From the Desk of James A. Tyner: The Violence of Health-Care Reform

9780803253384-JacketGray.inddJames A. Tyner is a Professor of Geography at Kent State University and author of Violence in Capitalism: Devaluing Life in an Age of Responsibility (Nebraska, 2016). The paperback edition will be released in the spring of 2018. 

We do not always ‘see’ violence as it happens. By this I do not mean that we are not present when a person is shot or stabbed or beaten. Rather, I’m referring to those underlying ‘structures’ or ‘conditions’ of violence that cause harm, suffering, and death. Elsewhere, Rob Nixon talks of ‘slow violence’: of violence that is unspectacular, for example death resultant from lead exposure. Here, people die; but their deaths are not as noticeable or notable, as for example homicide.

Readers familiar with the academic study of violence are well-aware of Johan Galtung’s distinction between ‘direct’ and ‘structural’ violence. Foremost among this distinction was the question of intentionality and agency. Following Galtung, direct violence occurs when there is an identifiable actor who commits an act of violence; structural violence, conversely, is said to occur when no such actor is identifiable. Galtung elaborates that with direct violence, harmful consequences can be traced back to identifiable persons; with structural violence, the act of blaming is no longer meaningful, in that violence is built into the structure and is revealed only as an unequal power. Thus, we do not ‘see’ structural violence because it is too often passed off as natural, normal, or unintentional.

In practice, however, structural violence can—and must—be understood as resulting from agency. Structures of violence, for example exposure to toxic chemicals (e.g. the water ‘crisis’ in Flint, Michigan) or being burned to death because of faulty safety regulations (e.g. the Grenfell Fire in London), are not blameless and do not simply happen. Similarly, what is happening in the on-going health care debates is decidedly intentional. People will die. These deaths are avoidable.

In 2010 then-President Barack Obama signed into law the Patient Protection and Affordable Care Act. Highly controversial and mired in partisan politics, the law was intended to make health care more accessible to approximately 47 million uninsured Americans. This was to be accomplished, in part, by requiring states to expand Medicaid eligibility to persons with income less than 138 percent of the federal poverty level.

Known derisively by its opponents as ‘Obamacare’, for seven years the Republican Party—with the support of a conservative US Supreme Court—has made innumerable efforts to repeal, replace, or otherwise let fail the Affordable Care Act. In 2012 for example the Supreme Court ruled that states could ‘opt out’ of Medicaid expansion; and in little over a year twenty-five states had in fact opted out. It was estimated that upwards of eight million men, women, and children would be denied access to satisfactory health-care because of these actions; and that upwards of 17,000 people would die.

Under the administration of President Donald Trump, and a Republican majority in both branches of Congress, efforts are underway to once-again repeal, replace, or let fail the Affordable Care Act. Estimates provided by the Congressional Budget Office indicate that the various bills forwarded by Congress will result in anywhere from 16 million to 22 million persons losing health-insurance within ten years. These proposed bills are remarkably unpopular; polls indicate that perhaps only 17 percent of the US population is in support of doing away with the Affordable Care Act.

What then, is the motivation for Trump and the Republican-dominated Congress? Answers are complex and include a palpable racism directed against former President Obama. However, a primary impetus is simply profit, for the proposed legislation not only seeks to do away with the Affordable Care Act—or at least significant portions of the law—but also attempts to provide obscene tax cuts to the very wealthy. As Erik Sherman calculates, the repeal or delay of taxes is expected to generate over $541 billion for the rich. Stated differently, for every person who dies because of a lack of health care, the wealthy will receive $3 million in turn. Such is the calculative demographics of life and death under capitalism.

Opponents to the Republican efforts have decried this as a tragedy; an injustice; and outrage. And rightly so. However, neither the media nor political pundits have couched the attempt to take away health care as violent. And yet, the proposed bills are decidedly, intentionally, violent. Sadly, even if Congress does not enact health-care reform; even if their ‘actions’ result in legislative ‘inaction’, violence has already been done: the violence resulting from elevated stress and anxiety levels, born from worries over the loss of health-care. And this is a form of violence that few will see—although untold thousands will experience directly.




Galtung, Johan. “Violence, Peace, and Peace Research.” Journal of Peace Research 6, no. 3 (1969): 167-191.

Nixon, Rob. Violence and the Environmentalism of the Poor. Cambridge, MA: Harvard University Press; 2011.

Sherman, Erik. “How Much is a Dead Poor Person Worth to the Wealthy? $3 Million.” Forbes June 26, 2017. []

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