by Mark Williams
(CV #40, August 2007)
Profit vs. health care
Who supported the dominance of the HMOs?
Nationalized health systems
The struggle for health care
. The system of free-market medicine in the US has produced one horror-story after another for the working masses. Profit rules in healthcare, and the masses suffer because of this. Health insurance costs and arbitrary denials of coverage by the insurance companies mean over 40 million people lack any health coverage. Even for those with insurance, the profit-drive of the insurance industry means denying adequate medical care, a heavy financial burden for premiums, and driving people to financial ruin to cover medical expenses they thought their insurance would cover.
. But the mainstream bourgeois politicians, Republicans and Democrats alike, promise that the health care crisis can be fixed without making serious inroads against the profit-driven medical industry. And this message is echoed in the mass media. The most the bourgeois establishment is presently willing to do to fix the system is finding new ways to extend the disaster that is the health insurance industry.
. The main merit of Sicko is that it moves the debate beyond this framework. It exposes the crimes of the HMOs which make vast fortunes by denying needed health care. While this is the main focus of the film, Sicko also hits at the big drug monopolies and other aspects of for-profit medicine as well. The capitalist debate on the heath care crisis confines itself to pointing out that there's tens of millions of uninsured; Sicko stresses that the problem is not just uninsured people, but that those with health insurance are also screwed. Thus, Sicko calls into question the whole notion of private insurance. Moreover, it goes on to show the superiority of nationalized, government-run health insurance systems, nationalized hospitals, and government-subsidized pharmacies, which exist in various other countries.
. In this way, Sicko helps give voice to the sentiments of countless workers and poor who are all too familiar with the dysfunctional American health system. There has long been a core of activists and workers fighting for universal national health care. This film will help push their cause to the fore. It will also, hopefully, draw new forces from among the working masses and poor into the struggle.
. Unfortunately, the film does not give a realistic picture of what the struggle for health care for the masses entails. It presents an idealized version of the national health care systems it examines in Britain, Canada, France and Cuba. It ignores how the nationalized systems have been under attack, and not only by right-wing politicians, but by liberal, reformist, and state-capitalist trends as well. As regards the US, Sicko only touches the tip of the iceberg when dealing with the treachery of the Democratic Party and its long collaboration with the private health care industry. But that's not to be wondered at seeing as Moore has for several years been touting rotten Democratic political candidates such as former imperialist presidential candidates John Kerry and General Wesley Clark.
. Sicko also does not deal with the issue that national health care is but one step forward and that
a thorough and lasting solution to many health care problems can only be solved when capitalism
is overthrown and the productive forces of society are under the control of the working class.
Indeed, it confounds socialism with everything from national health care in a Western capitalist
country to the phony communist regimes such as Cuba, or the former Soviet Union, where an
elite party/state bureaucracy lords over the workers.
Profit vs. health care
. Moore's film shows time and again how the profit-motive of the health insurance industry clashes with providing health care. The extent of the rotten treatment of the masses by the private insurance firms is illustrated by the fact that, according to the film, in only one week there were some 25,000 responses when Moore solicited health insurance horror stories. The film spends much of its time chronicling particular cases that represent the various abuses the masses commonly experience at the hands of the insurance corporations. Families face financial ruin because the insurers won't pay for certain procedures. There are workers of advanced age who must work until they die for fear of losing job-related insurance. There are people rejected for health insurance because the insurance company profile of them determines they might actually get sick. The film contains footage and interviews with people who are now dead because the insurance company refused to approve certain diagnostic tests, drugs, or life-saving procedures. In short, Sicko essentially (and rightfully) accuses the capitalist medical establishment of murder.
. The type of atrocities shown in the film are not simply the accident of this or that overzealous
bureaucrat. They are a direct product of the quest for profit. Sicko brings this point home by
interviewing some former health insurance "insiders". One, Lee Einer, reports how his job was to
find any minor technicality in a policy or in an application for insurance in order to deny
payment. He emphasizes it was not "mistakes" but a conscious policy to maximize profits. A
doctor who used to review cases for Humana, Linda Pino, is interviewed and seen offering
testimony before a 1996 Congressional hearing. She relates that her job was to find ways to deny
treatment. She and others who did this, got bonuses and promotions. Pino remorsefully tells the
Congressional hearing that she was responsible for the death of a man because she denied him a
needed operation. Yet she was rewarded by the health insurance company because denying the
operation saved the company a lot of money.
Who supported the dominance of the HMOs?
. Having correctly targeted profit as the villain, Sicko sets out to explain the connection between the medical establishment and the bourgeois political system. One aspect of this is how the greedy health management organizations (HMOs) came to dominate health insurance. The film doesn't mention this, but the system of private insurance prior to the rise of the HMOs was also woeful and in crisis. Prior to HMOs becoming dominant, "fee-for-service" insurance was more prevalent. Patients could go to the doctor of their choice and were reimbursed by the insurer a set amount of each particular medical treatment, with the patient paying the remainder out-of-pocket.
Sicko notes that the HMOs were given a big impetus by the Republican Nixon administration in the early 1970s. The film contains excerpts from a taped White House conversation between Nixon and John Ehrlichman, Nixon's top domestic affairs advisor, on health care policy. In this Feb. 17, 1971 conversation, Ehrlichman talks about his meeting with Edgar Kaiser, head of the Kaiser Permanente HMO. Ehrlichman says that health maintenance organizations should be a key part of Nixon's health care plans. Why? Ehrlichman explains that "Edgar Kaiser is running his Permanente deal for profit. And the reason that he can . . . the reason he can do it . . . I had Edgar Kaiser come in . . . talk to me about this and I went into it in some depth. All the incentives are toward less medical care . . . the less care they give them, the more money they make." Nixon replies, "Not bad." The next day Nixon gave a televised speech announcing his new health care initiative which touted HMOs as a key to spreading health care. These tapes show that Nixon and co. saw the HMOs as a way to keep health care limited and that the main purpose they served was to fatten the wallets of the health care executives.
. From the film, one would get the impression that the huge expansion of the HMOs since the early 1970s was backed only by the Republicans. But in reality, it wasn't only Nixon's gang. The Democrats gave a great boost to the expansion of HMOs as well. And the bulk of the class collaborationist trade union leadership jumped on board in touting the HMOs sponsored at the workplace, over the progressive alternative of national health insurance for all. Indeed, while Nixon's original HMO-expanding plans died, they passed in a different form in a bill sponsored by Democratic liberal senator, Edward Kennedy. Back in the 1970s, Kennedy was boasting "As the author of the first HMO bill ever to pass the Senate, I find this spreading support for HMOs truly gratifying. . . . . HMOs have proven themselves again and again to be effective and efficient mechanisms for delivering health care of the highest quality. HMOs cut hospital utilization by an average of 20 to 25 percent compared to the fee-for-service sector. They cut total health costs from anywhere from 10 to 30 percent. And they accomplish these savings without compromising the quality of care they provide their members."(1) Here we see the liberal Democrat Kennedy hailing private managed health care companies in the manner of Nixon they cut hospital utilization. As for Kennedy's boasting of the cost savings and fine heath care by the HMOs, Sicko itself shows that this is a joke as the HMOs have not provided adequate health care, but have succeeded in helping health care costs soar. In fact, these days Kennedy and most of the Democrats point out the evils of the HMOs. Of course at the same time the majority of congressional Democrats are still not willing to rid us of these parasites.
. After dealing with Nixon's plan, Sicko picks up the story of HMO expansion with the coming to power of the first Clinton administration. The film tells us that Hillary Clinton was proposing universal health insurance and that for this reason she, and the idea of universal coverage, was subject to a smear campaign by right-wing politicians and media. Indeed, Hillary's proposal came under a vicious attack by the conservatives. But Moore doesn't carefully look into Hillary's actual plan. This plan, far from actually providing proper and universal medical care, reconciled itself to the existence of the private managed care system, albeit with some reforms. Moreover, one of the reasons the bill failed was that it was so complex, it was virtually impossible for even its supporters to explain it, much less gather support for it. The complexity was largely due to the fact that it was crafted so as not to impose much on the private health care establishment. Despite the sops to the medical establishment, much of that establishment didn't like the bill anyway.
. While the early plans of the Clinton administration are whitewashed, the film does contain a scathing condemnation of Hillary in later years for becoming a tool of the health insurance industry and accepting huge campaign contributions from them. And it mocks how Bill Clinton caved in to the right-wing after its assault on the early Clinton health care plans, relegating Hillary to the mindless traditional ceremonial duties of the First Lady. But this is about the only criticism of any Democrats. After this lone example, the film stresses again merely how the Republicans are tied to the health care establishment. Sicko shows how Bush II's drug prescription bill for seniors was designed not so much to help seniors pay for medicine, but to help the big pharmaceutical companies and the HMO's divide up $800 billion in government funds between them. It contains scenes of Republican Congressman Bill Tauzin of Louisiana stumping for the bill, then, after its passage, accepting a $2 million check from drug companies' lobbying group to be its new CEO.
. True, the exposure of Hillary Clinton does give some idea that the Democrats are sold out to the
corporate health industry too. Still, the confusion created about the earlier Clinton administration
health initiative puts a damper on this, confounding the convoluted health plan of the early
Clinton administration with a real step beyond the nightmare of private health insurance. This
vacillating attitude toward the Clinton administration reflects Moore's own stand on the
Democrats, namely, that while they too sell out to big business, they do so less than the
Republicans. And this has been Moore's rationale in backing the Democrats and, in this way,
impeding efforts to build a political trend independent of the capitalists and their political
Nationalized health systems
. Sicko accompanies its exposure of the US health care system with promotion of the national health care systems in Canada, England, France and Cuba. It correctly points out that these systems are superior to the US system. Each of these systems has its own features: some nationalize insurance only; some have nationalized hospitals and other medical providers as well. They are universal, they often offer the patients a much wider choice of medical providers than HMOs here, they are a good deal more egalitarian, they often include meaningful price controls or subsidies for medicines, and so on. They are paid for by taxes. This means, unlike in the US, expensive treatments do not result in bankrupting patients with enormous out-of-pocket expenses. Moreover, these taxes are much less than what consumers have to fork over to the private US health capitalists, so these systems are much less expensive while providing better service. The key to all these systems is that health care is considered to be a public service and that the extent of private profiteering is small compared to the US.
. This is not the whole story with the government-run systems in these countries, however. Sicko omits any serious examination of how these systems are always in danger of being gutted or privatized. The national health plans are part of an overall capitalist economy, with its inevitable crises and efforts of the capitalists to force the burden of the crises onto the masses with budget cutbacks. This process of chipping away at the national systems has intensified with the influence of "free-market" neo-liberal ideology among both conservative and liberal governments around the world, and also state-capitalist governments (like Cuba and China).
. For example, for many years now the National Health Service (NHS) in England has undergone free-market reforms. This has been carried out by successive governments from the Conservative Margaret Thatcher through the Labor Party's Tony Blair. These reforms were based on copying features of the HMO system in the US. Indeed, one of the key ideologues of these market reforms was the American Alan Enthoven of Stanford University, who not only supports HMOs, but recommends that employers offer cheaper and crummier HMOs to their employees. (2) These market reforms have led to many hospital closures, cutbacks in the health care workforce, longer waits for medical care, curtailing certain procedures due to lack of hospital funds, and other abominations. Not surprisingly, this has led to a major increase in complaints from patients. All this only helps prepare the ground for an eventual outright privatization of the NHS.
. Cutbacks have damaged the national health insurance system in Canada, carried out not only by the openly bourgeois parties, but also by the provincial social-democratic governments of the New Democratic Party, which pretends to be "socialist."
. The medical system in Cuba is glamorized by the film, too. True, it is a superior to the US
system, and remarkably so given the weakness of the Cuban economy compared to the US. But
Cuba is also a country where market measures have been introduced into the dominant
state-economy on a wide scale. This has increased the gap between the oppressive party/state
elite which runs Cuba and the working masses. This gap also exists in health care, where the top
phony "communist" officials have access to superior medical treatment.
Are the national health systems safe
under the conservative and reformist governments?
. Yet "Sicko" creates the impression that everything is fine in the national health systems and that all the political trends in the country wouldn't dare touch them. For instance, in the movie Moore interviews Tony Benn, who has been a leader of the left-wing of the British Labor Party, a tame labor party that for many decades has, despite its often fiery rhetoric, sought to reconcile the workers to the capitalists. Benn assures Moore that the British National Health Service is so popular, no politician, not even Margaret Thatcher, would destroy it. True, Thatcher didn't dare abolish the NHS in one blow. But she, and subsequent governments, have been hacking away at it and want to make it run on the principles employed by private profiteers. And the more this system becomes frayed, the more the groundwork is created for its total destruction. Similarly, Moore's film promotes the idea that all the French governments won't go after their health care system because they are afraid of the masses. Sicko contains scenes of mass protests against cutbacks in France, which is good. But in fact governments of various trends in France, despite the protests, have been whittling down the social programs there. This will no doubt intensify under the present conservative regime of the notorious anti-immigrant racist Sarkhozy.
. This kindly assessment of all the bourgeois governments in countries with national health care creates the impression, without saying so directly, that these political trends will obey the will of the masses, albeit with a little prodding. This is similar to Moore's approach to the Democratic politicians in the US.
. In fact, Sicko's tendency to prettify various pro-capitalist politics at one point goes to the extent
of parroting the jingoist "anti-terrorist" garbage of the US imperialist bourgeoisie. Moore raises a
hue and cry about how the prisoners held at the US military base in Guantanamo, Cuba are
getting wonderful health care while certain rescue workers at the World Trade Center are
suffering without health insurance. Moore never bothers to mention that the Guantanamo
detainees have been held indefinitely as alleged terrorists, solely on the say-so of the Bush
administration without the administration producing evidence against them or allowing the
detainees to defend themselves. Obviously the rescue workers should be provided health care,
but linking that to justifying one of the notable human rights crimes of the so-called "war on
terrorism" is shameful.
The struggle for health care
. Thus, insofar as Sicko deals with what the masses can expect from various of the trends of bourgeois politics, it is not very helpful. The film deserves credit for raising that there is a crying need for national health insurance and maybe other aspects of nationalized medicine in the US, and for showing that such things have improved healthcare for the masses in country after country. But it doesn't give a true picture of what the struggle for national health care involves.
. What the struggle for health care really needs is the establishment of a trend of the working masses that has its own stand in opposition to that of the Republicans and the Democrats. Both these parties have extensive ties to the health care establishment and have worked to subvert the movement for national health insurance. True, a relatively small left-wing of the Democrats in Congress has supported a bill providing for national health insurance that would replace most of the private health insurance industry. This is bill HR 676 put forward by Rep. John Conyers (D-MI) in the House. Legislation such as this would be a step forward. This does not mean that the masses can rely on the Democrats to fight for this, however. The top Democratic candidates for president, like Hillary Clinton and Barack Obama, want nothing to do with national health insurance. A Democratic majority was elected to Congress, but as a whole they have no intention to push for national health care, either. What's needed is to build up a mass movement, especially among the workers and poor. This movement must be oriented against both capitalist parties, lest its energy be dissipated by the slick Democratic politicians who are tied to the health care industry.
. This is hardly something that can be left even to the likes of Conyers and others in Congress who support HR 676. Conyers and other "left" Democrats come to rallies for progressive causes, but they too are defenders of the capitalists and their world empire. They act as a force to keep the movement from "going too far" by bourgeois standards. That's why Conyers' idea of an anti-war measure is bringing back the draft. Conyers called loudly for the impeachment of Bush and Cheney, but he's retreated on that in order to please the leadership of the party. And no doubt, Conyers will rally the masses to vote for whatever dreg the Democrats put up against the Republicans for president, even though the candidate will likely be a stooge for the health industry capitalists.
. The masses also need to put their imprint on the crucial features of any national health care plan that is put forward. As we've seen in countries where such plans exist, the bourgeoisie seeks to erode the system. There needs to be vigilance against cutbacks, efforts to have the national system mimic the methods of the private capitalists, attempts to privatize the system in part or in whole, etc. There will also be a fight over how the system is financed. Will the tax burden fall on the masses or the rich? Will copays and other out-of-pocket expenses be allowed to grow?
. These issues too call attention to the need for the new and fighting organizations of the masses. For instance, there's a need for rank-and-file organization in the work places and trade unions. The present trade unions are under the thumb of a leadership dedicated to class collaboration. They are afraid of the employers and afraid of arousing the masses to struggle. And they are overwhelmingly tied to the capitalist Democratic Party. Some unions, particularly at the local level, have acknowledged the need for national health care. And recently the AFL-CIO at the national level has talked more about the government playing a central role in health care. But on the whole, the trade union leadership has been missing in action when it comes to mobilizing the workers on this issue.
. In addition, it is important for class-conscious activists to bring to the masses a clear perspective on the limits of even the best system of national health care under capitalism. So long as capitalism exists, there is always the threat that the victories in providing universal health care will be reversed. Nor can a national health system deal with many of the systemic causes of health problems for the workers and poor. National health care cannot solve the problems of workers being ground down by overwork or suffering other maladies due to their work conditions. It can't solve the question of poverty and racism that greatly affect health and are ingrained features of the capitalist system. Nor will national health care solve the giant environmental crisis that threatens the health and well-being of the masses.
. National health insurance, by eliminating one part of capitalist profiteering in medicine, will be
a great boon to the masses. But insofar as capitalist profiteering exists in the rest of society, the
masses will continue to suffer and their health jeopardized. A long-lasting and comprehensive
solution requires eliminating capitalism and the profit-motive altogether. This long-term solution
to the health care crisis is socialism. No, not the phony "socialism" of Cuba, China or the former
Soviet Union. What's needed is a genuine socialist society in which the workers run the
economy, both at each workplace and as a coordinated whole throughout society. In this way the
productive resources of society will be used not to satisfy the profits of a few, but to uplift one
and all. <>
(1) Opening statement by Senator Kennedy to the US Senate Committee on Human Resources, Subcommittee on Health and Scientific Research, March 3, 1978. (Return to text)
(2) See, for example, Ethoven's "Employment-based health insurance is failing now what?"
posted on May 28, 2003 on the web site "Health affairs: the policy journal of the health sphere".
Enthoven's advice to expand the market mechanisms within the NHS is summarized in
"Reflections on the management of the National Health Service" of 1985. (Text)
September 10, 2007.