susanrosenthal.com

by Susan Rosenthal

Everyone talks about the health-care system, but capitalism cannot deliver real health-care. A genuine health-care system would oppose profitable practices like hazardous work, adulterated food, industrial pollution and wars of acquisition. This can’t happen as long as profit comes first.

Capitalism does not guarantee the right to a healthful society. It does guarantee the right to make a profit, including the right to profit from injury and illness. As a result, all existing medical systems emphasis treatment (which is profitable) over prevention (which isn’t profitable).

What we call “health-care” systems are actually disease-care systems that respond to problems after they develop. This article concludes by describing what a genuine health-care system might look like.

A License to Kill

A profit-driven society cannot prevent disease,¹ because the primary source of disease is the drive for profit itself.

The assault on health begins at work. To raise productivity, maximum effort is demanded at all times. Add a lack of concern for worker health and safety and you have a recipe for disaster.

Every year, more than three million people (9,000 a day) are treated in U.S. hospital emergency departments for work-related injuries. Every year, between 5,000 and 6,000 die from these injuries, almost twice as many as died in the 2001 World Trade Center bombing. Globally, an estimated 250 million people are injured and 330,000 are killed on the job every year.²

In 2002, nearly 300,000 new cases of work-related illness were reported in the U.S. This figure is very low, because many diseases, including cancer, are rarely reported as having a workplace origin.³ One study conservatively estimated that 55,200 Americans die every year from occupational injury and illness.⁴

Instead of mandating safer work, the State virtually grants employers a license to kill. In 1970, Congress declared that causing the death of a worker by deliberately violating safety laws is a misdemeanor (not a felony) with a maximum sentence of six months in jail. This is half the maximum for harassing a wild donkey on federal land.⁵

In 2003, a New York Times investigation revealed that workers were being “decapitated on assembly lines, shredded in machinery, burned beyond recognition, electrocuted, buried alive…”⁶ The Occupational Safety and Health Administration investigated only 57 percent of these horrible deaths and laid charges in only seven percent of the cases it investigated, despite finding that

“Between 1982 and 2002, a total of 2,197 workers were killed on the job because their employers “willfully” violated safety laws. With full knowledge of their responsibilities, they ignored accepted safety precautions, removed safety devices to speed up production or denied workers protective gear.”⁷

The lust for profit kills in many other ways. Profit drives the manufacture of defective, dangerous products and toxic chemicals that harm the worker, the consumer and the surrounding environment. Profit generates grotesque inequalities that deny millions of people the basic necessities of life. Profit creates epidemics of mental illness rooted in social insecurity, meaningless work and dead-end lives. Finally, hunger for profit fuels deadly wars that threaten human survival.

Instead of tackling the sickness generated by the system, all existing medical models accept the system as “given” and restrict themselves to “diagnosing” and “treating” the casualties of the system. And it took a huge fight to get even that.

Holding the Line on Reform

Although profit-seeking generates widespread death and disease, those who reap the profits resist paying for workers’ medical benefits. However, the capitalist class cannot escape a fundamental fact: profit comes from exploiting living beings, whose productivity is linked to their health. So the fitness of the laboring class cannot be left to chance. This lesson was learned during Britain’s industrial revolution.

In the early 1800s, as greedy employers worked malnourished men, women and children around the clock, Frederick Engels observed,

“Women made unfit for childbearing, children deformed, men enfeebled, limbs crushed, whole generations wrecked, afflicted with disease and infirmity, purely to fill the purses of the capitalist class.”⁸

Drunk with profit, industrialists were killing the geese that laid their golden eggs. Unless workers could survive long enough to raise the next generation, there would be no more workers and no more profit. Alarmed by this prospect, pro-capitalist reformers backed workers’ demands for limits on the length of the workday and some support for working-class families.

Today’s capitalists understand that basic health and social services are necessary to sustain production. Here the interests of bosses and workers temporarily coincide. However, the capitalist class insists on determining how social programs will be funded, organized and administered, so they never exceed what the profit-driven system can accommodate.

During the social crisis of the 1930s, President Roosevelt conceded the New Deal, but excluded national medical care. To quell the protests of the 1960s, President Johnson conceded Medicare and Medicaid, but held the line on universal coverage. The resistance to national medicare is financial and political.

Nationalizing the medical insurance industry would rob the capitalist class of profit-making opportunities. Moreover, it would give ordinary Americans a sense of entitlement (the same sense of entitlement that blocks the wholesale privatization of Canadian medicare). For capitalism to stay competitive, the majority cannot be allowed to think that it has a right to anything.

As pressure builds to reform the American medical system, debate centers on which model of disease-care would be best. Unfortunately, the only models on offer (including single-payer) are based on the capitalist business model, which cannot deliver medical care as a human right. The business model of disease-care is based on:

• commodity exchange, where health services and medical treatments are sold and purchased
• exploitation of health workers, paying them less than the value of their services
• exclusion of health workers and patients from the decision-making process
• decisions on health policy made by corporate executives, and/or government bureaucrats
• emphasis on individual responsibility for health
• disregard for the social sources of illness and injury
• rationing

There are three types of business model: a market model, a State model and hybrid models that combine elements of the other two.

The Market Model

The market model of medical care features multiple, competing payers and providers. Because most people can’t afford pay-as-you-go care, medical insurance was developed to sell this model to a broader consumer base. By pooling the risk of needing treatment, insurance companies can lower the cost to each customer. This sounds good in theory. In practice, insurance companies resist selling policies to sick people, because the fewer services they provide, the higher their profits.

The market model is very bad at delivering medical care and very good at generating profit. While the U.S. economy grows less than three percent a year, annual profits for the drug and insurance industries range between 15 and 20 percent. Profit is generated by paying health workers less than the value of the products and services they provide and by charging for medical services that are never delivered.

Legislation that forces people to purchase insurance (mandated insurance) supports the market model.

The State Model

The State model of medicine comes in two varieties, socialized insurance (commonly called “single-payer”) and socialized medicine.

Under the single-payer model, the State functions as a giant insurance company, paying competing providers (for-profit and not-for-profit). Under socialized medicine, the State pays and provides medical services, so that all health workers (including doctors) are salaried government employees. Both variations are funded from the tax base, so that individuals do not pay out of pocket (or pay less). American examples of single-payer are Medicare and Medicaid. The Veterans’ Health Administration is an example of socialized medicine.

Compared to the market model, State models of medical care benefit from economies of scale and reduced profit-taking,⁹ so they can deliver more services to more people for less cost. Per-capita medical expenditures in the U.S. are twice as high as they are in countries that provide national medical plans.

State-funded medical systems provide many other benefits. Patients are protected from having to pay exorbitant medical bills. People can change jobs without fear of losing access to care. Businesses profit when governments shoulder the burden of employee medical expenses. And most physicians (including those in the U.S.) prefer national medical plans that cover everyone.¹⁰

Despite these many advantages, the State model meets all seven criteria for the business model, including commodity exchange.

To eliminate the selling and buying of medical services, the State would have to nationalize the entire medical sector (manufacture and distribution of pharmaceuticals, medical devices and supplies), employ all health-workers, including doctors and dentists, and fund the system so generously that even the rich feel no need to purchase “upgrades.” Moreover, any nation that managed to eliminate its internal market would still have to deal with the international market in medical technology. As long as profit rules, business will dominate medicine.

As the economy slows, pressure grows to privatize State-funded medical services. Bureaucrats are employed to measure “cost-efficiency” and achieve “cost-containment” by reducing the number and cost of services provided, forcing health workers to do more for less and outsourcing services to the private sector. All these measures spur the growth of the market model.

Hybrid Models

The market model leaves out too many people, and the State model limits opportunities for profit-taking. The result has been compromise - hybrid systems that mix elements of the market and State models.

Hybrid models reflect and perpetuate the class system. A basic basket of State-funded medical services provides for the majority (or at least for the indigent); insurance companies and employers fund additional services for middle-class professionals and more productive workers; and elite, “boutique,” services are reserved for the rich and well-connected.

Canada has a hybrid medical system. Thirteen provinces and territories administer medical care, resulting in 13 different payers with limited transferability between them. There is also a market of competing payers that provides workplace, group and individual insurance to cover services not funded by the provincial plans.

The United States also has a hybrid medical system, with the U.S. government being the largest single provider of medical funding in the nation. About 100 million Americans (one in three) receive medical care through State-funded programs like Medicaid, Medicare, the military and government employee health plans.

The basic difference between the Canadian and U.S. medical systems is the proportion of State-funding to private funding. In Canada, government pays roughly 70 percent of medical costs, while individuals and private insurance companies pay the rest. In the United States, this proportion is reversed.

Most health-care debates concern the extent to which health care should be socialized or privatized, with supporters of the State model arguing for more social control and supporters of the market model arguing for more private control. This is not a medical question.

A U.S./Canada team of 17 researchers (including prominent American supporters of the Canadian system) found no consistent difference in patient outcomes between the two nations.¹¹

Whether to socialize or privatize is a political question marked by conflicting class interests.

In general, the working-class majority supports the principle of health care as a human right and believes that society should take care of those in need. In contrast, the capitalist class believes that healthy people should not have to subsidize the care of sick people, and defends the right of business to profit from sickness. The middle class takes a middle position, advocating a mix of socialized and privatized medicine. Who can resolve this conflict?

State Expectations

“The State is guarantor of the conditions, the social relations, of capitalism and the protector of the ever more unequal distribution of property which this system brings about.”¹²

The capitalist State manages the system for the benefit of the capitalist class. But, that’s not how it looks. The State presents itself as a neutral force that serves society as a whole. As a result, most people look to the State to solve the problems of the market. Their faith is strengthened when the State battles medical corporations over the regulation of drugs, medical devices and medical practices. It looks like the State is protecting the public, but this is not the case. Blatant corruption must be contained to preserve the system of corruption.

The capitalist State cannot put human need before profit in any consistent way. The State will prosecute corporations like Enron, or individual capitalists like Conrad Black, to prevent their excessive greed from discrediting the entire system. At times, the State will even fight a section of the capitalist class to preserve the system as a whole, as it did in Britain during the industrial revolution and in America during the Great Depression. However, at all times, the State ensures that its “solutions” to social problems never challenge the profit system that created those problems in the first place!

The State works hand in glove with the market, regulating the size and fitness of the labor force to serve the needs of the business class. It does this by setting immigration policy, expanding and contracting the prison system and funding medical, education and other social services. A good example is the 1942 Lanham Act that provided federal funds for child care. During World War II, Lanham Act programs cared for an estimated 600,000 children, freeing their mothers to work in factories and shipyards. When the men returned after the war, federal funding for childcare ended, forcing many women back into the home.¹³

Advocates of State-funded medicine claim that, unlike insurance companies, the State will make health-care decisions based on what people need. In reality, the State provides only what penny-pinching government bureaucrats decide to fund. The government of Ontario, Canada, refuses to pay for drugs, dentistry, glasses, wheelchairs and other medical devices for the general population. People must pay out of pocket or buy insurance to cover such necessities.

To support its capitalist class, each State dissects medicine into parts that are priced and parceled out. The profitable parts, like pharmaceuticals, are handed to the private sector. The unprofitable parts remain in the public realm or are abandoned altogether. While this industrial approach to medicine is cost-effective from a business point of view, it fragments care, making it impossible to plan health services to meet population needs and to integrate prevention and treatment, hospital and community care.

As we shall see, the quality of medical care the State provides is not a measure of the benevolence of that State but a measure of the power of the labor movement to wring reforms from the capitalist class.

What is Health?

Before we can discuss what a genuine health-care system might look like, we must first define what we mean by “health.”

Under capitalism, health is defined as the ability to work, and sickness is defined as the inability to work. Disease-care systems research, diagnose and treat individuals whose ability to work has been compromised. Their goal is to return sick and injured workers to the job as soon as possible (and preferably sooner).

The decision of how long a disabled worker can be absent from work is seldom left to the worker, who cannot be trusted to put her employer’s interests above her own. Not so the physician, who is entrusted with rooting out the “fakers” and “malingerers” who want time off “at the bosses’ expense.”

In contrast to capitalism’s self-serving definition of health, which treats people like machinery, the World Health Organization defines health as: “A dynamic state of complete physical, mental, spiritual and social well-being and not merely the absence of disease or infirmity.”

We already know what people need to be healthy. In The Social Determinants of Health: The Solid Facts, Wilkinson and Marmot explain,

“What is striking is the…need for a more just and caring society, economically and socially…It is not simply that poor material circumstances are harmful to health; the social meaning of being poor, unemployed, socially excluded, or otherwise stigmatized also matters. As social beings, we need not only good material conditions but, from early childhood onwards, we need to feel valued and appreciated. We need friends, we need more sociable societies, we need to feel useful, and we need to exercise a significant degree of control over meaningful work. Without these we become prone to depression, drug use, anxiety, hostility and feelings of hopelessness, which all rebound on physical health.”¹⁴

While medical care is a commodity that can be bought and sold, health is priceless. Health is generated when people exercise control over their lives. Health is generated when people build strong social bonds, when they refuse to be divided, and when they pull together for everyone’s benefit.¹⁵

Because capitalism is dedicated to generating profit, it cannot also generate health. As we have seen, the two are incompatible. In order to generate health, we must start by identifying what people need and then create social structures and practices to serve those needs. Profit cannot be allowed to enter the equation. Such a service model of health care could exist only in a truly democratic society, where the majority controls how social resources will be used.

A Service Model of Health Care

A service model of health care would place healthful work at the core of its priorities. Work is the heartbeat of life, bringing people together to create our lives and society. How we organize work affects the health of individuals, society and the environment more than any other factor.

Capitalism organizes work to maximize profit, not health. As a result, working conditions injure, sicken and kill workers, products are manufactured without regard to their harmful effects, and the production process depletes and damages the environment. A service model of health care would solve all these problems by supporting workers to take collective control of their work, so they can redesign it to generate health, not sickness. Only healthy workers can be expected to produce healthful products and services in a socially-responsible way.

For starters, the workplace must be clean and safe, and the pace of work manageable and varied. Under capitalism, over-stressed health workers risk life and limb to care for others, yet most receive abysmally low pay and few if any benefits, including sick leave. Sick workers endanger vulnerable patients. A genuine health-care system would insist on healthful working conditions and ensure that sick, injured and frail workers receive the highest standard of care.

Removing the profit-motive will enable the majority to decide what to produce and how. We will finally be able to ensure that everyone has access to food, housing, clean water, sanitation, education, medical care and a say in what happens. Instead of depleting the environment, industry can be redesigned to replenish it.

Healthful work nourishes the human soul. When everyone pitches in, a sense of connection and belonging is generated. As we produce for each other and consume what we all produce, the current, alienating division between workers and consumers will break down. Human creativity will be unleashed, providing new options for generating health that are beyond our current imagining.

A service model of health care would:

• view health as the sum of all human activity and a shared social responsibility
• place work as the center of health and social policy
• ensure collective decision-making at work and in society
• pool all available resources to meet human needs
• promote shared responsibility for one another, the environment and future generations

Rejecting the Devil’s Bargain

Capitalism forces us to choose between “healthy” profits and the health of flesh-and-blood people. To support profit, we must sacrifice human health. To support human health, we must sacrifice the capitalist system. The cost of compromise, curtailing our demands to what capitalism can manage, is an unacceptable loss of health and life.

We must reject this devil’s bargain. We must stop the misery that capitalism creates, not restrict ourselves to choosing the most effective way to manage this misery. That means fighting for universal access to medical care, not as the end goal, but as the first step towards a fundamentally different society, one that will generate health instead of sickness.

Americans want a national medical plan, but Democratic proposals protect the insurance market. Instead of nationalizing the insurance industry, or even forcing insurance companies to cover everyone, politicians want to force people to buy insurance.

Mandated insurance cannot provide universal access, because insurance companies can still charge what they want and refuse to pay for treatment. Of the two million Americans forced into bankruptcy by medical bills in 2001, three-quarters of them had medical insurance when their problems began.¹⁶

The medical-pharmaceutical industry forms one-sixth of the U.S. economy. What social force can dislodge its stranglehold on the nation? Certainly not the politicians, who pocket millions of dollars from industry lobbyists who obtained this blood money by denying people medical care!

Establishing union-run medical plans is not the answer. At best, Voluntary Employee Benefits Associations (VEBAs) put union bureaucrats in charge of rationing medical services.¹⁷

The American Federation of Labor and the Congress of Industrial Organizations (AFL-CIO) have endorsed HR 676 (The United States National Health Insurance Act) which would establish a national insurance system. However, endorsements alone will not be enough to defeat a powerful insurance industry, overcome resistance to increased State funding and counter the right-wing campaign against “entitlements.”

A Fighting Labor Movement

Winning universal access to medical care will require mass mobilization. It took a revolution in France to scare Germany into establishing Europe’s first national medical plan in 1883. In Britain, the National Insurance Act of 1911 was rushed through Parliament during a strike wave. Canadian medicare was consolidated in 1972, the year of the Quebec General Strike.

The United States remains the only industrialized country without a national medical plan, because the American labor movement is so weak.¹⁸ Traditionally, U.S. labor has been divided by race and dominated by “business unionism,” which promotes labor-management collaboration. As a result, working and living conditions for ordinary Americans continue to deteriorate, along with their health.

Recent developments offer hope. The International Longshore and Warehouse Union (ILWU) called an 8-hour strike for May 1, 2008 to demand the withdrawal of U.S. troops from Iraq and Afghanistan. We must push all our unions to demand an immediate stop to these barbaric wars, so that billions of war dollars can be diverted into life-giving health and social services.

Increasingly, health workers are organizing against a medical industry that ruins people’s lives for profit. In 2007, union drives in the medical industry enjoyed a higher-than-average rate of success.¹⁹ Moreover, health workers are pushing for real improvements in working conditions and patient care, despite opposition from union bureaucrats.²⁰

Health workers feel a special responsibility to advocate for patients’ rights. To do this effectively, we must democratize our unions and stop the sell-out strategy of labor-management collaboration.

We need our unions to fight for higher worker-to-patient ratios, lower work loads and the right to blow the whistle on deficient and dangerous patient-care conditions. And we need the right to strike, when necessary, to win these demands.

The gap between what people need and what the system can offer is growing every day. And, every day, the world becomes a sicker place. Yet, no matter how sick people become and how many die, capitalism will prevail until the working class organizes a real alternative. Our challenge is to build a fighting, grass-roots labor movement that can win universal medical care and keep on pushing to create a truly healthful society.

References

1. Capitalism has delivered effective vaccines, but they must be purchased. As a result, preventable diseases, like polio, continue to ravage poor populations.

2. Traumatic Occupational Injuries. National Institute for Occupational Health and Safety. Accessed February 18, 2008. http://www.cdc.gov/niosh/injury/

3. U.S. Department of Labor, Bureau of Labor Statistics. Industry Injury and Illness Data - 2002. Summary News Release. http://www.bls.gov/iif/oshwc/osh/os/osnr0018.pdf

4. Steenland, K. et. al (2003). Dying for work: The magnitude of US mortality from selected causes of death associated with occupation. Am J Ind Med. May, Vol. 43, No.5, pp.461-482.

5. Cited in Barstow, D. (2003). U.S. rarely seeks charges for deaths in workplace. New York Times, December 22.

6. Barstow, D. (2003). U.S. rarely seeks charges for deaths in workplace. New York Times, December 22.

7. Editorial. (2003). Occupational hazards. New York Times, December 23.

8. Engels, F. (1844). The condition of the working-class in England.

9. Like military contractors, government-funded medical providers will over-bill for services they provide and bill for services they don’t deliver.

10. McCormick, D., Himmelstein, D.U., Woolhandler, S. & Bor, D.H. (2004). Single-payer national health insurance: Physicians’ views. Archives of Internal Medicine. February 9, Vol. 164, pp.300-304.

11. Guyatt, G.H. et. al. (2007). A systematic review of studies comparing health outcomes in Canada and the United States. Open Medicine, Vol. 1, No. 1.

12. Braverman, H. (1974). Labor and monopoly capital: The degradation of work in the twentieth century. New York: Monthly Review Press, p.284.

13. Tuttle, W.M. (1996). Rosie the Riveter and her latchkey children: What Americans can learn about child day care from the Second World War. In Smith, E.P. & Merkel-Holguin, L.A. (Eds). A history of child welfare. Transaction Publishers.

14. Wilkinson, R. & Marmot, M. (2003). The social determinants of health: The solid facts. Second edition. World Health Organization.

15. Rosenthal, S. (2006). POWER and powerlessness. Vancouver: Trafford.

16. Geyman, J.P. ( 2008). Missing the boat on health care? Tikkun, February 15.

17. Sustar, L. (2007). The UAW’s surrender at GM? Socialist Worker, September 21, p.11.

18. Quadagno, J. (2006). One nation uninsured: Why the U.S. has no national health insurance. Oxford U. Press

19. ASHHRA 30th Semi-Annual Labor Activity Report.

20. Rosenthal, S. (2008). War in the house of labor. April 21.  See also www.seiuvoice.org