The movie’s dramatic arc is built around 40-year-old George Bailey’s attempt to kill himself. The film opens with prayers offered up to heaven by townsfolk worried that George, who has gone missing on Christmas Eve 1945, is about to do something dangerous. “Please God,” his daughter Janie prays, “Something’s the matter with Daddy.” Somewhere up in the heavens, two senior angels hear those prayers and dispatch one of their apprentices, 200-year-old Clarence, to answer them.

George, Clarence learns, has convinced himself that he’s “worth more dead than alive” and is “thinking seriously of throwing away God’s greatest gift.” He is headed to a bridge above the canal in Bedford Falls with the intent to jump to his death so that Mary Bailey, his wife, can claim his life insurance and secure the $8,000 needed to save the family business, the Bailey Bros. Building and Loan.

Bound up in this convoluted plot is a short lesson about the way suicide functions as a religious provocation, and as an event with distinct legal and economic aftereffects.

Take George’s plan to defraud his insurance company. He is not the first person to try to make an intentional suicide look like an accident so that his beneficiaries can benefit. That sort of tragic scam actually has a long history. American insurance companies offered the first life insurance policies in the 1810s, and from the beginning they struggled to deter a range of moral hazards, including the perception that their policies offered perverse incentives to desperate people to commit suicide.

As Sharon Ann Murphy explains in Investing in Life: Insurance in Antebellum America, companies stipulated that they would not pay out in cases when a death could be shown to be premeditated. In 1823, the first life insurance policy ever issued by the Massachusetts Hospital Life Company said that “this Policy shall be void, null, and of no effect” if the insured “shall die by his own hand.”

Such terms quickly became standard and by 1945 every insurance policy said much the same. George Bailey is clearly wise to this because, rather than find a gun or a rope to achieve his purpose, he has decided to jump from a bridge in the dead of night in hopes that authorities will rule his drowning to have been accidental rather than intentional.

And he has good reason to think that they might.

In fact, verdicts of rational suicide (felo de se) are remarkably rare in American history. For decades prior to 1945, when suicide was suspected, coroner’s juries across the United States habitually handed down verdicts of accidental death or non-culpable insanity (non compos mentis). As I’ve found in my own research on suicide in 19th-century America, intentional suicide is notoriously difficult to prove in the absence of eyewitness testimony or a note attesting to the deceased’s state of mind.

Even today, standards of evidence for determining suicide still vary wildly from jurisdiction to jurisdiction. For a long time, coroners’ jurors had to weigh the impact of draconian laws which required authorities to bury the bodies of suicides in unconsecrated ground (or, in the case of colonial Massachusetts, by the sides of highways) and to confiscate the individual’s assets. Refusing to punish surviving family members who otherwise would have inherited those assets, many coroners’ jurors preferred to give the benefit of the doubt to those who seemed to have intended to die, a fact poor George Bailey was surely banking on.

Still, George’s plan to commit insurance fraud by disguising his suicide as an accidental death is full of holes. Had the Bedford Falls coroner conducted a postmortem, he would have found George’s life insurance policy is in his pocket, a sure sign of his deceptive intentions. George should have left it at home. If the policy itself were lost in the swirling waters into which he jumped, his widow Mary might have trouble making a claim on it. She might not know which company to approach. Even if she did, that company could refuse to honor the contract until the Baileys could produce the policy document.

Of course, Capra never lets things get that far. Clarence plunges into the river first, faking his own accidental drowning. And by doing so, he snaps poor, good-hearted George out of his self-destructive stupor. George dives in after Clarence to rescue him and both men struggle to shore and then into blankets provided by a tollkeeper in whose hut they recuperate. In the film’s final act, Clarence shows George what Bedford Falls would have been like had he never been born, a dystopian alternative reality that finally convinces George to beg for his life back.

This is dark and serious stuff and surely a sign of the times. During the Great Depression, commentators had worried that more and more ruined heads of American households were committing suicide. The same moral panic seized the nation again in the wake of World War II, as home front heroes like George and returning soldiers like his brother Harry tried to process all that they’d experienced and readjust to the rhythms of life in peacetime. Underreporting of suicide in the surviving statistical evidence makes it impossible to know whether or not attempts at self-destruction actually spiked during either period. But the hand-wringing continued nevertheless and It’s a Wonderful Life, which premiered in 1946, does its civic duty as a piece of earnest anti-suicide messaging.

It’s also a vehicle for Capra’s Roman Catholic worldview. As Malcolm Scott explains in Frank Capra and the Cinema of Identity, the film opens with prayers and concludes with the affirmation that God and his angels in heaven love us and want to save us. The original title of the script, by Philip Van Doren Stern, was The Greatest Gift, and on the question of the right to die, the film touts its religious values loudly and proudly.

“It’s against the law to commit suicide around here,” the tollkeeper reminds George after his failed attempt to take his own life.

“Yeah, it’s against the law where I come from, too,” adds Clarence.

Beneath its melodramatic veneer, then, It’s a Wonderful Life is a remarkably rich cultural artifact of the postwar era. It’s a manual for how not to commit insurance fraud, a strikingly conservative treatise that denies the individual right to suicide, and a haunting, pointed study of doubt, loss of faith, and the degradation of dignity.

The post Our Favorite Christmas Classic Is Really a Study in American Suicide appeared first on Zócalo Public Square.

That was one of the insights offered at the outset of Wednesday night’s well-attended Zócalo/Arizona State University event at Phoenix’s Desert Botanical Garden. The panel discussion featured Dr. Denis A. Cortese, emeritus president and CEO of the Mayo Clinic; Sir Malcolm Grant, chairman of NHS England; and ASU President Michael Crow, who moderated the evening.

In the case of Britain, Grant explained, the NHS was created by the Labor government in 1948 “in place of fear,” with a commitment to provide free medical service to all British residents, paid for by general tax revenues. Chuckling, Grant noted that the government initially thought the cost of NHS would decline within a few years, “after it had fixed most people’s problems.” Nowadays, NHS covers 60 million people and consumes 8 percent of British GDP.

In America, said Cortese, who now directs ASU’s Health Care Delivery and Policy Program, the same postwar period saw the Truman administration impose price and wage controls to stabilize an overheated economy and counter inflationary pressures. “But the government did allow organizations to compete for workers and talent by offering them health insurance and other benefits,” Cortese said. Thus the curious linkage that persists to this day between the workplace and health care.

Back in the late 1940s, Americans on average only lived two or three years after their retirement, but as lifespans increased, a new system was required to care for millions of Americans beyond the workplace. Medicare was born in 1966, with substantial bipartisan backing. It too proved a far costlier program than anyone had anticipated.

In framing the night’s discussion, Crow pointed out that of all major industrial nations, the United States spends the most per capita on health care (amounting to some 16 percent of the economy) and obtains relatively poor health outcomes (looking at life expectancy rates and other benchmarks) for that investment.

This was the second striking commonality to emerge in the comparative discussion of health systems. On both sides of the Atlantic there is a growing dissatisfaction that society isn’t getting its money’s worth for all its health care spending. And that is especially alarming because, as it is now, Grant said, “no health care system in the world is financially viable as currently designed.” He described the NHS, often beset by political meddling, scarcity, and labor unrest, as being on “creaky” footing.

“The NHS is the closest we British come to a national religion,” Sir Grant said, “which is good when it comes to ensuring it has enough resources, but not so good when it comes to reforming it.” (Though he and Crow both mentioned that in an analysis of 10 developed countries, the Commonwealth Fund still found the NHS to be the most impressive health care system.)

Both speakers took turns throughout the evening being slightly wistful about each other’s systems, with the American wanting more of Britain’s coherent strategy, and the British desiring more American-style “entrepreneurial spirit” in Britain.

“For all its flaws, at least the U.K. has a vision,” Cortese said. “We still haven’t developed a national plan and strategy” for our future health care needs.

While Grant pointed out that in some ways the British system is more fragmented than people expect, the United States in some ways has more of a national program than is often acknowledged, when you look at Medicare, Medicaid, and the health plan available to federal employees.

Crow described challenges that both systems face as the consequences of “well-intentioned design flaws.” He reminded the audience that it is hard to generalize about outcomes in American health care, because these are correlated to income levels, a reflection of broader societal inequalities. Geographic ones, too, Cortese added, by pointing out that the top third of U.S. states have health care outcomes that are as good as those in any nation, but our lowest-ranking states resemble Third World nations in their health profiles.

And for all their differences, in both Britain and America Cortese and Grant agreed that the health delivery systems’ incentives have been perverted by paying providers for services, instead of outcomes. As Cortese put it, the United States has developed “a totally rational delivery system predicated on the idea that if you’re sick, we make money.”

The question, both experts agreed, should be how do we reward people for keeping patients out of hospitals, not in them.

As they tackle that challenge, Cortese and Grant described both the English and American systems converging toward each other in several ways, with the NHS in Britain pushing some spending decisions back down to the regional level, and America seeking to get more of its patients’ data digitized and connected.

When Crow mentioned that many of the leading causes of death in this country are behaviors as much as diseases, both experts agreed that a greater emphasis need to be placed on preventive medicine, and looking at root causes of poor health behaviors.

“To take care of a population, you need to know who they are,” Grant said, and then adapt your care. The idea should be to standardize outcomes, not delivery tactics.

In a question-and-answer session that followed the discussion, a young cardiologist in the audience asked about the future for doctors who care deeply about patients and want to spend time with them and not be treated like factory workers on an assembly line. Cortese said that in communities like the Twin Cities in Minnesota and Seattle, physicians are becoming more accountable and exerting more control over health care by creating their own insurance systems.

And both experts agreed that in both countries, providers need to break away from the traditional mindset that hospitals, as opposed to preventive clinical centers and other health-care delivery platforms, are the center of the health care universe.

As Grant said, after asking the audience if anyone wants to check into one tomorrow: “Hospitals should be looked upon as a symbol of our health system’s failure.”

And that would be true whether the hospital is run by a national health service or a private company.

The post National Oversight or Not, All Health Care, Like All Politics, Is Local appeared first on Zócalo Public Square.

Not everyone agreed, of course. Government-sponsored health insurance would encourage freeloading, or at least result in a ton of bureaucracy, opponents contended. Why offer more power to the federal or state governments when most insurance could be handled privately?

Today, the debate rages on. While the 111th Congress passed the Affordable Care Act, which, among many changes, mandates that all Americans possess health insurance and requires private insurance companies to offer certain kinds of coverage, subsequent Congresses have voted to repeal the act. Even as Donald Trump has hinted at the value of national health care coverage, a spokesman has tried to clarify that he’s against “socialized medicine.” No one thinks that America’s health care system is perfect, but what really is the best way to for a country to treat its sick and pay for this treatment? Should nations try to partner with neighbors to create international systems, perhaps continent-wide, to ensure equal coverage for all? Or, conversely, should care be focused at the most local level, to be most nimble and creative?

In advance of a Zócalo/Arizona State University event on the best ways for countries to approach health care, we asked a variety of health-policy experts: Should health care systems be national? What are the advantages and disadvantages?

The post Is Universal Health Care an Impossible Fantasy? appeared first on Zócalo Public Square.

When I got home, I dug into the mystery of these stone stumps, discovering the profoundly insecure time before Americans had Social Security, when anxieties about death and finances ran deep in the American psyche. In response to these fears, the Woodmen of the World order and its progenitor and competitor, the Modern Woodmen of America, made life insurance approachable and fun by packaging it in the familiar fraternal-order culture of the day. The two Woodmen societies succeeded in selling fraternal insurance where others failed, thanks to their innovations, which included offering distinct tombstones, flaunting ax-twirling pageantry, and holding clandestine rituals that involved slapstick pranks and mechanical goat rides. Today, both organizations still exist as insurance companies, but they’ve shed the fraternal antics. It’s hard to imagine their previous incarnations, which resembled a combination of LinkedIn, GoFundMe, and Jackass.

Death was everywhere in 19th-century America: Fatal injuries, disease epidemics, and the Civil War made families acutely aware of mortality. For women and children, the death of a husband and father could tumble them into poverty. Only the wealthiest Americans bought private life insurance. Women were not allowed to take out policies on their husbands, and if the husband bought the policy on himself, the money wouldn’t be protected from creditors.

And then, grieving families faced another layer of shame. In 19th-century America, taking charity was seen as a sign of weakness: The thinking was, if a lack of industriousness made you destitute, well, then you got what you deserved.

The middle and working classes did, however, have a workaround. Men could join secretive boy’s clubs like the Freemasons and Oddfellows that provided networking, entertainment, and a moral education. If a man proved himself to be hardworking and of good character through his initiation trials, his social standing meant his family could quietly receive financial support from the lodge without the stigma of accepting charity.

After the devastating Civil War, well-established fraternal orders began to formalize their benefits into insurance subsidiaries. New secret societies known as “mutual beneficiary societies,” created with the explicit purpose of offering life insurance policies, sprang up around the United States. Largely excluded from the original fraternal orders, women and African-Americans even launched their own aid societies. Still, to join any fraternal order and receive its insurance benefits you had to prove that you were no slouch—a hard worker with high morals such as thrift, self-reliance, discipline, and generosity.

But it wasn’t all about restraint. Before the days of TV, radio, or fantasy football, fraternal lodges offered plays, rituals, and camaraderie and allowed men to let loose, which kept members coming back for more. The clout of being an insider and the endless pursuit of mystical, esoteric knowledge ensured that men would make their insurance payments for decades to come. The payouts were between $1,000 and $2,000, a lot of money at the time.

The Woodmen came late to the party—incorporating in 1883 as the Modern Woodmen of America—but their leaders’ entrepreneurial innovations breathed new life into the fraternal insurance game. Founder Joseph Cullen Root, a businessman in Lyons, Iowa, seized the opportunity to create his own fraternal order when the mutual aid society Knights of Honor, which almost went under because of the 1878 Yellow Fever epidemic, was selling its local lodge.

To avoid the financial pitfall that wrecked the Knights, Root made fitness a requirement to join his order, recruiting rural young men from the “healthiest states,” which meant those outside industrial New England. In the Woodmen, he fused Christian philosophy and pioneer values with ancient agricultural rites. “At that time, Root’s thought was that a cleared conscience and a cleared forest were synonymous,” says Bruce Lee Webb, who co-authored the 2015 book, As Above, So Below: Art of the American Fraternal Society with Lynne Adele. “The axe is an instrument clears the forest but is also useful for constructing buildings and making progress.”

Wielding aluminum-headed axes, members of Modern Woodmen lodges formed marching units known as the Foresters that performed precision drill routines in military-like uniforms. Eventually, there were roughly 10,000 drill teams nationwide. Dave Lettelier, curator of the Phoenixmasonry Museum in Havana, Florida, says that such pageantry appealed to young men who’d grown up in awe of Civil War heroes. The fraternal beneficiary societies made signing up for insurance seem glamorous.

After an internal dispute with the other Modern Woodmen of America leaders, Root left the organization in 1890 and moved to Omaha to form a nearly identical “speculative woodcraft” order: the Woodmen of the World. One of his innovations was to provide free tombstones—Root believed passionately that no member of his order should be buried in an unmarked grave. So for 10 years, the Woodmen gave its members grave markers in the shape of tree stumps, inspired by the Victorian Rustic movement. (For another two decades, the members put down $100 apiece to reserve theirs.) At a Woodman’s funeral, his personalized tombstone would be revealed in an elaborate ritual. The 4- or 5-foot-tall tree stump would be marked with the motto “Dum Tacet Clamet” (“Though Silent, He Speaks”) and rest on a stack of logs, each log symbolizing one of the deceased’s children. The local stone carver, who might alter the pattern, would add embellishments reflecting the Woodman’s personality, such as axes and doves.

The Woodmen tweaked another feature of the fraternal orders, most of which had solemn initiation rituals, loosely based on old Masonic ceremonies that symbolically forced recruits to confront their own mortality. Most societies had some macabre obstacle courses that ended with the young man facing a human skeleton lit by candles. According to As Above, So Below, in an early Woodmen of the World initiation, the blindfolded candidate wore weights symbolizing the “selfishness,” “hatred,” and “prejudice” he had to shed as he navigated a “dangerous path,” which involved wood boards on rollers, before he was allowed to see “the light of Woodcraft.”

The Modern Woodmen took such rites to new levels. They’d challenge recruits to put their hands in (fake) molten lead. Others were subjected to spanking machines and collapsing chairs. The Ferris Wheel Coaster Goat, patented and sold by a company co-owned by Modern Woodman member Ed DeMoulin, would flip the unsuspecting rider upside down and fire blanks from its rear.

What did a slapstick goat gag have to do with selling insurance? Everything. Besides reminding recruits that death was always at the door, the Woodmen “had to come up with all kinds of gimmicks to get people to join,” Lettelier explained. “When an initiate had to ‘ride the goat,’ everybody else would sit around the lodge room and have a big belly laugh. … If you ‘rode the goat,’ then you were in with the clique. Then that new member would bring in his buddies so the Woodmen could prank them. What it did was help build their insurance company.”

A group photo of Woodmen of the World with their goat mascot

Thanks to pranks like these—soon adopted by other societies—fraternal-order membership reached its peak or “golden age” in the United States between 1890 and 1930, with as many as one-third of American men belonging to at least one secret society. While that’s impressive, it still means about two-thirds of American families did without such a safety net.

The Great Depression killed the fraternal insurance business in two ways. First, many men were unable to make their payments. Secondly, FDR’s New Deal created Social Security in 1935, filling the need aid societies once met. Radio, movies, and TV supplied the entertainment that the orders once provided. Woodmen of the World embraced these new media in Omaha, establishing a radio channel and a TV station—which launched the career of a local comedian named Johnny Carson—before both were sold to Meredith Corporation in 1958. Today, the Woodmen groups have become all-inclusive not-for-profit insurance companies: WoodmenLife in Omaha and Modern Woodmen Fraternal Financial in Rock Island, Illinois. Unlike for-profit insurance companies, they put profits back into their members’ communities with programs for senior citizens, people with disabilities, and orphans.

“We still have an active Woodmen of the World lodge here in Waxahachie, Texas,” Webb says. “I’ve talked to them, and they said that they no longer do the different degrees. They meet once a month for a little banquet where they discuss their insurance premiums.” The goats, the costumes, and the rituals are long gone.

The post When Secret Societies Sold Life Insurance appeared first on Zócalo Public Square.

I say this both as a health-policy wonk, with my own health policy consulting firm, and as a husband and father. My wife and I live in Sacramento, California, and we have a five-year-old son. My wife also happens to have a pre-existing health condition. It’s nothing life-threatening but it’s just serious enough that she has been turned down for regular health insurance coverage. Up to a third of Americans face a similar issue, according to the Government Accountability Office.

Finding affordable, high-quality health coverage for my family has been, even for me, an “expert” in the area of health insurance, very complicated and frustrating. So I work with a health insurance broker to understand my options.

Currently, we have “COBRA” coverage for my wife, a type of health insurance you can get for 18 months after you’ve left employer-sponsored health coverage and that is available regardless of health history. It is expensive, though, costing us $655 per month. Then, since I don’t have an employer to provide coverage, I buy a separate policy in the so-called “individual market” to cover my son and myself. That costs $482 per month.

So before we get to any out-of-pocket medical expenses, we’re shelling out $13,644 per year in health insurance premiums. That’s actually quite a bit less than the average premium cost of $18,430 for people with employer-sponsored insurance (as calculated in the Milliman Medical Index of 2013), but the difference is that people with employer-sponsored insurance don’t have to take out their checkbook and pay the entire bill, since their company covers part of it and takes the rest out of their pay.

Our coverage is good for what we pay, but not extraordinarily so. It’s a pair of similar PPO (Preferred Provider Organization) products through Blue Shield of California that have a fairly broad network of doctors and hospitals.

Will my life get less complicated and frustrating on January 1, 2014, the day that health reform coverage starts? I believe it will.

One major improvement is that my premium payments for covering my family will drop. In California, a “silver” level Blue Shield PPO plan in the Sacramento region will cost us $997 per month, about $140 per month less than we now pay for roughly the same level of coverage. I came up with these numbers by looking at the plans that will be available on the website of Covered California, my state’s marketplace. (Every state will have its own, and the costs are similar.)

I can now purchase one health insurance policy for my three-person family instead of worrying about what to do when my wife’s COBRA coverage runs out. If one of us has a medical issue, our premiums won’t go up. And if one of us has a serious hospitalization, the medical bills won’t bankrupt my family. One major benefit of the Affordable Care Act is that it largely does away with the problem of giant hospital bills. It caps total out-of-pocket, annual spending on medical care at $6,400 for an individual and $12,800 for a family. These numbers will be even lower for working-class families.

One tradeoff for the lower premium and the added security of my family’s new health plan is that we’ll have access to a narrower group of doctors and hospitals than we do currently. But I have checked, and the doctors and hospital facilities that we are using currently are available in the plan’s network. So the numbers work out well for us. Better still, I’ll be paying this money into a health insurance marketplace that is simpler and more humane.

My wife and I make enough money that we will not receive any financial assistance from the federal government for purchasing health insurance. But healthcare reform was not passed solely to help the poor or unfortunate. The law is designed to make sure that even those of us who are relatively well off, like my wife and me, don’t end up vulnerable when we switch jobs or choose, as I do, to be entrepreneurs.

Things will be even better for people who receive subsidies to purchase private insurance. These are people making up to 400 percent of the federal poverty level—that’s about $90,000 in pre-tax income for a family of four.

Take a family of four buying the exact same policy—at $997 per month or $11,964 per year—that I will be buying in Sacramento. Let’s assume that their household income is $60,000 per year, placing them squarely in the middle class. The amount they will pay toward their premium is capped at 8.2 percent of their income on a sliding scale. So they will pay $4,913 per year, or $409 per month.  The federal government provides a subsidy of $7,051 to cover the rest of the premium. If that family were to choose the most affordable policy available in the region, an Anthem Blue Cross PPO at the “bronze” level, it would cost them only $162 per month.

These calculations can get complicated, but, luckily, consumers won’t have to run the numbers themselves. A website or a professional assister will take care of that. And remember that the law controls spending growth in the Medicare program and raises revenue to cover the cost of these subsidies, so Obamacare is not projected to increase the national debt significantly, if at all.

None of this means free healthcare is on the way. On the contrary, everyone with insurance will pay a significant amount in out-of-pocket costs if they access care, and everyone is required to have health coverage. There’s a very good reason for this. If people do not have adequate coverage, or any coverage, these costs are passed along to the rest of society.

And some people—in particular younger, more affluent men—will pay significantly more per month. But most people are not wealthy enough to fall into the groups that will pay significantly more in premiums, and many will pay much less.

A lot of us may fail to notice the benefits of Obamacare, just as we fail to appreciate most problems that are averted. If you leave a hospital and have “only” a $6,400 medical bill instead of a $40,000 medical bill, will you be happy—or upset that you have a $6,400 bill? Will people even notice if their health insurance covers a particular benefit now—or did they just assume that the benefits were covered? Because of health reform, millions of terrible moments—of frustration, of panic, even of bankruptcy—that would have happened will not happen. But it’s unlikely that people will understand the pain they were spared, if they never experience it.

Certainly, the Affordable Care Act has flaws. It awkwardly combines a Republican blueprint—the “individual mandate”—with Democratic engineering. So some of the nuts are screwed onto the wrong bolts. And if we don’t continue to service and repair the vehicle conscientiously, the whole thing is going to fly apart with us in it, Democrat and Republican alike.

Like many people, I’ve got my own views about what kind of a health reform law I might prefer in the abstract. I would take a page from John McCain and do away with the tax benefit for employer-sponsored insurance. But I’ve chosen to put that aside. We’re two months from the opening of the new marketplaces where people can buy health coverage. At work, I’ve been trying to help set up these new systems so they function well. At home, I’m getting ready to buy our new plan. I think it will benefit our family—and many others.

The post My Family’s Obamacare appeared first on Zócalo Public Square.