Healing Democracy: For a Socialist Campaign for Single-Payer Healthcare

By Aldous Reno and Florence Oppen

If you build a house for your family, it should be a place to live. Similarly, we the builders of this society should make our society a place to live, a place where people’s most basic needs are fulfilled. A most essential human need is access to medical care; for when we’re growing, aging, hurting, healing, and dying. When we slice off a fingertip while cooking, when a train-wreck migraine strikes, when our child breaks their wrist falling off a bicycle- someone is there to bring us the relief of the best medical technology in the history of humanity. At least, this is true for the few of us who have healthcare. For nearly half a million of us in the United States, this poignant moment of relief is nothing more than a bitter daydream. The reality is that most working people in this country are deciding whether we should go to the doctor for our migraine or just pop an aspirin and hope it’s not meningitis.
The healthcare system of the United States is one of the worst in the world. It reveals a major contradiction: we are the wealthiest society but the one with the least social care for its people, with double the number of preventable deaths than other wealthy countries like France.[1] This is because healthcare, like education or environmental justice, is not only a problem of numbers and funding. For us socialists, it has to do of course with allocating the necessary material resources, but it is fundamentally a problem of the social logic: organizing the economy. The explicit goal of the system we live in is not to provide quality medical care for all, it’s to generate profits in a monopolized market. In our society ruled by the making of profits, healthcare is considered a commodity, an exchange value to be bought and sold to the highest bidder to generate revenue for the very few.
For us, healthcare is and should be treated as a human right, as a use value that should be comprehensive and free of cost for anyone who needs it. We argue that healthcare is an essential collective obligation that we have to the people of our society, and yet for nearly all of our history it’s been treated as an exclusive privilege of the wealthy few. We the working people, the foundation of this society, not only argue that we deserve excellent medical care for all of us, but also that we are ready to fight for it on our terms.
With the election of Trump and the attempt to repeal the Affordable Care Act (ACA), healthcare reform has entered the arena of public debate once again. The time has come not just for meager reform, but complete revolution: single-payer free quality healthcare for all as a step to a fully socialized medicine .

The Intolerable State of Healthcare in the U.S.

When the term “healthcare” is used, it refers to the entire system of patients, care providers, facilities like hospitals, regulatory bodies, and in the case of the U.S., businesses. Our healthcare system is disparate and complicated. It is known and repeated over and over that the U.S. has one of the most expensive healthcare systems with a very poor return in exchange for its people. The Commonwealth Fund studies the healthcare data of the 13 wealthiest countries in the Organization for Economic Co-operation and Development (OECD). In its 2015 report it found that in the U.S. “health care consumed 17.1% of the nation’s gross domestic product (GDP) in 2013,” (it was 17.8% in 2015 and will reach 19.9% in 2025.[2] This is 50% percent more than the next-highest spender (France, 11.6% of GDP) and almost double what was spent in the U.K. (8.8%) – that with the U.S. being the only country in the list without universal health care coverage.[3] So the problem is not the resources put in healthcare, but the nature of the healthcare system and how it uses these resources to make profits for private insurers, providers, and pharmaceutical corporations.
Because the actual costs of providing medical care are not regulated or subsidized by the state, the tremendous cost of healthcare is offset for some people through insurance companies, or groups that extract money in exchange for agreeing to pay for some medical costs should they be needed. The $40 billion in profit made each year by health insurance companies [4] comes from the simple fact that most people don’t use the same value in medical care that they pay to have the possible security of.
Most people are covered through their employer under an HPO or a PPO insurance plan, yet today even after ACA there are still today 28.5 million uninsured people under 65. The difference between HPO and PPO is a joke of a choice between higher/lower costs and more/less coverage. In 2016, the average U.S. American family paid $18,000 in healthcare premiums [5]- 1/3 of total household income. Of course, a person might pay only $100/month for coverage, but this coverage won’t include many basic medical care necessities such as dental and vision care. This is less a “consumer choice” than a forced forfeiture of full coverage because it’s too expensive. Because it is commodified, our health itself is a gamble rigged against us.
People over 65 and with certain health conditions are eligible for a public program, Medicare. Veterans can obtain healthcare through the Veteran’s Health Administration, a fully integrated system that is a microcosm of universal public healthcare in that it has public facilities, publicly employed doctors, and is publically funded, though the availability and quality of care varies vastly between facilities. For those who are very low-income, including the unemployed and the working poor, insurance can be obtained through Medicaid, an insurance that is accepted by all public facilities, but not by most private facilities. Because public facilities are less funded than private and face a higher volume of patients, there is a tremendous disparity in the quality of care provided to Medicaid insured people. People on Medicaid are disproportionately black, people of color, pregnant women, and people living with HIV/AIDS, so healthcare disparities are strongly racialized and gendered.

The Working Conditions of Care Providers

The problem of unequal care is not lost on care providers, and in fact, the quality of care is strongly related to the working conditions of care providers. In the first place, becoming a doctor is one of the most academically elite processes in the country, and medical school is the costliest of any specialized school, with graduated med school students being $416k more in debt than the average college graduate [6]. The required time and monetary resources inevitably results in a privileged minority becoming physicians. On the other hand, becoming a registered nurse is significantly less resource intensive, requiring only a bachelor’s degree, and many programs are available at the community college level.
Doctors in the United States are spending an average of 8 minutes with each patient, and overall there are about 410 patients per doctor in the United States[7,8]. Most of a physician’s time is spent on administrative tasks. Nurses do have a lower ratio, with about 100 patients per nurse, but are expected to do the heavy lifting of medical procedures, patient assessment, education, and care. Supposed reforms to medical training programs limit the amount of time a physician can legally work to 20 hours per day. Nurses, similarly, work 12 hour shifts. Intuitively it’s a terrible idea to have constantly exhausted healthcare providers, and studies show that patient care suffers when healthcare providers are exploited.[9] It’s no coincidence that these trends in exploitation have increased as medicine has become an increasingly inaccessible profession, and as healthcare has become  more and more commodified in the last two decades. For healthcare workers and healthcare recipients, the need for complete transformation of healthcare from a product into a public right has never been stronger, and this transformation is a long time coming.

A History of Healers and Profiteers in the U.S

The idea of healthcare for people over profit is nothing new in the United States. Macho American darling Teddy Roosevelt was the original proponent of a public healthcare system, and his nephew FDR was later to bring the proposal for a single-payer system as part of the New Deal reforms, but it didn’t pass. The sole opponent of healthcare for all? The American Medical Association, a then small group of elite doctors who today are the most powerful lobbying group in the US. The AMA were completely opposed to public healthcare when FDR proposed it, when Truman proposed it, when JFK proposed it, and when Medicare was at last created in 1965 under Johnson[10]. With the voice of pro-corporate Reagan, the American Medical Association claimed that giving working people access to medical care would make them weak from a lack of personal responsibility. If it sounds fishy for a medical lobbying group supposedly dedicated to giving people medicine to say that giving people medicine will make them lazy, consider that the AMA has been criticized for holding a monopoly on legal medical terminology, and for trying to limit the availability of patient care providers to favor their own salaries [11]. The AMA was also strongly in favor of Reagan’s War On Drugs, another political project that created the prison-industrial-complex and gave the Land of the Free the highest population of prisoners in the entire world [12].
The development of private prisons and the for-profit medical industry go hand in hand. Ronald Reagan was the godfather of neoliberalism, an economic regime characterized by the infiltration of public funds into private industry, tax cuts for the ultra-rich, and the removal of rules for big corporations. This regime of commercialization helped explode the growth of HMOs (private insurance groups) in the 1980s, and by 1992 for-profit HMOs surpassed non-profits in enrollment [13]. Managed Care, a Medicaid more bang-for-your-buck program, kept health costs low enough during the 90s [14], but if there’s one thing you can count on a business to do, it’s to extract profits.
Today, employers are shoving more of the cost of premiums onto workers, insurers provide less services for more money, and more than 47 million people remain completely uninsured. Not only is it a serious public health crisis to have half a billion people who are an accident or common illness away from catastrophe, it’s an absurdity in the richest country in the world. In fact, the United States is consistently cited as the only industrialized country without universal healthcare, and the system that does exist is consistently ranked as the worst in the world [15].

This History of Single-Payer and The Affordable Care Act

Plenty of recent attempts have been made to achieve a single-payer system or universal healthcare in the USA. Single-payer means the establishment of a national health-insurance, this is why it is also known as “Medicare for All”. It is a system where a single public agency organizes the health care financing, and acts as a collective insurer, while the delivery of care remains in private (often for profit) hands. Single-payer will replace private insurances with a single public payer and manager that will ensure the access to basic medical services to all. This would be a huge step forward in the U.S. for we would see for the first time in history universal and comprehensive medical coverage. It will also cost less money than the actual ACA.
The Clinton administration proposed a universal healthcare plan in 1993 which was killed through a smear campaign from insurance companies [16]. In 2011, Vermont passed a bill enacting a single-payer healthcare system titled Green Mountain Care. In 2014, the plan was abandoned by politicians who couldn’t incorporate it into a national system of commercialized healthcare. Another attempt to universalize healthcare in Massachusetts (teasingly called ‘Romneycare’ for Mass. Gov. Romney’s hypocritical opposition to ‘Obamacare’), was created in 2006, and in 2009 transformed into a healthcare exchange market under the ACA. The program has had mixed results [17], unsurprising in the midst of broader instability in the US’s healthcare system.
In a maelstrom of political pressure and momentum, in 2009 the Affordable Care Act was passed and immediately the uninsured rate dropped by a greater margin than at any other time in history, with the strongest gains among young people, Latinx people, and poor people [18]. It allowed more than 12 million people to buy a healthcare plan on the new Healthcare Marketplace. It also resulted in expanding Medicaid in some states. Despite all this, the ACA has been a far cry from a universal healthcare reform. While originally the ACA contained a public option for those who couldn’t afford private insurance (a structure that already exists in the US as Medicaid, Medicare, and the VHA), at the last moment, a key Congressmen sold out to big insurance companies and demanded the option for a public insurance provider be removed [19]. Public healthcare thus remains a need of our dreams.
Ironically, the Affordable Care Act was not some progressive breakthrough for the Democratic party. The new system is very similar plan to the Health Equity and Access Reform Today (HEART) Republicans drafted in 1993 as a counter to the Clinton healthcare bill. At the time, Republicans were following a very important 1989 memo published by the right-wing think tank, the Heritage Foundation, titled “Assuring Affordable Healthcare for all Americans”. The neoliberal reasoning behind the Heritage policy paper is similar to the rationale that’s always pushed healthcare reform. It asserted that the current insurance system was already not working at the time because it was too “costly” (to the market) for workers to get insurance through their employers: “For the worker, these services are essentially “free,” and so he or she has little reluctance to demand them. Similarly, the hospitals and doctors who provide health care services know that the patient will pay little or none of the costs.”[20]
The author argued that the current situation was untenable and that “eventually the U.S. will have a “national health system,” in the sense of a system that assures each citizen of access to affordable health care. At issue is the kind of national system we should have.” For the Republicans it was important at the time to act quickly to prevent what they saw as a major disaster: a “government-funded national health system” like in Britain, Sweden or Canada, where “all citizens have virtually free access to hospitals and physicians, and government pays the cost.” The problem of this “horrible” idea for the neoliberal forces (and here both Republicans and Democrats agree with the reasoning) is that: “with government controlling the purse strings and a system that is free at the point of consumption, demand for services always outstrips the supply. Thus Britain has for many years functioned on a triage principle. Rationing based on such factors as age and political sensitivity in practice determine who gets what services.
A government funded healthcare system would mean for them “explicit rationing,” “endemic shortages,” “long waits” etc. It also means that if all employers need to pay for full healthcare of all of their workers and families, which for the Heritage Foundation is “admittedly politically attractive”, then “the potential cost of this mandate will be taken into account in hiring practices. Thus when a job applicant mentions that he has four or five children and his wife is without work, for example, the employer translates that into an enormous potential health care cost.” We see that both counter-arguments are unsubstantiated (or even blatantly false) and weak. They clearly show a commitment to reject any form of welfare state and protect the huge billions of profits of the healthcare industry.
Against this “socialist threat” of a single-payer or a fully socialized healthcare system, the Heritage Foundation proposed “The Heritage Plan” which has the core features of Obama’s ACA: “guaranteed universal access to affordable care”, with a mandate to control the “inflationary pressures in the health industry” and the concentration of “direct and indirect government assistance… on those who need it the most”; but also system that would “mandate all households to obtain adequate insurance.” This mandate to buy a healthcare plan is the most controversial part of ACA because millions of people simply cannot afford to buy a healthcare plan. Yet for the Heritage Foundation, this is a key feature of the reform, because it avoids making the government or the employer responsible (materially and politically) for providing healthcare and instead shifts the burden on each individual worker: “health care protection is a responsibility of individuals, not businesses. Thus to the extent that anybody should be required to provide coverage to a family, the household mandate assumes that it is the family that carries the first responsibility.” This ideology, that a market should provide a service but an individual is responsible for paying for this service (to the explicit benefit of the market), is one defining ideological characteristic of neoliberalism.

Healthcare Is Not a Commodity

As other socialists have argued: “The ACA keeps for-profit insurance companies at the center of the medical care system. The ACA system is based on a sliding scale of cost tiers referred to as the metal plans – bronze, silver, gold and platinum — in which the costs are managed through differing plans based on varying premiums and out-of-pocket expenses. For example, the “bronze” plan has lower premiums and higher co-pays while the “gold” plan has higher premiums but offers more coverage options and lower out-of-pocket expenses. Lower income workers are more likely to choose a plan with a lower premium, but their out-of-pocket expenses can be prohibitive if a health crisis occurs. Premiums continue to rise, with a projected 24% increase in 2017 and health care costs continuing to rise across the board. The massive overhead due to administrative costs of private, for-profit, insurance companies continues to contribute to the high cost of health care.” [21]
These problems occur for two main reasons: healthcare as a commodity is more expensive as a public service because of administrative, marketing, and, unstandardized services; and because the healthcare industry is dominated by major corporate monopolies that inflate prices to ensure their profits.
For example, in the U.S. healthcare system, promotional and advertising efforts consume up to 15% of the total revenue. [22] The Kaiser Family foundation found that in the case of Medicare that cost is only 2%, less than ⅙ of the cost for private insurers. [X X] However, the main reason for our expensive system is found in the billing of medical procedures: “In France, for example, a magnetic resonance imaging exam costs $363, on average, compared with $1,121 in the United States; an appendectomy is $4,463 in France, versus $13,851 in America. These differences stem largely from the fact that single payers — which is to say, governments — are typically able to negotiate more favorable terms with service providers.”[23]
Today 90% of the health insurance market today is dominated by 4 major corporations.[24] Like in all sectors of the economy, “free competition” and “consumer choice” are flashy lies, because in reality a tiny number of giant companies are the one setting the prices required to keep the cash machine functioning. In fact, since the ACA was passed in 2010, the 5 giants that control the health insurance industry have increased their profits and planned mergers to generated an even more monopolized market. [25] United Health Group, with 70 million subscribers, had a net profit of $184 billion; Anthem, with 39.9 million subscribers made $89 billion in profit, followed by Aetna, with 23 million clients and $63 billion in profits; Humana and Cigna scoring 14.2 and 15 million clients and $54.3 and $39.7 billion in net revenue respectively. The total in profits for the giant 5 last year alone was $430 billion. These profits are the strongest argument for national single-payer healthcare system; rather than paying for CEO’s jet flights and yacht vacations they’d be improving and expanding medical services.
During the summer of 2015, two key mergers were proposed: Aetna with Humana, and Anthem with Cigna. If that would had happened the top 3 insurers would dominate 80% of the health insurance market. In July 2016 the Department of Justice filed a lawsuit against these two mega mergers invoking the constantly violated “anti-trust” laws. Even though the court ruling managed to stop these mergers in February of this year (along with the fear that the ACA would be revoked), this trend toward monopolization has and will always exist under the current capitalist economic regime, in every sector that exists as a “market”. As a recent article explains “the trend toward monopoly in health care takes many forms, starting with a massive wave of hospital mergers and acquisitions…60 percent of hospitals in 2011 were controlled by larger holding companies. A full 40 percent of all hospital stays now occur in health-care markets where a single entity controls all of the hospitals. Another 20 percent occur in regions where only two competitors remain…According to the standard metric used by the FTC to measure degrees of concentration, the Herfindahl-Hirschman Index, not a single highly competitive hospital market remains in any region of the United States. By the same measure, nearly half of all hospital markets are uncompetitive….In 2015, the pace of hospital mergers and acquisitions increased by 18 percent over the prior year and was up 70 percent over the 2010 level.” [X] The pharmaceutical industry does not escape this sinister logic : “Basically the same dynamic is occurring everywhere in the health-care supply chain. In 2015, for example, mergers and acquisitions in the pharmaceutical industry reached all-time highs, rising in dollar amount by over 90 percent from the year before. Meanwhile, five or fewer firms control 75 percent or more of the market for most medical devices.”

The Republican Healthcare Bill Was Regressive

Despite the so-called win for the working people of this country in the name of healthcare reform when the Affordable Care Act was passed, the fragility of such a victory is demonstrated by how close the new Republican Congress came to completely repealing the Affordable Care Act, to be replaced with the AHCA. The Congressional Office of Budget Management showed that this “repeal and replace” plan would result in 14 million people instantly losing their healthcare insurance, a number that will grow to 24 million uninsured people in 10 years. This literal disaster was avoided only by the fact that the Republican Party was in such political disarray that it abandoned the gambit, at least for the moment.
Even a moderate victory for the working people of the US is easily toppled by the flailing baby hands of an orange menace. The lesson to be learned from these attempts to provide all people with healthcare is that when the choice is put into the hands of businesses and Congress (connected hand-to-pocket by lobbying), profit has always triumphed and always will.
The failure of the current administration to repeal the Affordable Care Act is only one of the many cracks in the Republican Party’s hegemonic control on the political establishment. On the other hand, the Democratic Party experienced total defeat in the complete loss of the most recent elections. While the two-party system churns in chaos, the tide of working people is coming up from below in favor of quality, public healthcare for all.
As socialists, we are against the AHCA or any other regressive reform, and we defend the progressive elements of the ACA because they represent a crucial improvement for the material lives of us working people.  Our task as socialists is to reset the framework of the healthcare debate and break away from the neo-liberal and privatized system of healthcare the ACA offers us.
Across the board, studies show that the American people are in favor of healthcare for all people[26]. Overwhelmingly, doctors support universal healthcare [27], and even the most elite institution of medicine has declared that universal healthcare has only positive outcomes in store for people’s health and economic gains from reduced medical costs [28]. The immediate savings from universal healthcare (through preventative care and the elimination of profits and bureaucracy) are estimated to be $570billion [29].

The California Single Payer Bill: A Step Towards Democratizing and Socializing Medicine

This fight to reverse the neo-liberal and corporate logic of healthcare as a commodity and assert that healthcare is a social right is coming to birth in California. In 2016, the immense popularity of Bernie’s “Medicare For All” among voters showed the favorability of a single-payer system. With an impending state election cycle, one of the strongest candidates for governor, Gavin Newsom, has declared that single-payer is on his agenda [30]. Of course, these figureheads are only responding to the movement of working class people who are making the demand at the grassroots level. Dozens of local labor unions and grassroots organizations are building a campaign for SB 562, the Healthy California Act, which would enact a universal single payer healthcare system. Among these unions are the California Nurses Association, ACLU of Southern California, the Alameda Labor Council, Unite Here Local 2, UAW Local 5810, UC-AFT, SF Building and Trades Council, United Educators SF, IBEW Local 332. This broad base shows that universalizing medical care is something nearly all working class people can support. The tactics of the campaign are public engagement through media and pressuring local politicians to promote SB 562. While this strategy can be effective in the short term for passing reforms, its tactics are very distinct from a movement that would engage working people to truly control the healthcare system.
With the 6th largest economy in the world, California healthcare workers are showing that when we organize ourselves through our unions, there’s a guaranteed victory for single payer healthcare in our future. But the drawbacks to state level universal healthcare in Vermont and Massachusetts, as well as the rollercoaster of reform at the Congressional level, give us important lessons to learn if we’re truly seeking transformation of healthcare, and not just temporary victories. While single payer systems will give everyone access to healthcare, the fundamental nature of hospitals, clinics, medical technology, and healthcare employment will still largely remain in the hands of private companies.
If we desire universal healthcare and just working conditions for care providers, we cannot leave power over healthcare infrastructure in the hands of a class which has historically always bartered away human rights for profits. Democracy and justice in medicine is not just everyone having access, it’s the care providers who are the foundation of healthcare having the power to make decisions about how our healthcare facilities are run, so that people’s care comes before penny pinching. This looks like democratically run unions, where nurses and doctors, not union bureaucrats, decide how to provide the best care through our work. This looks like fully funded neighborhood clinics, so that people everywhere can access care. This looks like free high quality public education for all, so that millions more people can become skilled healthcare providers without the crushing weight of debt and permanent burnout. This looks like addressing, at the roots, the public health crises from environmental pollution, unsafe working conditions, a broken industrial food system, war and street violence, and the condition of class oppression in this country. We cannot rely on policymakers, think-tanks, company CEOs, or the sometimes-treacherous union presidents to make these changes for us. We, the working people, must build the movement at the locals, and form a unified front of all workers that will consolidate our movements into a force to be reckoned with.
Health is life, and living together is society, so healthcare justice will not only be a transformation of how healthcare is carried out in the US, but how we collectively exist. Universal healthcare is on the ticket, but if we unite to democratically run the healthcare system, then justice is in the future.

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