Shopping is choreographed to be reassuring. The customer is always right. Have a nice day. You can forget that the sales ritual is civilizing predatory motives.

Everybody knows about used car salesmen and credit card scams. But I'm thinking of transactions where you watch paralyzed as teeth rip off an arm, as when you open a medical bill you can't hope to pay. Consider this: "A 2007 study published in the American Journal of Medicine found that 62.1 percent of all bankruptcies in the United States were the result of medical debt, up from just eight percent as recently as 1981."

Here's what's interesting. We know that medical costs keep dangerously escalating. And we know that pricing is irrational. Costs for the same materials and procedures can vary wildly from one provider to another. In "Why Medical Bills Are Killing Us" (Time, 2.27.13), for example, Steven Brill reports on "aggressive markups, like $283.00 for a 'CHEST, PA AND LAT 71020.' That's a simple chest X-ray, for which MD Anderson is routinely paid $20.44 when it treats a patient on Medicare, the government health care program for the elderly."

OK, the markup is obviously obnoxious. And yes, the bill's mystifying code and acronyms discourage the layman customer from challenging the prices. Even in person, such a transaction baffles accountability. Clerks operate behind glass windows, with actual providers out of sight. The transaction follows an impersonal routine, with forms to be filled and prices dictated by invisible protocols.

But why are those prices unaccountable and irresistibly rising? Medicare is economical because it can compare services and analyze provider costs and outcomes. Without Medicare, the $21 X-ray costs you $283. Why do you pay?  Because the transaction is based on death threats. The provider has what you need to live. The bottom-line choice is pay or die.

In this sense medical organizations, like mafia, operate an extortion racket with a smile. Fear of illness and death keeps the bottom line hushed. You observe the taboo because you want to believe it can give you more life, whatever the cost. The actual providers remain innocently detached from the billing process. It's not they who advise you to pay or die, but the insurance company or the hospital. The drug companies operate behind a pharmacy screen. You need the magical elixir at any price.  You can swallow any resentment in the hope of being freed from death-anxiety.

To a great extent all parties to such a transaction feel understandably innocent. "The system" is driving behavior, not particular people's decisions and an unspoken death threat. But if treatment fails and the taboo lapses, watch out.  That initial resentment may fire up a sense of betrayal and lead to a malpractice suit.

This sublimated extortion is more pervasive than you might think. Consider Wall Street's "too big to fail" banks. As in a terrorist threat, the banks hold up taxpayers for bailouts after the bankers' malfeasance has caused an economic crash. But the public pays, and declines to prosecute the "too big" perpetrators, because their "failure" threatens to kill the financial system and whack Main Street. It's a version of the protection racket, with Wall Street banks protecting the nation from their own violence.

 But speaking of protection rackets: the corporate military also thrives on death threats. The nation has no credible military enemies and yet spends more on weapons than all of its rivals combined. US invasions since Vietnam have been as costly and futile as they've been endless, yet at warnings about "national security," taxpayers freeze and surrender their wallets. No politician dares to say "no" in an increasingly militarized economy in which jobs, pensions, investments, and a revolving door to political influence are at stake.  Though all the terrorism to date has caused fewer casualties than a year of highway fatalities, the threat of death tyrannizes "the land of the free and the home of the brave." As with mafia, the veiled command is, "Pay or die." And as with most death-anxiety, denial keeps the threat ambiguous. Does anyone really believe "enemies" menace Hoboken or Palm Springs? We go along with the word of armed authority and the reflex fear of death in the back of the mind. And we pay: in effect, buying off anxiety.

Despite their massive drain on the budget, some of these expenses could be offset by taxing the rich as they used to be taxed. Ah, but the rich are "job creators," so making them pay their fair share would supposedly worsen unemployment, poverty, and social death. And social death can be as alarming as real death, as fired employees prove by "going postal" and shooting up the office to show that they still matter. 

Now the polite version of this economy would prefer to see extortion as heroic rescue. It's as if St George asks for payment up front before he rescues the princess and her city from the dragon. George has power, the princess has a ravenous reptile problem. Please pay the cashier. 

Over thousands of years, trade has evolved numerous rituals as safeguards against misunderstanding and rage. Handshakes and signatures seal bargains. Most transactions depend on imaginative sympathy, the ability to read other people's motives, so that the parties to a deal can estimate what things are worth to one another and satisfy everyone.

Even so, caveat emptor has persisted because we are mischievous animals who routinely use deception to get what we want. When one party to a transaction happens to have extraordinary power, the temptation to charge "what the market will bear" can be overwhelming. Greed is enticing, but so is the ease of dictating terms, which takes less work and feels less risky than negotiation.

 In the wild, predators prefer to prey on the young because they're less dangerous to attack. This is a powerful principle in business, too, as we see in the vulnerability of the naïve and the poor. Ideally the firm catches the isolated victim in the jaws of debt and interest, the contractual bite spelled out in fine print. As the documentary "Maxxed Out" illustrates, credit card and collection companies consciously seek out weak customers susceptible to gluttonous interest rates. To avoid risk, as in liar loans, the firm may resell the original mortgage, so you may not be able to discover who bit you. As the business drives toward monopoly greased by legislative favors, it becomes too big to fail and "the only game in town." Paralyzed customers make a trouble-free instant meal.

 The civilizing rituals of trade make terms such as "predator" sound extreme and moralistic. But in reality we do live by killing. Inescapably. A fisherman is a predator, so is the butcher "harvesting" a herd of cows. From the hunter's point of view, it's eat or be eaten. Think of the businesses that appeal to the predator in the customer by advertising a "Fire Sale," and, since we're dying, "No reasonable offer refused."

It's a marvelous example of our guile that political hacks were able to accuse government health insurance, which actually protects lone individuals from veiled commercial death threats, of being supremely vicious "death panels." The claim is even more hilariously sinister because the politicians warning about "death panels" were in fact pumping for the private insurance lobbies by threatening health care shoppers with death.

 You could suspect that one of the central jobs of any market is to tame or sublimate death threats. This is one reason for the world's fascination with crime shows, especially mafia, with its protection rackets and loansharking and the profound principle of "An offer you can't refuse." The urge to extort never sleeps. Now, how about the urge to reform?

1. <<http://www.huffingtonpost.com/wendell-potter/only-in-america-could-cos_b...

 2. <<http://readersupportednews.org/opinion2/272-39/16241-time-why-medical-bi...

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