Single payer aimed at maximizing cost-efficiency replicates capitalist approaches to health.

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.