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Medicare For All - Policy or Populist Sop?

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On September 13, 2017 Bernie Sanders, the independent Senator from Vermont and erstwhile Democratic Party presidential candidate, introduced his latest version of a reform of the US health care system that he called Medicare For All. While he acknowledged that the prospects for passing in Congress or being signed into law by the ruling Republican Party were nil, his stated purpose was to bring the concept of single payer health care into the conversation that has been on-going since the debate on and passage of the Affordable Care Act, aka “Obamacare”, in 2010.

In truth, this is not the first time that Sanders has introduced a similar legislation in Congress and it's not even the first time a single payer healthcare bill has been introduced this year. Democratic
Representative John Conyers, Jr introduced a Medicare for All bill in the House in January, as he has in every Congress since he was elected in 2003 and Sanders also introduced a version of single payer health care in 2013 in the Senate. What's different this year is the amount of support that both of these most recent iterations of Medicare for All have garnered with the elected Democrats. Conyers' bill has 120 co-sponsors in the House and Sanders' effort now has 16 Democratic Senators as co-sponsors. The number of co-sponsors in both the House and the Senate is the most ever for a Medicare for All health care bill and represents a rapid change in the position on this issue by many in the Democratic Party. This change also mirrors the rising support among the population of the US which now show 50% of the populace in favor of this most basic of all social democratic programs. It appears that the US is finally catching up with the rest of the world in acknowledging that health care is a right and not a privilege reserved only for those who can afford it.

The Democratic Party and Healthcare

But as noted by the number of co-sponsors and in spite of an 86% level of support by Democrats in polls on the issue, this acknowledgment of health care as a right doesn't really even have the support of the majority of the Democratic Party representatives in Congress in spite of its popularity with the base and with the people in general. For one reason or another, whether political inertia and cowardice, tactical considerations, or an actual ideological antipathy, the majority of Democrats in Congress still don't support any sort of single payer program. And even among supporters there is a suspicion that many representatives who actually are supporting the measure at this time are doing so only opportunistically, throwing a bone to the base while knowing that they haven't the power to overcome the united opposition of the Republicans. As proof one only needs to look at the most notable absentees in the list of co sponsors, the Democratic leaders of the House and Senate in Nancy Pelosi and Chuck Shumer.

This waffling shouldn't be a surprise to anyone. As we have noted before numerous times, the Democrats are a party of compromise. In spite of the optics of “resistance” in the era of Donald Trump and his “outrage of the week”, the Democrats rarely rise to the level of an opposition
party, much less any true resistance. Instead they do what they've always done, take the temperature of the social forces at work in society and compromise with the ones who seem to have the power and momentum at the moment. With the left and social justice movements like the Civil Rights movement of the 1950s/60s the compromise involved incremental changes that corrected some obvious wrongs while keeping the superstructure that supports the oppression in place. For example, the laws enforcing Jim Crow's overt oppression against black people were brought down, but the underlying economic and political realities of white supremacy stayed the same, as witnessed by the same struggle still being fought today.

But for the last forty years Democratic compromise has been with the neo-liberal Republicans. They've taken the worst that the most obvious representatives of the ruling class have proposed, gained a few, and oftimes temporary, concessions in order to make it a little more palatable to the working class and then voted for it, all the while calling it a “victory”. Although the examples are many, Obamacare itself is a prime example of how the process works in US politics.

During the period of time when the Affordable Care Act was debated and enacted, the Democrats held a majority in the House and a filibuster proof majority in the Senate. But instead of pressing this advantage in order to push through, or at least advocate strongly for, true healthcare reform, they compromised with the minority Republicans and right-wing, neo-liberal members of their own party to adopt a national version of the Republican health insurance reform from the neo-liberal and conservative Heritage Foundation. Thus Obamacare was born of this compromise with the right. They didn't even consider something as mild as a public option, a Medicare “buy-in” that would allow Americans to take advantage of a system that was already set up, proven, and working well for older citizens.

In the maintenance of bourgeois democracy, compromise might not be a bad word, but in an era where the system is breaking down and obviously isn't working for the majority, compromise means siding with the oppressor and not the people. The working class needs a party that will not compromise but will instead fight for them, openly and without apology in healthcare as in all struggles between the classes. This is not the Democratic Party by nature or function.

Sanders' Medicare For All

This is not to say that the Sanders effort is totally without merit. As said above, at the very least it brings the American healthcare system up to par, more or less, with the social democratic programs in effect in all the major developed countries and many of the lesser developed ones too by establishing health care as a right for citizens and even non-citizen residents. And it's undoubtedly better than the Affordable Care Act (Obamacare) which merely “reformed” the insurance industry by preventing the most egregious abuses of that industry being perpetrated on Americans who, through illness or accident, were forced to use the anarchistic American version of healthcare. It provides a free at the point of use access for all with no co-pays except for medications. It does cover abortion and other female healthcare services and even covers dental care, things either not covered by most insurance or covered at the will of insurance executives for a greater cost and of course, greater profit, and it provides funds for the retraining of healthcare administrators who would be affected and lose their jobs in the transition to Medicare for All.

But the Sanders' Medicare for All bill is far from what the bourgeoisie consider a “socialized medicine” program like the NHS in Britain. Instead of the vast majority of healthcare providers being paid by the government directly, the Sanders bill still leaves the private sector, and hence the profit motive, in control of the delivery of care. What it really does is centralize the administration of health care and put most of it in the hands of a government bureaucracy, albeit a bureaucracy with a proven track record at providing needed care at a low administrative cost. And it does provide the government as the “single payer” for all, but a few elective procedures like cosmetic surgery. So, in reality, the vastly expanded Medicare system would still be negotiating payment and treatment with entities and people where profit is the primary consideration and not the best interests of the patients themselves.

The funding method is still somewhat unclear as it's not explained in the bill itself and it doesn't outlaw for-profit facilities and insurance which, as stated above, would eliminate one of the primary ways to control healthcare costs. It provides a four year phase-in to the program with a public option (explained above) during the transition. As to the funding, Representative Conyers' bill is more detailed on this issue, and yes any single payer system will involve higher taxes on almost everyone to a greater or lesser degree. However, the bulk of those higher taxes, as per Conyers' bill and Sanders' published thoughts on the matter, would fall on the wealthier individuals and on businesses, many of which already spend a lot of money on employer based or individual policy health insurance as it is. With the burgeoning popularity of single payer, this debate over costs and payment for Medicare for All will most assuredly be big, nasty, and fraught with lies, damned lies, and statistics. A unified effort on a strategy is a must in order to be able to frame the debate around care, access to care, and the controlling of costs, rather than it merely devolving into a fight about higher taxes.

Since the Sanders proposal and the Conyers bill in the House are both already “dead on arrival” with no chance of passing either chamber, much less enactment into law, the purpose is not to provide a detailed bill, but merely, as Bernie himself said, to put the idea of single payer into the debate on healthcare. So, in the spirit of opening up the debate on healthcare in America, we are prepared to put forth our own modest proposal for a healthcare system that not only takes care of people, but assists in the transition to a socialist society.

Healthcare- A Transitional Program

We would begin by bringing all aspects of the healthcare industry into a non-profit status. For-profit hospitals and facilities would be outlawed and their owners' investments expropriated without compensation over a certain level of investment. This would also include support facilities involved in the production of drugs and equipment that are healthcare specific. Small investors (definition to be determined by the working class) would be bought out at a negotiated rate.

All wages would be raised to at least a “living minimum wage” as shown by an analysis of what that term means in each area. This analysis will be conducted by the working class and its elected representatives and not include representatives of capital, but will include items that anyone would need in order to exist in society in minimum comfort and personal security. Any wages for job descriptions that pay above the living minimum wage (physicians, nurses, some administration positions) would be set by the workers themselves depending on budget and in light of industry standards with provision for immediate raises for the living minimum if necessary to account for general economic conditions, i.e., inflation.

The books would be opened and all costs scrutinized by elected representatives of the facilities themselves and members of the communities and patients that they serve. These elected representatives would continue to receive their current level of compensation while working on an analysis of the costs of running the facility, as will doctors, nurses, and support staff that are actually working in patient care and plant maintenance. There would also be an elected board that would oversee the daily operation of the facilities and be paid the average wage for their profession. Patient care and worker well-being will always be the primary concern.

Any loans outstanding on either the facility or the equipment would be declared invalid and not paid, effectively expropriating from capital the facility and/or the equipment. Any equipment needed by direct care facilities would be approved and provided at cost where they are needed by healthcare boards made up of elected representatives of the facilities' workers and the communities they serve..

Funding for the facilities themselves would be provided by the workers' government in the form of a block grant based initially on the previous year's funding with provisions for extra money if it's proven to be needed for operation within said year. The elected workers' committees, paid the average of their profession, would be in charge of disbursing this block grant in cooperation with elected local community representatives, also paid the average wage of their profession in their community. A joint facility/community board would set goals based on projected healthcare needs of the community and the workers' committees would be charged with fulfilling those agreed upon “community needs” goals.

Big Pharma would be expropriated without compensation and brought within the nationalized system under workers' control. Owners would be expropriated without compensation and the laboratories and research facilities would be brought under the control of University research facilities that would also be placed under workers' control. Patents for medications would be paid to individual patent holders at a negotiated level, but expropriated from corporate holders. Then medications could be purchased and dispensed at the discretion of physicians to the patients on an as needed basis.

At the local level, for-profit clinics would be nationalized under workers' control and be opened to provide free at the point of use care for minor emergencies and non-life threatening medical needs. These facilities could be staffed by non-specialist general practitioners or nurse practitioners.

Work will be parceled out as needed to staff the facilities and to employ workers that are already on payroll with no loss in compensation. Provision will be made to allow staff to “float” as needed to facilities that are not fully staffed with no loss in compensation. A centralized system of community and/or area wide staffing will be set up to facilitate these needs. Extra compensation will be included for this level of “float” staff to account for travel expenses and time.

In addition to the expropriation of capital already listed above, this transitional healthcare reform would be funded by confiscatory taxation on wealth above a certain level and a tax surcharge on large corporate entities, plus any and all current money spent on healthcare by the government. Any additional monies needed would next be taxed at the level of current private insurance purchased by both businesses and individuals. Finally, if more is needed after these taxes are levied, then the taxation will be on a progressive basis with the more well off paying a larger percentage of their income.

Finally, any specifics not listed in this general plan will be left to the discretion of popularly elected local, regional, and national committees of the working class with the general purpose of redistributing healthcare dollars in a manner more appropriate to patient care and worker well-being and without regard for profit or excessive administration costs. All compensations to board and committee members, who serve at the will of their fellow workers and are subject to immediate recall, will be paid at the average rate of their profession in their geographical area. Membership on all committees and boards are to be rotated as often as practical in order to prevent the formation of any sort of entrenched and ossified bureaucracy that is out of touch with the demands and needs of the members and patients they serve. Workers must serve the needs of other workers because it's the right thing to do and not because it makes them rich.

From A Minimum Program to Socialism Via the Transitional Bridge

A transitional program for any economic industry is for the purpose of transitioning from what we currently have or from a minimum demand like the Sanders or Conyers Medicare For All proposal(s) into a full-fledged workers' government and to workers' power. It isn't meant to cover everything, but it does provide the outline of the bridge to full socialism rather than just a minimum demand.

Needless to say like every other attack on the evils of the capitalist system to carry it through will require a workers' government in power – resting on on democratic working class bodies. with the power to overcome the resistance of the capitalist class. To lead the struggle for a workers' government we need a workers' party.

But even with a workers' party, how could we implement the above mentioned ideas and proposals? Expropriation, workers control and health care for free under Trump? Not likely. So where should the structures come from that could ensure such an ambitious health care program as outlined above? Like we have experienced over and over again, we cannot trust the Democrats in the House or the Senate if we want to reach true healthcare for all. We also have experienced that our collective struggle and self-organization is powerful enough to bring change. Therefore, we need demonstrations, strikes and occupations if necessary to build up enough pressure to “convince” the owners of hospitals, insurance companies and the pharma industry to give us what we want. Decent health care for everyone, organized by ourselves! All Democrats that truly support Medicare for all will have no choice but to support us in our struggle and wouldn’t be able to merely talk about a Medicare for All in the far-off future, much less only the necessary compromises needed to secure Obamacare.

Since even Sanders' proposal is only for the purpose of debate with no possibility of enactment, then a transitional program for the healthcare system should also be open for discussion. We hope that all will discuss and improve our vision above in open and vigorous debate. We welcome the input. After all, it's all of our health and well-being we're discussing. Because what we have and what the dictatorship of capital wants for most of us will leave us dying in the streets.

Civilization demands healthcare for all. Anything else is barbarity. And since capitalism has proven that it won't provide us with anything, but barbarity, then choice is clear. As Rosa Luxemburg said over a century ago, it's “socialism or barbarism”. We choose socialism