by Joseph Green
(CV #40, August 2007)
Universal coverage vs. private insurance
The limits of single-payer plans and national health care
It's still connected to profit
What is socialism?
At the work place
Workers must put their stamp on the health system
. Medicine for profit is self-destructing in this country. Billions in profits are flowing to the insurance companies, pharmaceutical companies, and HMOs. Hospitals are being consolidated into large corporations. CEOs are raking in ever-larger salaries. But tens of millions of workers and poor people have no health coverage or inadequate coverage, and tens of millions more worry about losing their coverage. Every year more companies cut back on health insurance for their workers, and even workers who still have insurance find they have to pay higher premiums and co-pays while receiving less coverage. Medical emergencies bankrupt many people, even those with costly private insurance, as the insurance companies make up one pretext or another to cancel coverage when it comes time to pay for expensive treatment. Meanwhile even the hospital system itself is in trouble, with hospitals and emergency rooms closing around the country.
. The California and Massachusetts plans attempt to fix the system, while preserving the
insurance companies. They are based on the belief that the same profit motive that got medicine
in trouble will now fix medicine, if there is a complicated-enough financing system. As private
insurance become prohibitively expensive, they are pretending that they can make private plans
universal. And in the name of preserving health coverage, they are giving new subsidies to
corporations that want to drop their employers' health insurance.
Universal coverage vs. private insurance
. Universal health coverage exists in various forms in Canada, England, Cuba, etc. , and to accomplish this, all these systems infringe to this or that extent on medicine for profit. They all replace private insurance, at least for basic care, thus eliminating one aspect of medicine for profit. In Canada, that's the only marketplace aspect of medicine that is eliminated. In some European countries and Cuba, the hospitals and clinics are nationalized and doctors may be salaried employees of the state. In those systems, a bit more of the marketplace is pushed out of health care. In some other countries with universal coverage, such as France and Germany, there is a hybrid system of health care.
. National health programs are thought of as universal, but that's not always true. The French system of national health insurance, for example, evolved gradually after World War II, step by step covering more people, until the year 2000, when it finally covered the last 1% of the country that was uninsured. Also in 2000, the national system offered supplementary coverage, which is important under the French system and is purchased by most of the people from private insurers, to those under a certain income ceiling. There should be vigilance about whether national health programs are truly universal. Nevertheless, the wide coverage under these programs is a great advance on what we have in the US today. They ease conditions for the majority of the population. They proclaim basic health care as a right of the people, which everyone has come to expect. They remove the decision on most medical care from the realm of the marketplace. They free people from the fear that, if they get sick or have an accident, they will be ruined by the cost of medical treatment.
. In the recent decades of neo-liberal free-market fanaticism, most of these systems have been cut
back and starved of funds. The result has been waiting lines, sometimes lengthy delays in
treatment, and other problems. Some of them, such as the Swedish system, have been partly
privatized as well. But insofar as these systems still preserve universal coverage, they have done
so by continuing to restrict the operation of market forces.
The limits of single-payer plans and national health care
. A reasonable system of universal coverage in the US can only be established by restricting the market. A single-payer system would cut private insurance out of basic health care, and instead use a system of uniform government financing. This would eliminate the huge expense that goes to cover the large profits and administrative costs of the medical insurers, and to pay for the big apparatus devoted to denying people's medical claims. It would be a gigantic step forward.
. But single-payer health insurance would leave other aspects of marketplace medicine untouched. For example, for some time now the large pharmaceutical companies have been a major obstacle for affordable health care. They make extravagant profits, as the private insurers do. And they distort medical care and drug research towards the most profitable, rather than useful, avenues.
. The establishment of a single-payer system of national health insurance would not in itself solve
the problem of "big pharma". Even a full national health system, as implemented in other
countries, still leaves the pharmaceutical industry to be run for profit.
It's still connected to profit
. Thus a single-payer health insurance system or even a national health service is still not a full system of health care based on the people's needs; they are still not socialist plans, although they are often called such. Despite what the Republicans proclaim with alarm, and what many reformists believe, government programs in a capitalist country are not socialism.
. A national health care system is still connected to profit -- maybe not the immediate treatment, but various supporting industries are still run on a for-profit basis. In Canada, for instance, the medical supply and drug industries are run for profit, and the national health plan provides the customers for them. So drug prices, for example, are low in Canada only by comparison to those here in the United States. Patients pay for their own drugs, but, due to the federal Patented Medicine Prices Review Board, they get some price relief compared to what American patients pay.
. In Britain, like Canada, the medical supply and drug industries are run for profit. However, the National Health Service fills most prescriptions without charge; other prescriptions have a modest charge, which, however, is waived for certain categories of patients, such as children and adolescents, people over 60, those with financial difficulties or certain medical conditions, etc. This is important for the health and ease of mind of British patients. However, the National Health Service buys these drugs from pharmaceutical companies, which produce them for profit. So the overall cost of these drugs is a major issue for the National Health Service, and in particular for the "Primary Care Trusts" which run the NHS in each local area. The pharmaceutical companies make big profits on these drugs, and moreover, the decisions on what drugs to develop and how to do so are based on marketplace considerations.
. Aside from their connection to the supporting health industries, the national health plans, being
directed by the government, are run by the ruling class as a whole. We shall see that they are
prevented from infringing too strongly on the unhealthy practices of the capitalists, from
pollution to workplace conditions. And for the most part the doctors, as well as the government
administrators, remain a privileged elite, who run medicine as their private preserve.
What is socialism?
. Socialism isn't just a government program in a capitalist economy. The rule of the marketplace isn't eliminated by a bit of government regulation; it is just hemmed in and channeled a bit. Socialism, by way of contrast, means eliminating the entire system of production for profit.
. This doesn't come into existence all at once. It requires not just that the working class takes political power in a country, but a protracted period of social and economic change. The working class cannot simply replace the old CEOs and managers, but has to change the way workplaces and enterprises are run, and the way they are coordinated and managed. Step by step, the working class must learn how to control the economy, both as an overall whole and workplace by workplace. As a result, the economy will no longer be run on the basis of profit-making, but to satisfy people's needs.
. This will be a period of revolutionary transition to a new system. The government and politics won't be run by a rich elite, but by the working class, through its own political party and through mass organizations of the entire working population. This doesn't just mean technocrats or party officials administering the system, even socialist technocrats, but that the working population as a whole must be increasingly involved in directing production and dealing with all the common concerns of society as a whole.
. So the period of socialist transformation isn't just a change in the ruling party and in some political policies, but a new way of life for the entire population and a new system of running the economy. It is a transformation that will eventually result in eliminating all class differences. This type of socialism is workers' socialism or revolutionary communism, as opposed to the state-capitalism which pretended to be socialist, namely, the Stalinist system of the past or of Cuba or China today. It is what is needed to develop consistent mass involvement in, and control of, health care, not as an exception, but as a rule.
. Let's take a look at some of the problems of modern health care and see what a system of
national health care can do at the present time, under capitalism, and what a full or socialist
system of health care for the people should do.
. Take the problem of providing health coverage for all. This is one of the things that the better systems of national health care do accomplish. And it is vitally important. It means that workers are freed from the fear of ruinous medical expense if illness strikes their families; it also frees them from the fear of being caught with medical expenses while between jobs or moving to another city, or while unemployed or disabled.
. However, even with respect to the better national plans, there is constant pressure from the capitalist governments to curtail what they cover. As mentioned earlier, even in the richest capitalist countries, health plans, and social benefits in general, are being cut back. True, in countries with national health care, the system is so popular that it is often political suicide to attack it wholesale. So the governments chop away at it around the edge, removing this or that health procedure from the plan, or adding this or that co-pay or user fee, and instituting piecemeal privatization. Even as the productivity of the workforce increases, capitalism can't provide medical benefits on a stable basis. The workers of Canada and Western Europe will have to be vigilant or they will be in danger of losing their prized accomplishment of universal health care.
. In the US, with our millions of undocumented immigrants, it is important for the working class to insist that a single-payer system or a national health service should cover all immigrants, including the non-documented. If millions of immigrant workers and their families were to be excluded from coverage, this would be extremely unjust and would hurt some of the most vulnerable and exploited workers of our country. And it would reinforce racism against Latinos and other ethnic groups heavily represented among the excluded. It would also rebound on health care for other workers. It would hurt public health measures that have to be universal, such as medical measures against contagious diseases and programs for universal vaccination, thus hurting everyone. And the measures designed to keep out the excluded part of the population will introduce repressive features into the medical system.
. Socialist health care would be universal as a matter of course. Even today, when there is a great
deal of confusion about what socialism really is, it is taken for granted that socialist health care
means health care is a right for all the residents of the country.
. Next is the issue of preventive care. Today the public health authorities try to prevent epidemics and worry a certain amount about prenatal care, but otherwise, they generally leave it to the people to get whatever other preventive care they can afford. Many pregnant women don't get prenatal care; many people see a doctor only in an emergency room; and even the rate of vaccination is going down. For the tens of millions of the uninsured, there's virtually no preventive care.
. National health care plans generally do much better at this than marketplace medicine. This contrasts with HMOs. HMOs promised to do better at preventive care than other systems of private medicine, but experience has shown that they are half-hearted about it. HMOs may cover such things as vaccinations, annual checkups, and prenatal care, and they run a few programs to encourage their members to make changes in their lifestyle. But each year the annual checkup, if it is still done, becomes more and more of a brief formality, and their preventive programs are quite limited. For one thing, a system of preventive care costs money now, while the bad consequences of lack of care can often be put off to the future. And in the future, the person might not still be under that HMO, or some reason might be found to deny coverage for an expensive procedure. Indeed, some HMOs have gone so far that, when faced with a very expensive health procedures, they dig up the person's original application for health insurance and try to find some reason to invalidate it retroactively.
. Only a preventive system based on concern for health, not for the bottom line, can be reasonably complete. Moreover, preventive care should deal with workplace and environmental issues, which are major sources for injury and disease. But such action would interfere with capitalist interests. This is another reason why only socialist care can provide full preventive treatment. We shall return to the workplace and environmental issues later in this article.
. And what about two-tier care: quality care for the rich and something else for everyone else? Indeed, under marketplace medicine today we have multi-tier medicine: lavish attention to the rich; moderate attention to workers with health plans, so long as they are working; and emergency rooms for the poor.
. National health plans level out the treatment. However, under capitalism, the rich always leave themselves a loophole. The national Canadian plan covers basic care, but presently leaves other important aspects of health, including dental care (other than dental surgery) and prescription drugs, to the marketplace. The German health plan was something of a model for the Clinton administration's ill-fated health proposal; they started with the German plan and subtracted anything reasonable from it. But the German plan allows two-tier medicine: wealthier Germans are outside the basic plan and in private plans instead. And even where everyone seems to be covered by the same plan, the privileged are given red-carpet treatment.
. The plans to make private health insurance mandatory in the US, such as the California and Massachusetts plans, promise care for all, but they are multi-tier systems at best. The poor will end up with stripped-down, substandard policies, while the rich will get the best policies money can buy. The better national health care plans, by contrast, provide the closest to equal, quality care for all that is possible under capitalist conditions.
. Under socialism, two-tier medicine will be unheard of. The very division of the country into rich and poor is abolished under socialism. The extra privileges for the wealthy thus vanish too. Socialism also reintegrates mental and manual labor, thus eliminating another source of prejudice and privilege. When socialism reaches the point of classless society, then the very nature of society will make two-tier medicine an absurdity.
. Under capitalism, the features of universal care, preventive medicine, and a single standard for
all are where national plans are at their best. Even here we have seen that, while preferable to
marketplace medicine, the national plans have their problems. Now let's look at some other
health care issues, where both marketplace medicine and national health care fall on their face in
front of the necessities of today.
At the work place
. The workplace is a major source of injury and illness for workers. The ordinary capitalist disregard for their employees' health is growing as in the productivity drive that is making life hell for many workers. Indeed, as capitalist restructuring has led to workers changing jobs more frequently, the employers find even less reason to worry about using up workers through overwork.
. In this situation, speed-up has resulted in repetitive stress injury becoming a national epidemic. Meanwhile, you can take any job, no matter how pleasant in itself, and make it a nightmare by doubling or tripling its speed. And if that isn't enough, combine the job with additional responsibilities. Then add computer monitoring of the smallest details of job performance, and the stress itself will cripple.
. No national health system run by a capitalist government will stop this speedup. On the
contrary, it may inflict the productivity drive on its own medical personnel. So long as the
economy is run for profit, a plague of injury and misery will be upon us. Only under socialism
does the health of workers figure in as a priority matter in deciding the methods of production.
The integration of health care with the workplace will be one of the most important features of
. The environment is of tremendous importance to health, and many health problems are related to pollution. Since the medical establishment doesn't want to tread on the toes of industry, it has pooh-poohed this. This has helped the companies impose dirty environmental conditions, especially on the minorities and the poor. The rich think that they can go live in clean neighborhoods while only the poor will be poisoned.
. As a result, not only is pollution rampant, but the US government doesn't keep statistics of pollution as a whole and its health effects. Typically, when a particular pollutant becomes a problem, the government drags its feet. For example, it has long been known that millions of children (and adults too) have suffered from lead poisoning, which makes their lives miserable. The government didn't ban leaded paint for residential use until 1978, so that many homes still have lead paint problems today. And it dragged out the banning of leaded fuel in a gradual process that didn't come to a conclusion until 1996: the EPA used a process that took 25 years for completion. Meanwhile, even now, in many cities across the country, the water supplies are tainted, perhaps by lead pipes or solder; the local government salves its conscience by putting out brochures advising people to let tap water run for a minute or so being using it for drinking or cooking.
. It is only under socialism that environmental factors will be consistently and full involved in the
basic planning and perspective for industrial production. Indeed, preserving and improving the
environment will be one of the main motives of science and industry. Health concerns will be
fused with workplace and industrial concerns, thus allowing preventive medical care to reach a
new level of effectiveness.
. Doctors are trained to regard themselves as a professional elite, separated off from other health care workers as well as their patients. In the US, this is accentuated by very high pay. Doctors are among the best-paid professionals in the US, and they are paid much more than doctors of other countries.
. American doctors average about $200,000 per year, but the pay varies a great deal according to the doctor's particular field. Family or primary care doctors generally make far less than other doctors, and this is especially true of doctors in rural and poverty-stricken areas. But doctors in some specialties get much more than the overall average for doctors, and far more than primary care doctors; indeed, in a few specialities the average compensation for a doctor is $500,000 or more a year. Moreover status and influence in the profession is dominated by the higher-paid doctors.
. In recent year, private insurance companies and cost containment by government health programs have held back doctors' pay, as claims for payment are denied and rates of reimbursement are held down. Doctors find themselves harassed with increasing paperwork for insurance claims, restrictions on what they can do for their patients, etc. This can lead to two different responses: supporting the patients against the restrictions of the insurance companies, or striving to protect the doctors' privileged position. There are different standpoints among doctors, but the medical establishment remains conservative. The American Medical Association, for example, has consistently worked to protect the elite position of doctors, and it has been hostile to national health care: back in the 1960s it denounced Medicare as "totalitarianism", and today it opposes a universal national health system. Similarly it can be noted that doctors struck in Saskatchewan against the first provincial health plan in Canada.
. The high pay of doctors affects the cost of health care. Moreover, their high pay and professional elitism affect the nature of health care; it doesn't necessarily mean that they don't care about their patients, but it bears on whether most doctors will have sympathy for the particular problems of working people, on whether they will have respect for the experience of nurses and other medical personnel, and on whether they will be critical of the status quo, whether in medicine or otherwise, or be bastions of conservatism. And, among other things, it results in denigrating the status of lower-paid doctors, such as primary care doctors, and of the type work that is done by them.
. Meanwhile, a number of advances in American medical care have taken place through the pressure of mass struggle. There was not only a struggle to have more women and minority doctors, but to change the type of medical care that was offered. The anti-racist movement took up issues such as treatment for sickle cell disease and recognition of the widespread nature of lactose intolerance and that it is the normal condition for people from many backgrounds; the women's movement dealt with contraception, abortion, callous treatment of women, excessive use of hysterectomies, and many other issues of women's health care; gay people fought against the classification of homosexuality as a mental disorder, and for getting the threat of AIDS to be taken seriously; etc. Some sympathetic doctors and medical students have played an important part in these movements, even defying the very real threat of assassination in the case of doctors in pro-choice women's clinics, but in the main these movements represented mass intervention in health care, and they fought against the resistance of the medical establishment. These movements also helped break down, to some extent, the view that patients should simply follow the orders of doctors and the medical profession without question.
. Under socialism, mental and manual labor will be integrated in all fields, and hence in medicine
as well. This will facilitate involving the whole population in medical care, integrating medical
personnel with different specialities more closely with each other and their patients, and help
invigorate the whole field of medicine.
. Current medicine is pretty good at certain things: any problem that can be solved in isolation by taking a pill or cutting it out with a scalpel. But if analyzing the problem requires listening to the patient and investigating the environment or living conditions or workplace of the patient, things get worse. In fact, the drug industry spends billions of dollars each year to persuade doctors that the newest drug is the answer, and there has been a tendency in the treatment of some problems to respond too quickly with a knife. If the masses have suffered much from not being able to obtain needed medications and surgeries, sometimes they have also suffered from overmedication and the overuse of certain surgeries.
. National plans won't solve this in themselves. True, in the name of cost control, there will be pressure to limit certain medications and operations. But unless treatment is based first and foremost on concern for the patient, such cost control will mainly be denying treatment, especially expensive treatment. It will be a matter of chance whether it also provides better treatment.
. Socialist medicine removes the profit motive from the pharmaceutical industry and provides a
greater role for mass oversight of medical practice and patient participation. This creates the
possibilities of a medicine which looks more deeply into the causes of disease and the methods of
. Finally, let's note that poverty itself is one of the biggest causes of health problems. A national
health plan could help a bit: it would prevent impoverishment from medical bills, and it would be
especially important in allowing the poor to have medical care. But it could not eliminate mass
unemployment, discrimination against minorities, bad schooling, bad housing, and so forth. This
requires the social transformation of the entire society.
Workers must put their stamp on the health system
. A national health plan is not the same as a socialist plan. It would, however, bring needed relief for the workers today. But since such a plan is administered by the capitalist government, the workers must be vigilant to ensure that it would provide for their needs. This is especially true today, when many capitalists think that the chief virtue of "managed competition" and/or national health plans would be saving money for the corporations, and when many politicians are talking of restricting social services for undocumented immigrants.
. Under socialism, the population will no longer be divided into exploiters and exploited. The
population as a whole will naturally take a hand in something that interests it so much as health
care. But under the present system, national health care is subordinated to capitalist interests. So
it will not be sufficient to obtain a national health care plan. It will be continually subject to
cutbacks, and the character of the medical care will be subject to the profit-making of the health
industries. There will be a continual struggle between health care for profit and the medical needs
of the masses. So rank-and-file workers must organize, not just to obtain a national health plan,
but to influence how it's run. These struggles face us today. <>
September 10, 2007.