Introduction: Insurance and cost of living explosion
It feels almost redundant to describe the crisis that healthcare costs represent for many people today. Healthcare costs are one of primary causes of personal bankruptcy.1 Along with rising rent, health today is the sharp edge, the most obvious example, of a world we can’t afford. In 2016, US healthcare spending rose the most in 32 years,2 prompting increases in Obamacare premiums and arguably aiding in the election of Donald Trump.3 While calculating such things is head spinning, we can see Obamacare premiums that wind-up between $200 and $400, even for a worker who is barely employed.
Although the capitalist class is unmatched in greed, greed by itself does not explain the particular tire-fire quality of the crisis we see in healthcare. While a dizzying array of facts and arguments are offered today, I aim to show one can most easily understand the healthcare crisis as an integral part of today’s overall crisis of capitalist relations.
Consider the story of the Theranos Corporation, until recently headed by Elizabeth Holmes. This company tried to automate the process of drawing blood and testing it. Blood tests are naturally a big part of the healthcare industry and the ability to draw blood is a skill which an individual needs to be trained in. By attempting to create an automated method of drawing and testing blood, Theranos promised significant savings to the healthcare industry. As it turned out, that was impossible — not simply poorly done, but something that is entirely impossible with today’s technology. The explanation is a bit technical: blood, in fact, is not a uniform liquid but a complex substance — the Theranos approach of drawing small amounts of blood from very small blood vessels and testing it couldn’t work because the blood they wound up with simply didn’t have the same properties as the larger quantities of blood taken in an ordinary blood draw.4
And the thing is that while the Theranos story is a bit extreme, it typifies this moment. The various elements involved; the vast amount of money available for investment in healthcare, the hope to make a fundamental advance in automating a basic medical procedure, the deception involved in the research, and the final failure of this plan. All of these factors have been building within the American healthcare system for a while (since at least 1970 and arguably 1930).
While the progress of medical knowledge has shown continuous improvement, the productivity of the healthcare industry has seen very little increase, despite a huge number of ventures such as Theranos which promised increased productivity (medical records automation being perhaps the largest, but it’s a huge “space,” as entrepreneurs say). Still, a huge amount of investment has been “sunk” into healthcare enterprises and all these investors demand their payoff. In the course of the article, we investigate this process further but our summary is this: the healthcare crisis is inherently a crisis of capitalist relations.
Most articles about healthcare jump into the complex and jargon-laden debate on solving the crisis, being willing to use completely nonsensical sentences like “to promote healthcare excellence, let’s recognize approaches that assure value” with a straight face.5
All the details of the modern healthcare system are difficult to consider even for experts. The situation can leave one feeling hopeless and desperate, especially those of us who depend on care from one part of the healthcare system. We believe it is possible to sort out this situation by looking at the basis of the present society — wage labor, commodity production, and the dominance of capital. What we’re presenting is a broad outline — with details to illustrate the situation, naturally — but anyone seriously interested can discover more details, many more details than we can list here.
The healthcare system generates a stream of buzzwords, euphemisms, and jargon describing methods of care, policy, patient experiences, etc., etc. And since it is bureaucracy that millions of people operate within, a lot of people are comfortable with some of this terminology, other people might know none of it, but no one knows exactly what all of it means.6
We try to avoid such jargon, not because we aim for a partial or simplified description of the situation, but so we can give a clear overview of this situation as part of a process of transforming human relations.
Just defining “healthcare” and “system” shows the fuzziness of things and suggests that development transforms our relationship to health, to our bodies, etc., rather than just making us healthier. We could say a healthcare system is a way by which formal medicine arranges to treat a majority of serious ailments which a person experiences throughout life (mostly the ability to go the doctor when you are sick). But it also includes preventing epidemics; “being healthier,” “getting the attention you need when you are sick,” and “living longer” are three similar but not identical goals of a healthcare system — a person can live a healthy life but die younger than average through not getting care or being in an accident.
The first thing we’ll aim for is a historical summary that shows where we are in this process. We will then outline the treatment and finance parts of the US healthcare system, filling enough details to make the reader aware of the situation.
US healthcare history, 1850-1960
The bare beginnings of the “US healthcare industry” were after the US civil war when most of the first hospitals were constructed.7 Still, in the period from 1860 to 1920, most medical care was primitive and basic procedures like washing one’s hands only evolved gradually. In the early twentieth century, most doctors worked as individuals, scattered around the country, many barely qualified and until about 1920, able to prescribe opium freely.8 From here, a medical system involving a reasonable amount of science and covering a larger portion of the US population developed. This system, however, evolved by adding extra pieces every ten to thirty years while each existing part expanded in the meantime. One thing to keep in mind: in the beginning and all along the process, the creation of a healthcare system dealt with both absolute needs and defining the kind of need for medical attention that a person had when they were ill or distressed.
The real start to building a modern healthcare system was in the 1920s and 1930s and from then to the 1960s, the US created and enlarged various semi-socialized measures to build and pay for healthcare. Doctors became more highly trained (and better paid). Hospitals appeared, initially focusing on being a place for people to give birth safely.9 With hospitals came the Blue Cross and Blue Shield system (“Blue Cross/Blue Shield” was not a single insurance company but a set of standards which various insurance companies needed to meet). This system (controlled by the American Hospital Association and the American Medical Association, the primary hospital and doctor’s associations) was authorized to operate as a monopoly — charging each member the same rate and controlling a large percentage of the private health insurance market. Though having a near-monopoly health insurance, Blue Cross/Blue Shield both spread costs around to make healthcare affordable and operated effectively as a regulator of healthcare services. The association could determine what services were reasonable to cover, what prices were reasonable to charge for these services, and so-forth.
Opposition to anything smacking of socialism has dominated America’s political landscape for a long time — the “socialist” measure of charging everyone the same amount and limiting costs came as few patients could initially afford a hospital visit, especially in the depression era of the 1930s, and because many people had not yet learned the value of getting treatment this way. The military maintained a medical system for veterans as the US private hospital system expanded (starting with the Veterans Bureau in 1921).10 The military has long been the one place where Americans will tolerate “socialism.”
Employer-based health insurance appeared during WWII as way for employers to recruit workers without violating the wage-controls then in effect. It is important to notice the way that a reliable healthcare system served capitalist production by creating a reliable workforce.
Medicare was enacted in the mid-sixties as a way to give healthcare to the retired, the disabled, and the poor generally. Medicare was modeled on the Blue Cross/Blue Shield health insurance system, paying private providers based on a list of allowed procedures and prices.
Each of these parts of the healthcare system, as well as others, expanded coverage in the years leading up to the 1970s, creating a broad but haphazard healthcare system. A large portion of this progress in healthcare happened through building these large organizations; foundations, the government and even large capitalists, taking steps to benefit “society” — not all hospitals were run as capitalist enterprises, etc.
And this is only “natural” in a society where the majority works for little more than their means of personal survival and don’t have the skills and expertise to manage the whole of society’s capital investment, where their ideas and opinions are taken so as to be managed.
Further, as healthcare developed, as a “public good,” it needed to be regulated, again starting from the early twentieth century to the 1930s.11 Such regulation can work for or against a capitalist enterprise but naturally, the companies and industries that leveraged this regulation in their favor prospered.
It’s important to consider that from the start, healthcare skirted the edge of addictive relief from pain via the sale of opiates. A pure capitalist who merely sells an effect and looks for satisfied customers is purposefully blind to the difference between a patient whose treatment will lead to healing and an addict whose fix also leaves them happy but quite possibly dying (“who am I to judge people’s experiences?”, they might say).
The hand of the regulator forced the dope dealer out, allowing the more authentic doctor in. And here, what a healthcare regulator has to consider, that a pure “supplier of needs” does not, is what is necessary for the long-term survival of both the individual and society. None of this is “more socialist” than the thinking of the dope dealer. Rather, it is what’s needed to create and maintain a somewhat stable and functional capitalist society.
Regulation naturally has the drawback of preventing people from receiving plausibly beneficial alternative healthcare while having the benefit of preventing out and out fraud — when people need clean drugs to survive but want to avoid heroin as “medicine.”
And naturally the rise of medicine was multifaceted, of course, with dentistry, optometry, surgery, bone-setting, medical devices, out-patient care, and other practices having their own particular stories due to the specific needs of different parts of the human body. And we could speak of each separately, as they developed slightly differently. But they all ultimately have followed a similar trajectory.
All of these instances of medical progress involved trade-offs. In the case of women giving birth, the choice of an ordinary hospital birth, a cesarean section, or a home birth facilitated by a midwife, is complex (a home birth might be best if everything goes smoothly and if you have quick access to antibiotics if things don’t, etc. — if, if, if). The rise of doctors, mostly male doctors managing the birth, perhaps reinforced patriarchal and expert-based authority. The use of antibiotics as a way to treat infections was a more unambiguous good (though even that came with serious drawbacks). And you can trace ambiguities in a wide variety of treatments. Moreover, the progress of healthcare gave a sense of the general progress of capitalist society.
Also crucial to note is that many, even most improvements, in US health levels, could be attributed to public health measures. Agencies empowered to clear areas which tended to breed disease, the prevalence of sanitation, the addition of vitamin supplements into certain foods, and so-forth. Such measures were not simply single actions but policies carried out throughout society. For example, vaccinations may merely lower the transmission rate of a given disease, but this and treating those affected allowed health authorities to make what might were once common and deadly conditions very rare. Similarly, requiring that various foods contain minimum nutrients (adding vitamin or removing toxins) eliminated whole classes formerly common conditions in the early-mid twentieth century. Which is to say that the ability or not of public health officials to act to protect the entirety of society has been part of the rise of the healthcare system from the start.
Failed reform: 1970 to 2009
The upshot by the mid-1970s was a hodgepodge of programs that covered the majority of America’s healthcare needs but which “leaked like a sieve” — leaving a significant minority of people lacking a way to pay for the many expanding services offered by the system.
During this period, plans to plug the “holes” were made, areas covered by healthcare expanded, and the emerging “neoliberal” paradigm pushed healthcare finance from a role of supporting capitalist employment to a role of primary target for profitable investment.
The debate on healthcare reform started explicitly in 1970, with Edward Kennedy proposing what was effectively a “single-payer” system while Richard Nixon proposed a scheme for simply repairing the “holes” of the existing ad-hoc system (through various twists and turns, Nixon’s proposal thus evolved from Massachusetts’ Romneycare to the present Obamacare).12
These proposals were batted back and forth through this long period, only becoming law forty years later (but some more minor reform in the eighties — COBRA brought a half-assed portability of one’s employer health insurance and other measures, and perhaps more influentially, required emergency rooms to take all patients with life-threatening conditions, turning them into doctors of last resort in the decades that followed).13 In 1993, Bill Clinton’s Task Force on National Health Care, chaired by Hilary Clinton, proposed a “universal” health insurance plan with many similarities to Obamacare — everyone would need to buy health insurance, all large employers would have to offer health insurance and subsidies would supposedly help out those without employers. One reason that broad reform took so long was the situation only gradually became untenable as the costs of healthcare in the United States increased, first slowly over that period and then quickly.
Also, during the 1970 to 2000+ period, American capitalism went through various upheavals, with a key change involving the breakup and “deregulation” of a variety of industries. Many of these industries had been dominated by sleepy monopolies and semi-monopolies — trucking, finance, airlines, telephones, television, and so forth.14
At the same time, huge chunks of private money were allocated to investment in various healthcare ventures. For example, to allow Hospital Corporation of America, Community Health Systems, and others to begin binges of for-profit hospital purchases and so forth.15
Just as an example, Community Health Systems, now the largest hospital corporation in the US, was put together by the firm of “corporate raider” Ted Forstmann at this time. Moreover, in the process of intensified capital investment, which had continued to the present, companies were broken-up and rearranged in complicated mixes. Investors owned CAT scan machines and rented them to hospitals.16 Employment agencies hired emergency room physicians and contracted them out to various hospitals. Outside companies now sometimes provide “billing services” and the complete list of interlocked enterprises is likely beyond any person to understand.
All this capital investment did not absolutely change the basic way the healthcare workers operate — things might be more regimented or “flexibilized” but the basic activity of taking care of patients remained the same (making a diagnosis, washing an invalid, taking a person’s blood, or similar tasks require a living, breathing human to do). The overall aim of healthcare investment has remained private equity, or as Ted Forstmann put it: “to find hidden value.” Buying companies or pieces of companies, finding particular schemes to allow increased billings (raised prices), and to similarly reorganize processes to cut wages. And the proceeds could be used to buy more companies.
Of course, while they preserved the basic organization of a hospital and primarily got money through increased billings, some amount of profits also came from decreased wages and only a very small amount from actual increased productivity. And going back to the analogy of the heroin dealer — the model entrepreneur can mix together all streams of money and call the result “shareholder value.” Which is to say that whether an entrepreneur is broadly improving society by increasing the amount of healthcare provided or whether they are corroding society (even in the narrow sense) by reducing the quality and quantity of healthcare is semi-purposefully removed from any balance sheet considerations.
One of the sources of investment income was new, for-profit health insurance companies. By insuring the healthiest patients for less, these companies could pull these low-cost patients away from existing Blue Cross/Blue Shield insurers. So, in 1994, the Blue Cross/Blue Shield Network was forced to change its approach. It went from the policy of charging all customers the same fees to charging according to a person’s ordinary position.17
As we describe, capitalist investors have treated healthcare like any other mass-market commodity produced by a concentration of workers, moving as much as possible to the factory system. But the nature of human beings and what is needed to allow them to be healthy has prevented this process from succeeding and there is every reason to expect it to continue to fail. A variety of studies have shown no increase what-so-ever in productivity from spending on, for example, electronic data records. Many other automation efforts have failed (the example of Theranos mentioned above).
Basically, unlike earlier industries like automobiles, there have not been and cannot be fundamental increases in productivity to offset the flood of investment coming into the field.18 And this means the healthcare system only parasitizes, i.e., it constantly raises prices to compensate for this increased capital investment.
We have been careful to say here, “no fundamental change in healthcare productivity.” Certainly, some organizational tweaks can be helpful but to treat a human being is different. Healthcare is fundamentally a product of one human being paying attention to another human being, noticing the particular things happening with that human being, and taking action — the product of the uniqueness of human biology, see.19 The use of drugs, or machinery, or surgery certainly matters, but robots simply dispensing these can be never be adequate. Certainly, it is possible to achieve temporarily increased productivity if you have a “great team” at a given moment, or if the company simply cracks the whip, so to speak. Such actions ultimately seek to lengthen of the working day.20 Unlike the technology of robots and factories, one-time demands for more work can’t provide a stream of ever-increasing productivity.
A further important factor is that all of these investment-driven expansions hinged on the reorganization of labor processes to produce greater profits and reduce workers’ power. This is a standard tactic of capital in factories and all large-scale production processes, but a healthcare worker needs significant freedom to choose in order to be able to take care of a patient. So, in the case of healthcare, reorganization winds up, not increasing productivity, but having negative overall consequences. For example, by working people faster, the number of mistakes committed increases, which results in worse medical care.
Healthcare is a basic need, like food, shelter, basic clothing and so forth. It is one of the most “unexciting” commodities in the sense that nearly no one wants to go to the hospital. As multiple large private capitalists put money into all the various parts of the healthcare field, from hospitals to drugs to medical devices, however, they naturally engaged in an endless effort to sell healthcare as an “optional good” — and with that has come the bizarre modern language of hospitals and health insurance companies — fifteen euphemisms for “choice” and “healthy” within contentless advertisements that float like clouds across modern TV screens. This choice is a weird fiction, of course; when a victim of car accident is wheeled into the emergency ward, they can’t consult Yelp to determine which doctor they would prefer to operate on them. Moreover, simply organizing healthcare as a commodity in itself reduces its effectiveness. And it should be noted that public health as an approach bears no relation to the selling of commodities. Just for example, the massive increase in the consumption of corn syrup in soft drinks and the resulting increase in instances of diabetes and related conditions should have been a red flag for public health authorities, who are only now talking about the situation.
As a one-time maneuver to get profits, the creation of Community Hospitals, buying a hospital or healthcare company to extract whatever “hidden value” you can see, works well. The problem has been that this also leaves you with a chunk of capital which expects a continuous stream of income. And we have seen that a stream of productivity increases is simply not available to achieve this. So, the alternative available for an investor is to increase the price of the commodity that the center produces, to reduce the pay of the workers, and to reduce the quality and amount of the product sold.
Fortunately, or unfortunately, healthcare lends itself very well to allowing companies to buy pieces of the process and make extra money simply by jacking up the price (See: the stream of fraud committed by Hospital Corporation of America/HCA, formerly the largest hospital owner in the nineties and beyond — though fraud is what’s visible and tactics that are legal but abusive are what’s most common).
The fundamental problem is that human beings and our ailments are complex and difficult to understand in the best of circumstances. Honest healthcare professionals may disagree about the best course of action even with all the information available. Moreover, the information needed to treat a patient often can’t be reduced to digital form but instead requires interacting with the patient. Now, when money is involved, it only gets more complicated — if say, an insurance has to pay for a given patient’s care, they can go from preferring the cheaper care option among equally good options to forcing inferior and cheaper options on patients and doctors. Contrariwise, if hospitals know the state will be paying for a patient’s care, it can switch and prefer the most expensive options. And the selections of these perverse incentives are huge. Just for example, a certain kind of inflated diagnosis may become so common that regulators impose a control system to look for it — but hey, those controls also cost money and those costs too can be passed on to the state and the consumer.
Healthcare companies are now adept at profiting and expanding within this perverse environment. These sophisticated companies plan, write policy papers, contribute to politicians across the political spectrum, and help organize patient groups to speak in their interests. Their power has only grown relative to the would-be reformers inside and outside of the system.
Further, the situation is not simply increasing prices, large health companies have had a wide palette of options for extracting more money — if raising rates becomes politically unpopular, they can reduce services instead. By denying “preexisting conditions,” for example, health insurance companies found an effective way to deny individuals services. And companies in every part of the healthcare sector have discovered multiple means for maintaining their revenue streams (from hospitals charging extra straight-to-the-consumer fees to drug companies paying doctors to prescribe their product and way-beyond). Further, being politically sophisticated, these large companies are quite capable of holding price increases for a couple years if the political atmosphere is bad and only then making up for their losses by accelerated increases later.
And between presenting healthcare as commodity and bargaining over this range of “fraught choices,” a huge variety of technical terms, jargon, has arisen. With treatments, a matter of life and death sometimes, some patients have to fight for or against given diagnoses — while medicine becomes opaque to a whole other group.
The upshot is that healthcare regulation, the healthcare debate, and healthcare jargon is now constantly being tweaked in a many-sided tug-of-war between patient care, price hikes, and decreased healthcare worker autonomy. But with institutions effectively bound to win unless the struggle becomes collective.
Obamacare: 2010 to today
As the processes described above asserted themselves from the 1980s to the mid-2000s, the rate of US healthcare spending more or less doubled, reaching 13% of the entire GDP. As healthcare costs skyrocketed, America’s private payment system looked more and more dysfunctional. A significant percentage of Americans had no health insurance and got medical care only by showing up at the emergency ward — this miserable process involved sitting for hours in zoo-like conditions and then being billed thousands of dollars for either short or long-term care. The one advantage of this approach has been that sometimes refusing to pay is reasonably easy — the Federal government has had a program to repay hospitals when patients don’t pay in the emergency ward.21
Obamacare/ACA is the latest in the long line of efforts to reform US healthcare and the first overall fix the healthcare system to be actually implemented — a historical moment in bureaucratic wrangling if nothing else. The campaign to create Obamacare began at the point where the only changes that were allowed to be discussed consisted of changes to the bureaucratic framework, rather than the organization of society, not to even mention capitalist relations. The question batted back and forth was not “how can we assure each person gains adequate healthcare” but rather “how can one be make each person is insured,” which might indeed assure adequate healthcare, but might not be the only way to do so and it also might not assure adequate healthcare, or might result in onerous costs.
So, Obamacare tried to rationalize, or “plug the holes” in, the existing ad hoc system. With the ACA, government regulation forces everyone to buy health insurance or pay a penalty, it provides some subsidies to the poorer section of the working class, which otherwise quite possibly could not pay for this insurance, and government makes efforts to control costs (and imposes a series of ad hoc taxes to pay for all this).
Having government force individuals to buy a private product with no guaranteed price was naturally controversial — fueling right-wing opposition, but just as much demonstrating the state’s total commitment to the interests of the insurance companies (the bill itself having been written by Elizabeth Fowler, ex-VP of WellPoint).22
The model of the ACA hinges on the government being able to control the costs of the insurance which it now forces everyone to buy. But the cost controls in the ACA hinge on the same fairy tale which the healthcare industry tells about itself — that expansion through cost/savings is the benefit which capital investment will yield. The majority of the ACA’s cost-saving provisions are intended to help hospitals and doctors come up with ways to save money and then allowing them to split this saving, with the state acting for the patients. For example: “Accountable Care Organizations,” “doctors, nurses, and social workers band together to deliver continuous, coordinated care to patients. If they slash government spending, they get to keep a share of the savings.”23 The problem is when a company ultimately can only make money by increasing billings, giving them money when they achieve a given savings milestone means either they won’t bother with the milestone or they’ll lower prices one way to achieve the milestone while raising prices in another way to keep that crucial income stream.
At the start, despite these structural problems, the ACA was an improvement for quite a number of people — costs were reduced and the fear of termination for “preexisting conditions” receded. But the last seven years have seen these savings evaporate with US healthcare spending ultimately rising the most in 32 years in 2016 (to repeat from this article’s start), now up to 17% of the GDP for the reasons described above.24
Healthcare and crisis
We have sketched some reasons for the continual inflation we now see in healthcare prices. Now we aim to put this situation in terms of a broad political economy of this capitalist society. For us, a critical political economy is not simply about money and pricing. Rather, it encompasses the distribution of resources, especially labor-power, in a society.
This is a crisis of a capitalist society, a society in which a majority of people sell their labor to buy back the means of their survival, while a smaller minority own the means of production. At its crudest and most unvarnished, we have the labor market, where the capitalists buy the activity of workers as a uniform “substance” — labor-power. The capitalist contracts for a supply of the worker’s labor-power at the lowest available rate and how much or how little the capitalist makes has no relation with that wage.
The capitalists, overall, own the means of production and purchase the labor-power of the working class and pay wages with which the workers buy their means of survival — supplemented by extra means of survival the capitalists and the state provide, with the extra means naturally including healthcare.
To further illustrate the particular problem of how healthcare industry has expanded, it is useful to look at how, “taken in the small,” the expansion of a standard capitalist enterprise works. If we look an automobile factory, as technology progresses and more money is invested in the factory, the factory produces more cars — at the same time as it organizes the work to increase its intensity. Now, with more cars produced, it is possible for a factory owner to pay their workers a wage that will buy a car but a wage which at the same time still represents a smaller portion of the total output of the factory measured as labor. This may seem all well and good but things become more complicated if the factory worker tries to hire someone who expects a fixed rate, say a doctor. Because the worker is getting a small portion of all social payout, the worker has less ability to buy labor themselves. (see math box below)
We’ve noted that wages might decrease when we measure them as labor-value equivalent, even if the wages seem to increase in terms of the amount of factory goods they buy or the amount of money the wages are paid out as.
However, if a worker’s wages, measured in terms of labor-power, decrease, that worker won’t be able to pay for the services of other skilled laborers — say auto mechanics, or doctors and nurses. And since we’ve noted the tendency of healthcare to not experience great increases in productivity, this shows that healthcare would become more expensive over time, especially for workers, even without any of the changes involved in the healthcare industries in particular.
Here, we can see the healthcare crisis as part of the overall crisis of capital — capitalist investment has faced the problem of declining profits for a long period and has dealt with that problem by, among other means, opening all aspects of human relations to investment (in a more indirect way, making the distinction between the doctor and the heroin dealer fuzzier). In the US, this can be seen in unlimited rent increases one place, development on unprotected flood-plains in other place (with the results visible in Houston), and the cannibalizing of healthcare everywhere.
It is useful to measure this process using units of “labor-power” (units that represent the ability to purchase some amount of labor — an hour, a day, etc.). We can measure commodities, wages, and capital this way. (We will ignore for the time being the differences in the kind of labor employed). Using these units, we call the total amount society produces v, the surplus appropriated by the capitalists and the total mass of capital as C.
What does this get us? One thing we can look at is a simple equation for total profits in terms of labor-power units; s/(C). Profits equal the mass of surplus-value over the “total mass of capital”. Which is say – the “total mass” of Capital. We can divide C into constant capital c (small c) and variable capital (v). So profit becomes s/(v + c). The rate of exploitation is the proportion of their labor-power which capitalists fail to pay workers when workers sell that labor-power, r = s/v.
Now, we can divide the numerator and the denominator of the expression for profit by v, leaving us with (s/v)/(1 + c/v). Next, we note that c/v is the “organic composition of capital.” the ratio of fixed capital (equipment, raw materials, machines, buildings, etc.) to variable capital (wages). Now, we can use the equation to show the same results we talked through before.
And if we look at the way capitalist relations have developed, we can see c/v, the “total capitalization” is continually increasing — the mass, measured as labor value, of factories, mines, hospitals, warehouses and etc., is increasing relative to the number of workers employed. And to keep the rate of profit constant, i.e., make up for this, capitalists continually attempt to increase the rate of exploitation, not generally succeeding entirely (and thus the rate of profit declines).
The crisis of health
The US failed to create socialized medicine and gradually dismantled the socialized aspects of its healthcare system but we should be clear socialized medicine refers to healthcare being consigned to the whole of society — the socialized medicine of the United Kingdom or France serves to strengthen those capitalist societies rather than being anything like positive steps to socialism.
The changes that happened in the US were transformations of an already capitalist system. It was the transformation of the system into one which no longer considered its future — a system fundamentally in decay.
The expansion and racketization of healthcare naturally lead to the exploitation of all things on the border of healthcare. The expansion of institutional healthcare has led to a transformation of how human beings relate to their bodies, in terms of sickness and wellness, but also in multiple dimensions — how people think about pain and pleasure, how they think about “ableness” and gender, and beyond.
We’re purposefully only dealing with broad strokes in describing this. We’re giving a general outline not just because it’s a huge subject, but because any particular example involves some gray areas where we don’t want to present ourselves as authorities (even counter-authority authorities) telling a given person what part of their lives should or should not receive medical attention.
Some things are unambiguous, however. The rise of opiate prescriptions since the early 2000s has resulted in a horrific epidemic of addiction, overdoses, and death. The increase in prescriptions of psychiatric drugs to children is troubling and arguably is a cause of many problems later in people’s lives — again with the warning that just about everything has worked for some people and not for others. The quality of the American diet, of the degree of exercise, the level of ambient pollution, the amount of pain experienced in a wide variety of jobs, have all come together to produce at least two epidemics — the opioid epidemic and the diabetes epidemic, with the epidemic of unaffordable care also being a large one.
Thus, the crisis of healthcare today as inextricably tied to the general crisis of capitalism.
Conclusions — Such as we can manage
We can make few predictions about what, if anything, capital will do to solve its immediate crisis. The paradigm of Donald Trump seems to be to slash budgets first and make it work second. This kind of approach is a natural successor to the current neoliberal paradigm — first we cut healthcare so each person gets the minimum they can survive on and charge them the most we think they can pay. Then we just cut some more and see what happens. But capital so far doesn’t seem to have the guts to take up the knife and drag us into this grim, uncharted territory — thankfully for our basic survival. And moreover, this may be because cuts to Obamacare subsidies and Medicare would be direct cuts to the healthcare industry’s stream of profits.
As a counterpoint, it is in the interests of the Democratic Party to at least pretend to want single-payer healthcare, though the Democrats’ leadership make it clear this is a fantasy.
So, until a larger level of struggle appears, the practical fight may remain focused on fighting moves to reduce care and increase fees.
There is a key role for healthcare 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.25
Even ordinary reform would require halting a vast variety of the profiteering which drives healthcare costs currently. One more way the healthcare problem puts us in a bind is that everyone is invited to choose a side among the many trade-off debates which take place. The problem with variation on “choice” is it can quickly degenerate into “who’s the biggest wonk.”
But perhaps more importantly, ordinary reform will require health workers, those who actually provide healthcare, to gain as much autonomy from the bureaucracy above them as possible. If we can offer suggestions on reform tactics, it would be to demand results, not particular policy measures. Which is to say, if sufficient class struggle occurs that the working class can begin to demand a different course for healthcare, it will be useful if all of HMO-speak demands (“choice,” “quality,” etc.) are avoided and that basic services and empowerment for healthcare workers be at the center of any demands.
We communists may discuss possible reforms and things that we need now, which we may fight for. We also have to be clear that this is triage — dealing with the madness as well as we can now. We need to keep in mind that in this time of general madness, building the ability of ordinary people to fight together, as a collective defending their interests, is going to be as important an achievement as any immediate gain granted by current powers.
Only a community, an actively organized class, can even achieve the simple (but now empty) slogan of “a partnership” between patients and providers. The only situation which could build “healthcare under the control of patients,” or anything approximating any of the market euphemisms spouted by HMOs (“thrive,” etc.), is for the dispossessed to build their collective power on their own.
Moreover, even though it feels terribly far away today, we have to say that in a communist society, healthcare would be an extension of the universal care a human community would extend to each member.
1 Dan Mangan, “Medical Bills Are the Biggest Cause of US Bankruptcies: Study.” CNBC. (June 25, 2013).
2 David Lazarus. “Sick: The Biggest Increase in Healthcare Costs in 32 Years.” Los Angeles Times. (September 20, 2016).
3 Paul Demko. “Obamacare’s November Surprise.” Politico. (May 2, 2016).
4 Theranos Corporation Wikipedia entry.
5 Just to show that’s a real example — and to note that an infinite number of articles with similar opaque slogans can be found on the linked website.
6 Anna Gorman, “Many new patients overwhelmed by healthcare jargon,” PBS. (June 16, 2014).
7 “History of Public Hospitals in the US, 1860-1930: Emergence of Public Hospitals.” America’s Essential Hospitals.
8 “Good Medicine, Bad Behavior: Drug Diversion in America.” DEA.
9 Maiken Scott, “How did birth move from the home to the hospital, and back again?” The Pulse. (December 13, 2013).
10 “History — Department of Veterans Affairs.” US Dept. of Veterans Affairs.
11 Pure Food and Drug Act, 1905. First nursing home regulation came with social security. (1935).
12 The Kennedy Plan. The Nixon Plan and its resemblance to Obamacare.
14 See this list of deregulated industries.
16 See introduction to this paper.
17 Sarah Varney. “Did Blue Cross’ Mission Stray When Plans Became For-Profit?” March 18, 2010.
18 See the following article, and this one also.
19 Human Biochemical Individuality, a book by Roger J Williams is invaluable here. See also this.
20 If one wishes to dig into this concept (the intensification of the working day), Marx himself is good here.
21 By the Emergency Medical Treatment and Active Labor Act, see. Example in use.
22 Glenn Greenwald. “Obamacare Architect Leaves White House for Pharmaceutical Industry Job.” Guardian. (December 5, 2012)
23 Danielle Paquette. “What You Need to Know about Obamacare’s Cost-Cutting Measures.” Washington Post. (October 6, 2014).
24 See, for example.
25 S Nicholas Nappalos. “What’s at Stake in the Healthcare Debate?” It’s Going Down. (March 14, 2017).