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NEWS & LETTERS, April - May 2008EssayHealthcare and Marx's view of the futureby Htun Lin and Ron Kelch
--Karl Marx, "Private Property and Communism" In spite of all the overwhelming evidence that a universal single payer system is the most cost effective way for the U.S. to overcome the disgrace of now having 47 million uninsured, none of the candidates in the upcoming presidential election even challenge the wasteful and contradictory system based on insurance companies and pharmaceuticals as profit centers. Workers' concrete concerns on the frontlines of healthcare delivery (see Workshop Talks) pose profound questions whose implications go way beyond their reflection in the more visible political struggle over healthcare. For over a decade now healthcare workers, especially nurses such as the California Nurses Association (CNA), have fought to have a say in the quality of care they provide in their everyday working lives. Health workers have been pivotal in community struggles to save health facilities in poor areas. CNA nurses set up their own emergency Response Network (RNRN) after many volunteered to help New Orleans in the wake of Katrina. They deemed the government's efforts totally worthless and, even worse, reported that they confronted a host of chronic problems that had nothing to do with Katrina. Other healthcare volunteers set up free rural health fairs in affected areas to deal with those chronic illnesses like diabetes and kidney failure, and have been overwhelmed with the number of people and range of basic, but unattended, health needs. The model for RNRN is Doctors Without Borders, a prominent international human solidarity group. Direct solidarity is a response to healthcare as a business, which leaves the poor behind. Millions die in Africa from easily treatable diseases like malaria, which is only now barely getting some attention and needs relatively small resources to remedy. Millions more die from diseases controlled by patented and cheaply produced medicines, which are priced out of reach of most of humanity. CAPITALISM, HEALTHCARE AND THE STATEOur time's intense focus on healthcare signals a very different capitalist economy than the one Marx investigated as he mentions "health services" in his general view of a non-capitalist future in his 1875 Critique of the Gotha Program (CGP). For Marx, a new socialist reality emerges through the creative power of freely cooperating labor, and in CGP Marx briefly alludes to one measure for the birth and development of that reality as an instant surge, and then ongoing expansion, of production "intended for common satisfaction of needs" in areas like "schools" and "health services."* While a state-run single payer healthcare system shapes much discourse among healthcare advocates on what is needed today, for Marx, the political arena of the state is part of the alienation of workers from working out self-determination in their own everyday activity. If CGP's concept of satisfying common needs, including universal healthcare, grows out of the direct communal cooperation of workers themselves, how does that perspective relate to today's new kind of labor struggle among service workers in the health field, their direct solidarity on the ground with those needing care? This requires a broader look at healthcare under capitalism and the vicissitudes of the state's role. Healthcare is an industry where labor is immediately bound up with life. This immediate tie to life is social, directly involved with the care of another. The spread of disease is often bound up with social habits and, early on, resulted in social programs like sanitation and mass inoculation. When Marx wrote CGP, healthcare for individuals was mostly a privilege of the rich even in more developed countries. Generalized healthcare played a very small role and was on the margins of capitalist production--a social good, primarily undertaken by charitable and religious organizations. Things started to change in the 20th century. In an era of strong unions and scarce labor during World War II, the ship builder Henry Kaiser started a pre-paid medical practice, which became a model for health maintenance organizations (HMOs), to keep labor time lost due to sickness to a minimum. The height of healthcare as a social good in the U.S. came in the post-WWII world when strong unions like the UAW gave up on control over production but did fight for and win comprehensive healthcare benefits for each worker as well as the worker's family. While this was no challenge to the rule of capital, it was part of what Marx calls the "historical and moral element" that determines the value of labor power within capitalism (BF, 275). It set a standard for what a reasonable job would have to offer while those not in the work force were to be covered by state-run programs like Medicaid and Medicare. Whether it was the U.S. or countries like England and fully state-capitalist Russia, both of which instituted a single state-run health service, resources for healthcare were strictly limited by planning dictated by capital's need for accumulation. By 1980 healthcare constituted 8.8% of the U.S. economy, and the state's role shifted as healthcare itself also became a center of capital accumulation. Today healthcare constitutes over 16% of the U.S. economy. A crucial turning point came with new laws like the Bayh-Dole Act of 1980. This allowed researchers, whose research was funded by the federal government in publicly funded universities and by agencies like the National Institutes of Health, to patent and personally gain from this research. Capitalistic "science" is a distorted science when human achievements, what Marx called "the exoteric unfolding of human essential capacities," become a means for personal gain. In practice, science, like all human endeavors, is an inherently cooperative or communal activity based on accumulated knowledge. The knowledge base shapes the discourse through which new ideas emerge. An actual patent is often a rather small endpoint for a long collective process. Today life forms and knowledge of the human genetic code can be patented and bring in potentially astronomical profits. The promise of personal financial gain impedes the free sharing of knowledge and techniques, through which science develops. Capitalists turned to healthcare restructuring through the HMO model. They transformed the HMO concept into its opposite, using it to create incentives to retain revenue through rationing and limiting access to care. The HMO model became a way to rationalize work, as in any capitalistic venture, according to socially necessary labor time set across the industry. Front line healthcare providers responded with a movement for quality care. A highpoint in this struggle came in the late 1990s when CNA nurses staged a wave of strikes at Kaiser. They won some first-ever contractual rights over their work as caregivers. In this job capital's dominance is still formal because health workers manage the tools used to deliver care under the despotic authority of the cost cutters and access deniers. When the life of a human being is at stake, this can and does amplify caregivers' alienation. Often health workers, on their own time, do what needs to be done in spite of their overlords. The state's latest gambit in the service of capital is to designate nurses as "managers," ineligible to join unions, in order to gut their cooperative interference with capital's plan for healthcare. The U.S. healthcare system is one of rationing according to the needs of capital accumulation with some companies out to cut or eliminate their employee healthcare costs while other companies--manufacturers of medical technology and pharmaceuticals--are out to gouge the public and to get state assistance to become centers of capital accumulation in a global context. On the front lines of providing healthcare there is a new cooperative opposition to healthcare as a commodity and to science in the service of capital's reach for global profits. It is important to engage this new subjectivity from the vantage point of Marx's concept in CGP for post-capitalist reality and its immediate expansion of collective needs like healthcare. MARX ON COOPERATION AND THE NEW SOCIETYThe new direction posed by Marx in CGP begins from cooperative, or directly social, labor, in contrast to capitalism with its indirect socialization of labor mediated by value in things, commodities and capital. The foundation for the new reality is a new distribution of the means of production, spelled out as freely associated producers cooperatively putting them to use. The distinctive feature of a non-capitalist reality for Marx is not a new property relation, collective or private, but whether the cooperative relation to the instruments of production prevails over any notion of property and is truly freely associated. Marx saw indications of this non-capitalist future in the struggle of workers forced to cooperate under capital's "despotic" plan (BF, 450). Marx engaged the subject, the laborer, not from the perspective of capitalism's alienated labor, but rather from the perspective of a non-capitalist future. Alienated labor, as Marx put it in 1844, reduces the "life of the species into a means of individual life" (CW: 3,276). In Capital, Marx describes the new power arising in the "directly social or communal labor" (BF, 448) that emerges from within, and develops into a total antagonism with, the authority of capital: "When the worker co-operates in a planned way with others, he strips off the fetters of his individuality, and develops the capabilities of his species" (BF, 447). The context for Marx's positive concept of cooperative labor developing the "capabilities of the species" is the birth of industrial capitalism that brought large numbers of workers together in a single machine controlled process, a process which replaced manufacturing based on skilled handicrafts. Here all science goes into the machine, which as capital dominates laborers, not just formally, but in real life. The power of this cooperation is both taken for granted and constrained. Freely cooperating labor holds the possibility of real science that is one with life, where each one experiences their laboring inseparable from the "exoteric unfolding" and the ongoing confirmation "of human essential capacities." Sweated labor and machine controlled labor continue as a foundation for global capital's manufacturing. However, cooperative labor, in the face of revolutions in production, creates the basis for the "totally developed individual" (BF, 618). Marx anticipated that today's faster pace of revolutionizing production would develop the individual's sense of her relation to species capacities unleashed through cooperation. Medical care is a thoroughly cooperative endeavor, engaging the talents of many different workers who constantly add new skills with each biotechnical change. But in its capitalistic form new technologies, developed collectively but turned into instruments for private interests, turn the species character of new knowledge "into a means of individual life." There isn't a direct correlation between what Marx wrote on cooperation in manufacturing and service workers in healthcare today. Today's controversies in the health workplace point to the need to constantly re-create Marx's philosophy on the basis of new developments. The constant technological advances in medicine in a capitalist context have created a sharp contrast in the minds of front-line healthcare workers between the capabilities of the species and the concrete reality they face every day. What is new in the cooperative struggle of front-line healthcare workers over the last 15 years is not that there has been a workers' movement in the healthcare field, rather it has been the way that movement took up the issue of quality care in the face of healthcare restructuring, rationing, and neglect of great populations of the poor in this country and especially in the less developed countries of the world. HEALTHCARE AND THE FUTUREThe drive for quality care by frontline caregivers and direct solidarity with those deprived of healthcare in society cuts much deeper than the political struggle over a state-run single payer system, which even many big capitalists now support. As many have stated, the U.S. spends almost twice as much per person on healthcare as nearly every other developed country and, by any objective measure, is at the bottom of delivering health to its citizens. But it is workers in the workplace who confront capital's overriding imperative, which is not delivering health but capital accumulation. As many can attest, state run universal healthcare can be starved of resources by capital and become a bureaucratic quagmire for those in need. For Marx, only in non-value producing cooperation in which the scarcity of resources is not distorted by the uncaring brutality of value production, does expanding areas like education and healthcare become a quantitative measure of the development of a new human society. Today's economy, with its accelerated pace of revolutions in production, brings to life Marx's view that cooperating human beings, with each one embodying a variety of knowledge and talent, are the greatest productive force of all. That productive force falls into a deeper contradiction with the increasing presence of healthcare and knowledge in a capitalist economy. Expanding those two areas, in post-value production cooperation, can be directly a new form of distribution of the means of production. The front-line healthcare workers' movement for quality care, where women workers predominate, is a new passion that enlivens, with some actual content, what directly social labor can mean in a future shaped by MarxÕs concept of transcending alienated labor. NOTES* Karl Marx Frederick Engels, Collected Works (International Publishers: New York), Vol. 24, 85. Further references to Marx will have "CW" with the volume number and page number in the text, except for the commonly used Ben Fowkes translation of Capital, (London: Penguin, 1976) which will be referenced with "BF" followed by the page number. |
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