The health care debate

(Presentation at the Detroit Workers' Voice Discussion Group meeting of September 27, 2009, supplemented with additional material, some of which was suggested by participants at the meeting)

The system of medicine for profit has gone into crisis in the US. The increasing difficulty people have financing health care has reached the point of a crisis. Not only are there almost fifty million people uninsured, but tens of millions more of insured people find that they can't get care when they need it. For example, a recent study by the California Nurses Association shows that California health insurers deny more than one out of every five medical procedures which doctors prescribe for their patients, and this has resulted in the death of a number of insured patients. (See "California's Real Death Panels: Insurers Deny 21% of Claims: PacificCare's Denials j40%, Cigna's 33% in First Half of 2009", www.calnurses.org/media-center/press-releases/2009/september/california-s-real-death-panels-insurers-deny-21-of-claims.html.)

This growing crisis is the background for the health care debate that has broken out over Obama's proposal to make mainly private health insurance universal. There are so many different proposals, and some of the proposals are so complicated, that it's easy to get bogged down in a mass of details. To avoid this, I will concentrate on the class issues and general principles involved in the different health care proposals, rather than a mass of details. In the discussion afterwards, people can bring up any of the points for more elaboration.

And indeed,  health care is a class issue. That millions of people in the US who can't get adequate health care is an example of the brutality with which free-market principles bear down on the working class, and doubly so on the poor and the minorities. Health care is big business in the US, and it has  some of the most profitable companies around. But the profits of the health industry go hand-in-hand with medical crisis for the masses.

It's a class question, not a matter that nobody knows how to provide health care for an entire country. If providing health care were just a technical matter, it would have been provided to everyone in this country a long time ago. The fact is that most wealthy industrial countries do much better at providing health care to most of their inhabitants than does the US. From the relatively simple national health service in Britain and single-payer or government insurance in Canada to complicated hybrid systems of universal care in France and Germany, to Japan, Taiwan, and various other countries, health care is provided for almost everyone. Not surprisingly, the US doesn't fare particularly well in health statistics compared to other rich countries, but  the US is far and away the leader in the amount of profits flowing to the health industries.

It's not that the foreign systems of universal health care don't have their problems. They do. The bourgeoisie in those countries as well as the US is in love with market fundamentalism, and is seeking to pare down the social programs of the past. But it is the American position as the foremost market-fundamentalist power, and the fanatic adherence of the American bourgeoisie to market fundamentalism, that has led to the health care crisis here. Single-payer health insurance, such as that in Canada, would do away with most of private medical insurance, and the American bourgeoisie won't hear of that. A system similar to the National Health Service in Britain would also do this. Even the complicated hybrid schemes in various European countries, while using private insurance as part of their plan, regulate the insurance so stiffly that it would look like a government program to an American capitalist.

When we look at what  the Republicans and Democrats are proposing, we will see that the problem is this: the insistence of the politicians, in service to the bourgeoisie, on maintaining the profits of the private insurers and other health industries, and their insistence on maintaining deregulation, privatization, and market methods. The neo-liberals pretend that we will get health care, not through extending entitlements like Medicare to the entire population, but through everyone going on the market and trying to find private insurance. This is what is blocking health care reform.

Let's review the different standpoints of the Republicans and Democrats.

The conservative Republicans and the "teabaggers"

Let's start with the conservative Republicans. They have been shouting and screaming against the idea of health care reform, and have organized the "teabaggers" to go around and rant against Obama and his proposals. The conservatives and teabaggers have even descended into crude racist taunts at Obama, as well as presenting him as a Hitlerite, and one poll shows that 8% of the people in New Jersey believe that Obama is the "anti-Christ". According to this poll, among those who identify themselves as conservatives, 18% think Obama is the anti-Christ, and another 17% aren't sure about the matter.

Now, behind all this mindlessness and hatred for Obama, what are they advocating? It's that the present system is fine, and it should be perfected by just freeing up the capitalists a little more, deregulating a little more, and everyone will be happy. This is what the teabaggers mean when they shout against government interference in health care.

And along those lines, the main Republican plan in Congress consists of

A) curbing malpractice suits. This is supposed to be the cause of high medical prices. But various states have already done this, such as California and Texas, and it hasn't made much difference to medical costs.

B) allowing people to buy out-of-state private insurance. The conservatives want this because it would free up insurance from state regulation. But it wouldn't solve anything for people wanting health insurance. Since there isn't any state where the private insurers are doing a good job, having people buy a crappy out-of-state plan wouldn't be any better than buying a crappy in-state plan.

C) removing all regulations on the insurers and the health industries. There are articles and  books presenting deregulation as "consumer-centered" care, although it would really mean unrestricted profit-centered care. They claim that the health crisis stems from an insufficiently free market. Sometimes this can reach extremes. The table next to us at the Dally in the Alley was that of the Ron Paul people, and their so-called "campaign for liberty". The man I spoke to advocated that a true free market in health care would mean, not just no Medicare and no government health programs, but not even private insurance. Even private insurance was supposed to distort the health market.

These plans are delusional. It's like lemmings marching to the sea. The free-market plans would, indeed, help the health capitalists do whatever they want, but the health care crisis for the masses would get worse and worse. The only credibility that this mindless and fanatic conservative agitation has is that it plays on people's legitimate fears that Obama's plan would result in cutting some of their present health care coverage. As we shall see later on, there is a point to these fears, but trying to fight these fears by joining the teabaggers is jumping out of the frying pan into the fire.

Obama's plan

So this brings us to the Obama plan. Since the teabaggers denounce him as a "big government" man, a socialist, and so forth, one might imagine that he really is a radical, and that he wants major change. Nothing of the sort. In fact, his plan is to maintain the system of private insurance that is the problem, and to bail out marketplace medicine with some government help. Just like his bail-out of the banks was not a socialist step against financiers, but a way to keep the bankers solvent, so his plans for the health care industry are not a socialist step against the private insurers and the pharmaceutical companies, but an attempt to keep them happy. In fact he has been playing footsy with them, meeting with them to arrange the details of the plan, promising them major concessions, and so forth.

Obama's idea is to solve the problem of universal coverage by forcing everyone to buy private insurance. The lack of logic of this plan shows the desperate fanaticism by which the bourgeoisie clings to market principles. Problem: people can't afford to buy private insurance; supposed  solution: to require them to do what they cannot afford to do. This logic may, of course, meet the approval of the private insurers, who are rubbing their hands at tens of millions more policies financed by government subsidy, but it's not going to work.

Obama believes that he can square the circle, and have everyone buy private insurance, by giving subsidies to those who are in poverty. And, he thinks, he can find a good deal of the money to finance these subsidies by taking money away from one part of the health system and giving it to another. Later on I will go into who is going to lose under the Obama plan, but for now, let's just say that it is fantasy health care, a worthy successor of Ronald Reagan's voodoo economics.

The fact is that various states have already tried to solve the health crisis in the way Obama proposes. Currently, the model is the Massachusetts, where everyone is supposed to buy private health insurance or they're penalized. Those who can't afford insurance are supposed to be subsidized, except that immigrants are treated badly. I've brought to this meeting a 2009 report on the results of the Massachusetts plan ("Massachusetts' Plan: A Failed Model for Health Care Reform", February 18, 2009, www.pnhp.org/mass_report/mass_report_Final.pdf). It shows that, despite the legal requirement for universal insurance,  the plan hasn't provided universal coverage. True, there are more people insured under this plan than before, but unfortunately there is also a higher percentage of people who can't afford health care even though they are insured. In order for Massachusetts to provide affordable private plans to people, the private plans are often so meager as to be painful themselves. For example, many of the new private plans may have a $2,000 deductible, to say nothing of the various co-pays. We also have available at this meeting the August 2007 issue of Communist Voice which describes the Massachusetts plan (see www.communistvoice.org/40cMass.html).

The fact is that Oregon, Minnesota, Tennessee, Vermont, Washington, and Maine have also tried variants of the plan of  making private insurance universal, while subsidizing those who can't afford it. None of them have achieved universal coverage, and the document on the Massachusetts plan that I've brought to this meeting has graphs documenting the failure in these states. The usual result is that, after a while, the state finds that it is spending huge amounts of money and has to cut back its plan. The most recent fiasco was that of the collapse of TennCare, the plan whereby Tennessee moved people from Medicaid by putting them into privately-managed care programs. Eventually all of the private companies dropped out of the program and the state was left holding the bag.

The class basis of all these plans is that they are an attempt to solve the problem while leaving the profits of the private insurers and the health care industry untouched, and while continuing the path of privatizing government programs. No matter how much these plans flop, there is always a new one being promoted, because the bourgeoisie still believes in neo-liberalism. It will require the smash-up of neo-liberalism, and the mass pressure of the working class, to bring something new to the health care debate. And then it will be found quite possible to provide universal, quality care.

Tired-out principles of privatized coverage

Meanwhile, Obama's framework for a health plan follows the same tired old neo-liberal principles. It's based on the following ideas:

* There shouldn't be a new government entitlement, whereby people are guaranteed a certain level of health care, as Medicare somewhat does. Instead, people are to be mandated by law to find private insurance; and this insurance, especially for the poor, will be very spotty. Help may be given to those who can't afford the mandate — depending on who's in power and what the government budget is like — but in the final analysis, the individual is to be penalized if there is a problem.

* The private insurers, the pharmaceutical companies, and the hospital capitalists are too big to fail.

* The subsidies to individuals will, in effect, be subsidies to the private insurance companies.

* Employer-based insurance will be continued, thus keeping workers' health coverage tied to the health of their companies and the workers' ability to resist cutbacks. Workers will have to fight employer-by-employer over the extent of their benefits, and this is very difficult in the current great recession.

* The program will be revenue-neutral; that is, much of the cost for extending private insurance to more people will be borne by taking money away from other aspects of health care.

* Medical reform will be driven mainly by cost control over how much medical care is provided, and will have nothing to do with either restructuring the health industries, eliminating private insurance, or mass involvement in the orientation of medicine.

Yet at the same time, Obama promises that those who can't afford health care will be subsidized, that people will be able to transfer their health care from one insurer to another, and that there will be no exclusions for prior conditions. But how can he accomplish this, while implementing his principles? How can he avoid the problems that affected all the states that tried to do these things?

He can't. The attempt to do has resulted in a plan that is monstrously complex and involved. The House health care bill is over 1,000 pages. And it is reported that it schedules the implementation of this or that measure over a time period taking up to a decade. Right there, that should be a giveaway that something's wrong. Thus it isn't supposed to be until 2013, after the next presidential election, that the Health Exchanges are to opened, the Health Exchanges being where uninsured oeople are supposed to get their coverage. And other features of the plan would wait still more years to be put in place. An Afro-American political website, "The Black Agenda Report", commented acidly on this timing that Medicare, put into practice in the mid-1960s, managed to be up and running in eleven months, while today, in the age of computers, the Obama plan would take a decade ("Is the Obama Health Care Plan Really Better Than Nothing?", www.blackagendareport.com/?q=content/obama-health-care-plan-really-better-nothing).

This complexity reflects the difficulty in finding any way to extend private insurance to all, and it also reflects a deadlock between different capitalist interests — those of private insurers, hospitals, states with their Medicaid budgets, etc. — over what to do.  But it's also true that this complexity is itself a class issue. It helps the bourgeoisie, much of which can profit handsomely over a complex plan, while hurting ordinary people who are left bewildered.

When a bill's so complex, and when there are so many different programs and subsidies and exceptions and subclauses that differentiate the care one person will get from what another person will get, it divides up the population, and makes it hard for the masses to fight for their rights.

And the more complex a bill, the more room there will be for high-paid managerial consultants, lawyers to interpret the bill, and so forth. There will be more and more money for bourgeois and administrative positions, and less and less for health care.

Squeezing the young, the old, unionized workers, immigrants, and women

Finally, it can be noted that Obama, while seeking to conciliate and bribe off just about every capitalist interest involved, has made the plan repulsive to may people. This is the result of his revenue-neutral pledge.  Many natural constituents for health care reform, who might otherwise come out on the street demanding health care reform, face the possibility that Obama's plan, to this or that extent, will hurt them. This, as I mentioned before, is being exploited by the teabaggers for their own stupid, mindless, racist, and  nefarious interests, but we do have to recognize that there's a real issue here.

Let's look at some examples.

Obama raised the possibility of taxing so-called "gold-plated" employer-paid medical plans. But workers fought hard to get employer-paid benefits. It would be one thing to replace these benefits by a national or government plan: that would be an advance that would separate workers' health from their employers' whims. But to insist that these benefits be cut back, and to finger some of these benefits as the alleged cause of the high cost of medical care, is outrageous. The attack on "gold-plated plans" suggests that Obama thinks that cost-cutting should be accomplished by keeping insurance plans so filled with limitations and co-pays and deductibles that getting medical care would remain so financially painful that workers will shy away from using very much of it.

Obama would also finance the plan, in part, by massive cost savings in Medicare. He claims that this can be achieved by cutting reimbursements to doctors and to the HMOs who run the Medicare Advantage plans, which are a privatized section of Medicare. But it's hard to see how these cutbacks can be made without, in fact, cutting medical benefits. If Obama proposed to eliminate Medicare Advantage and replace it by extending Medicare benefits, that would be one thing. But to threaten the benefits many seniors already have is an entirely different thing.

The Obama plan stresses the need to enroll young adults, not for the sake of their health, but as a way of helping the private insurance companies keep down premiums for older workers. And on top of this, special plans for students and young workers are envisioned which would give minimum benefits, just as is presently done, by the way, in Massachusetts. Thus these plans make youth one of the villains of the drama, while the real villains are the corporate profiteers.

In his major speech of Sept. 9, Obama stressed that his plan would not give a penny to help undocumented immigrants. This means that his plan would leave out many workers in the direst need of help, and does not really aspire to be universal health care. This also helps alienate the large section of workers who are closely connected to the undocumented immigrants and concerned about them.

Obama also pledges that no federal money would be used to cover abortions. Does this mean that people who get subsidies under Obama's plan couldn't use their subsidy to buy a health plan that covers abortions, or does it mean that all private plans would have to drop coverage for abortion in order to be part of the Obama plan? Who knows? But whatever the answer, it's clear that Obama's betrayal of women's rights will hurt women's health care.

Thus workers, seniors (with their experience of Medicare), and young people, who should be enthusiastic backers of national health care, are made into targets of the plan, and all of them have reason to worry about what type of medical care they will be provided. Similarly, the Latino population will face pressure from the anti-immigrant provisions of the bill, while women are treated callously.

Thus the reality of the Obama plan conflicts with its promise of universal health care.

Alternatives, real (single-payer) and apparent (the public option)

It's no wonder that the Obama plan has gathered opposition even from some Democrats. So what is the alternative? A section of Democratic liberals are insisting that Obama make good on the promise for a public option, which would serve as an alternative to private insurance. This is the main issue the liberals are fighting on. However, the public option really wouldn't change the Obama plan very much. It was never intended to cover a large number of people: it wasn't supposed to be available to everyone. Moreover, it is being insisted that the public option would be run in the same way as a private insurance company, except maybe as a co-op. This would mean that it really wouldn't be that different from the private insurers.

Meanwhile, a section of the liberal Democrats talk about "single-payer health insurance", such as the plan put forward by the Conyers bill, HR 676. These plans would be roughly similar to the system used in Canada. They would not make private health insurance universal, but would eliminate most private health insurance. Instead, the government would pay the bills for the medical work authorized under this plan. It would be something of an extension of Medicare to the entire population.

This is a real alternative.  "Single-payer" health insurance would be a major advance. It would provide universal health care (provided all immigrants are included, as they are in the present version of HR 676); by its very nature, it would eliminate the worry about preexisting conditions; and it would also eliminate all worries about portability, since one would be covered anywhere in the country. It would manage health care more efficiently than private insurance, and cut out the huge overhead and administrative costs of private insurance.

This would be a real change in the health care system and a gigantic step forward. It is feasible, as its existence in Canada shows. It's simple and straightforward, and it puts everyone in the same category, which by itself is a certain guarantee against some types of abuses. It does all this by going against market fundamentalism — by making health care into an entitlement, and replacing private insurance by a government program. It is a reasonable plan and technically feasible; and it's reasonable and feasible only because it sins against market fundamentalism and takes one aspect of health care out of the reach of financiers and corporate CEOs.

Does this mean single-payer health insurance is socialism? No doubt it is in the eyes of the teabaggers. But, unfortunately, it is not socialism, but only a reversion to the capitalist "mixed economy", which was the theory preceding market fundamentalism. It's no more socialism than public libraries, public schools, the fire department, and the public water supply are socialism. Capitalism always makes use of the government to provide for services which can't be provided by the free market; and the bourgeoisie swings back and forth between using more or less regulation, more or less government intervention. It is in the interest of the working class that health care be regarded as a right of every citizen and that health insurance be turned into a government function; but that doesn't mean we should be under any illusions about health care becoming socialist simply because the government pays for it.

Meanwhile, Conyers and the congressional backers of "single-payer" aren't pressing very hard for it, since as Democrats they are beholden to the bourgeoisie and they know the bourgeoisie still isn't willing to go for it. Moreover, Conyers and other single-payer advocates usually obscure the class issues surrounding a change to single-payer health insurance.

For example, it is often presented that the change to single-payer would be easy, since there is no major technical obstacle to implementing a single-payer system. But the obstacles to implementing single-payer aren't mainly technical; they're based in the class interests of the bourgeoisie. Not only is the bourgeoisie as a whole still insisting on market solutions to everything, but over the last few decades the health industries have grown into extremely powerful financial interests. Consider the big insurers and HMOs, the  big pharmaceutical companies, the medical suppliers, and the increasingly-corporatized hospitals. They are influential, and they will oppose any plan that eliminates them, as the private insurers will be under single-payer, or restricts them.

Even back in the 60s in Canada, when single-payer came up, it took more than convincing the people of its desirability. It took standing up to opposition. Single-payer was first introduced in the Canadian province of Saskatchewan by the Cooperative Commonwealth Federation government of Tommy Douglas (the CCF was the predecessor of today's flabby New Democratic Party). It was immediately met by a doctors' strike, which failed due to lack of popular support. One might expect that, today in the US, the opposition of fabulously wealth insurers and other health corporation interests to single-payer insurance  would be much more fierce than that of the Saskatchewan doctors of the 1960s.

Moreover, it will be important for the working class to be vigilant about how new government programs, even a single-payer program, are carried out. Neo-liberalism, or market fundamentalism, isn't the only form of capitalism. When the bourgeoisie, faced by economic and environmental crises, turns back from market fundamentalism to the theory of the "mixed economy", it will be important to see that this is  not a turn to socialism, but only an adjustment in capitalism. It will be important for the working class to keep up mass pressure on the government regulations and government programs that are established, including health programs. Single-payer health insurance, or even a national health service, would not be the end of the struggle over health care.

If we want to be sure that all immigrants are covered by health insurance, we can't simply rely on the fact that the present draft of the Conyers Bill covers all residents. It will be necessary for the working class to organize and protest in defense of the immigrants, including the undocumented immigrants..

If we want health care to include abortion rights and contraceptive information, the working class had better be vigilant on this question. The conservatives who today organize teabaggers, and the corporate interests who fund them, won't go away in the future, but will continue to push reactionary ideas.

If we want to ensure that health care reform and cost-cutting doesn't mean restricting treatment for workers and the poor, but instead means restructuring the health care industries, curbing corporate profiteering,  eliminating the bad health care practices fostered by the big pharmaceutical companies, and so on, the working class is going to have to get organized in its own right.

Indeed, let's not forget that many advances in health care have come about because of mass influence. The large mass movements of the 60s pushed, not just for better funding of health care, but for better health care practices. It was the women's movement and pro-choice movement that not only fought for reproductive rights, but for more attention to women's health issues from breast cancer and menopause to assessing the differences in how medications and other treatments affect women and men. The black people's movement persisted in pushing for the issue of the sickle cell trait to be taken seriously. Gay people fought tor attention to be paid to AIDS. And the general movements against racism and sexism have had a lot to do with bringing more minorities and women into the ranks of doctors. Moreover, the overall atmosphere created by the mass struggles of the time resulted in eliminating a bit of the elitism and arrogance manifested by some doctors. Reforms like "single-payer", however important, don't do this in and of themselves; mass pressure is required. It is the mass struggle, and not deregulation or choosing between one or the other over-priced private  health plan, that will bring people- centered medicine.

So long as capitalism exists, there will always be need for this mass pressure, and the capitalists will seek to take back the concessions they make on universal health care and other issues. This can be seen if one examines the state of the European and Canadian health care systems which, while superior to the US system, are susceptible to neo-liberal cutbacks, and to being starved of funds. It is constant pressure from the working population of these countries that prevents these plans from being dismantled.

Socialist health care

Socialist health care is something that will exist only under socialism, when the workers are in control. It will resemble the best capitalist plans in being universal health care. But it will remove the profit motive not just from health insurance, but from all the health industries. And because the workers will take over the running of the entire economy, it will be possible to integrate health care more closely with taking care of workplace injuries, with providing guidelines to make the workplaces safer, with keeping track of the dangers of new chemicals, new products, and new innovations, and so forth.

Socialist health care will also differ from capitalist health care in radically curbing the elitism that persists in the present health professions. While there will always be a need for specially-trained medical personnel and doctors, the entire structure and ideology of a socialist system will provide a closer integration of ordinary workers and medical personnel, and more room for the masses of people to influence the practice of medicine. Also, as part of the  general linking mental and manual labor under socialism, a closer collaboration of medical professionals will replace the present vast gulf between doctors, nurses, and other health workers. The financial reasons for maintaining this elitism in health care, which operate powerfully under capitalism, will no longer exist under socialism.

Health care is a class question

Summing up, the present health care debate has become obscure because of the mass of details. But  underneath the complexities of the health care problem, we can see some basic  issues:

* It is not a technical problem to introduce universal health care, it is a class problem: the issue of overcoming market fanaticism. The  market-fundamentalist bourgeoisie doesn't believe the working class has any right to health care or anything else, and  powerful corporate interests in medicine would be harmed by government health plans.

*  We can also see that there is going to be a long fight on the issue of health care, even after the achievement of  single-payer health insurance, and even if Medicare were extended to everyone. That's because the high cost of health care, and the very treatments prescribed by doctors and others, are affected by the corporate interests such as the large pharmaceutical companies.

* Even though some capitalist interests may back this or that reform in order to get out from the burden of high medical costs, it is only the working class that will fight wholeheartedly for universal health care.

* And neither the Republican fanatics nor the Democratic Obama administration are on the side of the working class. Both the teabaggers and Obama, each in their own way, back market solutions and link up with various corporate interests. It is up to us to build an independent working-class movement, and to have this movement intervene as strongly as possible in the debate on health care. <>


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