[Lecture by Joseph Patrick in Oakland, California: January 3, 2010]
Introduction
At the moment, with regard to the health-care reform, we’re kind of in a state of, well, I guess we’re in the twilight area. Most of the debate is over with, there's a House bill and a Senate bill, and yet the final version of the bill is not quite there. That will be decided in the middle of January.
And what I wanted to start off by talking about, or what I wanted to talk about first, is a few things about the current debate – more specifically some things about the media coverage. For any of you who haven’t been reading the newspapers over the holidays, there’s two interesting phenomena that I wanted to point out.
The one thing is, the one overarching theme in the newspapers is: What does the health care reform mean for the politicians who have set out to reform the health care? How and to what extent will politicians manage to achieve what it is that they have set out to do? How will this affect them in the future, their career opportunities, majorities in both chambers of Congress? For instance, will the Democrats manage to get a 60-40 majority and put through a bill? Will Obama succeed in achieving the first element of his, let’s say, his programme of change with regard to his domestic policy? What are the implications of the fact that the Republicans, I think almost all of them, are against the bill? Will this affect the Democrats or the Republicans, positively or negatively, in the upcoming midterm elections? With questions like that, what is the media expecting of the audience? What should the public be interested in? They should be interested in what this health care reform means, well, for the ruling elite. What does this mean for their tactical manoeuvres?
A health care reform comes along, everybody knows or the idea is, that will radically change the way people get and access medical care. And the overarching issue is, what does this mean for the politicians? A nice little lesson on democracy.
The second overarching theme in the literature, well, in the newspapers, in television are a slew of comparisons and tabular calculations on what the two different reform bills might mean for various portions of the population. So, whether for seniors on Medicare, for small businesses, for employees in small businesses and large businesses, major corporations, what does it mean for families, etc.?
And what people can do or are encouraged to do as they take a look at the different tabular calculations, follow the ups and downs in the debate and calculate and speculate for themselves whether they’ll be better off or worse off on balance. For most people this means being stuck in the proverbial rock or between the proverbial rock and a hard place, either being unable to afford health care as it is or being unable to bear the cost of the obligatory insurance that they’ll have to purchase. But what is expected of them here? In this case they’re expected to be what they are: passive objects of the decisions that others make, according to their calculations.
What can they do? Well, they can cross their fingers and hope that the reform turns out, on balance for them, in a beneficial way. And in fact, as cruel as that kind of media coverage might be, it’s in fact rather fitting. It really is the case that medical care in the society is not simply a matter of, well, what do people need?, but of, what do people get? Rather, it’s a function of what politicians determine according to their calculations, whatever nature they might be. These calculations determine what kind of medical care people get. The people themselves, they’re the recipients of that medical care: poor quality, good quality, expensive or inexpensive. In any case, they have nothing to say.
That’s why I will approach the matter in a different way. I don’t want to talk about the possible implications of health care reform to the tactical manoeuvres of politicians. Nor do I want to talk about possible implications, ups and downs, for individual parts of the population. Instead, what I want to do is, well, if it’s the case that the kind of access to medical care that people get depends solely on the calculations the politicians and governments have, then it’s important to grasp the nature of those calculations. So what I want to do is something more fundamental:
What are the calculations that determine what kind and whether people get access to medical care? And that would involve basically three different questions I want to deal with, three different points, three chapters, if you will:
The first point I want to deal with is: What is the state’s, the modern capitalist state’s interest in public health, the health of the population? Why is it the case that right in the middle of the free market economy, the government is so extensively involved in the field of medicine, in medical care? What are the purposes, what are the origins of that, what is the origin of that involvement?
The second point I want to deal with is: How does the state manage health care? How does the state manage the issue of public health – in general and for the United States in particular? Why is it the case that health care is always too little and costs too much? Why is it in a permanent state of reform?
And the third point I want to make .... I want to talk a little about the current reform. Again, it’s not a final thing. We don’t know what the final bill will look like. The course that the reform debate has taken is very instructive. I say, it provides a nice lesson about the role of health and health care in modern capitalism, and especially in international competition. ... the particularity of the current reform.
1. The modern capitalist state’s interest in public health – for an economy that makes them sick
What I wanted to start off with is: What is the modern capitalist state’s interest in public health?
Well, one thing that the reform debate has made clear is: The government is extensively involved in the field of medical care – depending on the decisions that the government makes, the way that people get medical care, the kind of medical care they get can be changed radically. And for those of you who have followed the debate, you can see the big differences as we’ve gone down the line. Maybe 40 or 30 million more will be insured, maybe 35. It depends. And it’s true: In general the capitalist state is involved in every aspect of medical care.
The first field is research: organized as a wide range of programs to promote research in the medical field, to target particular diseases, monitor drugs, regulate drugs, monitor health care providers, gather and disseminate information and deal with health care issues of all time, of all kinds. There’s a Surgeon General that heads the public health service, researchers and so-called National Institutes of Health study causes, seek cures for disease, receive government report, government support and grants for doing so. And there is a Food and Drug Administration, which sets standards for what standards food production has to meet or what’s in food or what’s in drugs. There are government programs for Medicare, for people who are over 65, also uninsured, I am sorry, disabled. There is Medicaid for those who are officially deemed poor enough to receive government support – certainly not all the poor, but those who meet the official criteria – as well as the program to cover the children of uninsured families.
Clearly, this state has an interest in some level of medical care. At the lowest level this means guarding against, well, things like plagues, epidemics that could threaten the entirety of the population. But no state does usually stop there. Nor is it the case that the government demand that there be one kind of care for the rich and one kind of care for the poor. What people can afford is a different story. First of all, medicine is something that is classless. It is supposed to be the disease that determines the nature of the care. Nor is it the case that the state says, “Well, only for those people that are functional for the economy, they are the only ones that get care!” The only single payer insurance that there is is for seniors, disabled and the poor.
And this fact, that the state is so extensively involved in health care, is what, especially among the Left, gives the government such a good reputation. And the Left, many on the Left would say that the state is there and has a moral obligation to protect people from the vagaries of the market. The state is obligated to help people in need, take care of them when they’re sick. And these people analyze different governments according to this standard. Those states that do take care of the health of the population get an A+, those that don’t get criticized – for not living up to one of their major tasks.
What’s important to note about that is the fact that states are so extensively involved in the field of medical care, the fact that they go to great lengths to organize research, financing, delivery of care, is based on the fact that this very same state organizes and enforces a mode of production that does two things: makes people systematically sick and incapable of accessing the cure. In that sense, the good reputation that this state has is based on, well, the very bad things it does. It has a reputation of protecting people from the vagaries of the economy, the very same economy that this very same state installs, organizes and enforces. And this is a point that all sides in the health care debate simply take for granted. We do find all kinds of discussions and debate about what are the necessities of government health care, and what are the difficulties of government health care. What we don’t find is the briefest reflection on what it is that makes people so systematically sick in the first place, and so systematically unable to get care. This is also true for the Left, and maybe even especially true for the Left when they call on the state to fulfil its obligation. If they do, and I’m talking about the Left, they do offer an explanation for this fact, it is the greed on the part of individual corporations or individual employers, and moral failings on the part of the business world that’s at fault. The claim I want to make and prove here is that it’s worse than that. This systematic sickness, this systematic inability to get the cure is in fact a necessary consequence of the capitalist economy that this state organizes and enforces.
So, how does that work? In what sense is that true? Well, first of all, everybody knows, and these cases are pretty well known, the really extreme cases where this economy makes people sick. It’s things like BSE, or cancers due to toxic waste of various different kinds. There are movies made about them, they always end up in the headlines: about toxic waste landing in the air, the soil, the water, people that are injured because of gross violations to health standards, etc. But the normal everyday cases of sickness, although they’re just as well known, they’re mostly taken for granted. How? As a modern part of working life. These are the so-called occupational diseases we hear about, cases where work makes people sick. And if we take a survey of the working world, well, what do we find? First of all, heavy lifting, the classic, still around in many jobs, not only in the instruction, construction industry do we have arthritis and hernias but in warehouses and even in the most modern offices. It’s still around. And even in cases where machines take over much of the heavy lifting and moving, the repetitiveness, the one-sidedness and the sheer length of the working day produce the same result. Ruined backs, pretty much across the board, tendinitis of various kinds, carpal tunnel syndrome, also other forms of tendinitis from sitting at a computer screen all day, working on the assembly line or doing other forms of repetitive tasks. Not a big secret.
Also in many industries, depending on what industry you’re looking at, you find prolonged exposure to heat, dust, dirt, noise and toxins of various sorts. It certainly hasn't died out. The working day is long. What does that take, or what does that cause? Insomnia, sleep disorders of various kinds, digestive and nerve disorders, exhaustion, burn-out, mental anguish, it's one of them, I want to get to that point right now, ‘cause the working day is not only long, it’s also very intense. Cardio-vascular diseases, high blood-pressure, stomach problems even for managers, the famous manager problem, and above all the modern slogan stress. I’m sure any of you could go on and on about the various kinds of diseases that arise from the working world. And none of that is a secret. All of these ailments are well-known. But for the most part they get taken for granted. How, well, it’s just a part of modern working life. It’s part of our modern society. If we want this kind of well-being, we need to work, need to work hard, and working makes people sick. My favourite example of this, and probably it’s well-known to you, is these great TV advertisements for pain and head-ache medication and cold medication. It’s always great when I come and visit here and get to watch TV, they’re all over the place. And what’s nice about them is that there are these mini-vignettes on individual workers’ biographies. You just get presented to you, how the working world makes sick, it makes you sick: headache, pains of all kinds, hurting backs. And what’s the solution? Well, drugs. Why? What you realize in these commercials is that the fact that they’re sick is the least of their problems. The real danger is that the sickness might lead to their not being able to go into work the next day. Well, think about these commercials saying: Thank goodness. I was able to go in and perform the task that I’m supposed to: either that my boss expects of me or that I need to take care of in order to make a living. If their sickness leads to their not being able to go into work, that’s the real threat to their existence – and therefore also to their health.
Now again, this is normally accepted as, well, kind of an unfortunate part of modern working life. But if you think about it for a minute: In a rational system of production something like that would be absurd. If the purpose of work was to benefit people, benefit those people who are doing the work, then it would be absurd if the working process itself and the labor process ruined the health of the people who are to benefit from it. That would be an entire contradiction to the entire purpose of production. If it were the case and we had a rational system of production, producing for needs, well, it would be easy. The labor process and all the necessary tasks would be designed from the very beginning so as to relieve strain and stress. You wouldn’t work long, you wouldn’t work as hard. In any case you’d work so that the working process itself doesn’t make you sick, so that you can enjoy the benefits.
But, to take the converse: If work does make people sick, systematically so, and if their inability to work threatens their very livelihood, well, the conclusion I draw is that their work serves a different purpose. Work isn’t there to benefit those who are doing the work. The different purpose that they do serve is, well, real simple, as simple as it is brutal: turning money into more money, enriching the company that employs labor for the sake of its own wealth. Not the benefit of those who are doing the work, the benefit of those who are employing the work to turn the advance of money into more. That’s the purpose of their work.
I claim therefore: Labor as such doesn’t systematically ruin people’s health. That’s a question of how it’s organized. Wage labor makes people sick. Not work as such, but the capitalistic purpose of that work.
Well, how does that work? If that’s the purpose, turning money into more money, what does that mean for the livelihood of the workers? Well, it essentially means that's a cost burden. Their livelihood, that is the wages that they earn from work, should cost as little as possible, and for the wages they get, they should perform as much work as possible. This difference, this discrepancy between the amount that they receive for their livelihood and the amount of work that they have to perform, that is the source of wealth that determines the market economy, that is the source of the wealth of this nation, the profits of employers.
Well, what does that mean for working life? What does that mean for people who are cost factors, for production, a deduction from the purpose of the economy? Well, what it essentially means is the picture that I just painted, the small survey I took of the working world. It means working long hours and working hard. For the money you get, put in a lot of work, for the time that you’re there, put in a lot of work. Pack as much as you can into the hours that you’re there, and be there for as many hours as you can. Think of the TV ads: Maximize your output! Go the extra mile! Sacrifice your free time! Go in on that sick day! – in order to get ahead. It’s important to note about that: This is how established this purpose of work is. It’s not just the case that employers are yelling at their workers to perform all these things. These advertisements about medication on TV make that clear. This is something that workers themselves see as a necessity. They regard their sickness as a real problem. Of course, they don’t want to get sick. Not just because nobody likes to get be sick, but they know it’s a threat to their livelihood. They want to be able to perform more. It’s how established that purpose is.
Well, that’s one thing. Those are the consequences for the length and the intensity of the working day. But that’s just getting started. What goes for their wages and their working hours also goes for the conditions of their work. If the purpose is to minimize cost and maximize output, what does that mean for things like health precautions, for heat, noise, dust and toxins of various kinds? Well, these are also cost burdens. They need to be avoided or minimized if possible.
And again, for workers whose pay depends on the amount of work they perform, these precautions are also a burden. If you go into factories, you can find workers trying to circumvent all kinds of safety precautions because they know this is a threat to their wages. They know that if they don’t risk their health, they have a problem. Potential health dangers are risks that need to be taken in order to earn a sufficient income.
And because of that purpose of production, because that is the purpose of work, neither is it the case that technology, which would increase its productivity, one could say thus potentially making work easier, making less work necessary for the same amount of product. In this society, because of this purpose of production, technology makes work neither less nor any easier, doesn’t eliminate any sicknesses. At most it changes the kind of sicknesses that people get. It’s a classic thing. All of sudden people have tendinitis and back ache from sitting in a chair all day, instead of lifting thousands of pounds a day.
Why is that the case? Why is that the case that technology doesn’t do that? Well, same purpose of production. The purpose of technology is not at all to make work easier or less. Not to eliminate work, that’s not the purpose. The purpose is to eliminate, well, to eliminate the labor that companies have to pay for, to reduce paid labor, not labor in general. It means lowering the costs of production, increasing the profit margin while undercutting the competition. That’s why it’d be wrong to say, well, yeah, sickness comes from modern technology. Sickness comes from computers. Sickness comes from the kind of machines we have nowadays. Not the tools themselves, not the means but the purpose for which technology’s employed, that’s the reason. That’s why technological advance does not only enable people to work longer and faster. It requires them to do so. The cost required for implementing expensive machinery meant to lower wages means these costs have to be recovered. That means overtime, night shifts, working faster and longer with fewer pauses. That's the result of technological advance. Again: not because of technology or modern life, but because of the purpose of the economy. Long story 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 is responsible for the sicknesses attributed to modern society.
Still, that’s not it. I talked about in what sense the capitalistic working world is designed with the, well, not with the purpose but with the necessary result that people get systemically sick. The other side of that is: They’re systematically unable to access the cure, unable to heal themselves on their own power. Well, why is that the case? Precisely because of the purpose of the working world, that means that the people’s free time is anything but free. What that means instead is that free time is meant for two purposes: R & R, rest and recuperation, recovery from a working world that makes them ill, recuperation for a working world that makes them ill. The purpose of working life means that their free time is necessarily insufficient for getting well. Now this has different dimensions. The one dimension is time. Long working hours mean less time to rest. People simply don’t have the time required to recover from the week. The weekend is awfully short. And not only is the weekend always too short, but anybody who uses the free time for something like enjoyment – the reason people go to work is for their free time – the second they try to enjoy it, well, that means they have a tough time going into work on Monday. If they go out on Saturday night, if they go out on Friday night, this means that they are less able to perform for the coming week. As soon as people use the free time for the purpose of enjoyment, that collides with the objective purpose of their free time. What I mean: the objective purpose is what they really have to use their free time for, what it is functional for: to manage recovering for work.
That’s just one element. That’s the element of time. The other element, it’s probably just as obvious, is money. Because of the low wages demanded by the purpose of production, most people are systematically too poor to afford the measures needed to rest and recuperate. A house in the countryside? Forget about it! Or even if you do get a house further away from the noise of the city, you got a nice long drive. Vacation? For most people an impossibility. A home in a noisy neighbourhood is probably more likely. Also because of low wages, this means that there is really no weekend for a lot of people. Maybe they have a second or a third job, maybe that job is working under the table, maybe it’s over the table. Because of the low wages of work, that means there’s a lot of work. Speaking of the countryside: “Go out and enjoy nature!” Well, that’s getting more and more difficult. The same reason why health precautions are often neglected or very minimal, the same thing goes for environmental protection. That’s something I probably don’t need to say much about. It’s something that is well known and yet accepted as just a part of modern life. Pollution everywhere: land, soil, air, water.
And finally, food: antibiotics in the meat, preservatives, too much sugar and salt, and ... I’ll let you go ahead and look at various medical journals, if you want. Again, to make the same point: It’s not modern working life that’s bad for your health. It’s the capitalistic purpose of that work.
If we think of the debate, going back to the beginning a little bit, the debate about health care reform, and particularly want to pick on the left, who call on the state and its moral obligation to take care of the people. They really regard the state as the address of their concerns and say, “You are the one who has a moral obligation to take care of the people.” Ignoring or missing the fact that the economy is the reason that they are so sick and unable to pay for the cure. The reason why they need government intervention is a result of the economy that precisely this government installs and enforces. That state that they call upon does not prohibit any of these health dangers. Why? Well, the economy that produces these dangers is the economy that the state wants. It’s with the laws of private property that the state enforces that it makes people dependent on performing the kind of labor I just talked about and at the same time it’s the state and its laws on private property that empowers the other side, that is the employers, to make use of the labor in the way I’ve just talked about, for their enrichment and to the detriment of those that do the work. That’s not only the kind of economy that the state wants, that’s the kind of economy that is the source of the state’s own wealth and power.
That’s one side of the issue. The state doesn’t eliminate any of these dangers. At the same time this economy that the state wants undermines one of its own key prerequisites for functioning, one of the key conditions for its own success, and that is the health of the population. Not only is that a key prerequisite for the economy but also for the manifold purposes that the state has in store for the people. One of those things and one of the particularly important tasks is the military. The military is one of the major reasons why a state has an interest in preserving this key prerequisite for the economy and for state purposes. What comes out of this contradiction, the fact that the state wants and installs this kind of economy, and the fact that this economy undermines what it is that the state wants from the people, their ability to perform for many different tasks, what emerges from that is the need for regulation. And regulation always has two sides. That means forbidding unproductive harm done to people’s health, things like epidemics, those should be eliminated. And it also means, let’s say, for more productive ways of ruining people’s lives; the everyday working world. These threats need to be dosed, need to be properly dosed. You need to have limits on them. Imposing a limit on something, however, has a flip side. It means forbidding certain kinds of harm to people’s health, and it also means explicitly permitting other forms of harm to people’s health – up to a certain border. In that sense, the state explicitly exposes people to precisely these health dangers, precisely the same health dangers that the state or that many on the left, people in general, call on the state to protect them from.
This contradiction, ensuring a sufficiently healthy population for purposes that do systematic harm, the contradiction between the purpose of the economy and the consequences of the economy for its own functioning, for its own operation, this contradiction is the purpose of the modern capitalist state’s health care policy. That is the object that health care politics deal with. So instead of having a good opinion, a good fundamental opinion of the fact that the state takes care of health care, one will have to point out what a cruel object that is that the state takes care of when it takes care of health care.
Now I’ll be arriving at my second chapter:
2. Health Care Policy
What does that entail? What are the various purposes and contradictions that that involves?
One could picture health care policy as, to use a fancy word, a tripartite contradiction, a three-way contradiction. There are three equally important and equally antagonistic criteria the state is dealing with. The one point is: public health. The state has an interest in this key prerequisite of a functioning economy and a functioning people, a population. That’s the one criterion. The other one is the fact that the state insists that medical care, like every other good or service in the market economy, has a price. Every good, the production of every good, the production or the provision of every medical service, that’s a business. Private companies are allowed and encouraged to make their money providing these. They should do business in the production and provision of these goods, they should maximize their profits on the production and provision of medical care, be it in the form of medical technology, pharmaceuticals, doctoral care, hospital services etc. And it’s not just any business, if we take a look at the health care industry, and the pharmaceutical industry in particular. This is one of the premium growth industries in America and in any advanced economy. The health care industry is a huge part or creates a huge part of the wealth that this state wants. If you think about what Obama kept saying when he was justifying making certain compromises on his reform, he said, “You cannot just come along and radically change one sixth of the American economy.” The health care accounts for one sixth of the American economy. And this is an industry that the state wants just as much as it does the health care.
Well, the problem is: These two points, an interest in health care or in public health and an interest in an industry that makes profits on providing health, well, what that means is that for the overwhelming majority of the population the price that needs to be paid for this care is simply unaffordable. And it’s all the more unaffordable, the more urgently it is needed. Really extensive medical care simply is far beyond the reach of most people who make their living working for the enrichment of employers. I just remember reading a stat, I think I’m right in saying that serious illness or medical debt is one of the premier causes of or maybe the number one cause of bankruptcy in America. That’s an illustration of this contradiction: the fact that the state wants both of these things means that health care is absolutely unaffordable for most people. And because of this contradiction between the medical care that people need and the interest of turning money into more money on providing that care, no modern capitalist state leaves the financing of health care just up to the vagaries of the market. Instead the state is faced with the necessity of organizing the requisite purchasing power to do both these things: to allow people to purchase the medical care they need to function at some level and to provide a financial basis for a booming health care industry.
But that’s not where the contradiction ends. There’s different ways of organizing that purchasing power, different states have different ways of doing it. The UK, for instance, simply gathers in taxes from everybody and treats everybody for free. It’s just a part of its budget. In Germany it functions a little differently from how it does in France. In every case, however, organizing this purchasing power – given the fact that people can’t afford it – means imposing some kind of burden on the economy ... and that is the profits of business. That might go towards ensuring the desired level of public health, and it might also be used for providing a financial basis for the health care industry. At the same time it creates a burden – at least from the perspective of the state – an unwanted burden on those that are producing the wealth that it wants. So these three ends: a certain level of public health, profitable business in general and profitable business in particular – in particular in the sense of the health care industry – all stand in total opposition to each other.
We can go through it one more time: The purpose of the market economy means low wages and long working hours. That makes people sick; thus potentially unable to function as citizens, as workers, and it makes them incapable of mustering the financial power needed to support a booming health care industry. The state’s interest in a certain level of public health, in having the population function for the economy or for whatever other purposes the state has in store for them, means imposing burdens on those whose profits constitute the wealth of the nation. And 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 will undue harm to business in general.
All formulations for this tripartite contradiction that is health care policy. Well, that has two consequences: The one is that health care reform is here to stay. In every country health care reform is a permanent necessity ... is a permanent object of debate. I was reading a little bit in the New York Times, they had a nice piece on the whole history of the health care debate or the issue of health care in America, and it turns out that since Roosevelt it’s been on the agenda. Presidents and politicians have been trying to bring about health care reform for 80 years. In Germany it’s a funny thing: Every three years or so, more regular than the Olympics, you have a new health care reform that comes about. If you look up in Wikipedia, “health care reform in Germany” every three years you have a big reform. The reason for that is the whole object is a contradiction. And that’s why, depending on which side you look at, it stands in opposition to the other side. That’s why it’s a constant debate. The second consequence is: No two health care systems are the same. The various differences you find between different countries and their health care systems, well, these are different outcomes of how state and politicians manage to somehow find a connection or a compromise between these three different, conflicting goals. It looks different, no matter where you look.
If we take a look at the particularity of the United States: Even in the USA, you could say the home of free enterprise, at least the modern home of free enterprise, the government does not leave the matter of medical care up to the market. Above I mentioned Medicare and Medicaid, the two examples, and also a number of programs for the children of uninsured etc. At the same time the USA has never had a system of universal health care, and that really does make it an exception among advanced capitalist nations. It’s always been rejected because, simply considered, it is too expensive, too big of a burden on the economy. Instead the USA has traditionally let the issue of medical care be decided by a fight between capital and labor, between employers and the unions, and depending on whatever compromises unions managed to wring from the clutches of employers or whatever employers make medical care simply a standard part of their working contracts. Some kind of health care came out for, I’m not sure what percentage of the population, I think about two thirds. But the results of this health care system, this particularity, are pretty well known. On the one hand certain aspects or certain sectors of the America’s health care industry are simply peerless in terms of their profit margins. The US is also often praised for its medical innovation in all kinds of different fields. There’s a nice quote by Bob Dole on that. He said, “America has the best health care that money can buy. The problem is that very few people can afford that health care.”
That’s the other half of the US particularity. One could read off the stats – you probably know them: Forty odd million people uninsured, at least that’s 15 % of the population, a substantial additional portion of the population is under-insured, as it’s called. They have insurance formally, but in terms of deductibles, co-pays and what that insurance actually covers at all, it’s not even clear whether they have insurance. Medical debt is the principal cause of bankruptcies, as I pointed out. 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. The overall performance of the health care system is 72nd in the world. Lack of health insurance causes between, depending on the study you look at, 18,000 and 45,000 so-called unnecessary deaths every year. And the total number of people in the United States who die because of lack of medical care has been estimated to be nearly 100,000 people per year, and so on and so forth. You can go ahead and look at Wikipedia for all the stats, it’s not that important. It’s just interesting to get a look at what drastic state the health care is in.
[Audience]
I’m sorry: from people who die because of lack of medical care, whether insured or uninsured. Now, the more important point is that these health statistics, along with the fact that the USA, as I said, is the only major industrialized country without a system of universal health care, is a point that many on the Left never tire of making. Not even only on the Left. Many people of the population point to these statistics as something, as a matter of national shame, and at the same time, I think that Michael Moore, if any of you have seen Sicko, is a typical example of this, points across the border to Canada or points to Europe, makes these countries seem like a virtual paradise for workers.
[Audience: Comparatively]
Comparatively. I’m sorry. Will you say it again? What you said: Comparatively it is. But comparisons always have two sides. One thing is what makes them different. There are differences in the statistics. But what makes them the same? America is unique – in terms of the statistics and the way that it deals with this issue. But it’s only unique in the sense that the government here gives a, well, you could say: a radical answer to the same brutal question that every state poses when it comes to health care. And the question that it poses is: Can we afford health care? Can our economy afford the burden of health care? That’s a cruel question. The question is not: In this society what does our economy need to perform or to achieve so that people are healthy? This basic prerequisite of any purposes that they might have. It’s just the other way around: How much health can our economy sustain? And the fact that a question like that can even get asked proves that the talk of our economy and whether it can afford health care or whether we can afford the level of health care that we have is a lie. On the contrary, the idea of our economy, whether we can afford it, is a lie in the sense that the question itself makes clear that the economy is not at all there for people’s health. It’s just the other way around. Their health, their health care is there as an instrument of the economy. It’s subordinated to the purposes of the economy. That’s a proof that it’s not our economy but that there is an antagonism between the purposes of the economy and in this case the health of the people and their livelihood. The very fact that the question gets asked is a proof of that antagonism.
The question is: Can we afford to have so many people be sick? Can we afford to pay so much for health? And again I want to emphasize that this is the very same question that every single capitalist state asks itself, whether in Canada or in Europe or in America. This is the commonality. Instead of pointing out the differences, the comparative advantages of being a proletarian in Europe or being a proletarian in America – it’s even questionable if it’s any better – instead, take a look at the way that the state is calculating with the people. It doesn’t give you any reason to compare. Instead it gives you a reason to reject both or all answers to this cruel question.
With that I come to my third chapter, which is
3. The current reform here in America
So, why reform, why now? Again, as I pointed out, reform in every capitalist state is a constant necessity because of these different and competing interests. Now, in America, what is the reason for this reform? Obama, but not only Obama ... I would say it this way: They are giving the opposite answer to the same cruel question I was talking about. It said before that usually the answer was: We can not afford to have universal health care. At least at the starting point of the debate the answer was, or the diagnosis was: We can no longer afford not to have universal health care. Or we can no longer afford to have so many people uninsured. And for a lot of people this was a reason for celebration. They said, “Finally the government has recognized how important our health is.” But I would point out to them in what sense or according to ... or from which perspective their health is all of a sudden so important ... or their sickness is important: Their sickness is a burden for an economy that makes them sick. Here Obama asked the question again and not only Obama but even the business community, whole slews of politicians on both sides of the aisle, Nobel prize winning economists, all ask the same cruel question they always ask, and this time they came to a different conclusion: How much health care can we afford? Well, certainly we need to afford more than we are now. We can’t afford not to expand health care for the population. This was really the diagnosis that was at the starting point.
Why did they come to this different answer? Or arrive at the answer that they currently have? One point is: In a certain sense the state in America has always had to pay for the medical care of many sick people who didn’t have insurance. The classic illustration of that is: all kinds of people who are popping up in emergency rooms when their sickness has really reached a critical stage. And in many cases you can find stories of people getting turned away from emergency rooms even, but these were high costs for treating these people, and the calculation is that it will be cheaper to give them some kind of preventive care, so to extend the system of preventive care in order to eliminate the high cost of so many people popping up in the emergency room for diseases that, if caught earlier, would be able to be prevented. This is just one cost calculation. Second, and this is a more important point, the development of the economy itself has led to a decrease in the number of insured, an increase in the number of uninsured over the years. On the one side, the number of uninsured have increased because the companies are going bankrupt, industries going under and shedding their former employees. But on the other side, the economy’s success has had the same effect. The success of America’s economy has led to the same result. Why and how? Well, I talked a little bit about the purpose of technological advance in the production process, the purpose of making advances in productivity. Well, that means two things. First, constant decreases in so-called unit wage costs. You introduce technology into the production process, it doesn’t mean reducing labour, it means reducing the amount of paid labor. That is, people perform more work and get less money for that. Wages sink, relative to the amount of work performed. And these relative lower wages mean fewer contributions to insurance. Second, fewer workers are needed relative to the amount of work required and performed. That is the famous “downsizing.” Introduce technological advances into the working world, the one half of the working force, or one portion of the working force works more for less, and the other portion gets thrown out on the street. More unemployed, less people paying for insurance, and the problem is that this makes the insurance business less profitable. You can read about the fact that less people getting insurance means a weaker financial basis for insurance companies. That is something that insurance companies pass on to those that are insured, that means higher premiums, deductibles and co-payments and a narrow range of services, leading to the exact same things we talked about or the statistics we talked about a few minutes ago. Insurance is increasingly unaffordable and it covers less where it does exist.
I want to make a little digression on a certain issue at this point:
That, what I just talked about, the advance of this society’s productivity leads to a greater amount of sickness and inability to get the cure, that is the real nature of the so-called demographic problem that everybody talks about – both in Europe and America. The demographic problem is always illustrated by saying that – especially as the baby boomers get closer to retirement – the amount of people who are older are increasing and there are less active working people in order to pay into the pot to help these people get the medical care that they need when they’re older. You realize this demographic problem, even the term itself, describes the relationship as a kind of natural issue, a relationship between young and old. There’s more old people, fewer younger people, it’s clear that we need to reorganize the health care system so that the young can afford to pay for the old. The whole thing is pictured as if everybody is paying into a common pot, the wealth of the nation goes into one pot, there’s less people contributing to the pot and more people who have to take out.
[Audience]
Yeah, yeah, that’s the one thing that is secure about social security. You hear the point that society is depicted as a kind of collective, health care financing is a big pot that everybody pays into and draws from, and that couldn’t be less true. The real demographic problem is a relationship between two different, two other things. Not old people and young people, rather it’s a relationship of the amount of who need medical care and the amount of people that capital needs for its enrichment. If capital needs less people for its increase, less people get wages, less people are active workers paying into the pot, more people unemployed, more people who, as they’re older, are no longer useful for capital, therefore a bigger burden. It’s not a relationship of young and old, it’s a relationship of what does capital need and what do people need, or what do the people need in terms of medical care. That’s the antagonism in this so-called demographic problem. A small but important digression on that point. In any case …
[Audience]
Well, maybe someone else could say more about this if they are more familiar with but …
[Audience]
I wouldn’t really know what to say about this …
[Audience]
I’m getting near the end. By testing the ... Or do you want to postpone this question to the end, do you mean?
[Audience]
No, it’s fine. I was wondering … Maybe this is another point about the pot again. It’s often, especially in Germany, described as a cake. “The cake has to be bigger in order for it to be spread around.” And, again, the image is always that there’s a big cake that everyone pays into and everyone eats from. (I don’t know how you can pay into a cake, but it doesn’t matter.) The idea is that everybody eats then from the whole cake, so when there’s less people paying in, there is less people that can get things out of it. (Sugar, maybe.) The reality is that the entirety of the working population needs to be concentrated into the one piece of the pie that’s called wages. In essence this demographic problem is really one portion of the working class paying for the other, deductions from the wages, especially clear when it comes to Medicare – deduction, payroll taxes, deduction from wages used to pay those members of the working class that are no longer needed by capital. The entirety of the population is obligated to feed on this small piece of the cake that is the wealth of the nation. That is the pot. Again, the relationship is not: “What do we all pay in? And what can we all take out?” but: How many people does capital need? And how many people need medical care. That’s the antagonism.
OK. Back to the diagnosis. This combination of rising costs for health care, on the one hand, and the rising amount of uninsured has occasioned not only Obama, but Republicans on both sides, sorry, Democrats and Republicans, politicians on both sides of the aisle, and a bunch of Nobel prize winning economists and even business in general, to call for an overhaul of the health care system. And I don’t really want to go too much into the ins and outs of the reforms, but what I want to reflect on a little more is the character of this diagnosis. Or what was the diagnosis that led to the reform? America spends more on health care than any other country while America’s health statistics are worse than most other industrialized nations. Obama would get up and say: “We pay more for health care than any other advanced nation, I think, any other nation, and we get less out of it.” That’s a problem for the budget, and that’s a problem for the competitiveness of the economy.
I want to talk about the nature of that diagnosis. That’s something I want to reflect on for a moment. This diagnosis is as frightening as it is instructive. What does it tell us? The problem that Obama is addressing is not so much poor people’s health or rather: people’s poor health or what that can mean for something much more important than their health: the health of the budget, the solidity of the budget, and the health of the companies that make use of those workers, that make use of people. The problem that their poor health might cause, well, you could say that that’s an injury to the ability of the nation’s economy to compete against others. That’s a nice illustration of what I was talking about before: what public health really means. It doesn’t mean 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. The economy is not there for them, they’re there for the economy. Their poor health as such is not necessarily a problem. It’s what that poor health could mean for the health of more important purposes to which they are subordinated.
The second point is, it teaches us what the criterion is for public health. Throughout the talk I’ve mentioned several times that the state has a certain interest in a certain level of public health. Well, there’s no real objective criterion for how much health is enough or how much sickness is too much. There’s no objective yardstick for measuring that. But the yardstick that does get applied, in this case most explicitly, really gets to the heart of what people’s health is there for in the first place. When Obama looks abroad and sees this discrepancy between what America pays for health care and what it gets and what other countries and what they get, the question he’s asking is, “OK, our health statistics are worse and we are paying more. Is that a disadvantage for our competitiveness? Is that a disadvantage for us in our competition with other nations?”
Again, the economy is not there for the people, but in this case it’s an instrument not only for the economy but for the state in its international competition. Health care turns out to be even important for imperialism. The cure that is being discussed for this diagnosis, or on the basis of this diagnosis, one could say rather the debate over the cure between politicians, corresponds to the nature of this diagnosis.
What I want to do is just point out a few specific things about the Democrats and their bill to be presented and the Republicans. I don’t want to go into too much detail. I just want to pick out a few fundamental things. Two elements of the Democratic bill I want to point out: The one is the – and this will probably get in the final version – the obligation to get insurance, the obligation of everybody to buy insurance. The second thing I want to talk about is the obligation to offer insurance, for both companies and insurance companies.
The first thing: an obligation to get insurance. What does that teach us? That’s interesting. The starting point was: People are unable to afford the cost of medical care. They’re too poor to afford insurance. What’s the solution? Force them to get insurance. That’s a really nice illustration of what the problem with their poverty and their sickness is: It could create rising costs. People therefore 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 insurance companies and the health care industry. And the calculation is that if more people are involved in the insurance or are paying insurance, insurance is more profitable, insurance companies have more market power and hopefully they can reduce premiums and force down the prices of drugs and medical care. Again, it’s not about eliminating the causes of people’s poverty induced illnesses, but eliminating the problems that that may cause.
[Audience]
What I would say about that, too, is that the nature of the objection saying, “that’s not constitutional.” What I would say is that at that point, if you find out that this is the kind of calculation that’s going on: instead of asking, “Are the politicians really allowed to do that? Can the state really act that way?” first of all to take in the fact that the state does act that way and to take that seriously. What I’m saying is that it could be that they find out, “Well, we’re not actually allowed to do this.” They might have to take something back or find some kind of compromise. The point I really want to get at here is just the nature of the calculation that they have. And the logical ... the nature of this calculation is somewhat logical, given the way that they view people’s public health. And the reason that they view public health is not some individual moral failing, but it’s a consequence of the economy itself. These people’s livelihood, their health, is on the one hand a necessary prerequisite for the functioning of the economy, and on the other hand it’s a cost burden on the economy, and the economy makes them sick. That’s really the point I would emphasize. And here, really, the point is the obligation to get insurance. People have to make a financial sacrifice for their own health care that they can’t afford, so that the state and the economy can save on costs further down the line. The state will help them do that. There’s various kinds of subsidies, maybe, tax breaks, but it’s unclear even what will become of that.
The second part: obligation to give insurance, or to offer insurance. The one element that it looks like will get into the final bill is that insurance companies are no longer allowed to deny people because of pre-existing conditions and also won’t be allowed to drop people once those people get ill, to drop their insurance. And there’s various other kinds of regulations. It’s unclear whether they’ll get passed: things like obligating insurance companies to use a certain portion of their profits for providing medical care instead of profits or instead of investments, really force to take their earnings and reinvest them into medical care. Also things like these insurance exchanges, or in general rules about becoming more transparent, giving people a better or a clearer choice between different insurance premiums, it’s supposed to create more competition, etc. etc. What I want to talk about at this point, all these obligations that are being imposed on the insurance industry. On the one hand, they are to be taken seriously. Notice that the state does have an interest in ensuring some kind of public health and obligating not only people to make financial sacrifices, but also capital. On the other hand, what is the nature of that obligation? The nature of the obligation is: These companies should be forced to provide insurance and to do business with them. They should be forced to make a profit on providing health care. They should fulfil this certain function for the state’s interest and make a profit on it. That’s a nice illustration of the way that the state manages this contradiction. They should be able to do business, they should be able to make profits, but while fulfilling a need that the state has for these people’s health. One thing is clear, health will not come out of it, maybe some public health. The functional equivalent of health, not the same thing.
The second thing: obligation for employers to offer some kind of insurance plan. Now, it’s unsure what will come of that, but ... same thing: Companies should pay some kind of a ... not a penalty, but if they don’t pay, if they don’t offer insurance, they have to pay a penalty. The companies should make some kind of financial contribution to their own ability to make use of the labour of workers for their own enrichment. That’s the nature of the obligation. They might have to pay higher taxes, they might have to get tax breaks. In any case they have to offer some kind of insurance. That is an obligation, it is imposing a burden on capital, but what kind of a burden is it? “Contribute your part to the maintenance of the source of your own wealth. Contribute something, so that you can contribute to profit on these people to their detriment.” That’s the nature of the obligation.
So, so much for the Democrats. What about the Republican opposition? Maybe it’s just a small point, but it’s important. At the moment the Republicans have a very bad reputation among the Left: obstructing this landmark piece or reform, doing all they can to prohibit people from finally getting the medical care that they need, really being interested in just seeing people rot and die, so that insurance can make a lot of money and capital doesn’t get burdened. Well, that’s not quite right. In fact, it’s probably worse than that. Republicans haven’t been saying, “Ah, screw it, we don’t care if people die. We want profits.” They themselves point out that the health care reform is being brought about ... certainly might not lead to anything like an improvement of health. They point out instead that in standing health care to more people would mean spreading health care thin. It would mean under-insurance for many more people. Even worse state of insurance, even worse state of medical care for the overwhelming majority. They point out that many people will not be able to afford the good compulsive insurance, the insurance that the state requires of them. They point out that that would mean an increase of poverty across the board and lower quality of care across the board. What I would say about that is: That shows how much the faction of the state takes the poverty of people for granted. Quality care for all is simply out of the question. And on that point they’re in agreement with the Democrats. High quality of health care for all is a fantasy world that the American economy cannot afford. For the Democrats that takes the form of saying: “They have to pay a financial sacrifice, so that they can get any kind of care, and no, this might not be the best care, but it will reduce costs.” It’s the way they agree about this point. The Republicans may be a little starker when they say ... it’s more of a stark expression of that same point. They say, “It’s clear from the beginning that not everybody is going to be able to get care. This will mean just worsening health care for those that have insurance. And this point of agreement: that this economy simply cannot afford the health care of the people, simply cannot afford medical care, this is a question that people should ask, or this is a question ... to put it another way: That diagnosis, that this economy cannot afford their medical care, if that’s the case, people should ask themselves if they can afford this economic system.