The United States is doing well. Economic indicators are in good shape: the unemployment rate rests around 3.8% – a 50-year record level – and, at 3.2% for the first quarter in 2019, economic growth has surpassed expectations. Exports are increasing while imports have slowly decreased. Disposable personal income increased by 3% whereas prices only increased by 1.9%. The housing market has grown considerably since 2017, and cranes dot the landscape in many cities, from Oklahoma City to San Diego to Austin.

But the story told by figures, indicators, and composite data omit crude truths that explain extremist votes, polarization, withdrawal and the pervasiveness of populism. These truths have been documented for years by photographer Chris Arnade, and he has published a book with Sentinel about them with the provocative title of “Dignity: Seeking Respect in Back Row America.”

It is precisely the lack of dignity within the American health system’s operation that journalist Sarah Kliff regularly discusses. Over the course of the past year, she decrypted 1,200 bills for emergency services and the astronomical amounts within them: $40,000 for stitches, $25,000 for half-hour-long scans, $369 to put a Band-Aid on a child’s scraped finger, $39.95 to place an infant on its mother after a Caesarean.

She tells stories like that of a mother whose two-year-old child swallowed an adult medication, which precipitated a trip to the emergency room as recommended by the Poison Control Center. There they waited to see if the child’s status got worse. The medical bill meter starts when you pass through the ER doors, leading to a downward spiral of debt. This is the story of families who sometimes need to declare bankruptcy in order to resurface after a medical event and of individuals who choose to skip diagnostic tests (colonoscopies, blood tests) for financial reasons, and of diabetics who ration their insulin because of its cost.

For those without insurance, according to the United States of Care as of April 1, health insurance premiums are rising more quickly than income and deductibles have increased on average by 60% in five years. The number of uninsured, at its lowest in 2016, is rising quickly: 28.9 million no longer have any form of medical coverage.

And so, insured or not, many Americans struggle to access health care, and the reason is primarily financial. According to the Commonwealth Fund, the United States spends 17.7% of its GDP on health – quite a long way off from other industrialized nations. However, it’s not because they offer more services, but because of the disproportionate cost of services and medications. For example, a 2014 congressional report evaluated the cost of a bronchodilator (Salbutamol, the famous blue pump), which increased by 4,000% in one year. These facts logically have a negative impact on the hope for universal health care (among the lowest in the OECD, the Organisation for Economic Co-operation and Development) and on the increasing maternal mortality rate (a unique occurrence among OECD countries).

These facts are also related to the recent outbreak of measles cases (which, by the way, upset far fewer people than the four cases of Ebola diagnosed on American soil in 2014). In fact, in 1999 the National Vaccine Advisory Committee published an article in the Journal of the American Medical Association linking barriers to health system access, parents’ lack of information, decline in vaccine coverage and measles outbreaks. Because people can’t regularly see a doctor, the practice of self-medication and self-education is increasing and the relationship with medicine is shaped by social networks, as explained in recent articles in the Journal of Medical Internet Research. The permanence on the web of a 1998 article in The Lancet that supported the link between vaccination and autism, which has since been refuted, feeds conspiracy theories. Thus, over the course of a single quarter in 2019, the Centers for Disease Control and Prevention confirmed 704 cases of measles, a figure unheard of since 1994.

In this context, the fact that the Donald Trump administration has filed a brief asking a federal court of appeals to strike down Obamacare is far from insignificant: A decision like this could, according to the Health Policy Center, leave 20 million Americans or more without medical coverage – the total number of uninsured would surpass the population of Canada. Without insurance, more and more individuals will make harrowing choices between food and medication, school supplies and health care; this will entrench deep divides in this society, further isolating those who must sometimes content themselves with waiting to die … at the city gates.