The deepening failure of Obamacare and the capitalist U.S. health system have created a moment of transformation in the United States, where neoliberalism has come home to roost. Outside the United States, national health programs that have achieved universal access to services also are facing varying levels of crisis. In the recent collaborative book I coordinated, Health Care Under the Knife: Moving Beyond Capitalism for Our Health, the contributors analyze these changing structural conditions and argue that the struggle toward viable national health programs now must become part of a struggle to move beyond capitalism.[i]
Although we finished the book before COVID-19 spread worldwide, the pandemic reinforces the presentation and conclusions about the need to move beyond capitalism for our health. For instance, the book helps understand why:
- Capitalist-oriented industrial agriculture and its destruction of habitat are the upstream causes that led to the COVID-19 pandemic as well as other past and future pandemics of devastating, emerging viral pathogens.
- COVID-19 may trigger a collapse of the global capitalist system but it is not the cause.
- Health-care and public-health systems organized around capitalist principles don’t do well in pandemics, compared to those not organized around capitalist principles.
- The current economic collapse, triggered by a pandemic, opens a door for revolutionary transformation.
Neoliberal policies have led to privatization, cutbacks in public-sector services and institutions, and public subsidization of private profit making through transfer of tax revenues into the private insurance corporations. A growing financialization of capitalist economies includes the increasingly oligopolistic and financialized character of health insurance, both public and private. The financial flows of both public and private health insurance programs increasingly merge with those of the broader finance capital and real estate industries (the so-called FIRE sector: finance, insurance, real estate).
In addition to these financial changes related to neoliberalism, those struggling for just and accessible health systems now need to confront the shifting social class position of health professionals. The social-class position of physicians and other health professionals has changed drastically in the United States and most other capitalist countries. Previously the majority of physicians worked in individual or group practices. Although some were employees receiving relatively high salaries and benefits, most were small entrepreneurs. In the “fee-for-service” system, they seldom accumulated capital on the scale of industrialists or financiers, but they still saw themselves and others saw them as members of an “upper class.” Some Marxist-oriented theorists of class viewed them as members of a “professional managerial class.”[ii]
Physicians increasingly have become employees of hospitals or practices at least partially owned by large health systems. In a large 2015 survey, 63 percent of all U.S. physicians reported being employed, including 72 percent of women physicians.[iii] These changes mainly reflected the increased costs of owning a private practice due to billing and other administrative requirements. A study in 2019 showed that administrative costs of interacting with public and private payers in the United States averaged about $169,300 annually for physician’s practices, or 21.8 percent of gross receipts, versus $36,825 and 10.8 percent in Canada.[iv] As a result, U.S. doctors mostly have become employees of hospital and health system corporations, where relatively high salaries tend to mask the reality of employee status.
With loss of control over the work process and a reduced ability to generate very high incomes compared to other professional workers, the medical profession has become proletarianized.[v] Due to a mystique of professionalism and incomes that remain high, physicians usually do not realize that their malaise reflects their changing social-class position. In a way, they have joined that highest stratum of workers to which V.I. Lenin and others referred as the “aristocracy of labor.”[vi] From Samir Amin’s perspective of political economy, the current wave of “generalized proletarianization” has engulfed the medical profession: “A rapidly growing proportion of workers are no more than sellers of their labor power to capital… a reality that should not be obscured by the apparent autonomy conferred on them by their legal status.”[vii]
Beyond the changing class position of health professionals, the coming transformation will need to address the oligopolistic character of the insurance industry, the consolidation of large health systems, and the financialization of health services within global capitalism. In the United States, Obamacare has increased the flow of capitated public and private funds into the insurance industry. Through this process, Obamacare has extended the overall financialization of the global capitalist economy. This process has occurred in the context of financialization in the national health programs of other countries, especially in Europe, that previously have served as models in proposals for change in the United States. In this sense, the financial flows of health insurance cohere with John Bellamy Foster’s comment: “At the more stratospheric level represented by contemporary finance, the general formula for capital, or M-C-M′ [money-commodity-more money], is being increasingly supplanted by the circuit of speculative capital, M-M′, in which the production of use values disappears altogether and money simply begets more money.”[viii]
In this context, it is important to reconsider the distinction between national health insurance (NHI) and a national health service (NHS). NHI involves socialization of payments for health services but usually leaves intact private ownership at the level of infrastructure. Except for a small proportion of institutions like public hospitals and clinics, the means of production in health care under NHI remains privately owned. Canada is the best-known model of NHI, but South Korea and Taiwan also follow this approach. Despite their undeniable accomplishments, all these insurance systems have suffered from the inherent contradiction of public subsidization for accumulation of capital in the private sector, even if institutions that provide services legally maintain a “not for profit” status. In the United States the single-payer, “Improved Medicare for All” proposal of Physicians for a National Health Program (PNHP), as well as the U.S. Congressional legislation that embodies the singer-payer approach, is based on the Canadian model of NHI.[ix]
NHS, by comparison, involves socialization of both payment for health services and the infrastructure through which services are provided. Under NHS, the state generally owns and operates hospitals, clinics, and other health institutions, which become part of the public sector rather than remaining under private ownership and control. In the capitalist world, Scotland, Wales, and Sweden provide examples of NHS, where most health infrastructure exists within the public sector and most health professionals are employees of the state. The state apparatus includes elements that provide “welfare state” services like health care and other elements that protect the capitalist economic system. In the socialist world, Cuba offers the clearest remaining model of an NHS in which a private sector does not exist. The legislative proposal introduced in the United States during the 1970s and 1980s by Representative Ronald Dellums explicitly adopted the goals of a NHS.
In the United States, PNHP’s single-payer proposal for NHI emerged from a retreat in New Hampshire during 1986, where activists struggled with these distinctions. Although most participants at the retreat had worked hard for the Dellums NHS proposal, they reached a consensus—albeit with some ambivalence—to shift their work to a NHI proposal based on Canada. The rationale for this shift involved two main considerations. First, Canada’s proximity and cultural similarity to the United States would make it more palatable for the U.S. population, and especially its congressional representatives. Secondly, a Canadian-style NHI proposal could be “doctor-friendly.” Under the PNHP proposal, physicians could continue to work in private practice, clinics, or hospitals. The main difference for physicians was that payments would be socialized so that the physicians would not have to worry about billing and collecting their fees for services provided.
While PNHP has achieved great success in its research and policy work, these efforts, and those of many other organizations supporting single payer, have not yet generated a broad social movement in behalf of a Canadian-style NHI for the United States. Under the Trump Administration, popular and Congressional support for single payer have increased, partly with the leadership of Senator Bernie Sanders. Meanwhile, the neoliberal model with all its benefits for the ruling class and drawbacks for everyone else has maintained its hegemony in national policy. Partly as a result, physicians and other health professionals have become proletarianized employees of an increasingly consolidated, profit-driven, financialized health care system. And under Obamacare, the capitalist state has continued to prioritize protection of the capitalist economic system, in this case by overseeing huge subsidies for private insurance and pharmaceutical corporations.
Under these circumstances, it is no longer evident that socialization of payments for health services under a single payer NHI is the only goal toward which progressive forces should struggle. This comment applies to the United States, but also South Korea, Taiwan, and Canada, whose single-payer NHI programs all have struggled to assure access and to control costs. These problems arise from the inherent contradictions of maintaining a public funded NHI within an overall capitalist political-economic system, where private health institutions, private practitioners, and pharmaceutical and medical equipment corporations all receive payments from the socialized NHI programs. PNHP calls for the removal of for-profit corporations from U.S. health care, but the Medicare for All legislation proposed by Bernie Sanders and colleagues in the U.S. Senate and Congress backed off this requirement.
In addition to the contradictions of NHI, the dismantling of the NHS in England and weakening of NHSs in other countries during economic crises have demonstrated that socialization of infrastructure in addition to financing also remains vulnerable in the context of global capitalism. In short, the long-term stability and success of NHI programs and NHSs will not occur within the context of capitalism as we know it. In this statement, we are not arguing for abandoning our struggles for national health programs within capitalist societies. But we are arguing that, to achieve national health programs that will remain viable over a long term, a much more fundamental transformation needs to reshape not just health care, but also the capitalist state and capitalist society.
There are four main priorities for action in the United States and in other countries affected by the neoliberal, corporatized, and commodified model of health care:[x] 1) a sustained, broad-based movement for a single-payer national health program that assures universal access to care but that drastically reduces the role of corporations and private profit, as a step toward moving beyond capitalism and beyond the inevitable contradictions that capitalism generates for national health programs; 2) an activated labor movement that this time includes a well-organized sub-movement of health professionals such as physicians, whose deteriorated social-class position and proletarianized conditions of medical practice have made them ripe for activism and change; 3) more emphasis on local and regional organizing at the level of communal organizations as envisioned by István Mészáros and attempted in multiple countries as a central component in the revolutionary process of moving “beyond capital”;[xi] and 4) carefully confronting the role of political parties while recognizing the importance of labor or otherwise leftist parties in every country that has constructed a national health program, and understanding that the importance of party building goes far beyond electoral campaigns to more fundamental social transformation. All these priorities emphasize the urgency of creating bridges that link health activism with social movements that focus on social-class oppression, including poverty and inequality, racism, sexism, environmental degradation, militarism and imperialism, and the dominant ideologies that lead women and men to accept pathological social conditions as normal.
The forces that resist these changes command wealth and power that emanate from a tiny part of the U.S. population (less than the 1 percent made famous by the Occupy movement) and an even tinier part of the world’s population. Those in this minority no doubt will continue to fight ferociously to preserve the profound advantages they gain from the status quo, of which capitalist health care figures as only one part. Though the power of this small number should not be underestimated, neither should ours. The road ahead is a steep one, but given the fragility of our harsh capitalist system together with the discontent and suffering it breeds, it is one that we can and must surmount.
As the contradictions and weaknesses of global capitalism grow more profound and as the need for revolutionary transformation becomes clearer and more urgent, a non-exploitative health care system has entered the realm of the imaginable and the possible. The road leading to that place, for all its challenges, must become the road that travels “beyond capital” and beyond capitalism. We are in the midst of a struggle to create a fundamentally more just and equal society, “a world to build”[xii] that is both healthier and happier. To build that world, we must move beyond capitalism for our health. If we fail and the tiny group that benefits from current arrangements prevails, it will be because we have allowed that to happen, so let us choose to win.
Howard Waitzkin is Distinguished Professor Emeritus of Sociology at the University of New Mexico and Adjunct Professor of Internal Medicine at the University of Illinois. For many years he has been active in the struggles for national health programs in the United States and Latin America. He is the author of Medicine and Public Health at the End of Empire and coordinating author of Health Care Under the Knife: Moving Beyond Capitalism for Our Health, available from Monthly Review Press.
[i]. Howard Waitzkin and the Working Group on Health Beyond Capitalism, Health Care Under the Knife: Moving Beyond Capitalism for Our Health (New York: Monthly Review Press, 2018). The International Journal of Health Services published an earlier, expanded version of this article: https://journals.sagepub.com/doi/pdf/10.1177/0020731420922827.
[ii]. Barbara Ehrenreich and John Ehrenreich, “The Real Story Behind the Crash and Burn of America’s Managerial Class,” Alternet, February 13, 2013, http://www.alternet.org/economy/barbara-and-john-ehrenreich-real-story-behind-crash-and-burn-americas-managerial-class; Barbara and John Ehrenreich, “The Professional-Managerial Class,” Radical America 11/2 (March–April 1977): 7–31.
[iii]. Carol Peckham, “Medscape Physician Compensation Report 2015,” http://www.medscape.com/features/slideshow/compensation/2015/public/overview#page=9; Elisabeth Rosenthal, “Apprehensive, Many Doctors Shift to Jobs with Salaries,” New York Times, February 13, 2014, http://www.nytimes.com/2014/02/14/us/salaried-doctors-may-not-lead-to-cheaper-health-care.html.
[iv]. David U. Himmelstein, Terry Campbell, and Steffie Woolhandler, “Health Care Administrative Costs in the United States and Canada, 2017,” Annals of Internal Medicine 172 (2020): 134-144, doi:10.7326/M19-2818.
[v]. John B. McKinlay and Joan Arches, “Toward the Proletarianization of Physicians,” International Journal of Health Services 15/2 (1985): 161–95; Adam Reich, “Disciplined Doctors: The Electronic Medical Record and Physicians’ Changing Relationship to Medical Knowledge,” Social Science & Medicine 74/7 (2012): 1021–28.
[vi]. Eric Hobsbawm, “Lenin and the ‘Aristocracy of Labor’,” Monthly Review 64/7 (December 2012): 26–34.
[vii]. Samir Amin, “Contra Hardt and Negri: Multitude or Generalized Proletarianization?,” Monthly Review 66/6 (November 2014): 25–36.
[viii]. John Bellamy Foster, “The Epochal Crisis,” Monthly Review 65/6 (October 2013): 1–12.
[ix]. Physicians for a National Health Program, “The Medicare for All Act of 2019,” http://pnhp.org/what-is-single-payer/senate-bill/the-expanded-improved-medicare-for-all-act/.
[x]. Waitzkin and the Working Group on Health Beyond Capitalism, Health Care Under the Knife.
[xi]. István Mészáros, Beyond Capital (New York: Monthly Review Press, 1995).
[xii]. Marta Harnecker, A World to Build: New Paths Toward Twenty-First Century Socialism (New York: Monthly Review Press, 2015).