Deaths of Despair and the Future of Capitalism

Deaths of Despair and the Future of Capitalism

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  • Update Date:2025-09-07
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  • Author:Anne Case
  • ISBN:0691217076
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Summary

A New York Times Bestseller
A Wall Street Journal Bestseller
A New York Times Notable Book of 2020
A New York Times Book Review Editors' Choice
Shortlisted for the Financial Times and McKinsey Business Book of the Year
A New Statesman Book to Read




From economist Anne Case and Nobel Prize winner Angus Deaton, a groundbreaking account of how the flaws in capitalism are fatal for America's working class

Deaths of despair from suicide, drug overdose, and alcoholism are rising dramatically in the United States, claiming hundreds of thousands of American lives。 Anne Case and Angus Deaton explain the overwhelming surge in these deaths and shed light on the social and economic forces that are making life harder for the working class。 As the college educated become healthier and wealthier, adults without a degree are literally dying from pain and despair。 Case and Deaton tie the crisis to the weakening position of labor, the growing power of corporations, and a rapacious health-care sector that redistributes working-class wages into the pockets of the wealthy。 This critically important book paints a troubling portrait of the American dream in decline, and provides solutions that can rein in capitalism's excesses and make it work for everyone。

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Reviews

Carolyn Bruckmann

To the brave souls who managed to make it through the audio book version — I salute you & your ability to digest charts verbally To everyone else — read!

felix

Weirdly conservative, pro-capitalism whilst underlining how capitalism is destroying humanity, a bit reductive and overly dry。 A confusing conglomeration of a book。 Not sure how to feel。

Chet Taranowski

A good review of this topic backed by some solid numbers。 The book points out that non-degreed working class whites are in big trouble (suicide, drug overdoses and alcoholism) and it looks like it is getting worse。 Perhaps we should seriously start thinking about how we can help this group。

Laura Trombley

Excellent treatise This book, along with “The Hardhat Riots” help explain what is happening in America today。 I would go a step farther to blame the MAGA movement and the Capitol riot on this underlying sense of loss that the uneducated formerly middle class segment of our society has experienced。 This book goes on to proffer some solutions。

John Davie

This is an awful book。 I feel defrauded。 This book provides no meaningful analysis of the tragedy of capitalism's victims。 It instead reads as a neoliberal defence of capitalism in spite of the human toll the book is supposed to be looking at。This book is also tinged by racism, classism and sexism which makes it painful to read, take this passage on women and marriage:"For the women, one might wonder why they make the choices they do; it is no secret men are no longer bound by the old rules, and This is an awful book。 I feel defrauded。 This book provides no meaningful analysis of the tragedy of capitalism's victims。 It instead reads as a neoliberal defence of capitalism in spite of the human toll the book is supposed to be looking at。This book is also tinged by racism, classism and sexism which makes it painful to read, take this passage on women and marriage:"For the women, one might wonder why they make the choices they do; it is no secret men are no longer bound by the old rules, and that, if a woman has a child she is likely to face a cycle of economic hardship, emotional instability, and lack of support from which some will find it hard to escape。 Yet they may have limited choices。 When so many women are prepared to engage in sexual relationships outside marriage, it undercuts the bargaining power of those who would prefer to wait。"Don't waste your time reading this, don't borrow it from the library and DEFINITELY don't buy it and support these horrible authors。 。。。more

Parker

It's a hard book to read (it's called Deaths of Despair and the Future of Capitalism, it was never going to be rosy), but it's very compelling。 That being said I took economics in university, so I understand that this is something that is sort of up my alley as it is。 I find economists think about the world in such a unique way, and examining problems from that perspective is so interesting。For those that don't want to trudge through a dreary book, the bottom line is essentially this:"The increa It's a hard book to read (it's called Deaths of Despair and the Future of Capitalism, it was never going to be rosy), but it's very compelling。 That being said I took economics in university, so I understand that this is something that is sort of up my alley as it is。 I find economists think about the world in such a unique way, and examining problems from that perspective is so interesting。For those that don't want to trudge through a dreary book, the bottom line is essentially this:"The increase in deaths of despair was almost all among those without a bachelor’s degree。"。。。 "The widening gap between those with and without a bachelor’s degree is not only in death but also in quality of life; those without a degree are seeing increases in their levels of pain, ill health, and serious mental distress, and declines in their ability to work and to socialize。 The gap is also widening in earnings, in family stability, and in community。 A four-year degree has become the key marker of social status, as if there were a requirement for nongraduates to wear a circular scarlet badge bearing the letters BA crossed through by a diagonal red line。" 。。。more

Alex

A little dry at times and heavy on data but a very good primer on how letting the markets run healthcare has been an utter failure。 The solutions put forth do not go far enough but the one I can get behind is ending the bachelors degrees be-all and end-all for post high school。 Trade schools and apprenticeships need to be view as equally valid options。

Jessica V。

Many, if not most, of the issues explored here were not new to me, but I gained more insight on the state of employer-based health care in the United States and how it is wrecking havoc on everyone and everything。 It was a difficult read but a necessary one。

Peter

Case and Deaton emphasize their faith in capitalism, and they're moderates in various ways -- skeptical of medicaid for all, not in favor of high marginal tax rates on the richest, etc。 And yet they still back a $15/hr minimum wage (all evidence suggesting it would not cost jobs, since employers know they're paying people less than what they're worth, and there are counter-examples)。 They still emphasize that a free market is inappropriate for health care (and that what we have is no free market Case and Deaton emphasize their faith in capitalism, and they're moderates in various ways -- skeptical of medicaid for all, not in favor of high marginal tax rates on the richest, etc。 And yet they still back a $15/hr minimum wage (all evidence suggesting it would not cost jobs, since employers know they're paying people less than what they're worth, and there are counter-examples)。 They still emphasize that a free market is inappropriate for health care (and that what we have is no free market, it's a vehicle for upward wealth transfer), and advocate for universal health care in some form and a reduction of the power of insurance companies and hospital executives。 And they see our democracy as failing, specifically failing to represent working people, a feature exacerbated by the decline of unions。The opioid epidemic they see just as the most egregious manifestation of the healthcare industry's "rent-seeking" reverse-Robin Hood wealth transfer。 And as being made possible by the fertile ground caused by the destruction of the working class。 They point out that the epidemic of "deaths of despair" is, so far, uniquely American, brought about in large party by the relative absence of a social safety net to cushion large changes in the economy。 Other countries, like the UK, could follow (though e。g。 the NHS makes it unlikely to be so severe)。 And so could other classes: the book is all about the massive division in wealth, health, and wellbeing between those with color degrees and those without。 But those with college degrees could be the next to suffer the consequences of globalization and automation without any policies designed to help those who miss out on its benefits。 Case and Deaton express their optimism that politics can change -- with the example that 70% of voters think that the minimum wage should be raised。 We'll see if there's any justification for that optimism。 。。。more

Gibson

This is an equivocal book, the two academic authors treading a careful academic path through uncertainty and ambiguity。 This is refreshing in a way, lacking the dogmatism of some, yet hard work because of that。There is some repetition, usually to ensure that an important point is clear within a complex set of circumstances。 This is probably inevitable in a volume which strives for precision in an emotionally charged field characterised by strongly partisan opinions。Deaton’s Great Escape is excit This is an equivocal book, the two academic authors treading a careful academic path through uncertainty and ambiguity。 This is refreshing in a way, lacking the dogmatism of some, yet hard work because of that。There is some repetition, usually to ensure that an important point is clear within a complex set of circumstances。 This is probably inevitable in a volume which strives for precision in an emotionally charged field characterised by strongly partisan opinions。Deaton’s Great Escape is exciting and engaging。 This book is hard work in comparison。 Hence 3 stars for a balanced approach with a bonus for avoiding oversimplification。Perhaps there is more realism here。 If anything is to be done in the USA and if we are to avoid the same mistakes elsewhere, then we need a great deal of hard work to overcome the inertia in the former and the momentum in the latter。The authors make their value judgments explicit where needed and despite the odds, are optimists offering sound options for improvement in the USA and avoidance elsewhere。I have visited the USA only a few times this century and without exception everyone I have met has been helpful, intelligent and interesting。 I have twice needed medical attention for my wife and in each case it was both excellent and extremely expensive。 I can afford all the insurance necessary。 This book is about people less fortunate than me。 People for whom Case and Deaton’s book provides needed advocacy。I recently re-read Shakespeare’s Macbeth。 The chilling words of the two murderers co-opted by Macbeth remind us all that there is no-one as dangerous as a person with nothing to lose。 Which is why, if normal human empathy is not enough, the people being left behind in the USA and elsewhere have to be given due compensation。 Case and Deaton offer some options。 。。。more

Sharath Reddy

Fact driven review of what has happened to the jon college educated population over the past 40 years。 Explains the success of Trump quite clearly

Natalia Young

Seamless

Tommy

More of a “Warren 2020” than a “Bernie 2020” style critique of our current system, but that doesn’t mean it wasn’t a good read

Adam

Two economists analyze and attempt to explain the surprising increase in mortality rates among non-college educated, middle-aged white males over the last 30 years in the U。S。 A bit dry, but full of important information。 There are multiple factors involved, but the biggest culprit is our dysfunctional, bloated and parasitical health care industry。 What a surprise。

Chris

This is a fairly comprehensive rundown of the conditions which both ends of the political spectrum cite as the basis for an urgent need for radical change。 If you are a dutiful left-leaning news consumer like me and read The New Yorker and listen to PBS andNPR and (mostly) nod along with Bernie when he speaks there won't be much new or surprising here。 The 3-star rating is due to the pedantic and repetitive qualities that the authors couldn't rise above。 I don't, however, dispute that it is very This is a fairly comprehensive rundown of the conditions which both ends of the political spectrum cite as the basis for an urgent need for radical change。 If you are a dutiful left-leaning news consumer like me and read The New Yorker and listen to PBS andNPR and (mostly) nod along with Bernie when he speaks there won't be much new or surprising here。 The 3-star rating is due to the pedantic and repetitive qualities that the authors couldn't rise above。 I don't, however, dispute that it is very informative and would encourage anyone with unformed views on these topics to give it a try。This book is so bleak that they actually include a suicide hotline number in the preface。 There is clearly something afoot which is driving the interest in Socialism among younger Americans (the authors are confirmed and unapologetic Capitalists) and interest in QAnon among others。 Case and Deaton are capable guides through the economic conditions of 21st century America which have driven so many of us to desperate extremes。 They emphasize the opioid epidemic as an example of the evils poorly regulated Capitalism and (mostly repeat now-familiar) excoriations of Pharma, doctors, money-grubbing politicians, and of course the Sachler family。 But the story is much bigger and longer than opioids。 They rightfully compare the 21st century effects of globalization on working class Americans to the alienation and dislocation of urban African-Americans in the 1960s-80's。 The loss of meaningful work exacerbated by the social isolation of falling marriage rates and rising inequality along with other factors form the special alchemy of American dissatisfaction。The authors return again and again to the need for healthcare reform。 I couldn't agree more。 I've long thought that healthcare costs will eventually cause such a drag on the economy that it will force our national hand on the issue。 Case and Deaton state this case nicely。 Market capitalism simply cannot provide acceptable healthcare in a nation like ours。 They explicitly do not favor a single-payer system but advocate for reasonable change。 It's hard to believe that we can't better allocate the 17。7% of GDP that we spend on healthcare if we can ever overcome the very strong forces who oppose change。They touch on, but don't adequately emphasize for my tastes, the rise of the administrative class in the US economy。 We now have armies of administrators at institutions like universities and hospitals which didn't used to even exist。 They have largely wrested control of the budgets of their institutions and become expert at enriching themselves and augmenting their ranks。 In turn, they've eviscerated the working class jobs at their institutions by contracting out every conceivable low-skilled task so as to avoid any long-term pension or healthcare "liabilities。" One of the stats that caught my attention was that healthcare benefit costs can amount to as much as 60% of the cost of hiring a low-wage worker。 To shed these costs, much of the economy has turned to the WalMart model of hiring armies of just-under full time workers or just farming out the jobs to contractors。 Those administrators' bonuses aren't going to pay themselves!So, again, this book has a lot to offer。 Actually, I'd recommend it to a college-age person or an ambitious HS student to give them a pretty solid background to discuss recent American socio-economics。 。。。more

Mary Licking

This paperback version has a Preface to the Paperback, written in September 2020, that the hardcover lacks。 By September 2020, there were 200,000 deaths from COVID-19, which the authors call an underestimate。 Citing the Monthly Labor Review, they say, "In June 2020, the Bureau of Labor Statistics calculated that more than a third of those with a high school degree but no college were "highly exposed" by their occupation, as opposed to a fifth of those with a bachelors degree。" The statement fits This paperback version has a Preface to the Paperback, written in September 2020, that the hardcover lacks。 By September 2020, there were 200,000 deaths from COVID-19, which the authors call an underestimate。 Citing the Monthly Labor Review, they say, "In June 2020, the Bureau of Labor Statistics calculated that more than a third of those with a high school degree but no college were "highly exposed" by their occupation, as opposed to a fifth of those with a bachelors degree。" The statement fits in with a main theme of the book, that since 2000 those with less than a bachelors degree are increasingly disadvantaged in America。 Drugs, suicide and liver poisoning from alcohol are the causes of the deaths of despair comprising the subject of this book。 To reverse the trend, possible solutions are offered。 Thank goodness those with the scholarship to describe the problem so well put time and effort into what they see as a way out of this。 An unanswered question they raise is whether other affluent countries will be following America down this dark path。 I am so grateful someone saw this phenomenon, researched, and reported it。 。。。more

Bonnie

This has been a heart-breaking read。For decades life expectancy in the US was on the rise。 However, this is no longer the case。 It is mainly the white non-Hispanics who contribute to this result。 And within this group it is predominantly the less educated without a bachelor’s degree。 Increasingly, they suffer deaths of despair: suicide, drug overdose and alcohol related deaths。 The authors – two economists, Anne Case and Angus Deaton a Nobel Prize laureate – analyse this phenomenon in quite som This has been a heart-breaking read。For decades life expectancy in the US was on the rise。 However, this is no longer the case。 It is mainly the white non-Hispanics who contribute to this result。 And within this group it is predominantly the less educated without a bachelor’s degree。 Increasingly, they suffer deaths of despair: suicide, drug overdose and alcohol related deaths。 The authors – two economists, Anne Case and Angus Deaton a Nobel Prize laureate – analyse this phenomenon in quite some detail。 At first, they describe what can be learnt from data from various sources。 In the next step they analyse the connection with the economic system。 Then, they turn to the reasons why capitalism is failing so may。 The last few pages are dedicated to the question what can be done。 Page by page in this factually written account I got an idea on how the white middle class crumbled and all but vanished。 The disillusionment with the American Dream tangible: The idea that anyone can become successful based on his or her personal merits – meritocracy – has its downsides。 It means that someone has to pay the prize。 The result is an upward redistribution of wealth in a win-loose game。 The opioid crisis being the best example: some win, many loose。 And there is no quick fix。 Any solution is doomed to failure, because there are still many people who benefit。 And these are the one’s represented in the circles of power。How could it come this far? 。。。more

Josh

Does a really good job laying out the issue they've identified。 I'm not sure I got that much more out of the book length treatment than I did from the initial wave of articles when this phenomenon was initially discovered and published。 The amount of data they have to describe the 'what' of this problem is immense, but their theorization of 'why' does not have the same level of depth。 The causal pathways from 'loss of *good* non-college jobs' to 'deaths of despair' is at once probably true and u Does a really good job laying out the issue they've identified。 I'm not sure I got that much more out of the book length treatment than I did from the initial wave of articles when this phenomenon was initially discovered and published。 The amount of data they have to describe the 'what' of this problem is immense, but their theorization of 'why' does not have the same level of depth。 The causal pathways from 'loss of *good* non-college jobs' to 'deaths of despair' is at once probably true and under constructed in the text itself。 Their list of culprits is also underwhelming, as they largely let rising inequality and shareholder based governance off the hook compared to rising, and privately provided healthcare costs。 I think they're trying to let late-stage capitalism off the hook and shift the blame to one rent-seeking industry, when so many other industries are moving to the same model and trying to permanently bifurcate this country based on class。 Their fixes are underwritten in the text, and underwhelming on the whole - fixing healthcare costs without addressing the economy and wages as a whole won't change the loss of prestige and ability to function as a breadwinner without a college degree that they've theorized are causing these deaths。 。。。more

Emma Ratshin

whew i’m parched。。。 that book was DRY!!! but seriously though the authors both had such wonderful voices。。。 when they let them shine through! i also don’t agree with all of the policy suggestions (why is work in particular SO enriching when using ubi to learn/create community also gives the same social value??)。 but it was a worthwhile read。 i’ll probably cite it in my thesis like once。

Ryan Carson

A frightening specter has haunted America over the last 40 years。 The rise in suicides, overdoses, and morbidities from alcoholism and drug use among those without a college degree raises many questions about the function of democracy, corporations, and the future of capitalism in America。I’m often frustrated by discourse around capitalism today。 We can’t excoriate capitalism for every issue we have on capitalism。 Racism, inequality, theft, and abuse all took place long before Adam Smith penned A frightening specter has haunted America over the last 40 years。 The rise in suicides, overdoses, and morbidities from alcoholism and drug use among those without a college degree raises many questions about the function of democracy, corporations, and the future of capitalism in America。I’m often frustrated by discourse around capitalism today。 We can’t excoriate capitalism for every issue we have on capitalism。 Racism, inequality, theft, and abuse all took place long before Adam Smith penned The Wealth of Nations in 1776。 Likewise, we can’t glorify the free market as the antidote to all our ills。 A third way exists, with careful regulation, and elimination of rent seeking, to ensure that capitalism and markets work in everyone’s favor and not just those with enough money to lobby Congress ad nauseam。 This book goes a long way in correcting those problems, and I HIGHLY HIGHLY recommend it。 Like, go buy it right now。 Start reading it。 And then, write a review and reflect on what you need to do to protect yourself and those around you from a darker future。We can’t ignore what’s going on in the rust belt。 At the core of the rise in suicides and abuse site problems that will ultimately affect all of us, sooner or later, and meanwhile many are painfully dying as the byproduct of the greed of the Sackler family, who recklessly pushed OxyContin on doctors and patients in full knowledge of its addictive dangers。 Unfortunately, there isn’t a clear solution to what in reality is a whole cluster of social, moral, political and economic problems causing deaths of despair。 What remains quite obvious is that any economic problem is also political, and we must fight harder to remove money from politics, advocate for the least of us, and strengthen individual power over corporations。The rise in “deaths of despair” among those without a college education over the last 40 years raises many problems we must deal with。 The authors are somewhat scarce on policies to address these problems, but have an excellent overview of the research 。。。more

Alvaro Hidalgo Rodriguez

Yes, things are getting worse for a lot of Americans, and it is finally catching up to us in terms of our life expectancy and overall satisfaction in life。 This book highlights the complex web of reasons why people are becoming so desperate that they are endangering their lives both consciously and inadvertently。 Before this book, I thought poverty itself was probably the biggest contributor to the widespread unhappiness we see around us, but this book argues for other factors being more importa Yes, things are getting worse for a lot of Americans, and it is finally catching up to us in terms of our life expectancy and overall satisfaction in life。 This book highlights the complex web of reasons why people are becoming so desperate that they are endangering their lives both consciously and inadvertently。 Before this book, I thought poverty itself was probably the biggest contributor to the widespread unhappiness we see around us, but this book argues for other factors being more important, such as an erosion in our sense of community and other social institutions。 In the end, it is clear that the problem is very complicated and that if we don’t change our course, things will deteriorate further。 Good addition to the literature on what is wrong with the American way of capitalism。 。。。more

Carl

I'd give them 5 stars for the first 80% of this book where they demonstrate great courage, energy, & analytic dexterity in diagnosing the problems besetting working people in the US。 Then come the final chapters where they recommend the solutions to the problems they've described。 By this juncture, it seems, all of that courage, energy & analytic dexterity have been exhausted & they turn timid & lame。 All in all, a good book diminished by a disappointing conclusion。 I'd give them 5 stars for the first 80% of this book where they demonstrate great courage, energy, & analytic dexterity in diagnosing the problems besetting working people in the US。 Then come the final chapters where they recommend the solutions to the problems they've described。 By this juncture, it seems, all of that courage, energy & analytic dexterity have been exhausted & they turn timid & lame。 All in all, a good book diminished by a disappointing conclusion。 。。。more

Santiago Zapata

This review has been hidden because it contains spoilers。 To view it, click here。 La complejidad de las "deaths of despair" va más allá de la raza, la edad, el ingreso。 Los autores exploran datos históricos e hipótesis que logran respaldar para fortalecer y poner en evidencia que hay un grupo demográfico en Estados Unidos sufriendo de muertes por desesperación。 Los opioides, la falta de regulación en la competencia de mercados, los vicios del sistema de salud, la innovación disruptiva y la psicología de este grupo demográfico, son algunos de los factores en los que profundiza La complejidad de las "deaths of despair" va más allá de la raza, la edad, el ingreso。 Los autores exploran datos históricos e hipótesis que logran respaldar para fortalecer y poner en evidencia que hay un grupo demográfico en Estados Unidos sufriendo de muertes por desesperación。 Los opioides, la falta de regulación en la competencia de mercados, los vicios del sistema de salud, la innovación disruptiva y la psicología de este grupo demográfico, son algunos de los factores en los que profundizan los autores。 Un fenómeno que puede empezar a tomar fuerza en otras naciones 。。。more

Biff

This was a good discussion concerning the considerable social and economic issues facing lower class (mostly white) Americans, which issues have led to alcoholism, drug abuse, and suicide。 The authors (co-authored by Angus Deaton) argue their points using data that one must assume is accurate。 A damning finger is pointed towards those who push more and more wealth into the top 1% of the population。 The primary culprit is the federal elected government which has been overly influenced by lobbyist This was a good discussion concerning the considerable social and economic issues facing lower class (mostly white) Americans, which issues have led to alcoholism, drug abuse, and suicide。 The authors (co-authored by Angus Deaton) argue their points using data that one must assume is accurate。 A damning finger is pointed towards those who push more and more wealth into the top 1% of the population。 The primary culprit is the federal elected government which has been overly influenced by lobbyists for large special interest groups, especially healthcare and tech organizations。 The authors put forward some solutions which sound possible but pale in the light of reality, unless there is a substantial groundswell of support from the vast majority of Americans。 。。。more

Olivia Rowland

Utterly baffled as to how people can study capitalism in this way and still support it。 The authors’ single mention of racism represents a huge oversight of how structural economic racism created this whole situation。

Lisa Kranz

Great book - I listened to the audio version。 This book is well researched and explained。 I found myself “rewinding” many times because every fact presented was so staggeringly interesting - I felt I should be taking notes the whole way through the audio book。 This book - about the socio-economic divide in America and the crisis of the people at the lower end is enlightening and depressing at the same time。

David Neely

The authors described with great detail the despair of poor undereducated white people in the USA。I was quite disappointed in their final chapter, What to Do? They named issues that needed to be addressed: opioids, healthcare, corporate governance, tax and benefit polices, etc, but the only concrete answer they gave was in wage policies: raising the minimum wage to $15 an hour。

Toby

It’s no small shame the authors fail to recognize the class warfare they so aptly and keenly describe,

Dustin

I loved this book because it provided ample data surrounding the challenges that face America's working class。 The two economists who wrote the book did a good job of making their case and cataloging what many have tried to express in feeling alone。 I appreciate that they pointed out where "the market" has been altered and has failed, where rent-seeking and upward redistribution has altered the landscape。 The authors didn't abandon capitalism; they did point out where we need to make changes and I loved this book because it provided ample data surrounding the challenges that face America's working class。 The two economists who wrote the book did a good job of making their case and cataloging what many have tried to express in feeling alone。 I appreciate that they pointed out where "the market" has been altered and has failed, where rent-seeking and upward redistribution has altered the landscape。 The authors didn't abandon capitalism; they did point out where we need to make changes and provide better opportunity。 Their desire is for a more fair America。 It was a good book for our book club, even though the topic is troubling。 。。。more

Jesse Field

Americans had been living longer and healthier lives since at least the 1940s, if not earlier, but the trend has begun to reverse in more recent years, especially for white Americans who don't have college educations。 A large portion of the deaths bringing the numbers down among these Americans, the authors find, are largely explained by patterns of addiction, especially to opioids and alcohol, and suicides -- as a category, 'deaths of despair。'In 2017, more than 158,000 people died from the com Americans had been living longer and healthier lives since at least the 1940s, if not earlier, but the trend has begun to reverse in more recent years, especially for white Americans who don't have college educations。 A large portion of the deaths bringing the numbers down among these Americans, the authors find, are largely explained by patterns of addiction, especially to opioids and alcohol, and suicides -- as a category, 'deaths of despair。'In 2017, more than 158,000 people died from the combined factors drugs, alcohol and suicide。 Following the Durkheim social science model, the authors look to disruptions in the social fabric to explain this。 For example, many Americans are living with pain, according to survey studies, including both depression and just plain physical pain: and these are connected to higher use of drugs and alcohol, and suicide。 The crisis of opioid addiction is a stunning case of iatrogenic deaths, meaning they were caused by doctors。 And that's because they were given bad incentives in a badly incentivized healthcare industry。 “The opioid epidemic did not happen in other countries both because they had not destroyed their working class and because their pharmaceutical companies are better controlled and their governments are less easily influenced by corporations seeking profits," the authors coolly note。 Here we can see that Case and Deaton stress the structural connection between the faults of the healthcare system and the larger erosion of employment and educational gains among the American working class。 It's a stunning and damning set of data with analysis。 Then comes the deeper analysis from their perspective as academic economists studying the poor and working class。 Neither poverty nor inequality per se explain deaths of despair; it's more about the long-term deterioration in opportunities。 Race even seems to play an ironic role here: the rise of a stronger black middle class means that poor whites feel they've lost an advantage, adding to their despair。 So have the decline of social activities and participation in the community -- we are healthier when we go to church, note Case and Deacon。 Not that the curious social dimension of this problem lets the economic system off the hook; rather, the authors have used all this data and analysis to execute such a sharp rebuke to capitalism that they have to plead with us to believe they are not Marxists, but capitalist defenders。 Capitalism fails first and foremost in the healthcare system, they say。 It costs more, yet delivers worse results。 And now the whole system acts as a massive protection racket。 Legislative activity always draws lobbyists to defend the industries and trade groups, the classic example being Obama's decision to let go of the public option, along with other buy-offs to get the Affordable Care Act passed。 This is the central piece of evidence to the authors that capitalism in America requires greater regulation to combat the fact that "large parts of the American economy have been captured to serve the wealthy with the consent and connivance of government。" Hospitals act just as other firms, and regularly conspire to raise prices and lower wages。 The authors call on the term "monopsony" from a previous economist, to describe the situation where one buyer gets to set the wages, as with workers in rural areas。 A major result of this is that workplaces have become more hostile -- often a maintenance worker, for example, works not for the firm, but for a contracting agency who pays less and gives no benefits, nor any sense of company as steward。 Less educated workers live in a much more hostile world than did less educated workers of half a century ago。 Much of this hostility can be seen not only in the United States but also in other rich countries。 Wages and working conditions have deteriorated in several of them; they too have experienced a decline in manufacturing in favor of services, slowing rates of economic growth, and a decline in unionization。 But these other countries do not face the costs of the American healthcare system, and they have much more comprehensive systems of social protection。 None has seen wage stagnation for as long as has the United States。 All of which could explain why we do not see epidemics of deaths of despair across the rich world。 Yet it remains a real concern that, for all less skilled workers, Western capitalism has a clouded future。 What to do about the situation? Declare our values! So say the authors in a final chapter that is also a manifesto。 Big pharma should be more firmly regulated, and we should come to terms with the fact that this industry is no free market, and never could be, really。 As for reforms to the healthcare industry as a whole, it will require a payoff of massive scale: The healthcare lobby is the most powerful in Washington, and it is almost certainly impossible to have reform without paying them off at the time of the reform。 The alternative is to keep paying them off forever, and a well-designed reform, with cost control, will slowly reduce the tribute we have to pay them by controlling the diffusion of ever more expensive treatments that do little。 Again, we emphasize that while the questions involved in designing and financing an alternative scheme are challenging, the problem is not one of finding a large amount of new money to fund a new entitlement program。 The money that is already being spent is more than enough。 The problem is in part one of technical and financial engineering, of finding ways to reallocate money, and in part a political one, of doing the engineering in a way that buys off the opposition of those who are currently benefiting, while recouping this buy-off over time。 The Labour Party minister of health, Nye Bevan, when he opened the British National Health Service in 1946, was asked how he dealt with the doctors’ lobby, which had compared him to a Nazi medical führer。 His response was that he succeeded “by stuffing their mouths with gold。” New laws should also be put on the books reforming corporate governance, tax and benefit policies, giving us a stronger safety net。 People want and need the dignity of work, which is why the authors don't support a universal basic income scheme。 Patent law shouldn't hurt innovation like it does now。 Google and Amazon should pay for using the data they acquire from users。 The education system requires wide-ranging reforms, as well, though they don't know exactly how to deal with that one。 I finished this one last month, but it was marinating in my head a long while after。 There is much to follow up on here, and I hesitate to criticize or nitpick when the argument is so wide-ranging, yet hard-hitting。 In any case, if the biggest issue in America isn't the interconnected corruption of lobbying and the healthcare industry, well, then it must be number two or three。 One would think we would prioritize these very real problems with some of the available solutions one of these days。 。。。more