Healthcare: From Private to Public
Nowhere is the chaos and insecurity of a society in transition felt more universally than in healthcare. Two distinct classes with opposing interests are facing off in a struggle that will determine the future role of healthcare in our society. On one side stands a corporate class, whose interests require private ownership of health resources. On the other side is our working class in need of freely distributed healthcare. The focal point of the battle today is Medicaid, a publicly funded health insurance that is mainly distributed privately, covering 74 million working and poor people in this country.
The political roots of the assault on Medicaid and threats of abandonment of any governmental responsibility for healthcare lie deep within Southern history. The Southern politicians, that currently hold key positions in shaping the future of healthcare, revel in maintaining the impossibility of the past in the present. You can’t go back. Georgia’s Tom Price of Health and Human Services is committed to the federal defunding of Medicaid and the vouchered privatization of Medicare. Attorney General Jeff Sessions, nationally propelled from his racist Alabama history, is pushing for a thoroughly discredited new war on drugs. South Carolina’s Scott Mulvaney, the Director of the Office of Budget and Management, and a founder of the Freedom Caucus, is hell bent on punting crucial health coverage regulations to the states.
A “states rights” application to healthcare did not begin anew in January of 2017, but rather relied on the ignominious history of Wall Street’s control of the South. From slavery to Jim Crow and the Dixicrats to the Tea Party and “Freedom Caucus”, subjugation of the South and the intended isolation of the Black worker has been the strategy of the ruling elite, to maintain political control of an increasingly destitute working class of all nationalities and colors.
Southern Roots Shaping Healthcare
An 1860’s plantation physician who provided rudimentary healthcare to enslaved humans, wrote, “To save [the plantation owner’s] capital was to save his Negroes.” It was slave labor that built an empire of cotton and it was Wall Street that held financial hegemony of the cotton trade. From slave to wage labor, the needs of capital dictated the development of U.S. healthcare, and the South was key. Following the defeat of Reconstruction, John Rockefeller’s “Hookworm Project” was designed to eradicate the lethargy-producing and productivity-lowering hookworm epidemic in the white workforce of North Carolina’s textile mills. As Richard Brown writes in Rockefeller Medicine Men the hookworm project was “directed ultimately to integrating the Southern economy into the national dominion of Northern capitalists.”
Health policies in the South were not limited to the goal of profitability through productivity. The infamous Tuskegee Syphilis Experiment, started in 1932 and continued for 40 more years by the U.S. Public Health Service, stained the relationship of health institutions with Black communities far beyond the 600 men involved. Eugenic practices, especially those related to involuntary sterilization, were rampant. “In the South, rendering black women infertile without their knowledge during other surgery was so common,” wrote Harriet Washington in Medical Apartheid, that the procedure was called a ‘Mississippi appendectomy.’ Eugenics also targeted the most impoverished Southern white women. The U.S. healthcare system was molded out of the violence, segregation and white supremacy necessary to subjugate Southern workers, but was erected by Wall Street to control the entire U.S. working class.
History informs the present. The powerful structural reforms of Medicare and Medicaid in the 1960’s capped a period of expanding capitalism and the end of explicit de jure segregation, an obstacle to industrial exploitation of cheaper, non-union Southern labor. Medicaid in Southern states, demeaningly constructed and highly restrictive, was successfully used as a wedge to prevent the expansion of Medicare to all. By the time the last Southern states instituted Medicaid in 1972, there were about 19 million enrolled in the nation as a whole.
Today there are over 74 million people on Medicaid in the U.S. They are in the bulls-eye of the assault on healthcare today. The growth in Medicaid numbers reflects the growth of a new class of workers whose need for healthcare is no longer tied to capital’s need for profits. The health insecurity that Southern wage workers have rarely escaped is now spreading across broad sections of the working class.
The status of healthcare in the Southern states is a roadmap of where things could be headed, in the absence of class unity capable of seizing the reins away from corporate care to human care. Southern states have the highest rates of uninsured, infant mortality, rural hospital closures, and morbidity in the country. Eight Southeastern states account for roughly 30% of all preventable deaths from heart disease, cancer, stroke, respiratory illnesses, and unintended injury. Mississippi has the highest rate of infant mortality in the country, with nearly 9 deaths per 1000 live births. Seven southern states account for more than 50% of all rural hospitals closures since 2010. Southern women rank lowest in all health and well-being indices.
The southern legacy of Medicaid as a compromise with Dixiecrat politicians, is the political weapon now being brandished universally to a working class, whose ties to capitalist production is being severed through labor-replacing technologies.
States Rights Revisited
The Supreme Court ruling that upheld the Affordable Care Act’s (‘Obamacare’) individual mandate, also ruled the Medicaid expansion unconstitutionally “coercive” to states. The former was necessary to sustain the private insurance market place, a central goal of the ACA. The latter resulted in making Medicaid expansion optional for states. With the exception of Arkansas and Louisiana, no Southern state expanded Medicaid. Eighty percent of those falling in the Medicaid coverage gap live in the South. Four states – Georgia, Florida, Texas and North Carolina – hold 2/3rds of those uninsured due to their refusal to expand Medicaid. Southern Blacks are twice as likely to fall into the coverage gap than whites, and Latinos are more than three times as likely to be uninsured, translating into thousands of preventable deaths and undue suffering.
Temporarily shelved “repeal and replace” schemes, regulatory powers, and/or Congressional budgets cuts extend Southern inequality, and universalize it to the most impoverished workers of all nationalities, colors, and genders throughout the country. Every proposal punts Medicaid to the states, withdrawing federal funds, weakening or eliminating federal protections, and ending Medicaid expansion. State waivers to apply punitive measures like work requirements, drug testing, co-pays, and watered down benefits are promoted by Price and Congress, potentially resulting in a massive transfer of public funds to private wealth – a tax cut of $765 billion for the richest and a cut to Medicaid of about the same amount over a decade. The assault on government-supported healthcare, even when distributed almost entirely by private entities, is an expression of the State apparatus stripping down to its most basic and violent control functions of Immigration and Customs Enforcement, the military, and the police.
From Resistance to Revolution
If the status quo was viable, “resistance” would be sufficient. Even the ACA’s subsidization of the commercial insurance market is not sustainable. Nationalization of the financing and delivery system is necessary. The administration and regulation of healthcare to the states is a reflection of and response to fundamental disruptions in the role of U.S. healthcare under capitalism. Making comprehensive and universal healthcare a necessary public infrastructure is illusive to a corporate State. The healthcare system’s origins were rooted in securing a productive workforce capable of reproducing itself in the interests of maximum profit from the plantation owner to General Motors.
The introduction of labor replacing technology over the last 30 years in the factories and fields, stores and schools, banks and telecommunications and in clinics and hospitals, is reducing labor to contingent, “gig,” part-time, temporary, unemployed and underemployed. Robots and 3-D printers don’t need healthcare, but they are shaping technology’s role inside the healthcare system and in society as a whole.
All of society is experiencing the disruptive transition from labor-intensive industry to labor-less technologies. The infamous “medical-industrial complex” superstructure that was built around an industrial society is in disarray. The hegemonic control of the usual suspects at the top of the healthcare food chain like insurance companies, big Pharma and mega hospital corporations are now competing for investment funds with Amazon, IBM and Google. These corporations are spinning off new companies making wearable behavioral healthcare apps, predictive-diagnostics and artificial intelligence applications.
The healthcare industry has become a very lucrative investment, employing 16% of all private sector jobs and more than 1/6th of the overall economy. But the pandemic of hospital and pharmaceutical mergers and acquisitions, ignited by electronic medical records and the ACA’s Accountable Care Organizations, fueled huge health-sector debt, soaring to over 300% since 2009. Debt fuels speculative investing that in turn sets the basis for a collapse, that could make the mortgage bubble look like a pimple. These internal contradictions to capital are among the causes of Congress’ inability to restructure the complexities of the healthcare system in any way other than to benefit the corporations. Couple this with the fact that the public insurances of Medicare and Medicaid pay for about 50% of all healthcare costs, with nearly all of that going to private entities, and capitalism’s inability to deliver secure healthcare for all is nakedly exposed.
The introduction of advanced technologies has caused an irreversible antagonism and polarized class interests. Technologies and exponentially expanding knowledge that could yield enormous advances to health are instead wielded chaotically for profit, not healing. The ruling class’ reliance on the historic methods of political control to isolate the most destitute section of the working class, uninsured, underinsured or on Medicaid, is a sign of their strategic weakness, even as they mount their tactical offensive. Medicaid must be defended as a critical tactic toward developing class-conscious unity.
Strategically, improved Medicare for all is the path to equal, quality comprehensive health services, as part of the total transformation of the healthcare system – from corporate to community – from private to public and from commercial health insurers to nationalization of the abundance of health resources to end the scarcity of health distribution.
November.December 2017 Vol27.Ed6
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