Healthcare: It’s All of Us or None of Us
Medicare and Medicaid were passed 50 years ago this summer. Today, there is massive restructuring of healthcare going on in America. It is aimed at maintaining existing property and power relationships but is taking place at a very different time in history.
Enactment of the Affordable Care Act (ACA) has supposedly taken the fight for access to healthcare off the legislative agenda, but not out of the emerging struggles of the working class, especially among the dispossessed and displaced, for access to health care as a human need.
Medicare and Medicaid: “Not Your Father’s Insurance”
The passage of Medicare and Medicaid in 1965 was a part of the last structural reforms from a still expanding capitalism. They were also a consequence of the Civil Rights Movement, a powerful social movement that temporarily coincided with the interests of capital for maintaining a stable workforce. That era is over. The growth of technologies in production that eliminate human labor have thrown capitalism into irreversible crisis.
Healthcare resources historically purposed with maintaining and reproducing a healthy productive workforce are now being used to build a healthcare system that preserves corporate profit and denies health care to those who are no longer needed by the economic system. Giant corporate health systems, private health insurance policies with unaffordable deductibles, premiums and coinsurances, and privatizations of Medicare and Medicaid, reflect a society increasingly alienated from its government. The narrative of the 1960s has shifted from expansion of coverage as a public good to increased corporate profit at the public’s expense, and for many, the cost of their very lives.
Medicare and Medicaid policy reflected the inequality central to the social reforms in the 1960s. Medicare, tied to Social Security and financed by working labor, held the mantel of “dignity” and “deserving” because the worker contributed to it throughout his or her working years. Medicaid was intended to cover some sectors of the poor. Medicaid “recipients” were stigmatized as “undeserving,” “public charges” and worse. While Medicare had uniform national standards, Medicaid left it to the states to determine means-tested eligibility and scope of coverage. From the outset Medicaid was unequal and restrictive, especially in Southern states, where poverty was most concentrated.
Even so, these reforms didn’t come without a fight. The Mississippi Freedom Summer of 1964 was already waging a war on poverty. The Medical Committee for Human Rights (MCHR) was embedded in the social struggle for equality and entered the fight for healthcare in Mississippi. Freedom Schools ran classes on public health. The Mississippi Freedom Democratic Party program called for Medicare for All, rather than grossly unequal state-based Medicaid programs. The Black Panther Party incorporated health education into their schools and called for Free Healthcare for all oppressed peoples. Equity and universality in the fight for healthcare has always been a ground-up struggle, not a benevolent act of Congress or presidents.
What has been won over the past 45 years is being further eroded, while the need for healthcare continues to grow. The Health Maintenance Organization Act of 1973 offered businesses cheaper health insurance options. HMOs became so restrictive that they provoked spontaneous consumer revolts. The Tax Equity and Fiscal Responsible Act of 1982 (TEFRA) set the basis for a huge privatization of Medicare with the creation of Medicare Part C Advantage Plans. These private commercial insurance plans paid directly out of Medicare’s Trust funds are notorious for overcharging it. In the 1990s, Blue Cross/Blue Shield sponsored state legislation all over the country enabling their conversion to for-profit status. The Medicare Modernization Act of 2003 that created Medicare Part D subsidizes the pharmaceutical industry while explicitly prohibiting any price control of medicines.
The government is restructuring healthcare in ways that reflect changes in the economic base. Spun as a response to skyrocketing health costs allegedly caused by a chaotic fee-for-service system, the effects of these massive privatizations have done nothing to reduce costs. Fee-for-service is declining, but in its place is a consolidation and concentration of corporate healthcare. Exploding costs of over $2.3 trillion are being borne by an increasingly impoverished working class – employed and unemployed alike.
As labor-replacing technology and outsourcing shrank the unions of the industrial working class, comprehensive and affordable health insurance declined. Medicaid enrollment has grown in many states because of increasing impoverishment. By 1971, when most Southern states had accepted Medicaid, there were roughly 14 million people enrolled. Those numbers doubled between 1990 and 2010. Today there are over 72 million people on Medicaid. Most glaring is the growing number of uninsured, from around 20 million in the 1970s to over 45 million today, even with so-called Obamacare. The narrative became more transparent during sequestration in the Budget Control Act of 2011. The call was outright “austerity” and, once again, it was austerity for the working class and a bonanza for corporate healthcare.
Healthcare and Power Relations Today
These changes affect the way power is wielded today. Every stage of development in the crisis of access to healthcare has been met with resistance. The struggle for a national health service (nationalization) in 1977, led to vitriolic red baiting and character assassination of the legislation’s sponsors. A compromise position for a national federally funded public health insurance system (single payer) was advanced and looked to Canada rather than Cuba for its model. The strength of these fights has been the challenge to the power of the private insurance industry. The weakness has been the focus on policy changes without disrupting capitalist private property relations.
But capitalism is being disrupted. Healthcare is a basic human necessity and is central to the economics and politics of any society. For many, particularly those holding generational traumas from slavery, genocide and white supremacy, medical institutions have never been benign. Struggles for the right to healthcare have always forced a fight for power. The current construct of a healthcare system is being fostered by the State to protect corporate ownership. It makes healthcare a struggle for power for the class as a whole. “It’s all of us or none of us!”
Our corporate care system is now 17% of the GNP. The fight to protect health reforms born of the social and trade union movements of industrial capitalism in the 20th century are proving to be a mismatch with the 21st century State and its health empires. Both the delivery system and financing of health are on trial. The fight to protect the reforms of 50 years ago has to be positioned in the economic and social realities of today.
The initial aftermath of the Affordable Care Act (ACA) altered the framework of the struggle for healthcare for all. Passed in 2010, the Act has resulted in strengthening corporate control of healthcare. A public subsidy to support purchase of private insurance hardly guarantees access to healthcare. The Act offers regulatory improvements for some while explicitly excluding many immigrants and all undocumented workers from coverage. Upcoming cases before the Supreme Court on the ACA challenge not only the subsidies, but also the weak employer mandate. Employers use the Act as ammunition for workplace changes to cut hours, workforce numbers, and or family coverage in order to avoid mandates and penalties. The Supreme Court upheld the ACA in 2012, but removed mandatory Medicaid expansion, calling it “coercive,” and thus left millions of those most in need uninsured, 75% of whom are in Southern states.
In response, a new stage of struggle for healthcare is emerging. Moral Monday demonstrations in North Carolina and Georgia target the failure to expand Medicaid. In the face of the breakdown of all public infrastructures, the fight for healthcare equity, wellness and healthcare as a human right intersect with more and more fronts of social struggle. Michigan nurses joined with Detroit’s struggle to turn on the water, calling the shut-offs a public health disaster and demanding that water be available to all. The needs and leadership of poor women, increasingly led by women of color, were on the move fighting against last year’s “Hobby Lobby” decision, that handed over women’s reproductive health rights to certain employers’ control. Skilled trades and other unions are battling the ACA’s threat to multi-employer insurance coverage. State governments have targeted both the healthcare and retirement of public employees. Nurses launched a campaign in response to the Ebola outbreak, exposing decimated national and international public health services after decades of cutbacks and out-sourcing. Health consequences of fracking, environmental degradations and climate change are mobilizing thousands.
More challenges lie ahead. Applications for Medicaid waivers, especially from Southern states,propose adding premiums, penalties and “personal responsibility” requirements for recipients if “outcomes” are not met. In other words, the patient has all the responsibility, but no rights. Congressional proposals call for catastrophic cuts in Medicare and Medicaid and removal of any semblance of governmental responsibility. Electronic medical records and Medicare regulations that ignite the creation of Accountable Care Organizations (ACOs) are increasingly driving regressive reimbursement practices. Contradictions between healthcare delivery and health insurance payment are taking no prisoners, causing public safety net hospitals, rural hospitals, independent physician practices, and smaller community based care to wither away. There were $143.3 billion in healthcare institutional mergers and acquisitions in 2012. Corporate healthcare is being fostered by a corporate State.
This stage of corporate healthcare cannot be separated from the decay of capitalism in irrevocable crisis. An increasingly impoverished and economically insecure working class is faced with the same enemy, a State with no obligation to the people. Few young people taking to the streets today expect Medicare to be there for them tomorrow. The technological power that can enable thousands to quickly mobilize is the same force that necessitates and makes possible distribution of healthcare freely for all ,based on need not income. As the public insurances of the past are destroyed, revolutionaries face a choice: rely on and politicize in the interests of a new class forced to fight for healthcare as central to the fight for power over our society, or leave the field to the corporate restructuring of healthcare. Let’s make this a 50th anniversary of Medicare to reclaim the fight for a society that can truly make healthcare a right for all.
May/June 2015 Vol25.Ed3
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