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Utopia and healthcare—1

from David Ruccio

This is the first in a series of blog posts on the utopian dimensions of healthcare.

I’ve written quite a bit about the U.S. healthcare dystopia over the years—including a seven-part series back in 2016.* But I haven’t yet addressed the utopian dimensions of healthcare reform.

The appearance of the new issue of Jacobin Magazine, titled “The Health of Nations,”  is a good occasion to start that discussion. Adam Gaffney starts with much the same question that provoked my own series of blog posts: “if American health care used to be so much worse, why is it in crisis now?”

In part because, despite such wide-ranging reform, the system’s injustices remain unresolved, pervasive, and deadly.

The figures tell the story. Even without Republican rollbacks, twenty-eight million have no insurance, and, according to the Commonwealth Fund, some forty-one million are underinsured. A substantial portion of the nation—predominantly those of low and middle income and disproportionately people of color—cannot afford to see doctors, pay for medicine, or go to the emergency room.

Families who bought silver plans on the Obamacare marketplace still have $8,292 deductibles, but less than half of American households can cover even a $4,000 deductible. Patients take twice-a-day medications only once, skip doses, or fail to ll their prescriptions to save on co-payments. And of course, people die — tens of thousands of people a year—because they lack coverage.

But the crisis in American health care isn’t simply that the ACA didn’t go far enough: it’s that there’s no ACA 2.0 available to finish the job. Real progress has been made, but the incremental reforms left us with a deeply inhumane system.

The problem, as Gaffney sees it, is that 

the Right is on the prowl, offering a slew of tired, malicious nostrums about personal responsibility, while liberal reformers have mostly run out of ammunition. But the Left has not, and single payer is now the only potent policy weapon still on the table.

I agree that the Right is attempting to dismantle many of the supports and safeguards, however limited, that are already in place. And liberals simply have nothing new to offer. But, beyond that, should the the utopian horizon for healthcare reform, at least from the Left’s perspective, be limited to Medicare-for-all?

The case Gaffney makes is quite persuasive:

Almost everyone—sick and well, insured and uninsured—has something to gain from this system. Single payer’s universalism is its strength, and the reason we can win it. But the Medicare-for-all movement is both a means and an end: it will clearly make for a happier and healthier nation, but it can also can become a unifying issue within a larger egalitarian political project at a moment of political crisis.

The universalism, I concur, is its strength—much like Social Security, which represents a collective bond whereby current generations of workers contribute to supporting previous generations who are now retired. Single-payer is the use of tax revenues, levied on individuals and corporations, to finance the purchase of adequate healthcare services for everyone. And, yes, it certainly can serve as a key issue within a larger egalitarian project.

But the Medicare-for-all proposal only gets at how healthcare is financed, not how it is produced or provided. It substitutes single-payer for private insurance and individual payments (for copayments and deductibles, and absurdly high expenditures for those without insurance). But it still leaves the mostly profit-driven system of U.S. healthcare services (along with hospitalization, pharmaceutical drugs, nursing homes, rehabilitation facilities, and so on) in private hands.

It therefore doesn’t include a critique of how healthcare is currently provided—by doctors, nurses, technicians, and other healthcare professionals and aides who are forced to have the freedom to work for large profit-making conglomerates—or any kind of proposal to expand the diversity of healthcare providers—whether at the local, regional, and national level, which would include more democratic, cooperative or worker-owned healthcare enterprises.

That’s a utopian horizon—covering both the financing and provision of healthcare—worth articulating and fighting for.


*The series started with the problem that, compared to other countries, Americans pay more but get less for their healthcare continued with an analysis of what workers are forced to pay to get access to the healthcare system, the role of healthcare insurancepharmaceutical companieshospitals, the double squeeze of declining real incomes and higher healthcare payments, and finally the case for universal, affordable, high-quality healthcare.

  1. March 11, 2018 at 11:13 pm

    I would add to this excellent summary three things: (1) prevention, still inadequately supported in our culture; (2) alternative medicine which, in my experience, has served me well and been much more affordable; and (3) health services in rural America.

  2. March 12, 2018 at 1:07 am

    Any kind of healthcare for all must be accompanied by the development of the medical resources sufficient to provide healthcare for all. In the present system care is rationed by both the payment system and by the availability of medical personnel and facilities.

  3. March 12, 2018 at 8:48 am

    should the the utopian horizon for healthcare reform, at least from the Left’s perspective, be limited to Medicare-for-all?

    Many thanks, David, for asking this question and for highlighting the important ways in which Medicare-for-all would still fail to provide the American people with the ‘utopian’ healthcare system they deserve.

    Back when I was in grad school, I took an Economics of Healthcare elective, in which we studied the HC systems in 6 different countries and were charged with “fixing America’s healthcare system” in our term project.

    Early on, I thought I’d come up with some clever amalgam of elements of different HC systems, but ended up advocating for England’s NHS approach on pure economic grounds.

    I justified my recommendation on the overarching need to eliminate the perverse incentives that existed in America’s HC industry, driving up costs across the board.

    The main culprit for these runaway costs was understood by industry analysts to be the market behavior of privately-owned, for-profit health insurance companies.

    This, because these companies did not much care about the rapid increase in HC service costs, so long as they would raise premiums sufficiently every year to 1) cover the payouts they had obligated themselves to, 2) cover the cost of lobbying + super-sized ‘campaign contribution’ to members of Congress, and 3) generously reward themselves with ever increasing levels of compensation every year.

    This background reality gave all HC providers who received insurance payouts a very real financial incentive to increase their prices as much as they possibly could every year, which was quite a lot, since no price competition existed between different HC providers.

    What this state of affairs does do is give providers an institutional incentive to over-prescribe care that is not actually necessary.

    The “tinkering” solution that apologists for the insurance industry came up with to control HC costs was: Managed Care.

    Incredibly, while Managed Care did slow down the rate of growth of price increases in those areas where it was practiced, it did so in a way that gave providers a new perverse incentive: to under-prescribe care at a certain point (once the budgeted amount was approached).

    There is really only one way to avoid giving health care providers a perverse incentive to either over-prescribe or under-prescribe care, and that is by giving them a reasonably generous salary for simply “doing what a doctor/hospital does” for a certain number of hours per week.

    When this is done, providers become primarily motivated by their desire to do a good job at their chosen profession (for if their performance is no longer approved by their competent peers, they will no longer be able to work in the field).

    The health care industry is one industry that we should not want to see corrupted by perverse institutional incentives. Because there is no price competition between the different providers of health care in America, and there are substantial barriers to entry, it is impossible to justify a reliance on a ‘free market’ to provide HC services at the lowest cost.

    The only problem with the NHS is that it is seriously underfunded (Brits pay less than half of what Americans pay for their HC). Waiting lists for elective surgery could be dramatically reduced with additional investment in extra facilities, surgeons, etc. Optimal dental care needs to be included in the services that the NHS provides for ‘free.’

    With a few such changes, the NHS would indeed be THE utopian model that other countries should want to emulate, providing the best possible care for all in need of it at the lowest possible cost.

  4. Miguel Bedolla
    March 12, 2018 at 3:16 pm

    Any real health care reform must include a radical change in the way American medical students are selected so that economically disadvantaged students, of all colors, have access to it. It must also change the way students finance their education. Given the social worth of every physician, society must pay for the education of everyone of them and, upon graduation, draft them into the Public Health Service, or the Armed Forces, to serve for a number of years equal to the years society, all of us, paid for their education.

  5. Craig
    March 12, 2018 at 6:03 pm

    The real problem with healthcare and every other sector of the economy is that theorists think they’re advocating free markets when what they’re actually advocating is financially rigged, chaotic and hence ethically unenforceable “markets”. This is true of both capitalist and democratic socialist theorists. They’re all habituated to and blinded by the imminently parasitical current monetary and financial paradigm of Debt Only. Break up that most basic problem and glaringly contradictory monopoly by integrating the new paradigm of Direct and Reciprocal Monetary Gifting and its policies and regulations into the economy….and we’ll have real change that will truly benefit all agents instead of “Change You Can believe In” and 3rd rate populist demagoguery like “Make America Great Again”. Then a truly fair and ethical social contract can be honestly created for the first time, and all of the understandably angry yet reactionary social and political manifestations we’re seeing world wide can fall back into rationality or at least crawl back underneath the rock they came from.


  6. Miguel Bedolla
    March 12, 2018 at 6:27 pm

    It is impossible to have a free market, perhaps any market at all, when you have organizations like the AMA watching over state boards to keep monopolistic control over who is licensed to provide care. Licensing was introduced by Frederick II Barbarossa to protect patients from the “imperitia medicorum.” Licensing, and specialty certification, may do some of that protection, but more than anything else, they function to protect membership in the monopoly and income earned from the practice of medicine.

    • March 12, 2018 at 8:01 pm

      It is impossible to have a free market, perhaps any market at all, when you have organizations like the AMA watching over state boards to keep monopolistic control over who is licensed to provide care.

      This is a good point. Certainly one of the ‘market failures’ of the health care industry in America has been the barriers to entry that have been erected by the political activity of the AMA.

      When you get right down to it, what is it that primary care physicians are paid their high salaries for? Answer: their accumulated knowledge/memory of details about symptoms. The thing is, in our modern high-tech age, we have computers that memorize all such knowledge much more efficiently than any med student can over several years study.

      One thing we can do to reduce this particular cost in health care—from an economist’s perspective—is train people in a year or two to learn how to collect symptoms and observations re: a patient’s health and put that info into a computer, which will provide as good diagnoses, prescriptions, etc., as any top physician could.

      Of course, becoming familiar with how to respond to the info and how to interact with the patient are things that require training over a period of time. But it’s not as though the knowledge required to carry out such interactions is so profound that only an elite few can be expected to master it.

      As you suggest, any serious attempt to lower medical costs would involved a willful decision to ‘flood the market’ with physicians. Any economist who does not advocate this is a complete fraud.

      Surgeons, of course, are another matter. Lengthy apprenticeships seem to be quite necessary…

      • Miguel Bedolla
        March 12, 2018 at 8:24 pm

        Indeed! It takes too long to train a family physician (and all physicians); it takes 11 years (4 years of college, 4 years of medical school and 3 years of specialty training) when you could actually train them in four (2 years of college and two years of medical school). This brings to mind a phenomenon that we could call “Curriculum Inflation.” Physician Assistants can do the work of a family physician. In the early days of the profession, they were trained with two years of college and two years of physician assistant studies. Now they need 4 years of college and 4 years of physician assistant studies in order to go and deliver the same care, with the same quality, that they were delivering earlier.

  7. Craig
    March 12, 2018 at 11:06 pm

    Let’s not forget that insurance comes to us from the rackets. The coercion is simply a little less overt now is all. Also, as Minsky correctly observed “the fundamental vector of capitalism is up” and when a sector like healthcare/medicine is riven with monopoly associations it makes the force of that vector even greater.

    And of course the utterly integrated monopoly paradigm of finance is more than happy to contribute to same both from the upper bound of cost and so price and from the entirely missed lower bound of costs/price.

    All the more essential that the twin policies of Wisdomics-Giftonomics (universal monthly dividend and 50% retail discount/rebate) be implemented so that the “impossible” , i.e. price deflation be integrated into profit making systems.

  8. March 13, 2018 at 12:52 pm

    Health and health care are complex topics in US history. First, each person was expected to take proper actions to ensure a healthy body and future. Those who did not take such responsibility were often considered undeserving of help or intervention from healers or medical providers. While this is in large part the result of America’s fundamentalist Protestant religious history, it is also a result of the US being a frontier society through its first 100 years and then a frantic capitalist society beginning after the Civil War. This is further ambiguous due to the evolving status of American Protestant theology, the American frontier, and American capitalism. Second, not till after World War I did America have in place health care treatment options that could be called both effective and structured to make them available to most Americans. Before this most health care was provided at home, through local healers or druggists, or through midwives and the like. Medical training and treatment by professionally trained doctors was not widespread in the US till the 1930s in cities and after WWII in rural areas. The fee for service model for health care was invented in the 1950s. Third, as suggested, the biggest obstacle to receiving professional health care for US citizens was and is cost. Until the 1970s most poor and minority Americans and many “middle-class” Americans simply could not afford to see a doctor or be hospitalized. As unions strengthened after WWII shared-cost programs were organized. Also, many businesses organized health care cooperatives for their employees, based on the recognition that healthier workers are better for profits. Finally, there is what might be called “the character of America.” Historian David E. Shi describes it thus, “Americans were a restless, ambitious people, seeking new ways to get ahead by using their ingenuity, skill, faith, and tenacity. The country’s energy was dizzying. Everywhere, it seemed, people were moving to the next town, the next farm, the next opportunity. In many cities, half of the entire population moved every ten years. In 1826, the newspaper editor in Rochester, New York, reported that 120 people left every day, while 130 moved into the growing city. Frances Trollope, an English traveler, said that Americans were “a busy, bustling, industrious population, hacking and hewing their way” westward in the pursuit of happiness.” (circa 1840) Americans have tended to hold onto this vision of themselves, even when it was inconsistent with the world situation. It has created continual uncertainty and problems for health care in America. Aside: you see it everyday in the remarks of loyalist Trump supporters. For example, consider this report from WaPo reporter James Hohmann about recent interviews with such loyalists, https://www.washingtonpost.com/news/powerpost/paloma/daily-202/2018/03/13/daily-202-trump-supporters-in-pennsylvania-embrace-his-obnoxious-personality/5aa7119030fb047655a06c32/?utm_term=.f7c09b4d69b2&wpisrc=nl_daily202&wpmm=1

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