how there’s the generations-long fight to guarantee healthcare as a right, right? So they use rights-based language. But the way to get there, they’re not saying that the fight is going to be won by guaranteeing that right as a matter of policy as a matter of what we embed in our society. No, they follow that up, like on the way to getting that embedded as a right, we’re not there yet, we can’t guarantee that. So on the way, we’re going to do this thing where we make sure that people have “access.” So again, it’s this thing that, like, it plays this middle game of not guaranteeing the thing, not just saying everyone will be guaranteed to have healthcare. No, it’s that they have access to coverage, which means more money for the insurance industry, not actually access to doctors in their own communities,
Adam: Because you have to maintain the private insur — and to be clear, like, this is one instance where we know explicitly that the extent to which Biden is conservative on single-payer healthcare system is not something he’s forced to do by the Republicans. It is an ideological belief because he was asked when he was running in 2019, if you had the votes in the Senate, and single-payer healthcare was at your desk, would you sign it? And he said, no, I would not sign it because we can’t afford it or whatever kind of austerity bullshit. So it is an ideological commitment. This idea of access in his wiggle room was this idea that he was gonna support a public option that poor people could afford. That way you maintained the sanctity of private health insurance even though with the robust public option, that wouldn’t really work. But as many health insurance lobbyists and spokespeople were quick to say is that a robust and free public option would render the vast majority of private healthcare pointless, other than kind of boutique plans like they have in Europe. This is an instance where this access language really does preserve the status quo that you’re going to increase access to private sector for-profit health insurance, again, an industry that absolutely 100% has no reason to exist. It doesn’t provide anything. It’s just a superfluous middleman that exists to pull resources in the least efficient way possible. Biden, when he ran in 2020, his platform reaffirmed this when they once again use this access language around healthcare: “Democrats will keep up the fight until all Americans can access secure, affordable, high-quality health insurance — because as Democrats, we fundamentally believe healthcare is a right for all, not a privilege for the few.” But again, they’re not saying they’re going to work to make it a right, they want a right in an abstract sense or an afterthought. But what they want to do is fight until all Americans get access.
Nima: Right? They believe it’s a right, but they want to provide access. [Laughs]
Adam: Yeah. Right.
Nima: So then in June of 2021, The Washington Post actually just regurgitated wholesale the White House PR line in a story that they headlined, “Record 31 million Americans have health-care coverage through Affordable Care Act, White House says.” And the article summarized and embedded a video of Joe Biden and Barack Obama chatting about their incredible accomplishment of providing access to healthcare for millions. Let’s listen to that clip.
Barack Obama: The effort was worth it. The families that have been able to care for their loved ones, be cured, have access to care. That all makes it worthwhile. So I just want to thank your administration.
Nima: I mean, it’s probably funny when he’s thanking Joe Biden’s administration anyway.
Adam: And of course, the Washington Post editorial board, which likes this access language uses themselves all the time, repeatedly, demagogues against Medicare for All and other forms of single-payer healthcare, which make healthcare a right rather than health insurance something one can vaguely access. The Post also conveniently doesn’t mention that ACA premiums which were already extremely expensive have been rising overall since the law’s passage in New York City and Washington DC, for example. The proposed rate increases for 2017 were among the highest at 16%. And in 2023, according to Axios, “The average silver plan benchmark premium increased from $438 to $453 in the last year for a 40-year-old nonsmoker.” “Markets with a single insurer had premiums that were $128 more than in markets with five or more insurers.” Because insurance companies get to choose whether they participate. “States like West Virginia and Wyoming had the highest average benchmark premiums in 2023, at over $800.” Now, a lot of this is kind of state by state and some Republicans make it more expensive than it has to be. But the general idea is that in many places, in most places, depending on your income, you still have to pay $400, $500, $600 a month to have “access” to health insurance. This is, of course, not even including deductibles, co-pays, et cetera. Which is why, according to the Kaiser Family Foundation, the health insurance funded think tank, roughly 28 million Americans are still without healthcare in this country. And depending how you parse it, an additional 60 million are underinsured. And so did that increase access to health insurance, the ACA? Is it better than nothing? Yeah, but what if there’s a third option? And “access” again, really does obscure and avoids this rights-based language. And that’s why I think it’s so funny, it’s so tortured, when people try to use the rights-based and access language even though they’re fundamentally describing two different phenomena. Because you don’t have access to rights, you either have them or you don’t have them.
Nima: Right, you don’t have to be able to access the thing. What the access language does — access to money maybe to then give that money to industries that shouldn’t even exist because we don’t have rights to things that we need.
Adam: Right. One place we saw this increasing access framing that was quite subtle, and we argued and argued at the time was somewhat sinister was the development of the people’s vaccine by Dr. Peter Hotez who has become a bit of a punching bag for the right of late so we’re going to try to go a little bit easy on him. But basically, according to KVUE in January of 2021, they reported that the Baylor generic non-patent vaccine was supported by the Gates Foundation among many others. If he was developing this in parallel with Operation Warp Speed to create a cheap substandard alternative and he was supporting the effort to pass a TRIPS waiver at the WTO, which would free up the intellectual property of the mRNA vaccine, which we talked about a lot on the show, which was an effort by over 100 Nobel laureates, 400 different progressive and human rights groups, including Human Rights Watch, Amnesty International, Doctors Without Borders, etc. We’re all calling on the WTO to free up the mRNA vaccine patents around 2021, 2022, which they of course, never ended up doing. The Biden administration supported nominally but ended up not doing anything about it.
And not just for this particular pandemic, right? COVID, but future pandemics. That idea is that if there’s something that’s sweeping through the globe, and killing millions of people, you should probably not profit off of the private, intellectual property of that vaccine. Peter Hotez, however, dismissed that he refused to support the TRIPS waiver. And when asked about it, dismissed it as a kind of pie in the sky fantasy, which I think puts that framework in sort of clear focus, which is creating a quick, fast, relatively cheap vaccine is not in and of itself bad if it’s done in concert with freeing up the IP so we can have the mRNA vaccines mass produced in Africa, Asia, which we know they can be, right?
The New York Times reported that over 200 different facilities could have produced these vaccines, they ended up not doing it, obviously, because of intellectual property rules. It really does expose the limits of this charity model, because again, he’s not going to get money from these big donors, all of whom are funded by pharma or have ideological commitments to the intellectual property regime, as does Bill Gates, if he undermines the fundamental premise of the intellectual property regime. And so this kind of access language, even for someone that again was basically given saint-like status in the media. Like I think the right wing attacks him for all the wrong reasons. But he really was at the height of the effort to free up the IP for the vaccines, you know, he was being interviewed by Michelle Goldberg and completely dismissed the importance of the TRIPS waiver. And this is why creating this kind of subprime vaccine for Africa, Latin America, in parts of Asia, can be kind of sinister because again, it sounds good to increase access to have another cheap vaccine. But in this case, the effort to make a parallel strategy of both that and freeing up intellectual property so they could scale up production across the Global South without having to worry about IP lawyers from the Global North suing them, I think really kind of exposes the limits of this kind of access liberalism.
Nima: We also see this kind of framework with the introduction of what we now hear as AI therapy or mental healthcare. These apps and chatbots that are now ubiquitous. Now, presented as yet another form of access, these faceless platforms are no replacement for actual human counselors and therapists, of course. No one who has a certain kind of income or has “access” to human therapists would actually ever choose to, like, confide in or seek therapy from a chatbot rather than their doctor or their therapists, right? So you can kind of see where this have and have not dichotomy really lands. And yet these chatbots are really deemed to be the latest in improving what else? Access.
So for instance, you have NPR in January of 2023 with this headline “Therapy by chatbot? The promise and challenges in using AI for mental health.” A few months later, the BBC in April of 2023 had this headline, “would you open up to a chatbot therapist?” The article read in part, “While anyone with a concern for either his or herself, or a relative, should go to a medical professional in the first place, the growth of chatbot mental health therapists may offer a great many people some welcome support.” Yet, the article doesn’t really bother to explore the issue of why the so-called great many people aren’t getting the care they need and why they would need to resort to a chatbot.
The same month Al Jazeera, April of 2023, had this article, “ChatGPT is giving therapy. A mental health revolution may be next.” This article states that “in theory, AI therapy could offer quicker and cheaper access to support than traditional mental health services, which suffer from staff shortages, long wait lists, and high costs.” The article also quotes a Georgetown medical student to lend legitimacy to the claim of increasing access. The student rightfully notes that psychotherapy can be expensive with long waiting lists, but continues this way, saying, quote, “People don’t have access to something that augments medication and is evidence-based treatment for mental health issues, and so I think that we need to increase access, and I do think that generative AI with a certified health professional will increase efficiency.” The article acknowledges the ethical concerns about standards of care, but this is relegated to the end of the article. It’s buried when it actually should be more like the lead. Nowhere does the piece seem to be that curious about why people who can’t afford therapy are only given the options to either use a garbage kind of chatbot or not get the care that they seek and need.
Adam: Yeah, because to be clear, every one of these stories is not a story about a new emerging exciting tech. They’re a story about how the private sector has fundamentally underresourced and irrationally supplied an essential part of human survival and thriving and living, which is healthcare and mental healthcare. There’s a failure of the free markets to provide enough doctors, to provide enough health professionals. So the articles are not about what can the state do to train more people, to pay better, to scale up and meet the human needs required in healthcare. It’s, well, the free market has spoken, it’s just the fucking way it is. And 30, 40, 50 million people can’t “access” healthcare. So what is this new bullshit gimmick we can do instead of having a rational, planned way of doing this? These are stories fundamentally about the failures of capitalism, and then the barons of capitalism, Silicon Valley, Wall Street, they get to come and say, oh no, we’re going to solve the problem that our false austerity and P&L formulations have created to begin with, right? It’s this really great way you’re the cause of and solution to every problem, right? That’s how these things typically work.
And again, these journalists just aren’t really going to question the premise and sort of take it for granted that people in rural areas, people can’t afford it. Poor people and Black communities, Latino communities, they don’t have “access.” So instead of saying, well, why is the government than not making sure we can have more people doing these jobs, they just assert a bunch of labor shortages, which again, are false, they’re not needed. There’s nothing organic about these labor shortages. We just say well, the free market is spoken.
One sector we see this “increasing access” language all the time to promote substandard conditions for the poor is housing. Increasingly, as again I’ve noted before, lowering standards of housing for the poor is presented by very smart, savvy people in media as expanding access or increasing choice. Things like tiny homes, new laws permitting basements and garage living spaces, living in cargo containers, in homes without kitchens or private toilets are presented as fresh ways of increasing access to homes with the idea that there’s something natural or organic about supply and demand housing. And if poor people can’t afford homes, the solution is not to again have the state help provide affordable housing for the poor. And to scale up the construction of new social housing. The solution is to take environmental union regulations, things of that nature, which again, I’m not saying are always perfect, but it’s to get rid of those altogether.
Nima: Yeah, basic standards of human survival, of standards of living that include, I don’t know, being able to access sunlight in your apartment.
Adam: Yeah. So increasingly, there has been an effort by the really, really smart and savvy wonks like Matt Yglesias, Eric Levitz to get rid of windows so they can convert office buildings into housing. And this is, of course, none of these people. Matt Yglesias is not going to live in an apartment without a window in the bedroom. And he never will, not in a million years. Again, just like he’s never going to use AI chat therapy. But to increase access to the poor, we’re just going to keep lowering, lowering standards. And again, one or two here or there, you’re like okay, sort of maybe I could see that. But it’s part of a broader narrative of just eroding the quality of life for the poor, using this false austerity regime, which again, does not organically have to exist.
Nima: Yeah, we saw this also in the realm of finance, especially during the cryptocurrency frenzy of 2022. One of the more insidious angles of crypto peddling was that it would be “inclusive” for those who didn’t have access to banking systems who are “unbanked” or “underbanked” as the term goes. CNBC stated as much on March 11 2022, with a headline: “How technology is helping improve financial inclusion around the world.” Here’s an excerpt: “Cryptocurrency bulls have long pointed to the accessibility of the asset class, and some even say that investing in the digital coins could help close the racial wealth gap in the U.S.”
So crypto here was seen as a way to redress racial exclusion, right? This was the new predatory inclusion that we saw, not just in housing, but now the financial industry as well. Most other examples come from the industry itself because a lot of mainline media actually avoided this kind of inclusive crypto framing. Even the Brookings Institution published an article in October 2022, debunking the industry’s claim of “inclusivity,” which noted, for example, that many crypto platforms typically require a bank account to use cryptocurrencies, which actually defeats the entire purpose and premise of serving the unbanked through crypto, and that crypto was a purely speculative asset promising no real financial stability whatsoever. Upon the collapse of the crypto bubble, this became all the more evident.
Adam: Yeah, and a lot of these people peddling crypto to Black communities and Latino communities, other underserved communities, they’d always say, oh, well, they’re not being banked. You know, they’re not being supported by Wall Street’s traditional banks, even though again, Wall Street also props up the crypto industry so the whole thing is stupid. And you’re like, well, yeah, but what if this horrible scummy pyramid scheme is not the only option to giving people the ability to have credit or to have money? What if we should give them government checks? UBI? God forbid, reparations, right? It’s such a blinkered way of thinking about the world.
It’s like, there’s nothing or this subprime thing I’m shoving down your throat, and those are the only two options. And if you question those two options, if you say, what about the third option, right, especially as a journalist, then you’re no longer being neutral or objective. You’re being ideal, the dreaded i-word, being ideological, you’re sort of asking questions that are outside your tech beat or housing beat or healthcare beat, right? And the problem is that so much ideological work is done just by asserting this dichotomy, that it’s either child labor or you starve. It’s either sweatshop or you’re a child prostitute. It’s either you’re gonna be homeless or you’re gonna live in a fucking shipping container. That’s it, there’s no third option. And if the journalist broaches the third option, they’re viewed as being recalcitrant, far-left assholes who are asking too many questions that are outside the scope of a sort of beat journalist, right?
And that’s bad, especially with the rise of this “access” increasingly in the space of healthcare, which we’re going to talk about with our guest where we see this more and more and more where the pseudo half-assed, not workable technology is increasingly pitched as this progressive enlightened way to democratize healthcare when the opposite is happening.
Nima: Yeah, so to discuss this more, we’re now going to be joined by Beatrice Adler-Bolton, writer, artist and co-host of the Death Panel podcast about the political economy of health. She is the co-author — with her podcast co-host Artie Vierkant — of the book, Health Communism: A Surplus Manifesto, which was published by Verso Books in 2022. Beatrice will join us in just a moment. Stay with us.
We are joined now by Beatrice Adler-Bolton. Beatrice, thank you so much for joining us again on Citations Needed.
Beatrice Adler-Bolton: Thank you. It’s so nice to be back. Always a pleasure to be here.
Adam: Thank you so much. So, I want to begin by focusing on the framework we’ve been discussing at the top of the show, which is the idea of increasing access. Once you see it, you kind of can’t unsee it, especially again, as we’ve kind of listed, the examples, the majority of them are in healthcare, but specifically the latest trend I want to touch on is this use in mental healthcare. NPR, uncritically cites one Silicon Valley CEO is saying AI will “broaden access to care.” The Washington Post tells us “existing mental healthcare is expensive, inaccessible for many people and often have poor quality” then follows this up by saying chatbot can help alleviate this problem. I want to talk about the rise of the specter of AI, which I distinguish from the rise of AI as such, which is I think, largely a kind of category trick around the space about mental healthcare and healthcare more broadly as a sort of suppose solution to increased access for those who can’t afford to talk to in the case of mental health, actual human beings.
Beatrice Adler-Bolton: Yeah, I mean, AI has been a part of healthcare already for a long time, but much of it has been operating sort of on the provider end and has been less visible to patients for the last few decades and more visible sort of, to workers who are spending 11 hours a day slogging through electronic medical record systems. But the recent focus on, in particular, generative AI as a solution to healthcare inaccessibility has been really discussed so much recently in the media through this lens that’s totally smothered in like a techno capitalist utopianism. But it’s also much more, I mean, I hate this word and framing, but it’s much more “consumer-focused” than ever before in the worst way. In the last few years, we’ve seen somewhere between 10,000 and 20,000 new mental healthcare apps that have been launched. It’s truly staggering.
Adam: I’m sorry, what was that number again?
Beatrice Adler-Bolton: Somewhere between 10,000 and 20,000 apps. Yeah.
Beatrice Adler-Bolton: The number actually is also hard to track because the apps are constantly being developed and then disappearing from the App Store sometimes overnight. And part of it is because a lot of the growth is in products done by teams who are not really necessarily building these things for long-term support, a lot of them are sort of small, but we tend to think of the upper-tier kind of luxury mental health apps like Calm or Happify that really are sort of advertised everywhere. And there was a huge explosion of these advertisements and the utilization of these apps during the pandemic. You know, I think, particularly framed in the sense of like, well, this is increasing access. This is providing therapy to folks who can’t access therapy in person.
But again, this is something that has been there for a long time. One of the first CBT computer programs was this mass-market, robotic therapist that was supposed to walk patients through these scripted procedures of cognitive behavioral therapy, which was all the rage in the late 80s and 90s. And even going back further for example, there’s ELIZA, which is a very famous and well-known computer program created from 1964 to 1966 at MIT that was supposed to emulate a psychotherapist. So this is sort of way beyond things like mental healthcare apps that send you a curated list of resources when you confess to suicidality, for example, or apps that are replacing employee mental healthcare benefits and people’s insurance plans. We hear about that one a lot from Death Panel listeners, you know, those are also a huge part of it. In many ways, the mental healthcare apps are a kind of canary in the coal mine of what was coming in terms of the explosion of not just predictive AI in healthcare but of generative AI in healthcare. And so I think these AI therapy chatbot apps really deserve a lot of attention and scrutiny, the kind that they rarely, frankly, if ever get from journalists who are really all too happy to just regurgitate press releases from these companies about the alleged success of their products.
But chatbots in general have been exploding in the healthcare context. And CBT apps that are supposed to sort of bully you into weight loss are very common or less anxiety or whatever. And these products basically most if not all of which are pretty sinister, late capitalist market solutions to our terrible for-profit genre of care. These chatbots range from programs to educate people or as I said, sort of give them nudge reminders towards health or wellness goals. There are AI coaching apps, AI apps that are supposed to be helpful for patient advocacy, to organize your medical records, chatbots that try and use natural language processing and generation to interview people about their symptoms over text messages that then extract data to then suggest a diagnosis and connect them with a specialist. I mean, it is really just such a mess.
But what is so key to consider is the way that these things are framed. As you mentioned, in the case of mental health AI, in particular, these products are described in a really important way. You know, we know that mental healthcare is financially inaccessible, right, like, this is very common knowledge. There are a few reasons for that. One is that people can’t afford care, half of Americans are going to need mental healthcare at some point in their lifetime. And many of them are not going to be able to access it for a variety of reasons that are all pretty much directly resulting from our system of health capitalism. I mean, this is really you know, what we talk about all the time on Death Panel. But some of what is going on here is the result of there not being enough people to provide care. Many rural areas have few if any mental healthcare providers. For example, there was a 2018 study that showed that about half of US counties did not have a practicing psychiatrist.
Beatrice Adler-Bolton: Data from the Health Resources and Services Administration that was released in March of 2023 showed that over 160 million Americans live in areas with mental health provider shortages and that it would take about 8,000 to 10,000 more providers immediately injected into the system to meet that gap. But again, things would still be spatially inaccessible because those providers tend to also concentrate in areas where people can afford to pay out of pocket for some or all of their mental healthcare. People with Medicare and Medicaid, people who can’t pay out of pocket for mental healthcare, they’re restricted by a really narrow network of providers who are even willing to take insurance, let alone Medicaid, because the reimbursement is so low. There’s a lack of providers who people feel comfortable with. Care is long term and providing this care is a really intimate experience. And a lot of these therapists are white, and not all of the United States is white. And so one other thing that’s really difficult is these companies often build themselves as, like, fulfilling some sort of health equity access goal by connecting vulnerable populations to specific therapists. And that’s really where the language of access comes in, you know, yes, this is technically a way to access care. But the ability to access affordable care is not the same as getting the care that you need, or often, in the case of these AI apps, getting any care at all. Access to care is not care.
Adam: There’s a false austerity here, again, every one of these articles says, you know, there’s a shortage of therapists or shortage of nurses or a shortage of this. And you hear this all the time, right? Shortage of truck drivers, shortage of teachers, there’s always this assumed shortage. And it’s like, you know, obviously, these are essential social functions and an irrational economy, you would be spending billions of dollars again, maybe I don’t know, God forbid, we cut out one of the stealth planes or cruise missiles and we invest in some rural mental health, we invest in more Black and Latino people in mental health, you know, focusing on those communities, we pay them well. There’s a sense of oh, that’s just the way it is. There’s just a shortage.
And as we’ve talked about on the show to death, like shortages, yeah, okay, sometimes there are non-austerity reasons why that is like World War One, and a bunch of people go away, maybe there’s some farmer shortages. Okay, fine. But generally speaking, the shortages are artificial or they’re not about rationally allocating a country’s resources. They’re about maximizing profit, which is not the same thing as a rationally planned economy. And so the false austerity then if you just sort of accept it, and you move on to the “solution,” then things like giving poor people chatbots makes sense in that kind of dreary neoliberal framework.
And what we said at the top of the show and what we say all the time is that like, nobody with any amount of money ever, in a million years is ever, ever, ever going to use a chatbot for therapy. None of the CEOs of the chatbot therapy apps are going to use them. And it’s like you said, sometimes some technology can be beneficial. Technology’s not inherently sinister, like pinging you to remind you to go to your doctor or whatever, helping you organize your prescription drugs. Even if we lived in a communist country, socialist country, whatever, you’d still need those things. But there’s this idea that somehow these things are laws of nature handed down by God, and of course, they’re not.
Beatrice Adler-Bolton: Yeah, and I mean, these AI therapy chatbots, you know, it’s really important to mention that their business model depends on things not changing. They are often the first to lay out these claims about the inaccessibility of the healthcare system. But they also as you’re saying, Adam, they’re always going to go in hard naturalizing that inaccessibility as the way it has to be because these chatbot apps, they really depend on medical care. remaining inaccessible. That is literally their business model. They treat the lack of a real comprehensive system of care as an opportunity for them to make a market.
And when they talk about it, you know, they say things like, they are, “delivering a scalable solution that can help solve for gaps in care” or like, “well past the point where the only solution in sight is a one to one in-person visit with a human.” “We need to find innovative ways to meet the vast unmet needs safely and effectively.” These apps aren’t even framed as therapy replacements but as using techniques of therapy to create an “effective gateway to mental health support” or to provide “a reinforcement to human-delivered treatment,” or as an approachable and accessible option for care. I mean, heinous.
Adam: Well, they always say that there’s like, oh, like, we can’t replace it. Because again, empirically, they can’t, right? Like I mean, people have studied these things. Skeptical, obviously, there’s some institutional pushback from professional therapists and their trade organizations. There’s people who’ve looked at this and say, well, this obviously doesn’t really do anything. And the second the listener knows it’s a chatbot or they’ll say chatbot assistant, I know some people try to use this weasel thing where they basically have like, a quasi-therapist in some lab somewhere in a low-income country. And they’ll have AI prompts, but they’ll like technically push send, and so it’s not, you know what I mean? They’ve tried that one, too. They sort of use these weaselly kind of workarounds.
Nima: Or they just claim that it’s supposed to be supplemental to something else that you’re getting, assuming that you’re trying to get something else.
Adam: Supplemental means a low-wage worker in Kenya or India presses, like, enter. And then they say, oh, it’s human-assisted AI, or you know what I mean, I’ve noticed many of these kind of weasally workarounds because it’s all about just cutting labor costs.
Beatrice Adler-Bolton: Yeah, and I mean, they talk about their products as if these apps can single-handedly rebuild and reconnect with the disparate parts of our nonexistent healthcare system. It paints a future where bots can really replace doctors and nurses and they peddle these talking points, like religious leaders, you know, why do anything differently when there can just be an app for that is really kind of the dogma here.
Nima: I kind of want to talk about the whole “there’s an app for that ‘’ mentality and how it really reinforces this access above all rather than quality, rather than universality. Rather than things that don’t rely on these weasel words like access or even affordability, right? Accessibility and affordability often go hand in hand. And so, Beatrice, I’d love to hear about how I know we’ve been talking about this, like chatbot therapy as a way to, you know, codify a two-tiered healthcare system through AI. What else have you seen? I mean, you cover this so well, and you explain it so well. Where else have you seen this reliance on tech as giving access, making things either free or affordable or ad-driven? That you know, yes, you have to maybe wait for your data to come back while watching an ad for Tiktok. Where else have you seen this reliance on tech as being a savior to access or affordability really showing itself to just you know, further entrench this idea of a class divide. Some people are going to have all the access and afford all the things the way they should, the way it’s most helpful. But for everyone else, well, you know, at least you can get this kind of stuff like, where else do you see that in our healthcare system?
Beatrice Adler-Bolton: Oh, my gosh, it’s all over. It’s all over the healthcare system. And let me tell you that it is fucking worrying and stressful. For example, I don’t like telling personal stories on podcasts, but this is a really good one that I had to share. I recently requested my medical records from one of the hospitals that I receive care at. What I was sent was a nearly 7,000-page PDF. No doctor is ever gonna read that, right? So what came with it was this AI-generated summary, which to be fair, had a warning on it that it said, you know, this may be inaccurate. But what that summary said was that my 10 plus years of blindness by degenerative neurological autoimmune disease, that all of these very sort of documented symptoms that are all over my chart, that those were secondary conditions to a diagnosis of depression, which was something that was added by one doctor who didn’t know me and saw me one time in an ER visit in 2011. So that was added into my chart and has stayed in my chart. And the AI dreamed that depression was the cause of a disease that has disabled and blinded me for over a decade, you know, proof of which is well documented in my chart.
But that bias that we have, you know, structurally within society and within medical education and just culture in general against chronically ill people like me that chronically ill people are just a bunch of malingerers who are playing too sick to work, who are achieving some sort of secondary gain from exaggerating our illnesses, all that stigmatizing stuff that chronically ill people like me have to deal with daily bled into that summary. It was part of how the algorithm clearly was taught to understand a medical chart like mine. And it’s honestly terrifying to see how one diagnostic code that’s sort of put in your chart from one doctor someplace, how that can really shape what the final result is.
And again, we all understand how little time doctors actually spend with your chart. So what is the doctor gonna do look past the summary, right? Like, even though it says this may be inaccurate, still, when held up next to a 7,000-page medical chart, the amount of junk data that electronic medical records generate is itself one of the biggest problems that AI and healthcare is seeking to solve. And, of course, the really, really frustrating thing is that some of the same companies who make these softwares that rule the lives of everyone who needs medical care, things like Epic, the MyChart system that Epic owns and runs, this is, like, massive, and this year, a huge part of the narrative around generative AI and, like, ChatGPT has been really characterized by a lot of these, you know, sort of ideas about exactly what happened with my chart, right? How can we take all of this data that the move to electronic health records has generated that can be so difficult to sort through and take literally hours and hours and hours to properly go through? How do we take that and translate it into something that can be “efficient,” and what they’re really talking about is the fact that providers — medical providers — they don’t get to spend very much time actually looking at the charts of their patients. And so if we can sort of provide these quick summaries, they can help facilitate maybe three, four more appointments in a day and then increase the revenue by a day for that particular specialist or whatever, it’s kind of a trickle-down model of cost-effective efficiency porn, kind of. The implication is always that AI is more accurate, more safe, faster, and cheaper than real human medical professionals. And it’s difficult because it’s not benign.
You know, during the early days of COVID, Epic, which is a private company so its algorithms are shielded from scrutiny by their corporate firewall, you know, that you can’t actually ask them for the data for how they sort of construct the algorithms that they use. And they’re really wacky private company that is known for, for example, spending ridiculous amounts of money on their schlocky tacky roadside attraction-style themed offices that have, like, a Harry Potter conference room and slides, you know, this is the leading electronic medical record software. They rolled out this triage algorithm much more broadly that had barely been tested during the early days of COVID. It was called the Deterioration Index. And it was used to predict which COVID patients might become critically ill, requiring ICU admission. So it’s essentially a triage software. And it spits out a score on the patient’s My Chart screen every 15 minutes, which is calculated by comparing things like vitals, breathing rate, blood potassium level, you know, and measuring it up against big datasets of you know, what is the average person of this age and this weight and this height’s vitals supposed to be? So, you know, ultimately, this was rolled out at hundreds of different hospitals in the United States. And it was prominently displayed as a main feature of a medical chart of almost every single patient admitted to those hospitals as an inpatient.
And since vitals can change moment to moment, doctors and nurses that listen to Death Panel have told me that these scores are often functionally useless — they will hop around all over the place in the course of an hour. And, again, Epic is a private company. They don’t let people look at the data that was used to train this. Epic is the largest electronic health record company in the United States. They have private health information, and the health records for 250 million people. They also have over 20 proprietary algorithms that are designed to predict things like how long a patient might be in the hospital, which patients are going to become seriously ill. And they have another one that’s in extremely wide use that’s used to predict sepsis is only right, about 60% of the time, but this is one of the leading causes of death in hospitals. And they’ve got this brand new product. Ugh, this one’s terrible. It’s a Chat GPT four-powered product that Epic and Microsoft co-launched called the Slicer Dicer. Have you all heard of this?
Beatrice Adler-Bolton: Okay. So the Slicer Dicer basically facilitates the processing of really large amounts of patient data to help basically save money for hospital executives. But of course, it’s also talked about as basically potentially curing cancer through big data, and this is really just sort of the tip of the iceberg. You know, there was reporting from The Verge in 2021 that Epic pays bonuses back to healthcare facilities that use its algorithms through this internal financial incentive program. You know, these algorithms often don’t work like they’re advertised. And it just goes on and on. We don’t know, for example, if the Deterioration Index is adjusted based on a patient’s race, which is a practice that is widely used, horrible, and which has no justification. You know, we don’t know if the algo popping out triage decisions in hundreds of hospitals during COVID incorporated race-adjusted scores. And the rushed uptake of a flawed blackbox tool, like the Deterioration Index is often talked about as if the rush itself is the problem, or just the AI itself, being unable to be screened by researchers for bias. And it’s not just the AI that’s the problem. It’s also, the kind of true danger here is the problem that the AI is supposed to solve, which is the fact that people really can’t get the care that they need. And we need to change everything about how we do medical care, starting with severing capital from health, but these AI solutions and the information and media economy which sprang up around these products are a major dynamic in the ongoing manufacturing of consent that healthcare innovations will always be limited by imposed, unnecessary, and as you guys have both said, you know, absolutely artificial scarcity. It’s not a system of healthcare at all — it’s a system of extractive abandonment. And the chaos of the pandemic and the strain that the sociological production of a kind of premature end to the pandemic has put on the system has also helped to accelerate the widespread deployment of these untested, sketchy, clinical prediction tools that are now again talked about with like, quasi religious-like fervor.
Adam: Well, it’s important to solve the problem that you helped create. So one of the reasons we argue that the “increasing access” is particularly sinister, and we think, effective framing is because it takes the codification of an apartheid health system for the rich and poor. Again, no one making X amount of money is ever going to use anything that’s automated, ever, right? And it makes it seem like charity that, like I just said, the sort of problem becomes the solution. The poor are being served by a market rather than being exploited by using shoddy subprime products, that perhaps maybe the idea that there’s something inherently important about equity or quality, simply doesn’t really register in this dynamic. And I want to talk a bit about framing these exploitative systems as charity, which you see a lot obviously in the health insurance industry, which is obviously the most parasitic industry in the history of the world. It has, like, literally no reason to exist, right? Some innovations from big pharma, right, are biomedical tech, like, okay, well, that’s, you know, that’s useful, like, you know, I use a Dexcom. I’m a type one diabetic, I’m like, that’s a pretty good innovation. I’m sure it could have been developed under a different economic system, but it’s like it has some value, right? Health insurance has literally no reason to exist. And yet you watch health insurance commercials, or you listen to health insurance lobbyists, or you listen to politicians defending private health insurance companies, and they act like it’s a charity. And you see this a lot with these for-profit ventures that are used to exploit the poor, provide substandard products. They treat it like they’re all basically going to do missionary work. I want to talk about this idea of conflating privatized healthcare with some help providing healthcare.
Beatrice Adler-Bolton: I mean, this is such a long and fraught part of American health history. You know, it’s always been a battle between, you know, what care is needed, and how that care can be monetized and turned into a market. There is a kind of frustrating consistency to the way that we see, for example, like a healthcare reform proposed. And what is often out on the table, for example, is essentially just a public-private partnership that is going to put public money towards products developed by private companies to manage and provision health resources. And oftentimes what gets lost in the translation is the actual point of what was trying to be solved in the first place. It’s like that promise of, you know, we have a healthcare issue we need to fix or remedy become secondary to how are we going to sort of make this attractive to the private company that’s going to take it over.
So whether you’re talking about looking way back into the history of Medicare and Medicaid and the ways that those were set up. The actual original proposals for Medicaid, for example, were written by Aetna lobbyists. So the fact that Medicaid, which many people understand to be a large public insurance in the United States, Medicaid is actually mostly privatized. States have Medicaid programs, and they contract with individual insurance companies who then get the contracts to manage those plans. And it’s up to them to find a way to sort of make a profit out of the difference.
And I think so often, our discourse around health in the US and also to an extent, this is also very true globally relates so much more to the cost of health, or the cost of care, and then to anything that you might actually think could be the real priority. You know, for instance, we don’t talk about someone’s experience of the healthcare system as being a valuable data point for influencing how we should change it. Like when was the last time you saw a health reform that was really centered in the experiences of a patient or the needs of healthcare workers, for example. And I think it’s really difficult to even have an experience of healthcare in the United States without, for example, being exposed to extreme debt or having to endure a sort of, kind of judgment that your care is unnecessary or unworthy, when it’s absolutely not. And this manifests in so many predictable ways.
You know, the charity industrial-complex is like an invisible web, it’s everywhere, and it’s nowhere. It’s like the safety net that catches the social safety net. And we talk about preserving private insurance companies as if this is really a priority that we have to make sure these companies are taken care of, in a way that has so much care and deference that you never see turned towards health workers or people who need care. And, you know, ultimately, the thing that’s so frustrating is that in a lot of these instances, you know, this manifests in so many predictable ways that you see over and over. Liberals like to stop the conversation at demands for access, like they want access to affordable care, access to universal healthcare, something about universal access to affordable care, maybe, or access to affordable care as a right, whatever. But we have access, you know, the care is available in theory, but not in practice. And access to care does nothing for you if you don’t get the care, especially if that access was granted by a racist algorithm. I mean, in many ways, the promise of access to affordable care is the most honest way that we talk about what the actual goal of US health reform is. It’s not about getting people care. But it is the most accurate way to describe what is on offer in American health policy, which is access and access only. This is what we do. We stand up a big policy, but it’s like there’s always a little fine print there. It’s so classic for health policy, especially in the United States. And it is all over both the liberal and conservative political agendas. I mean, think back to that classic tweet from Kamala Harris, the one that everyone made fun of all those years ago now, where she proposed student loan forgiveness for Pell Grant recipients who start a business that operates for three years in disadvantaged communities. Classic.
Beatrice Adler-Bolton: Democrats are like that when it comes to health reform, right? And when it comes to frameworks of access to affordable care. And Republicans, well, they’re there to say, yeah, but we need to add a work requirement. We need to avoid fraud too. As my Death Panel co-host, Jules Gill-Peterson always says, these are complimentary antagonisms. And the common goal is to maintain these markets of extraction, not get people the care that they need. That’s why they can’t say healthcare as a human right. They’d be lying if they did. And that’s where the access language becomes so useful. The care is there, it’s just up to each and every individual to pull themselves up by their bootstraps and access it.
Nima: Yeah, it’s like harrowingly accurate, actually. Considering Citations Needed is a media criticism podcast, I do want to talk about journalists’ responsibility here and the kind of media’s role in this. You know, as we talked about earlier on the show, reporters really are not that well-equipped or potentially are just constitutionally unwilling to challenge the basic premise of austerity as we’ve been talking about. The one that really props up this “increasing access” linguistic framework. So it’s simply taken for granted that some people, some communities can only get either horrible, substandard care or nothing at all, right? There’s no, like, third option. You know, it’s a similar logic to, like, the one presented by high-profile defenders of, like, low labor standards, like one of our favorite people to talk about on the podcast, Nick Kristof who once said, you know, “Two cheers for sweatshops.” It’s either, like, you sew soccer balls in a factory under 140 degree heat or you’re a victim of sexual trafficking. It’s one or the other. And like, you know what one is going to be deemed worse than the other and so, the slightly less terrible one seems to be like, well, you know, that’s maybe not so bad. That’s at least something, right? It’s at least access to a better way. Can we talk about how much this ideological work is being done by the mere assertion of this austerity mindset? And how that’s repeated ad nauseam in our press? Why is this the case? How is this so entrenched, and also, because you do so much amazing work on this and discuss it on your podcast so thoroughly, what are some ways, Beatrice, that you think journalists can attempt to, you know, complicate this premise, right? To maybe challenge the basic framework that they use so often.
Beatrice Adler-Bolton: I mean, it’s hard to answer this one with brevity. But to put it most simply, I think it’s important to remember here that power is always going to seek to stabilize and reproduce itself. And that the commodification of health is also a major part of how power keeps itself safe. The book that I co-authored with my co-host, Artie, already called Health Communism is really looking at sort of how the problems with what we call healthcare and within the very idea of what health itself is come down to issues of political economy. As we talk about in the book, you know, ending the commodification of care would destabilize the key dynamics that maintain capitalist hegemony. So if we want to change healthcare, if we want to improve access actually, because for example, you know, folks in rural areas, they don’t have access to care. Care is concentrated and metered out in ways that are uneven, and that harms folks, and that is not true access, right? But if we wanted to really fix healthcare, to make it truly accessible, we can’t just tweak around the edges, you know?
And journalists play a huge role in normalizing the idea that the political horizon is quite narrow here, and who the experts are is often very clearly pointing to people with expertise, people who work for maybe a big healthcare AI tech company who are pitching how their AI is going to cure cancer and save hospitals, you know, $100,000 a year or something. And ultimately, it’s sort of who are we giving attention to? Who was considered to have expertise here? And the last people that are often asked about, you know, how they feel about these things, and whether or not they’re helpful and whether or not they met anyone’s needs are the people with the actual embodied expertise of what it’s like to live through accessing your healthcare in the American capitalist healthcare system. The idea that the best option to fix what we have is some grifter, AI gimmick product that analyzes patient data and maybe breaks up union organizing by health workers. You know, I’m joking but not really. I mean, these are the priorities and values that are embedded in the political economy of healthcare AI. And this is all over the way that the media talks about it completely uncritically.
I pulled some examples of terrible headlines. This one comes from a sponsored post from MIT Technology Review that came out in late July 2023. “AI Builds Momentum for Smarter Healthcare.” And this one uses the argument that AI is the answer to the kind of mythology that’s constantly rolled out by the pharmaceutical industry that pharma’s high prices are justified by the ridiculous financial risks that they’re exposing themselves to. Then you have you know, a Forbes piece that was published August 1, “AI And Automation: The Vital Signs Of A Modern Hospital.” Another Forbes, “How Generative AI — A Technology Catalyst — Is Revolutionizing Healthcare.”
This is not the revolution in healthcare; this is a further entrenchment of systems of extraction and commodification. But the amount of times that you see people discuss these products, discuss these innovations, and then completely uncritically reproduce ideas, that the way that the austerity, abandonment, and extraction of the healthcare system is is absolutely the way it’s supposed to be as if it’s a law of nature as firm, solid, and agreed upon as the ubiquity of gravity or something. But the bottom line is, is that these are not simple problems to fix. None of the issues in any of our healthcare systems are unique to one system, to one category, to electronic record software, to a batch of bad doctors, or to you know, a rampantly racist AI. And folks reporting on this have to consider that in their coverage and analysis, you know, none of the issues in our healthcare system are unique to one country either. These aren’t uniquely American problems. For example, the NHS has been testing mental health apps to see if it could help alleviate demand for specialist mental healthcare because there is a years long waiting list in the NHS.
Nima: In the UK, yeah.
Beatrice Adler-Bolton: In the United Kingdom. And so you know, the logics of the American healthcare system that are often tested out in the US, they’re exported globally. And we’re seeing these trends towards increased privatization of national health systems as an answer to the strain that is caused by decades of austerity itself. So the answer to austerity becomes more austerity. And we have to ensure that people have access to the care that they need, but it’s also really crucial to actually scrutinize the fine print and details carefully. If you look at, for example, these AI chatbot mental healthcare apps, they claim that they’re very successful. One of them recently was FDA-approved as a breakthrough medical device, which means that it had to meet the designation of somehow having statistically significant endpoint improvements over existing therapies, meaning that this app was able to show a study to the FDA and say, our app is better than in-person therapy, and they got FDA-approved. And that study, I mean, you won’t be surprised that study was, you know, less than 200 people, it followed people for two months, there was no follow-up. The kind of trusting these companies at their word, trusting their intent, all of that is built up into the reinforcement of power and also the reinforcement of the idea that the primary issue that’s going on when you seek or access healthcare is who is going to pay for it? And that is not what should be at the center of any of our concerns when it comes to provisioning care and ensuring equitable access to care.
Nima: Well, I think that is an amazing place to leave it. Thank you so much for joining us. We’ve been speaking of course with Beatrice Adler-Bolton, a writer, artist and co host of the great Death Panel podcast, which covers the political economy of health. She is also the co-author with her podcast co-host Artie Vierkant of the book Health Communism: A Surplus Manifesto, which was published by Verso Books just last year. Beatrice, cannot thank you enough for joining us again on Citations Needed, especially for this season seven opener.
Beatrice Adler-Bolton: Well, thank you for giving me a chance to rant about my favorite thing, which is access pathology and why it is the worst thing in healthcare politics possible.
Nima: That’s right. Don’t take our word for it. Listen to the Death Panel podcasts. Beatrice, thanks so much again for joining us.
Beatrice Adler-Bolton: Thank you, guys.
Adam: Yeah, I think that so many of these problems are foundational problems to resource allocation. In the US, every study shows spends twice more than comparably wealthy countries on healthcare with absolutely worst outcomes. It’s a deeply inefficient system. And these are fundamentally allocation of resource questions. But everything is just presented as a natural organic mode of austerity that needs to exist. And anyone who questions that austerity premise in the dichotomy that’s presented to them by the general kind of swimming in the ocean of ideology but also, these PR reps for these apps and these other kinds of newfangled solutions to increase access, they’re seen as suspect, and I think that they really has to change because again, if I’m working on my fifth article about how there’s a shortage of nurses, or a shortage of mental healthcare, or a shortage of resources in rural areas, then this is a this is not a story about technology. This is a political story. This is a story about political choices.
Again, I know it’s a lot to ask of someone to venture too far out of that but shouldn’t there be a quote by progressive policies to do this. Well, one way we can solve the lack of mental healthcare in rural areas is to provide better incentives and training and increase their salary by $20,000. And make sure we have people from rural communities that are getting free education to go study to be there. I mean, there’s all these other solutions we can do. But it’s just oh no, you’re going to talk to a fucking Chat GPT guy who’s going to spat out a bunch of cliches. And it’s so bleak. It’s such a myopic way of viewing the world. It’s such a sad way of viewing the world. It’s a sad way of viewing humanity.
Nima: Well, because it relies on these kind of market assumptions or the assumption that there are market solutions and you need access to the market rather than what the market is selling. Like you need access to the market, which also relies I think, Adam, on notions of individual responsibility, which are embedded in this idea of access. So you may have access, but then it’s on you to make sure that you have the money to pay for the thing that you have access to. Or if you have access and just need to sign up for something, you need to make sure that you fill out all the forms that you can get online, that you have broadband in certain areas to allow you to then access the thing. And if you don’t, that’s on you because the access is there. But if you can’t then do all the work to get the thing, even if you have access to it, then it becomes your problem. So like you have access to certain ACA healthcare plans, but if you don’t make enough at your three jobs to cover that, well, then that’s on you. Because the access is there, the market, or the government has done its job, right, the lowest possible bar of presenting the thing, like in a store window that you can see. And all you got to do is go in the store and have enough money to get the thing. But if you don’t do that, that is your problem because the access is there. So that’s another thing that this access framework does. It’s not just about this austerity mindset. It’s also about then putting the ultimate acquisition of the thing on you as a consumer, as a citizen, as a member of a community that has been disinvested in or can’t actually afford those things. But hey, you have access. So it’s not the system’s fault, then it’s a personal failing.
Adam: Yeah, and the solution is to just create 10,000 more apps to do the thing that again, the state could do if they really wanted to do and they have the resources to do.
Nima: Right, if that were actually the goal.
Adam: Which it’s not.
Nima: Which it’s not. And so on that light note, [laughs] we will end this season seven premiere of Citations Needed. Thank you all for joining us once again. We are keeping all the optimism and positive vibes that we always have. It’s gonna continue through season seven. Don’t worry, folks. The show that you know and love is here to stay. [Laughs] So welcome back. We had a lovely break, but we are all the more excited to now be back. Stay tuned for more full-length episodes of Citations Needed. Of course, more news briefs coming your way. In the meantime, you can follow the show on Twitter @citationspod, Facebook Citations Needed and please do become a supporter of the show. It really will help the show continue. You can do that through Patreon.com/citationsneededpodcast. All your support through Patreon is so incredibly appreciated. Again, we are 100% listener-funded. And as always, a very special shout-out goes to our critic-level supporters on Patreon.
Our senior producer is Florence Barrau-Adams, Producer is Julianne Tveten, Production Assistant is Trendel Lightburn. Newsletter by Marco Cardano. Transcriptions are by Mahnoor Imran.
This Citations Needed episode was released on Wednesday, September 13, 2023.
Transcription by Mahnoor Imran.