[Lecture by Joseph Patrick in Oakland, California: January 3, 2010]
(1) The modern capitalist state’s interest in public health – for an economy that makes them sick
a.The state is heavily involved in every aspect of medical care: medical research, as well as the financing and delivery of healthcare: It organizes a wide range of programs to promote research, target particular diseases, regulate drugs, monitor health care providers, gather and disseminate information and deal with health issues of all kinds. There is a Surgeon General that heads a Public Health Service (PHS). Researchers in so-called National Institutes of Health (NIH) study causes and seek cures for serious diseases. The state grants fellowships for health research to scientists and physicians, while billions of dollars each year are granted to support the research of university and other scientists and physicians. The PHS also administers grants to states and local communities in order to secure public health. Then there is the Food and Drug Administration (FDA).
Then there are government programs such as Medicare for seniors over 65 and for various categories of disabled people. There is Medicaid for those deemed officially poor enough to receive government support, as well as a program to cover the children of uninsured families.
A modern capitalist state clearly has an interest in some level of basic medical care for its citizens. At the lowest level, this means guarding against various diseases that could threaten the entire population, but it doesn’t usually stop there. Nor is it the case that the government demand that people only be kept as healthy as they need to be in order to perform in their various economic functions. Medicare for seniors, Medicaid for certain sectors of the poor. Nearly everyone gets treated when they show up in the ER. The state doesn’t order doctors to provide one kind of care for the rich and one for the poor. Sicknesses are to be healed.
The fact that the state is so extensively involved in the field of medical care has earned it a good reputation among the Left, and has also given rise to the notion that the government has a responsibility and a moral obligation for the health of the population. Many on the left would say that the state is there to protect the health of the population from the vagaries of the market. States that follow through on this obligation deserve respect and recognition, those that don’t are criticized for not living up to one of its major tasks.
However, the fact that advanced states are so involved in the field of medical care, the fact that they go to more or less great lengths to organize and support research and the delivery and financing of medical care, is based on the fact that this same state organizes, supervises and enforces a political and economic system that does two things: makes people systematically sick and incapable of accessing the necessary medical care.
That is a point all sides to the healthcare debate simply take for granted. There is all kind of debate and discussion about the necessities and difficulties of organizing a national healthcare system, but what we don’t find is the briefest reflection on why it is that people so sick and so unable to pay for the cure in the first place. The left, by calling on the state to fulfill its moral obligation to public health, takes for granted that the overwhelming majority of the population is dependent on government intervention in order to maintain any kind of health at all.
And if they do offer any explanation for this fact, it is that greed and moral failings on the part of certain major corporations. But unfortunately, it’s much worse than that. This systematic sickness an inability to access a cure is a necessary consequence of the capitalist economy organizes and enforces.
How is sickness systematic?
The extreme cases in which capitalism makes people sick always make it into the headlines: BSE, cancers due to toxic waste of various kinds in the air, water and soil. But the normal everyday cases, although just as well known, are simply taken for granted as a part of modern working life. These are the so-called occupational diseases.
If we look around the world of work, what do we find?
Heavy lifting still around in many jobs. Arthritis and hernias not only in the construction industry, but in warehouses and even offices.
Even in cases where machines take over much of the heavy lifting and moving, the one-sidedness, repetitiveness and the length of the working day produces the same result: more or less ruined backs, tendinitis etc from sitting at a desk or staring at a computer screen all day, working on the assembly line.
In many industries, prolonged exposure to heat, dust, noise, toxins of various sorts.
The working day is long: insomnia and sleep disorders, digestive and nerve disorders.
The working day is intense: cardiovascular diseases, high blood pressure, and stomach problems (even for managers!). Stress.
None of that is a secret, all of these ailments are well known. But for the most part, they get taken for granted as a part of modern working life. The most typical example of that are the TV advertisements for pain, headache and cold medication. Nice mini-vignettes on how the stresses and strains of work make people sick. But that’s the least of their problems. If they have a headache, then they can’t go into work or they can’t perform their job to the employer’s expectations. And that is a threat to their livelihood.
In a rational system of production, that would be absurd. If the purpose of work was to benefit people, then it would be absurd if the working day and the labor process ruined the health of those meant to benefit from production. The labor process and all the necessary tasks would be designed from the very beginning so as to relieve the workers of strain and stress as much as possible.
But if work does make people sick, and if their inability to work threatens their livelihood, then their work serves a different purpose: turning money into more money, enriching the company that employs labor for the sake of its own wealth. Labor as such doesn’t systematically ruin people’s health, wage labor does. Not work as such but the capitalistic purpose of that work.
If that is the purpose, then the livelihood of workers is a cost burden. Their livelihood should therefore cost as little as possible, and in return they should work as much as possible. That difference between the amount of work they perform and the amount of money they receive is what this economy is all about: profit, an increase of the money a capitalist advances for the purpose of his own enrichment.
Well, what does that mean for working life when it comes to the health of those doing the work?
Extensive and intensive working days. Working long hours and working hard. That’s what the boss expects, but that’s also what people know they need to do to get ahead. Think of the TV ads: maximize your output and minimize your rest, go the extra mile, sacrifice your free time in order to get ahead, go in on sick days.
Also, health precautions for heat, noise, dust and toxins of various kinds also represent costs for the company, and therefore need to be minimized. And for workers whose pay depends on the amount of work they perform, these precautions also represent obstacles. Potential health dangers are risks that need to be taken in order to earn a sufficient income.
And in capitalism, technology that increases productivity, thus making less work necessary to produce the same amount of goods, and making work easier, makes work neither easier nor less. It doesn’t reduce work-induced illnesses, but at most creates different kinds of illnesses.
Why? The purpose of technology isn’t to reduce the amount of labor, but to reduce the amount of labor a company has to pay for. It means lowering the costs of production, increasing the profit margin while undercutting the competition.
Technological advances might mean less work is needed to produce the same result, but in capitalism that means people are able to work longer and faster. At the same time, those workers who are no longer needed get tossed out on the street. Not exactly good for their health.
And technological advances not only enable people to work longer and faster, it requires that they do so. The costs required for implementing the expensive technology required to make production less expensive have to be recovered as soon as possible before the competition catches up or even overtakes you. That means overtime, night shifts, working faster and longer with fewer pauses.
In short, labor doesn’t make people sick, wage labor does. Technology doesn’t make people sick, its capitalistic application does. Not the production of useful goods, but the production of profit – the defining purpose of the market economy – is responsible for the sicknesses attributed to “modern society.”
Why are people systematically incapable of getting well on their own power?
This capitalistic purpose of work and its consequences means that peoples free time is anything but free. That time is required for r and r: recovering from work that makes them sick and recuperating for work that makes them sick. And the capitalistic purpose of working life means that their private life is necessarily insufficient for getting well.
- TIME: Because of the long working hours demanded by the purpose of making a profit, people simply don’t have the time required to recover from the stress and strain of work. Not only is the weekend always too short, the actual use of free time for the purpose of enjoyment collides with the necessity to recover for the next week.
- MONEY: And because of the low wages demanded by the purpose of turning a profit, most are too poor to afford the measures needed to recuperate. A house in the countryside, vacation? Nope: a home in noisy neighborhoods. For many this means taking an extra job or two, either under the table or officially.
- NATURE: And speaking of the countryside – the capitalistic purpose of work also means that environmental precautions entail costs that need to be avoided or at least minimized. The consequences are clear enough: bad air, polluted water, dying forests.
- FOOD: And finally, there are antibiotics in our meat, preservatives and too much sugar and salt. Go ahead and look medical journals for details on the deleterious consequences for people’s health.
In short, profitability is bad for your health. Not modern life, but the capitalist economy.
The state does not prohibit all these health dangers. The economy that produces these health threats is the economy that the state wants. With the money economy it installs, with the laws of private property it puts into effect and enforces, it makes people dependent on performing wage labor, and it empowers the owners of the means of production to make use of labor the way they do – for their own enrichment and to the detriment of those that do the work. That is the economy the state wants; that is the economy the state establishes as the source of its own wealth and power.
But at the same time, this economy undermines one of the key prerequisites both for its own functioning and for the manifold objectives that the state has in store for the people – the health of the population. Human capital and military, but also the general will of the population to perform in any of the roles assigned to it.
What emerges is the need for regulation. And that always has two sides. That means forbidding unproductive damages to people’s health and allowing productive damages to people’s health in measured doses. That means imposing limits on the amount and severity of health dangers, and by converse that means licensing a certain amount of health threats. By placing restrictions on the extent to which a firm can place its employees in danger, it explicitly acknowledges a company’s right to endanger and harm the health of its human material within defined boundaries. The state distinguishes between permissible health threats and permissible injuries on the one side, impermissible health threats and injuries on the other.
That is what public health is all about – not healthy citizens, but functioning citizens. And that can go hand in hand with a good deal of sickness, but demands regulation and proper management.
(2) Healthcare policy
Ensuring a sufficiently healthy population for purposes that are good for accumulating capital and bad for their health; the contradiction between the purpose of the economy and the consequences for its own reliable and long-term operation – that is the purpose and the contradiction of a modern capitalist state’s healthcare policy. That is true for every state, regardless of the differences between different nations’ healthcare systems, and regardless of the differences between parties within a single nation.
Let’s take a closer look at the contradictions of healthcare policy. It is a tripartite contradiction.
First, the state has an interest in public health…
But on the other hand, the state insists that medical care, like every other good or service in the market economy, is a business. Every medical good and every medical service has a price. Private companies are allowed and encouraged to make and maximize profits on the production and provision of medical care, be it in the form of medical technology, pharmaceuticals, actual doctoral care, hospital services, etc. The health care industry, and the pharmaceutical industry in particular, is one of the premier growth industries in America. Healthcare accounts for one-sixth of the American economy.
And as is well known, for the overwhelming majority of the population that price is unaffordable – the more so the more urgent medical care is. Extensive care for more serious conditions is simply unaffordable for most people, who make their living working for enrichment of their employers. (Serious illness is one of the most common proximate causes for personal bankruptcy, and medical costs in general are one of the major sources of indebtedness.)
Because of this contradiction between people’s needs and the interest of turning money into more money – which is the organizational principle of the entire market economy – no modern capitalist state leaves the financing of medical care to the vagaries of the market. Instead the state is faced with the need to organize the requisite purchasing power for achieving the desired level of public health and for fostering a successful healthcare industry.
However, that means imposing additional costs on employers. That might go toward ensuring the desired level of public health and creating a profitable market for the healthcare industry, but that also means damaging the health of business in general and thus the wealth of the nation. Extreme caution is required.
These three aims – a certain level of public health, profitable businesses in general and a successful healthcare industry in particular – all stand in total opposition to each other:
- The purpose of the market economy means low wages and long working hours that make people sick, and thus potentially unable to function for the economy or as citizens of the state. And it makes them incapable of mustering the purchasing power to finance a profitable healthcare industry.
- The state’s interest in a certain level of public health, i.e. in having the population function for the economy and for whatever other purposes it has in store for them, means imposing burdens on those whose profits constitute the wealth of the nation.
- The principle that medical care is and should be a profitable business entails that it is out of most people’s reach and that the purchasing power required to sustain that business would do undue harm to business in general.
This has two consequences:
(1) Healthcare reform is a permanent item on the agenda of every modern state. Even Teddy Roosevelt, all the way up to Clinton. Every few years in Germany.
(2) No two healthcare systems are the same.
Let’s take a look at the USA.
Even in the USA, the home of free enterprise, the government does not leave the matter of medical care up to the market. Above I mentioned Medicare and Medicaid, and there are also a number of programs for the children of uninsured, etc.
At the same time, the USA has never had universal healthcare, making it an exception among the more advanced capitalist nations.
Universal healthcare has always been rejected because it has always been deemed far too expensive. Providing healthcare for everybody regardless of their ability to pay for care, has generally been regarded as an intolerable burden on “the economy”.
The USA has traditionally let the issue of medical care be decided by a fight between capital and labor. Either unions have managed to wring health plans from the clutches of the employers, or employers have made health plans a standard part of their contracts with employees.
The results of this healthcare system are well known. On the one hand, certain sectors of America’s healthcare industry – e.g. the pharmaceutical industry – are international leaders in terms of business volume and profitability. The US is often praised for its medical innovation in all fields. It is sometimes said that America has the best medical care money can buy, but that a great number of people just can’t afford it.
40-odd million people, or 15% of the population is completely uninsured, and a substantial additional portion of the population is "underinsured", or less than fully insured for medical costs they might incur. Medical debt is the principal cause of bankruptcy in the US. The US currently has a higher infant mortality rate than most other industrialized nations. In terms of life expectancy it ranks 42nd in the world, a few spots behind Chile and Cuba. In 2000, the WHO rated the overall performance of the US healthcare system as 72nd in overall performance.
Lack of health insurance causes between18,000 and 45,000 unnecessary deaths annually. The total number of people in the United States, whether insured or uninsured, who die because of lack of medical care has been estimated in a 1997 analysis to be nearly 100,000 per year. And so on and so forth.
These health statistics, along with the fact that the USA is the only major industrialized country without a system of universal healthcare is a point that many on the left never tire of making, a matter of national shame. And they often point across the border to Canada or across the Atlantic to Western Europe, often making these countries appear to be a downright paradise for the wage-dependent and socially disadvantaged.
And indeed, America is unique – but only in the sense that the state here traditionally gives a radical answer to the same cruel question posed by every advanced capitalist state:
Can we afford healthcare? What kind of healthcare can we afford? Can our economy support the burden of providing everybody with healthcare? Not: What does our economy have to achieve in order to provide for this basic prerequisite of a good life, but how much health can our economy sustain?
That this question can even get asked is proof that the talk of “our” economy and of whether “we” can afford healthcare is a lie. A clear illustration of the fact that the economy is not there for the people’s sake. On the contrary, their health is an instrument of an economy that makes them sick; their health is subordinated to that economy. The healthcare question is proof of the antagonism between the economy and the majority of the population.
(3) The reform
So why reform?
a. First of all, reform is a constant necessity, because of the different competing and conflicting interests involved, all of which the state acknowledges and looks to promote: a basic level of public health, a minimal cost burden on both business and the nation’s budget, a thriving healthcare industry.
Now in America: Obama, but not only Obama, are giving the opposite answer to the same question. Can we afford health? How much can we afford? Now: we can’t afford not to expand healthcare for the population.
- In a certain sense, the state has always had to pay for the medical care of many sick people who don’t have insurance. Many people eventually pop up in the emergency room once their condition has reached a critical stage. The idea is that precisely because of the failure to provide more comprehensive preventive care, the costs are higher down the line.
- Second, the development of the economy has led to a decrease in the number of insured over the years. On the one side, the number of uninsured has increases because of companies and industries going under and “shedding” their former workers. But on the other side, the economy’s success has had the same effect.
Capital’s advances in productivity mean two things: first, constant decreases in unit wage costs, i.e. the amount of wages relative to the amount of work performed. And these lower wages means fewer contributions to insurance. Second, fewer workers are needed relative to the amount of work required and performed. Both make the insurance business less profitable. That is something that insurance companies pass on to those that are insured, higher premiums, deductibles and copayments, a narrower range of services. Insurance is increasingly unaffordable and it does covers less.
- That is the real issue behind the so-called “demographic problem.” That is normally illustrated with reference to the fact that the baby boomers are reaching retirement, and in general the population is getting older, i.e. there are more and more retirees for less and less active workers. Therefore, the healthcare system will be faced with much greater costs for healthcare. That is often presented as a kind of natural relationship between young and old, in which the youth have to take care of the old. The society is pictured as a collective, and healthcare financing as a big pot that everyone pays into and draws from.
But that couldn’t be less true. The real demographic problem is a relationship between the amount of people that need medical care and the amount of people that capital needs for its own accumulation. When capital succeeds in producing more goods with less people, making more money with fewer workers, this means that fewer people earn lower wages and thus can afford medical care. Profitable medical care needs to be spread more thin, because profitable business requires fewer people.
b. This combination of rising costs for medical care and the rising amount of uninsured has occasioned not only Obama, and not only the Democrats, but politicians on both sides of the aisle, a slew of economists, and the business community to call for an overhaul of the healthcare system.
Summary of the diagnosis: America spends more on healthcare than any other country, while America’s health statistics are worse than most other industrialized nations. That is a problem for the budget, the competitiveness of the economy.
That is a diagnosis that is as frightening as it is instructive.
- The problem is not so much people’s poor health, but what that could mean for something much more important: the solidity of the budget, the ability of the nation’s economy to compete against others. That illustrates nicely what public health means – not whether people are healthy, but whether the state of their health and their medical care represents a burden for the nation’s budget and for the competitiveness of its economy.
- What is the criterion for public health? There is no objective criterion, no objective yardstick for measuring how much health is enough, and how much illness is tolerable. The yardstick that does get applied gets right to the heart of the purpose of public health, at what it is that people should be healthy for. When Obama looks abroad and sees this discrepancy, his concern is: Is that a disadvantage for our competitiveness? People’s health is a means of competition for the nation and its economy. The economy is not there for the people, the people are there for the economy and the state in its competition.
The cure, or rather the debate over the cure, corresponds to the diagnosis.
Two elements of the Democratic bills: an obligation to get insurance and an obligation to offer insurance.
An obligation to get insurance: People have to make a financial sacrifice in order to save the state costs for medical care down the line, and to provide a more robust financial basis for the insurance business, ieally allowing them to lower their premiums and the cost of care. And the state provides subsidies to help them do so. If they don’t buy insurance, they get to pay a penalty for a certain level of insurance. It is not about eliminating the causes of people’s poverty induced illness, but about managing the costs of that poverty, while making sure that the healthcare industry doesn’t take too much of a hit.
An obligation to offer insurance: no denial for pre-existing conditions, no dropping in the event of illness. More transparency with more competition (with or without the public option), a higher percentage of their earnings for medical care. That is a clear example of how the state organizes this contradiction between the need for medical care and the business of medical care: insurance companies should make money on providing insurance and financing medical care.
Obligation for employers to offer an insurance plan or pay a penalty, and the state is willing to help out with subsidies and tax benefits. They should pay a higher price for maintaining the source of their enrichment. And because their enrichment is what it is all about, caution is required. Blue dogs democrats.
The Republican opposition: Among the left a very bad reputation. Business go, healthcare no. That’s not quite true. They point out that extending health care to more people would mean spreading health care thin, meaning even more widespread underinsurance for the overwhelming majority. Many people will not be able to afford compulsory insurance, and those paying insurance will have to finance more people, which means an increase of poverty and lower quality of care across the board. That is how much this faction takes the poverty of the people for granted: quality care for all is simply out of the question.
And on that point, the Democrats are in agreement. High quality of healthcare for all is a fantasy world that the American economy cannot afford.
And that is a message people should take to heart. This economy cannot afford their medical care. The people should ask themselves if they can afford this economic system.