What's at stake in the health care debate?

The debate in the United States over how to provide health care to a nation increasingly burdened by the costs and dissatisfied with the status quo has returned with a vengeance. S Nicholas Nappalos comes at these issues as a nurse and organizer, and tries to unpack the implications of the growing health crisis, what alternatives we really have, and what health for-and-by workers and the community could look like.

Submitted by s.nappalos on May 5, 2017

Originally published March 13, 2017 at Recomposition. The 2016 election cycle has shown that health care is lining up to be a key fight in the next few years. The Affordable Care Act (aka Obamacare) is looking increasingly weak as soaring costs of insurance, drugs, and equipment are eroding whatever meager benefits there were in reigning in the all consuming burden of the American health system.⁠1 Bernie Sanders made a medicare-for-all proposal a cornerstone of his campaign, something which the National Nurses United (NNU) and Our Revolution has vowed to keep fighting for.⁠2 Colorado had a similar single-payer plan on the ballot where insurance bureaucracies would have been replaced by a state-run insurance program, but would retain private health institutions and medical industries.⁠3 Hilary Clinton fended off the insurgent challenge of Bernie supporters, but not without having to pay lip service to their cause.⁠4 Poll after poll demonstrates popular support for nationalized health programs across Americans.⁠5 While Clinton indicated a need to revisit the vague “public option” Wikileaks later exposed her method of dividing her private positions, disclosed to Wall Street firms in her infamous paid speeches, and a separate public one.⁠6 None of this is earth shattering, but it shows that all the power brokers have been honed in on health.

A slow moving crisis

It looks to become even more central however. Estimates are the medicare funds will have to reduce benefits within two decades.⁠7 States that did not expand Medicaid have offered private market based plans that within a few years are already not affordable even with subsidies.⁠8 Where Medicaid was expanded projections for expenses are to rise significantly putting strain on already underfunded systems that suffer from severe shortages of specialists and resources.⁠9 In reality we are witnessing the slow unfolding of a multi-decade health care crisis. Health-related spending makes up roughly a quarter of the entire federal budget and is expanding rapidly. Medicare, Medicaid, and Children’s Health Insurance Programs alone represent 16% of the federal budget and are projected to grow substantially.⁠10 It is the largest portion of federal spending outpacing both social security and the military.

The drivers of this are our nearly singular combination of unregulated profiteering industries and particularly pharmaceuticals, medical equipment, and a multi-layered mediating bureaucracy that introduces inefficiencies into an already top heavy industry. The American health crisis is deepening not only because of excessive bureaucracy introduced by the byzantine insurance system, but also due to its embrace of both protecting industry through strict intellectual property rights and placing barriers to any regulation of prices for pharmaceuticals and equipment. It’s worth noting that health insurance and hospitals themselves are barely profitable with the median around 3% which is near inflation levels only. The profit tends to go to all the feeder industries selling products used by patients and purchased by health institutions.⁠11 An Institute of Medicine report identified nearly 800 billion dollars in waste created by unnecessary services, excess administration, inefficient service delivery, overcharging, fraud, and failing to utilize potential preventative measures.⁠12

These factors have made it the most expensive health system in the world.⁠13 The people of the United States pay more than any other country for our health care, and with poor outcomes across a wide array of metrics. The political implications of this are not hard to see. The more political discourse digs in around the health system as a test of capitalism itself, the stiffer the resistance to reforming the obvious and preventable issues with it. The main players still see defense of vested interests in health care as an ideological defense of capitalism.

Holding to that position increases public spending however and is increasing the federal deficit each year. Dismantling the drivers of those costs, in private hands, would lead to real economic losses with implications for the world market. Some authors have noted that pharmaceuticals were the stars of the market for decades, and have been in a decline that has not been recovered.⁠14 Further cutting into those losses may have more disruptive effects in an economy that already has challenges ahead represented by geopolitical conflicts in Asia and Europe, and an anemic recovery to the global economic crisis of 2008.

With the failure of Colorado is to forge ahead (and other states before it) and the victory of the Republicans across the board in this year’s election, meaningful reform seems quite unlikely in absence of a movement that can force their hands. Some other states may try the route of the ballot initiatives that failed in Colorado, Oregon, or Vermont’s legislature’s push. The disparity of forces between vested capitalist interests and their lobbying power and the electoral process itself makes it a near certainty of failure without a widespread popular change in attitude and action.

Can single-payer save us?

These problems will not go away for the rulers simply by ignoring them. With a single-payer program there would be substantial savings for the country as a whole and indeed millions of people will have their lives changed for the better. Any reduction in the vast waste that we’re chained to and an expansion in access to quality care is something we should cheer and fight for. Single payer would reduce some of these costs, in part through eliminating unnecessary layers of bureaucracy and negotiating lower prices through economies of scale. This has been the traditional progressive answer for these reasons to all things health related.

Despite whatever positives however the fundamentals would remain, with much of the control in the hands of the same drug companies, equipment and product manufacturers, and broken institutionalized practices of American medical professionals (such as reliance on specialists, the persistence of fee for service payment, and over use of capital intensive health techniques). Cutting the costs of the insurance industry would be a positive step, but it’s not a panacea, and it’s not clear whether it could prevent a crisis that is already happening.

Universal Medicare would certainly be more expensive than the system of the Veterans’ Administration (VA). One Congressional Budget Office study showed the VA to be twenty one percent cheaper than care under Medicare.⁠15 The VA which shares some similarities to the National Health Service of the UK wherein the system owns the entirety of health services from hospitals, pharmacies, equipment, and hires the staff. By eliminating paying outside private entities, the VA and NHS thereby reduces the profit otherwise paid to private companies at each stage. While Medicare-for-all would eliminate insurers as secondary payers, such companies are deeply entangled in Medicare itself. Private companies provide supplemental plans for necessary services not covered by Medicare and as well as processing claims for Medicare itself.⁠16 Without an elimination of private billing for services those additional administrative costs would remain. Medicare-for-all would not mean an end to Blue Cross, Aetna, or United Health necessarily.

Nor should health advocates glamorize European style public health. Across the world public health is under attack. Right and left governments have target slashing spending and limiting access. Ideology certainly is a component of this, but objective budget pressures are driving these forces. Universal public health care is worthy, but it is not a panacea. Americans would likely face the same attacks even were there such a victory as institutional pressure to put the burden of care onto the working class will remain.

If legislation granting universal Medicare is unlikely, VA-for-all is a lone voice in the wilderness. One could imagine the resistance likely to nationalizing private hospitals, clinics, and pharmacies. And yet if there is no substantial reform, what is the real cost paid to all of those services with a shrinking working population, jobs being lost to automation, and a growing base of those who will need care for decades? Should conflicts heat up, what would be the effect on the market if health advocates won such a struggle and take health institutions outside of the world of profit so to speak?

Health care is at the center of stressing both market and state forces and this presents an opportunity for movements that challenge capitalism. This crisis in health is not just about the policies of different players (liberal and conservative, socialist and reactionary), but about more fundamentally capitalism’s capacity to provide for health needs. Market allocation and private industry are central to the failures of the American system, things not easily hidden when confronted head on. Globally speaking the industries that profit off health, both public and private systems, have been some of the leaders for investors generally. Losses within health care could spell deep trouble for the economy across the board and perhaps tip us back into recession or depression in the context of a world that has not fully recovered from the shocks of 2008. Even in countries with overtly state-provided healthcare similar elements of crisis have been building in the past decades around run away costs, shortages, and declining quality of care. Health care is a key sector for radicals to make our case and put the ruling class on the defensive.

Health is bigger than our health care

Demanding universal health care has been a broad call amongst US progressives for the past 50 years or so. Is that really the main issue though? At its heart single-payer is about how we allocate existing health resources. Yet we do not only want to more equitably and economically distribute health, but also improve it. If you think about it, universal health is a fairly open demand. It could be redirected to any number of outcomes including universally terrible health. There is an insidious medical apartheid that punishes various sectors (workers, women, blacks, latinos, and indigenous, etc.) while granting luxury health services to a tiny elite. There is a clear move towards diminishing care for the public in general with overall declining standards of living. This year life expectancy declined for the first time in decades without much protest or reaction from the political establishment.⁠17 Instead we are utilizing our collective resources towards the high-tech capital intensive care that benefits a tiny section of the population. Merely asserting universal care without contesting the monopoly on wealth and power that the entrenched capitalist class wields would not fundamentally change the exclusion of the working and under classes from quality health care.

What we want then is not only universal health access or affordability, but a different vision of the health of our society. Supporters of the status quo are already starting at a weak point: saddled with debt, their various solutions failing, and objective stresses that make reforms hard going. We can challenge them by putting forward proposals for health based on liberatory and solidary values that addresses our everyday reality, and show how capitalism and the state work against health.

There is a key role for health care workers to play in this fight by exposing the injustice we see, advocating for our patients, and leveraging our power as workers to move the discussion in a more radical direction. Healthcare workers networks could provide the structure and voice of struggles that mobilize the communities receiving the services and challenging administrators and legislators tasked with imposing austerity and maintaining our unequal health system. The power brokers fear the attention health workers draw with the clear sympathy of the community, and their capacity to turn public opinion against their enemies with public actions. Direct action by health workers is a powerful tool that could oppose the Trump presidency’s anticipated attacks where the disarmed liberal opposition will likely stand idly by.

At the same time mobilized movements of patients and communities could destabilize the government’s attempts at austerity and create political crises. Such pressure can be transformative when we go on the offense and not merely get saddled with defending a system under fire in a crisis that is not our own. Mobilized patients and workers together would prove a particularly difficult body to demonize, and may be strong enough to split support traditionally held in check by fear mongering against health reform. An anarchosyndicalist approach in particular, with it’s emphasis on direct action, self organization, and advocacy of anti-state and capitalist solidarity within workplace and community organizations, is well positioned to take on the systemic aspects of the crisis and at the same time organize local alternatives to daily needs of workers and patients.⁠18 The uniqueness of the convergence of forces (state, work process itself, and society as a whole) give a special power to workers action directed against the state and towards the collective health of society.

In general we should fight for whatever we can get. That being said, it’s important to contest the debate and the form it takes as the limitations with Medicare-for-all above demonstrate. If we don’t, we will get whatever serves the interests of the same groups that have mangled the present system. A full theory of health is beyond this short article, but is a clear necessity given the scarcity of progressive proposals that go beyond access and reform of service delivery.

Any strategy for fundamental change in health care will have to grapple with immediate, medium, and long term issues. The focus here will be on the medium and long term as they are consistently neglected due to the previous desperation to achieve single-payer of any kind. The lack of a clear alternative vision does weaken the movement by giving the impression that the present is inevitable, and privatization the only way. The incoming Trump administration has already made noise around cuts to Medicare and Medicaid, attempting to privatize Social Security, and perhaps going after subsidies in the Affordable Care Act.

In the short term health movements face a steady current towards further privatizations that will increase costs and thereby further endanger both public safety nets and the health system in general. This may represent intentional crisis mongering to justify further austerity in some cases. We should defend against any such attacks. Yet it’s important to recognize that pure defense is likely to allow conservatives to draw lines that are favorable to them (unending escalating costs, poor quality of care, need for more choice/options, etc). For that reason in the short-term it will be important to formulate places where we can expose the failure of the entire system to provide needs, mobilize people around those barriers, and use direct action to improve the care we’re providing and receiving. One response that addresses costs is to call for integrating privatized services within health systems to reduce administration and bring for profit enterprises under public or community cooperative structures. Likewise much of the costs are related to unnecessary and ineffective treatments related to industry-led medicine and a model of treating illness that is widely acknowledged to be problematic. Demanding a shift to preventative population health approach including addressing psychosocial could provide substantial savings and increase the quality of care for individuals while addressing our poor performance on national health metrics.

Issues in focus should include the amount of time allowed with providers (which is set by reimbursements and the system of payments amongst all insurers), rationing of services that have strong evidence demonstrating efficacy and preventative capacity (physical therapy, access to strong multi-disciplinary holistic care for certain chronic diseases, robust patient education, etc), how electronic health record software is allowed to dominate care time for the sake of largely bureaucratic and legalistic concerns (to the benefit of the bloated software industry and with poor outcomes for patients). Thus a short term strategy should combine defense of safety nets with going on the offense in ways that seek to open up care while exposing the vested power interests bankruptcy in providing real solutions. Such fights could build the foundation of a health care movement in the medium term as well as in other sectors.

In the medium term, there must be a shift from contesting elements of the present system to transforming the underlying structure and logic that perpetuates these cycles of crises, inequity of health, and health oppression. In order to make those necessary changes profit and hierarchical power have to be removed from the functioning of the health system altogether. This cannot be done under either a state or private system as both rely upon the reproduction of wealth and power relationships for their basic functioning. The focus then must be upon struggles that provide a connection between fundamental aspects of the health system and the experiences of the exploited and oppressed.

For one inequality and the domination of health resources by the wealthy is a clear problem. Any solution must propose reallocating health spending away from the skew towards capital intensive medicine for the few and in the direction of population health for the many. This will involve significant struggle not only around state allocations and taxes, but also in terms of local struggles to ensure communities are treated equally across different counties and regions and contesting wealth extraction within workplaces and population areas. This can be achieved in different ways taxes being the most obvious, but we shouldn’t rule out direct expropriation to collective structures outside the state. The double edged knife of state-provided health is that you inherently hand over key decision making power of those effected. An alternative would be to obtain control of common self-governing health institutions and fund them through expropriating wealth of the capitalists where capital cannot be completely defeated. There are many smaller steps that can be taken in that direction in the meantime.

One thing that must be put on the table is to gain more direct control over how health programs are implemented, funded, and distributed. A productive conflict is to be had in taking on state and industry monopoly of decisions here. Particularly in the case of women, marginalized racial communities, and workers the necessity of having those effected gain a direct role in shaping the priorities and realization of health care. Health institutions reflect the societies they develop within and reproduce power relationships that exist throughout society. This is to say our health care is a racist, sexist, ableist health care and one in which the decisions over the health of the exploited and oppressed are held in the hands of people who neither understand nor share the interests of those served. Both the oppressive power exerted against populations can be attacked as well as imposing the right to assert autonomy over care of those effected. It is likely that the incoming regimes will be vulnerable on these points as they prove unwilling to accommodate clear inequities and institutionalized health racism, sexism, and oppression of those with chronic diseases.

Organized collectivities asserting the legitimacy of their place in organizing their experience of the health system could provide energy towards further struggles in health and beyond. Along with patients, workers themselves have clear knowledge of the issues within the field which should be married to such a movement in discrediting the positions of management, capital, and the state. Workers movements should likewise contest more control over policy, direction and administration of health institutions, and do so under self-organized workers councils allied with organized communities. This could take the form of combative communal structures uniting neighborhood, municipal, and regional community councils with horizontal workplace councils which expropriate and demand wealth from both the state and capital, and challenging the control of existing public decision making bodies.

Most importantly there is an opportunity to change what is considered a part of health. Health is not merely treating existing diseases or avoiding potential disease. Human flourishing is an expression of good health. It is also something that societies can inhibit or promote. Many things that have been constructed as natural are in fact socially shaped illnesses. For example, suicide, traffic fatalities, and concentrated urban violence represent challenges to the capitalist city and of course are significant causes of morbidity and population health burdens. Such phenomena have deep impacts on multiple points of the health system. A robust health movement could challenge urban space, transit, education, and even the type and availability of work itself in the medium term. Bringing these issues under debate and organizing actions around such, patient and workers movements could further weaken the enemies of public health and broaden the appeal of a direct action movement aimed at the welfare of society as a whole.

The automation revolution underway threatens to make our bodies mere appendages with sedentary work becoming the norm. The pantheon of chronic diseases associated with inactivity have an inherent connection to these capitalist led shifts in the production process. It is another point for a liberatory health movement to demonstrate the connection between systemic exploitation and epidemics. Liberation of time for physical activity and the fight for more human scale work that incorporates the needs of bodies could be a powerful challenge to narratives try to put the blame on individuals.

Growing social isolation is a recognized health danger and obviously connected to broader social ills. Massive resources are poured into creating infrastructure for commerce and consumption, whereas much of social planning overtly tries to minimize social interaction. This has in turn been internalized to an extent with a culture in the US of anxiety towards social interaction. Yet there is already a current underfoot of people longing to connect and interact with others outside of their chosen social circles. Health advocates can demonstrate the impact of organized social isolation arising from the priorities of the planners, legislators, and capitalists who organize collective resources in the interests of the powerful. Part of our fight is to assert new ways to utilize the time and spaces available to us for restorative and necessary social experience, and to fight for expansion of those basic human desires. As capitalism seeks to harness our time and bodies towards profit alone, such a movement can raise awareness of that tension and counterpose it to a society based on solidarity and collective enjoyment of what can be developed in common.

These few examples are far from a comprehensive list of what might be raised in a thorough rethinking of our health. But what about our long term goal? What is an alternative view of health if not a private or state-led system? We should not put too much stock in speculation and crafting blueprints. Any society-wide plan could only be created through the experimentation, input, and crafting of countless individuals. That doesn’t mean we couldn’t or shouldn’t propose broad outlines that can serve as inspiration and ethical guides. The basic functioning of any health system is to help individuals and populations achieve the greatest capacity their bodies and minds can attain. Health in short would be one portion of our quest for meaningful lives. A true alternative to the present would be a system that seeks to mobilize resources on the basis of social solidarity toward maximal expansion of individual development. This would require orienting towards health demands of the population rather than a supply oriented system such as those we see at present.

What this looks like is actually relatively simple. Workers and the community make the decisions over how to produce and distribute health resources. Workers would organize how they produce, but under the priorities and direction of community needs. Health resources would be distributed based on the needs presented with changes coordinated in realtime by workers councils and effected communities. This system would eliminate the administrative infrastructure and replace it with self-organized communal and workplace structures. It would likewise cut the vast waste and harm from unnecessary treatments aimed at profit, insulate the public from the machinations of power which today operate through money and control over hierarchies within the state and health institutions, and could provide society in general with a thriving population with positive ramifications throughout. We also have historic models we can look such as the CNT’s health services during the Spanish revolution of 1936 which approximates such in key ways.⁠19

A revolutionary health movement’s job is to put things like this one the table. Inherent to this is the fight to social space for living and play, meaningful social lives, the capacity to build families and circles, to be able to use our bodies each day and not merely for those who have time and money to afford it, and to develop our full mental and physical capacity to our own self-chosen ends without the exploitation of our bodies by workplaces, businesses, and governments. We are living in a time of unparalleled opportunity for this movement. The challenge is to now find ways in our daily lives to bring together others into an organized force that can disrupt the grip the powerful hold over health, and coalesce into a movement for more fundamental change.

1 Lazarus, D. Sept. 20, 2016. Sick: The biggest increase in healthcare cost in 32 years. http://www.latimes.com/business/lazarus/la-fi-lazarus-rising-healthcare-costs-20160920-snap-story.html

2 Our Revolution. https://ourrevolution.com/issues/medicare-for-all/ Accessed Dec. 2, 2016.

3 Luthra, S. Nov. 9, 2016.Ballot Initiatives: Voters Reject Calif. Drug Pricing Measure; Colo. Single-Payer System. http://khn.org/news/calif-voters-reject-high-profile-drug-pricing-measure/ Accessed Dec. 2, 2016.

4 Newkirk, VR. (2016). Medicare for more:

Hillary Clinton’s new proposal to expand coverage for middle-aged adults provides a glimpse at how she would make Obamacare her own. The Atlantic. Accessed 12/15/16. http://www.theatlantic.com/politics/archive/2016/05/clinton-new-medicare-proposal/483806/

5 Kaiser Family Foundation. Feb. 25, 2016. Public Split On What to Do About the Health Care System. Accessed Dec. 2, 2016.

6 Wikieaks. HRC Paid Speeches. https://wikileaks.org/podesta-emails/emailid/927 Accessed Dec. 2, 2016.

7 Sahadi, J. Jun. 22, 2016. Social Security trust fund projected to run dry by 2034 http://money.cnn.com/2016/06/22/pf/social-security-medicare/

8 Tolbert, J., & Young, K. (2016). Paying for Health Coverage: The Challenge of Affording Health Insurance Among Marketplace Enrollees. Kaiser Family Foundation. http://kff.org/health-reform/issue-brief/paying-for-health-coverage-the-challenge-of-affording-health-insurance-among-marketplace-enrollees/

9 Cassidy, C. (2016). Rising cost of Medicaid expansion is unnerving some states. Associated Press. Accessed 12/15/16. http://bigstory.ap.org/article/4219bc875f114b938d38766c5321331a/rising-cost-medicaid-expansion-unnerving-some-states

10 Congressional Budget Office. (2016). The 2016 Long-term budget outlook. Accessed 12/15/16. https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/51580-ltbo-one-col-2.pdf

11 Kliff, S. (2015). 8 facts that explain what’s wrong with American health care. Vox. Accessed 12/15/16. http://www.vox.com/2014/9/2/6089693/health-care-facts-whats-wrong-american-insurance

12 Smith, M., Saunders, R., Stuckhardt, L., & McGinnis, J. M. (Eds.). (2013). Best care at lower cost: the path to continuously learning health care in America. National Academies Press. Accessed 12/15/16. http://www.nationalacademies.org/hmd/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America.aspx

13 Squires, D., & Anderson, C. (2015). U.S. Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countries. The Commonwealth Fund. Accessed 12/15/16. http://www.commonwealthfund.org/publications/issue-briefs/2015/oct/us-health-care-from-a-global-perspective

14 For example Pain, E. (2011). A Pharma Industry in Crisis. Science Magazine. Accessed 12/2/16. http://www.sciencemag.org/careers/2011/12/pharma-industry-crisis

15 Congressional Budget Office. Dec. 2014. Comparing the Costs of the Veterans’ Health Care System with Private-Sector Costs. https://www.cbo.gov/sites/default/files/113th-congress-2013-2014/reports/49763-VA_Healthcare_Costs.pdf Accessed Dec. 2, 2016.

16 Rover, J. (Jan. 22, 2016). Debate Sharpens Over Single-Payer Health Care, But What Is It Exactly? Accessed Dec. 2, 2016. http://www.npr.org/sections/health-shots/2016/01/22/463976098/debate-sharpens-over-single-payer-health-care-but-what-is-it-exactly

17 Stein, R. (2016). Life expectancy in U.S. drops for first time In decades, report finds. National Public Radio. Accessed 12/16/16. http://www.npr.org/sections/health-shots/2016/12/08/504667607/life-expectancy-in-u-s-drops-for-first-time-in-decades-report-finds

18 For more on anarchosyndicalist organizing, see Solidarity Federation. (2012). Fighting for ourselves: anarcho-syndicalism and the class struggle. Freedom Press. http://libcom.org/library/fighting-ourselves-anarcho-syndicalism-class-struggle-solidarity-federation

19 See the chapter on the socialization of health services in Leval, G. (1975) Collectives in the Spanish revolution. Freedom Press: London. https://files.libcom.org/files/Gaston%20Leval%20Collectives%20in%20the%20Spanish%20revolution.pdf