Capitalist Crisis
in Healthcare



California residents are facing a medical emergency, caused by the greed and anarchy of capitalism in health care.   There is  a dangerous shortage of emergency and critical care beds because of massive closings of hospitals over the last five years.  These hospital closings, job eliminations, and patient care cuts were deliberately done to increase profits.   The cuts have produced untold misery for patients and healthcare workers.   They have also produced obscene profits for health maintenance organizations  (HMOs).
But healthcare is no longer profitable.   Capitalist healthcare has produced its own downfall.   Hospital closings, job eliminations, and patient care cuts are one-time-only savings that cannot be repeated, and other healthcare costs have continued to rise.  At the same time, the HMOs are in a dog-eat-dog struggle to steal each other's members, so they have kept their premiums down to undercut each other. The result is that after six years of record-breaking profits, HMOs have had two years of huge losses.
Their  immediate solution will be simply to raise premiums, but this is already causing a crisis.    HMOs and employers are refusing to pay hospitals higher rates, and hospitals are refusing to cover patients without the higher rates.  The health industry's  long-term solutions will be more consolidations, a new round of massive hospital closings,  a whole new form of managed care with more "teeth" to severely ration patient care, and abandoning the poor and the old.
As international financial crisis spreads and worsens, and as war over oil and world resources approaches, a major battle over healthcare is developing between two groups of capitalists. Some capitalists in private healthcare want to renew their profits by cutting their own costs more. But the more dominant capitalists have a more long- term outlook, and are more concerned with   reasserting the US as a world power. These capitalists  need overall health care drastically curtailed "in the national interest," and don't trust the marketplace to do this.
Like so many of the "reforms" offered by capitalism in crisis, this restructuring of health care will actually be fascism with a liberal cover.   Any attempt to make meaningful improvements in healthcare directly challenges the needs late-20th century capitalism. Capitalist healthcare cannot be "fixed" without challenging capitalism itself and finally smashing it.
PROGRESSIVE LABOR PARTY envisions a communist future where workers control society.    We would work to supply each other's needs, not to make profits for an elite. Health care will exist to improve the quality of our lives rather than making money. This would make our work and our lives much richer and more integrated. There would be no reason for the horrors of racism, sexism, poverty, or managed care. Our fights against our downward spiraling wages, working conditions and standard of living can develop into a movement to unite, to act, and take power as a class. That is the purpose of PLP.
Read our newspaper CHALLENGE/DESAFIO about the day-to-day struggles to make this dream a reality.

   a dangerous shortage of emergency and critical care beds ...

In January, 1998, it became obvious that there is a healthcare emergency in California. The shortage of beds in Emergency Rooms and Critical Care units threatens everyone, whether they have medical coverage or not.
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hospital cuts deliberately done to increase profits ...

This crisis is the result of a  policy of increasing profits by closing beds, units, and entire hospitals, and by laying off thousands of hospital workers.
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  . untold misery for patients and healthcare workers ...

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obscene profits for health maintenance organizations ...

The cuts have also produced obscene profits for health maintenance organizations.
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But healthcare is no longer profitable..

Those glory days of gigantic profits are gone with the wind.   Having gutted health care, the financial geniuses of the "health industry" are looking around in disbelief, wondering where their profits went. "I don't think anyone knows where we are going," said Marilyn Moon, a health economist at the Urban Institute in Washington. "This is a wacky period in health care." (NY Times, 1-5-98)
With all respect to Ms Moon, it's not "the period" that's wacky. It's the greed and anarchy of capitalism that's wacky. The savings from hospital closings, job eliminations, and patient care cuts, are one-time-only savings that cannot be repeated, meanwhile healthcare costs continue to rise, particularly pharmaceuticals. At the same time, HMOs have been in a dog-eat-dog struggle to capture each other's members, and have had to keep their premiums down to undercut each other. The result is that after six years of record-breaking profits, HMOs have lost large amounts of money for the last two years.
The tendency to self-destruct is built into capitalism; there is no way it can escape. On one hand, capitalists must expand their business and get more customers, because if they do not, their competitors will force them out the market: it's grow or die. On the other hand, in order to grow, capitalists, must sink more and more money into buildings and machinery, and interest on the necessary loans, so their profits-per-dollar-invested decrease. Inevitably, the system crashes. Because workers are enmeshed in capitalism's machinery, our lives become part of the wreckage. What's happened to healthcare is an illustration of this.
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The HMOs' immediate solution will be simply to raise premiums. ...

The  immediate solution will be simply to raise premiums 5-15%, but this is already causing a crisis.   Health insurance buyers and employers are refusing to pay higher rates, and hospitals are refusing to cover patients unless the rates are raised.   Return to top of document.

But the HMOs' long-term solution will be more consolidations and ...

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A major battle over healthcare is developing between two groups of capitalists. ....

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The rulers of this country may well move healthcare away from the for-profit HMOs ...

Hard as this may be to believe, it is quite possible that the dominant capitalists of this country will move health care away from the for-profit sector, and turn it over to "non-profits" like Kaiser, which will become quasi-governmental. They will probably use people's anger at for-profit health care as an opportunity to make this move in the guise of reform. To many, this move will look progressive, but it is not.

A recent NY Times article (6-1-98) shows how trying to reform healthcare through the proposed Patients' Bills of Rights will strongly favor large HMOs with their own doctors, so-called Group Practice HMOs, like Kaiser.   The reform legislation mandates that HMOs must publish extensive and detailed statistics about their quality of care.    In theory, the patient can then choose HMOs and doctors with good statistics.  But this theory ignores the reality of who controls health care.  Only the large HMOs with their own doctors charting on their centralized computer patient records  will be able to meet the requirements of the reform legislation.   In this way,   patients' justifiable demand for accountability will speed up the monopolization  of hospitals and insurers, and open up patients to more coercion and worse medical care in the future.  In more detail, the article says:

"But the experts also know something the politicians won't say. These bills of rights, the product of a consumer backlash against restrictions imposed by the HMOs, are almost certain to do the opposite of what consumers say they want. Rather than expand consumer options, they will drive patients into restrictive types of HMOs that limit patients to a small roster of doctors. The bills could also wipe out old-fashioned fee-for-service health insurance, which puts medical choices completely in the hands of doctors and patients."
Patients' rights have broad support among health policy experts who say they will make insurance companies accountable for the quality of care they provide. The idea is that if every plan reports clear data on mortality, morbidity and patient satisfaction, consumers can reward the best plans with their business.

The patients' rights bills would demand substantial record-keeping. how many of its youngsters receive vaccinations,... how many diabetics are checked for high blood pressure and how many coronary patients take beta blockers ...How many of the plan's asthmatics return to normal work schedules without repeated visits to hospital emergency rooms?... How many of the plan's diabetics successfully control their blood pressure?
HMOs can handle demands for extensive data collection, typically by steering patients to a small roster of doctors and by using "gatekeepers" to intervene between patients and specialists. They also provide the plan a single place to find any patient's complete medical record. That makes tracking outcomes possible. By comparison, looser forms of managed care, like Preferred Provider Organizations, allow patients to see nearly any doctor, but require them to pay more for those who are not members of the plan. There is no one place to find a patient's complete record so plans must sift through claims submissions to figure out which treatments their patients received.
The bills would tighten the grip of managed care because they impose elaborate record-keeping requirements on the health plans, aimed at making them publicly accountable for how well they prevent, treat and cure illness. What the politicians won't yet admit is that accountability clashes with something else something else patients prize: choice.

This restructuring of health care will actually be fascism with a liberal cover ...

When we talk about turning health care over to quasi-governmental "non-profits" for a much tighter, more centralized rationing of patient care, we are talking abut fascism. Fascism can exist years before world war, or concentration camps. Capitalism inevitably leads to periodic crises of decreased profits. And when this happens capitalism switches from "democratic" mode to fascist mode to regain its profitability at any cost.

"Removing profit from health care" will mean the rulers have decided real healthcare is too expensive and should be abandoned so they can use the money saved to make greater profits elsewhere or rebuild their factories and military.  "Single-payer" will mean the rulers have decided to use the government to enforce healthcare rationing.

Fascism involves (among other things) three elements, all of which can be seen in the US and US healthcare:

   Fascism is collaboration of unions with the dominant capitalists, and the co-optation of  unions and opposing groups to confuse and then obliterate class consciousness of workers.  


Let's try to look at these elements separately.

Fascism is using force and threat of economic ruination to wring more profits from workers:

For the past twenty years, the rulers of the US have been setting the stage for using force and threat of economic ruination to extract more profits from workers, through huge cuts in wages and services, especially health.
"Persons will be recognized as in need of, and then denied, benefits that the medical care provision system is capable of providing. ... These decisions (to withhold treatment) are likely to be made when any of the following conditions are met: (1) the treatment is determined to be futile, (2) the patient declines treatment, (3) the quality of the patient’s life is unacceptable, or (4) the cost of providing care is too great. ... Only when society is fully able to come to grips with death and dying is it likely that policies and procedures for decisions not to treat will not only will be formulated, but will also be followed. This period is likely to be hastened as financial constraints force the issue." (Health Care Technology and the Inevitability of Resource Allocation and Rationing Decisions, Journal of the American Medical Association 4-22-83 p 2208)   A cost-benefit analysis showing that care of very low birthweight babies is not economically justified, based on the expected lifetime earnings of the infant. ("Economic evaluation of neonatal intensive care of very-low-birth-weight infants", New England Journal of Medicine 308:1330-1337, 1983) (Setting the stage for denying care to those who are not "economically productive.")   A survey of patient deaths in Seattle extended care facilities, showing that doctors were willing to withhold antibiotics to 40% of patients with fever, the majority of whom died. "Physicians have been accused of prolonging life at any cost. However, surveys of health professionals have found that many (50 to 70 per cent) are disposed to withdraw or withhold life-prolonging treatment." The question of whether the patient expressed a desire to continue living is never even mentioned in the article. ("Nontreatment of Fever in Extended-Care Facilities, New England Journal of Medicine, 5-31-1979, p 1246 (Popularizing the idea of killing unproductive people who might use up resources.)   A prominent British neurologist wrote in 1975 that "no person with severe handicaps is likely to be able to earn his living in competitive employment, unless his IQ is at least 100." He developed a set of rigid criteria to determine which newborns with spina bifida should receive aggressive therapy. These criteria include consideration of the infant’s "social condition" (economic resources of the parents.) (J Roy Coll Phys, 10:47, 1975) (Popularizing the idea of letting economically unproductive people die without treatment.)   Return to "fascism".
  Fascism is increased monopolization of the economy ...

The federal government has allowed, and even encouraged, monopolization on the part of "non-profits," particularly Kaiser, which are associated with the dominant Rockefeller-based capitalists. It has allowed them to form bigger and bigger conglomerates. At the same time, the government has attacked for-profit HMO conglomerates associated with the "new" capitalists, forcing them to break up.

 Return to "fascism".
  Fascism is merging business and government ...

Kaiser and other "non-profits" have made moves to integrate themselves with government-supplied health care. They have involved themselves in movements to federally regulate healthcare delivery by HMOs, and in a federal initiative to extend healthcare to more children.  The money  for these "non-profits" comes largely from bonds issued by state health facilities financing authorities, which charge no interest to the HMOs.

     " ... as beds empty, private hospitals are competing head-on with public hospitals for privately-insured patients and even Medicaid (Medi-Cal) patients. ... The SEIU Research Department has identified the key conditions for keeping these institutions competitive: strong political and community support, stable funding, a well-developed clinic structure, recognized specialties, and a competitive cost structure. It's clear that keeping costs competitive will be key to the survival of public hospitals. For SEIU healthcare workers, this means working with management to address the future of public hospitals -- while defending worker's rights and protecting the quality of care."   And just in case anyone doesn't understand what "competitive cost structure" and "working with management" means, SEIU spells it out in Findings About Healthcare Industry Restructuring and Implications for Our Union:  
"In order to maintain a patient base, public hospitals will be forced to compete with private hospitals. ... Implication: Many public hospitals will need to change to survive/prosper in the new marketplace. These changes will involve cost cutting often in the staffing area ..."  
Kaiser wrote in its Southern California Regional Business Plan for 1995-1997, which calls for massive layoffs, deskilling and job restructuring that it intends to "mitigate any potential harmful actions on the part of the labor unions" by continuing to develop "strong relationships with its union leadership." (The Link, CNA Kaiser Interfacility Newsletter, 9-95) (#3, Collaboration between unions and rulers)  
SEIU  told its members to cross the picket lines of northern California RNs who are striking against patient care cutbacks and hospital closings. Kaiser's position is that it will "bargain" with AFL-CIO unions over patient-care-quality issues, but not with the California Nurses Association. (#3, union-boss collaboration, obliterating class consciousness)  
On February 5, 1995 the San Francisco Chronicle ran an article claiming that CNA claims of deteriorating patient care at Kaiser were false, citing figures from a liberal business think-tank which purported to show that Kaiser nursing care was actually improving. (Kaiser has repeatedly refused to show patient care statistics to the CNA.) The Chronicle writer, Carl T. Hall, is an AFL-CIO shop steward on his job. (personal communication) (#3, union-boss collaboration, confusing the class consciousness of workers.)  
This is exactly the same rationalization the AFL-CIO uses to justify its partnership deal with Kaiser: we must help "non-profit" healthcare against for-profit healthcare. Promoting the "non-profits" by saying "Pursuit of corporate profit and personal fortune have no place in caregiving, " sounds good, but it ignores the fact that as capitalism goes further into crisis, its government will use "non-profit" health providers to severely restrict the flow of health care and make much greater profits for the class that runs the government. Whatever its intent, this babble about eliminating profit from healthcare has the effect of spreading passivity and setting us up for the kill. There is no way to escape profits under capitalism; only communism can give us life without profit.    Return to "fascism".   PROGRESSIVE LABOR PARTY:  a communist future where workers control society.
What does Progressive Labor Party mean by communism?


Our vision is a society run by the working class, with no profits, and no money. We produce the things we need and give them to each other. With no economic basis for racism, sexism, or elitism, we could struggle to develop our real human potential.

Under capitalism, the 1% that rules society has more wealth than the rest of us put together . They have built an entire apparatus to legitimatize, legalize, and secure this system of theft. This apparatus includes the government, the schools, the media, the universities, and the police and prisons. You can add many more parts yourself. Communists call this apparatus "the state".

These capitalists are not about to hand us control of society on a silver platter. Quite the contrary, the disaster of capitalist healthcare is a reflection of the entire economy. Capitalism is now in a world-wide crisis of inability to sell its goods; its high-flying global economy is rapidly crashing into depression and conflicts of major capitalists over markets, cheap labor, and raw materials, chiefly oil. The fascism we see being imposed on us in health care, the murder and massive jailing of our youth by the "justice" system, the forced labor of welfare recipients and prisoners, all this is being imposed to force more work out of us for less money, to take away our services, and to gear up to fight in world war. We seem very weak.

  On the other hand, the rulers’ hospitals, factories, schools, and armies are all staffed by workers like us. We have no interest in killing ourselves for our bosses on the job or in battle. And we have every interest in overthrowing our bosses. We believe that inspired by a vision of a communist future, we can fight all the aspects of fascism in a way to develop our ability to unite, to act together, and to forcibly take power as a class. That is the purpose of Progressive Labor Party.

What would healthcare be like in a communist society? Here is some of what we want:

Healthcare would exist to improve the quality of life, not make profits. This means we, the working class, would make healthcare decisions based on OUR needs. For example:

WE will decide how many hospitals and clinics were enough in our city or area.

WE will decide when our patients need to see specialty doctors.

WE will decide our staffing levels.

WE will decide when our patients are ready to go home.

WE will decide how much training was necessary for our different activities.

WE will decide whether it's better to treat a particular condition at home.

But would "WE" always agree with each other on what's best for all of us?

Probably not! Our existence has both collectivity and individuality; we all have our individual strengths and weaknesses to contribute. What's important is that the basis for making decisions would be our collective good, and that a mass communist party would exist as a framework to discuss questions and carry out our decisions.

For example, in the mid-60's, when millions had communist aspirations in China, some providers and patients preferred traditional medicine while others preferred western medicine. People argued over which form should be the medicine of the new society, until they realized there weren't enough practitioners of either type, and they needed to use everyone that was available. The communist party developed a plan to integrate the two disciplines. Traditional and western providers worked together in each clinic and hospital, discussed patients together to make sure all were getting the best care possible, learned from each other, and often devised new treatments based on both methods. (Joshua Horne, Away with All Pests)



There would be equality .  No one owning hospitals, food stores, or housing, to enrich themselves.   No one to force sending patients home or onto the streets while they’re still sick.   No one with power over us who would try to bribe us to scrimp on patient care.   We wouldn't all have the same tastes, and people's needs would be different, but we would all have the same standard of living.   At times this would mean sharing adversity, too. For example, as the working class begins to win in armed revolution, we can be sure the present rulers will try to destroy the nation's infrastructure, including hospitals, rather than let us take possession of it. During the rebuilding phase, there's no doubt about it: things will be difficult. We believe in an environment of collectivity and equality, people's best aspects will come forth. Even under capitalism the spark of this spirit flashes: In the huge 1993 Mississippi River flooding when urban black prisoners from Chicago prisons were sent into rural white downstate Illinois towns to repair levees and save towns, strong suspicions and antagonisms melted away, and strong attachments developed in many cases. (NPR news programming)   Mental and manual labor would not be separated as they are now. Each person's work would involve both mental and manual labor. Elitist stratification would not be allowed.
    During this same period in China, huge resources were put into healing workers injured during the rapid industrialization. Huge advances were made in microsurgery, and surgeons from many countries came to study the new techniques of repairing hand trauma. These advances were the logical outgrowth of striving for communism, which values manual labor as much as mental labor, and makes each nourish the other.   Communist merging of mental and manual work can make healthcare work a smooth continuum of skills where everyone can develop their potential.  Think about the awkward working relationship between nurses and new medical residents: As doctors-in-training, the residents are supposed to give the orders, but the nurses have to prompt the new residents on what orders to give.  It's not the new residents' fault, they've had very little patient contact. Think how much easier it would be to learn to be a doctor, if you'd already been a nurse for years, and an aide for years before that. Better yet, think of how these jobs could be combined, so clinicians could smoothly increase their skills, instead of hitting barriers where you can't get a "better" job, or the only "better" jobs are management, so you become clinically useless. The only reason for the capitalist boundaries between Aides, Nurses, and Doctors is to enforce aclass-based pecking order.   We would be able to prevent and treat disease in entirely new ways if people's work involved both manual and mental labor, and both are given respect and validity. Once again in mid-60's China, liver cancer was very common in a large area where there was lots of hepatitis because of frequent fecal contamination of water supplies by flooding rivers. From the village level up there was huge campaign to drill thousands of wells each day to provide safe drinking water. Hepatitis was drastically reduced, very quickly. Cancer scientists said, "Now in 20 years, we'll know whether hepatitis causes liver cancer." Combining mental and manual labor, combining theory and practice, gives "epidemiology" a whole new outlook. (report of Stanford Medical School dean returning from China, early 1970s) Contrast this with capitalist cancer research, where it is almost impossible to use population studies to tell whether a substance causes cancer, because nothing has been done to eliminate the known carcinogens like cigarettes and industrial pollution. Cancers from known carcinogens swamp out cancers from the substance you would like to investigate.  
We would do our work for free, and get our needs free also.
  If you were to ask nurses, or other health workers what we would really like, the vast majority of us would say we want to be able to provide good health care for our patients without interference from the hospital, and we want to know we will have food, shelter, medical care, education, and free time for our families and our friends.   So the time we're conscious that we need money isn't while we're working, it's when we need food, shelter, clothing, transportation, etc. We need the money because the bosses who own the farms, the apartments, the clothing factory, the bus line, etc have stolen what "their" workers have produced, and we need money to buy it back from those bosses.   A hospital worker wrote up an experience on the question on money and wages:
   I went into an operating room in our hospital to adjust some equipment.
The room was filled with stainless steel and hard tile, but the nurses
had dimmed the lights, and were moving quietly and speaking in soft voices.
A delivery was in progress.

"When you feel a contraction coming, press against my hand."
"That’s good. Now breathe deeply, and let’s get ready for the next one."
"Very good!   Each time, you’re opening up a little more."
What quiet intensity!
What incredible focus!
What a privilege to work where life is being born!

No matter how much they try to make us forget it,
The administrators, with their power suits and spreadsheets and efficiency reports,
are completely foreign. They haven’t a clue. They’re just feeding off us.

 My friend works at a different hospital.
She nursed a preemie as small as a Cornish game hen into a thriving baby.
She worked with the whole family.
Later, she called the parents at home to see how the baby was doing.
They read her the letter they’d sent the hospital about her.
It was very touching.

 Later, my friend got a letter at work on midnight blue stationery with gold stars:
"Thank you for co-operating with our Customer Relations program."
"Please accept this coupon for a free yogurt in our cafeteria."

How dare these parasites think they can bribe us with yogurt!
Plying us with trinkets for what comes from our best nature!

But isn’t the whole wage system like the yogurt?
No amount of money can equal the work we do,
whether it’s resuscitating a baby,
or stopping the spread of disease by collecting infectious waste.

As far as we’re concerned, we work for each other.
The nurses don’t pay me to fix their machines.
The parents don’t pay the nurses for delivering their babies.
Why can’t we run all of society like this?

Finally, we would like to include a letter from Progressive Labor Party's newspaper, Challenge. It is the grandmother of a baby who was born at the hospital where a reader works.
   Her "fee" is the equivalent of three dollars, if people have it, or a chicken or a promise of some favor if they don't. Several times, she emphasized, "The money means nothing, it's all for love!" When asked if this was common in her village, she said "Of course, nobody has any money. We just help each other." The nurses and I were moved and inspired to hear health care described in such a completely different light.

At first it seemed an amazing co-incidence that we met this woman the same week as Challenge published an article on how humanity worked for free for much of history. But as an earlier article had pointed out, examples of working-class heroism are all around us. We have good reason to trust that our class can create a society where money means nothing, it's all for love.

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