Long before the novel coronavirus existed, Anne Case and Angus Deaton, two Princeton economists, were chronicling the ways in which Americans, failed by their governmental, economic, and health-care institutions, were spiraling into “deaths of despair”—the increasing number of deaths from alcohol, addiction, and suicide in the white working class. The concept, introduced in an article in 2015 and expanded upon in a recent book, drew immediate attention and debate.

As these same institutions falter in the weak and inadequate response to COVID-19, Democracy asked Case for her thoughts on how the pandemic is making the problem she and Deaton identified worse, and the steps we need to take to fix things.

This is the first entry in a new series we’re launching called “Voices of the Viruses”—interviews by journal staff with intellectuals, policy-makers, frontline activists, and others who are thinking about or trying to mitigate the pandemic’s worst effects. Editor Michael Tomasky spoke to Case by Zoom. This transcript has been lightly edited for clarity. Also, you can read Democracy’s review of Deaths of Despair, by Rahul Gupta from our Spring 2020 issue, here.

Michael Tomasky: Here we are with Anne Case. So you and your husband, Angus Deaton, have written a book that has received wide acclaim and really started a conversation. Please describe the book to readers.

Anne Case: We wrote a book called Deaths of Despair and the Future of Capitalism. And in the book, we document the fact that American capitalism is no longer working for men and women in the U.S. without a college degree. And that’s about two thirds of Americans age 25 to 64. We start by documenting the despair, the fact that lives are coming apart. The fact that deaths from suicide, drug overdose, and alcoholism, which we call the deaths of despair, have been rising since at least the early 1990s for people without a college degree. And then we go on and dig, to try and unearth what we think are the reasons behind that phenomenon.

MT: So just quickly go through the main reasons.

AC: Sure. We think a way of life has ended for people in the U.S. without a college degree. And we think that the long-run consequences comes from a labor market that turned against lower skilled workers in the eighties and nineties. And it left people without hope and left people without good jobs. And without good jobs, people felt they couldn’t get married. People would cohabit, they’d have children, but those cohabitations were fragile.

So their job situation was fragile, their home lives were fragile, they lost touch with community. And that gave way to a Durkheimian recipe for suicide. And we think that part of the reasons that that happened in the U.S. are happening elsewhere in the world—automation, globalization. Those happened in Europe as well. But we don’t see these deaths of despair there the way we see them in the U.S.

So we asked, well, what’s different about the U.S.? Part of it is that we unleashed very heavy-duty opioids onto the general public, and they landed on soil that was very fertile. People were looking for a way to numb themselves or to feel better about lives that were coming apart. But the other thing that’s different about the U.S. is the way that we fund our healthcare system, that we have an employer-based system. Which was something I think we’ll come back to when we talk about COVID, with 38 million people having filed now for employment. A lot of them lost their health insurance when they lost their jobs. But we’ve let our health care industry just run out of control so that health care costs in the U.S. rose from being 5 percent of GDP in 1960 to being 18 percent of GDP in 2019. So we’re letting this industry eat our economy from the inside out. And that has effects on whether or not firms feel they can afford to hire low-skilled workers. If they have to pay their share of a $21,000 a year premium to keep those workers.

MT: So let’s shift now to talking about the virus. The impact of this on the kinds of people you write about is, I should think, very, very severe. Have you looked at that?

AC: Yeah, we’re currently looking at that now. There have been things written recently that say, well, if you look at the Great Recession, suicide rates went up by X percent. But we think that those analyses miss something really important—that suicides were rising before the Great Recession, they rose during the Great Recession, and after—a very smooth increase over the period from the early 1990s to 2018, which was the most recent year we have data for. So we think that it’s possible that people who are isolated may find themselves at higher risk of suicide. We think people who are isolated may be at higher risk for heavy drinking or for taking opioids without a companion who could possibly administer Naloxone, which helps with an opioid overdose. But we think that those numbers…we’ll have to wait and see what they look like. We don’t know yet just how bad this will be for them. But we think that some of the numbers are certainly not correct.

MT: They’re too low or too high?

AC: Too high. One thing we know as well is that, for the first time in 20 years, mortality rates from drug overdose fell from 2017 to 2018. We know from the early release data that starting in early 2019, drug overdose deaths in the U.S. started to rise again. This was well before the anything COVID was on anyone’s radar screen. So it’s possible that drug overdose deaths are rising still. But how much of that we’ll be able to pin on the crisis and how much of that is due to the fact that this really heavy duty street fentanyl has made its way off the Eastern seaboard and is moving West in the country, killing more people, we’re going to have to do a really careful analysis to figure out how much of that is happening.

MT: So that development with fentanyl is happening coincident to the onset of the virus?

AC: It started happening before the virus hit. So we’re going to have to see how much of the overdose deaths that we see during this period are attributable to the COVID crisis and how much of them were coming down the pike whether or not there was any COVID epidemic.

But one of the things that COVID does lay bare is the fact that it’s crazy to tie health insurance to people’s employment. When that many people lose their jobs through no fault of their own because we close down the economy and they lose their health insurance at the same time, we put millions of people at risk who should not be at risk and who may end up with tens of thousands of dollars of medical bills that they can’t pay. And we think that this may actually cause there to be substantial change in the way we fund our healthcare system.

I was skeptical we’d ever get there in my lifetime, but I thought something was going to have to break very badly if we were going to see that kind of change. What’s happening right now may be that very bad break that causes people in the middle of the distribution, which is where this discussion is going to have to take place, to start talking about serious reform of our system.

MT: What would you like to see most of all?

AC: Most of all, what I’d like to see done would be cost control. Our system is twice as expensive as the European countries, even though our life expectancy is lower than any of the countries in Europe and our health metrics are poorer than most countries in Europe. We have allowed Big Pharma, hospitals, device manufacturers, and a subset of doctors to keep raising prices beyond anything that makes sense. And that is bleeding the entire economy, including our low-wage workers. It’s bleeding us dry. So I think that coverage would be a lot less of an issue if the costs were a lot lower.

MT: What are a couple of specific cost-control measures that, if you could wave a wand, you would want to impose?

AC: Well, right now the FDA approves a drug, then Medicare must pay for it and then they must pay the price that Big Pharma decides to charge for it. So immediately you’ve got a situation where the government, who’s the big player on this, can’t have any say at all on the prices charged.

I would love to see fewer lobbyists in Washington. Right now there are five lobbyists from the healthcare industry for every member of Congress. And very recently we’ve seen what that has meant. That has meant that in December 2019, during discussion of the budget bill, the left and the right both agreed that surprise medical billing should be taken away and should not be allowed. Right now, you could have insurance for a hospital, but if you’re taken to an emergency department, that emergency department may very well not belong to the hospital, and you could be slapped with thousands and thousands of dollars of medical bills when you are in no position to negotiate.

The left and the right both thought this is horrible, “We should get rid of this.” Well, hospitals leaned on important members of Congress, and it got stripped from the budget bill. Same thing happened when, in the very first relief bill for COVID-19, billions of dollars were given to Big Pharma to help them do research on vaccines. But they took the teeth out of cost control for those vaccines, should they ever be discovered, even though we paid for the research that went into them. So we’re up against an incredibly powerful industry that’s 20 percent of our economy now. Our best estimate is that over a trillion dollars that we spend on healthcare is just excess spending. It’s waste. It’s money that’s coming out of the pockets of regular people. It’s coming out of the pockets of state taxpayers, because states have to pay their share of Medicaid. And to do that, they have to increase fees at once-great state university systems, they have to do less infrastructure repair. There’s no part of the economy that really isn’t touched by the fact that these costs are out of control.

MT: Talk a little bit about COBRA. Millions of people are going to be relying on COBRA, but that’s really expensive for most people.

AC: Yeah. It’s out of reach for a lot of people. So with COBRA, if I lose my job, I am allowed to keep the health insurance that my company had for me, but I now have to pay the full freight. On average, employers pay 71 percent of a healthcare premium. So imagine that there’s a quadrupling of your spending on your health care. For a lot of people, $21,000 a year for health care is more than they can afford. If they’re earning 30, $35,000 a year, there’s no way they can keep body and soul together. So then they’re dumped.

MT: Your book has a critique of contemporary capitalism that goes well beyond health care. What has the virus and the crisis particularly laid bare about contemporary American capitalism?

AC: There has been a ripping of the social contract between labor and capital in the United States that’s been going on since the ’70s. Part of that has been the result of globalization first cars from Germany and Japan and then full on globalization, so there’s been a real reduction in the power of workers to share in the benefits that come from globalization. And there are benefits. The pie is getting bigger, but labor’s share of that pie is getting smaller and smaller. Part of that is that workers have no representation in Washington to speak of, relative to the big tech companies, relative to the big corporations. Labor unions have almost no representation. And as we know, if you don’t have a seat at the table, you’re probably on the menu.

MT: The crisis, as you suggested in some earlier comments, is likely to be a big political inflection point in this country. Things can go in one direction or the other. How confident are you really that we’ll be able to use this crisis to move the country in a better direction?

AC: That’s a very good question. I mean, when you think back to what happened after the Great Depression, right? In the United States we had Roosevelt, and in Germany, the rise of Hitler. I actually think that either of those is not beyond the possibilities. This is an extremely dangerous time. The crisis itself currently, also somewhat ironically perhaps, although there are lots of reasons we can discuss why this is the case, has hit the blue states hardest right now. In terms of deaths, 80 percent of the deaths have been, so far, in states with Democratic governors. So perhaps it was inevitable that there would be this politicization of the crisis itself. But we’ll see what happens since we know the virus is calling the tune right now, and we don’t know what’s going to happen as it moves from the densely populated blue states to the less densely populated red states, we just don’t know.

MT: Let’s head toward the wind up by talking about the people you wrote about. Just on a human level, how much can people be expected to take?

AC: Well, it’s a hard question. When people lose hope, right, then we think that they need something to soothe the beast, and they turn to drugs, they turn to alcohol and a fraction of them also kill themselves. We think that in 2018, 158,000 Americans died from one of those causes. That’s up from 65,000 in 1995. So it’s kind of like an excess death of almost 100,000. So it puts it on a par with where we are with COVID right now. But the difference being with COVID, hopefully there’ll be treatments and a vaccine. But this invisible epidemic, there’s reason to believe it’s going to have run its course. Things have been getting worse, and we don’t see them getting better until there is some discussion about how we bring status and meaning and better jobs back to the almost two-thirds of Americans now who don’t have the BA that we’ve made into the status symbol for U.S. workers.

MT: When do you expect to start to see good numbers that will permit you to start to think about what impact the virus has had on addiction and deaths of despair?

AC: So with the drug overdoses, there are early release numbers, so we should be able to look at those and track those. For suicides, suicides are slower because they have to be checked by a medical examiner or coroner. And so those numbers, we won’t have for a whole year. And for alcoholic liver disease, probably the same, but all three of them were rising. In 2018, when we saw a little dip for drug overdose mortality, suicide mortality and alcoholic liver disease mortality were continuing to rise. So we have no reason to expect that those are just magically going to improve during this period of lockdown and social distancing.

MT: Try to leave our readers with one little reed of optimism if you can.

AC: The optimism would be that if we can make use of this crisis to bring real change to the health-care industry, that will improve lives all across the board. There was something that was going to have to break. Perhaps this is it. And then we’ll see a real discussion about how we fund health care and bring down its costs in line with what is expected in the rich world.