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ISR Issue 56, NovemberDecember 2007
Health vs. wealth
National health care: a dream deferred
By NANCY WELCH
“WHERE ARE the bodies?” That’s the question medical anthropologist Susan Starr Sered asked when she returned to the United States in 2003 after having lived for two decades in countries with generous national health programs. “If forty million Americans don’t have health insurance,” she asked Rushika Fernandopulle, a Harvard physician specializing in health policy, “where is America hiding its uninsured sick and dying citizens?”1
Sered’s stark question is even more pressing four years later with the news that, as the number of uninsured has climbed to 47 million, the United States has slipped still further in international health rankings: forty-second in life expectancy, forty-first in infant mortality.2 The U.S. Census, which counts as uninsured only those who lacked insurance for a full calendar year, shows one in six people going without health coverage. Add in the number of people who lost insurance for part of the year, and the picture dramatically worsens: 82 million—one in three non-elderly Americans—with two-thirds losing coverage for six months or more.3 Even more likely to face going without health coverage for at least part of the year were African Americans (43 percent) and Latinos (nearly 60 percent).4 The consequences of the health-care system’s racist rationing are lethal: The infant mortality rate for African Americans—13.7 for every 1,000 live births—is more than double that for white Americans5; while accidents lead the causes of death for white Americans ages twenty-five to forty-four, heart disease is the number one killer of young African Americans.6
It is now widely known, thanks to Michael Moore’s documentary Sicko, that lack of health-care coverage kills some 18,000 Americans under the age of sixty-five every year.7 But the annual death toll from the for-profit health system in the U.S. may be even higher. A full body count would include not only those who died from lack of care but those who died because of the care they received—including 2,047 unnecessary deaths each year at for-profit hospitals and 2,500 excess deaths at for-profit kidney dialysis centers.8 A complete accounting would include the tens of thousands of people whose desperate stories mirror those showcased in Sicko: covered by private insurance or Medicaid but denied treatment or postponing treatment because of costly co-pays. In a ground-breaking study, Harvard Medical School researchers David Himmelstein and Steffie Woolhandler found that individuals with a history of serious illness—including stroke, cancer, heart attack, emphysema, and diabetes—were twice as likely than others to be unable to obtain care, despite having private insurance or Medicaid.9 All told, writes Johns Hopkins health care policy analyst Vicente Navarro, citing research by Himmelstein and Woolhandler, U.S. rationed care is responsible for nearly 100,000 deaths every year.10 It’s a figure that shouldn’t surprise us—not if we consider, with sociologist Jill Quadagno, that in for-profit health care the “law of inverse coverage” reigns: “The more coverage you need, the less you will receive.”11
So where are the bodies? As Sered and Fernandopulle point out, “we don’t see corpses on the streets of Chicago or Des Moines” because America’s sick and dying are warehoused in prisons (including at least a quarter of million people suffering from mental illness), abandoned in homeless shelters (where a New York City study found a death rate four times that of the regular population), or tucked out of sight in hospital end-stage wards (Medicaid coverage only kicking in once an illness is deemed terminal).12
But some of the dead are in plain view. Take the appalling case of Edna Rodriguez. Early last summer the nation listened in horror to broadcasts of the desperate 9-1-1 calls made by her boyfriend and a bystander from the LA emergency room where she lay unattended and dying. When, just a week later, George Bush callously proclaimed, “[P]eople have access to health care in America. After all, you just go to the emergency room,” even the most jaded commentators were stunned. “He thinks we already have universal health care,” marveled Salon.com’s Tim Grieve. “Maybe he thinks that’s free for everyone, just like it is for him.”13
Today the witless president stands virtually alone—or joined perhaps by Fox’s Bill O’Reilly who insultingly claims that uninsured Americans are choosing to purchase flat-screen TVs instead of health care14—in refusing to acknowledge the disaster of U.S. health-care delivery. For the overwhelming majority of Americans, on the other hand, the argument for a national, single-payer program—where the government covers hospital stays and doctors’ visits, eliminating the need for some 1,500 private insurance companies, each with its own bureaucratic requirements and exclusions—makes complete sense. Well before Sicko appeared in U.S. theaters, a CNN poll found 64 percent of respondents agreeing that, “government should provide a national health insurance program for all Americans, even if this would require higher taxes.”15 In California, the nonpartisan Public Policy Institute found support running two to one in favor of “a universal health insurance program, in which everyone is covered under a program like Medicare that is run by the government and financed by taxpayers.”16
These polls gauge a sentiment that’s not entirely new. In 1984, at the height of the Reagan revolution, 75 percent of people polled by the Washington Post and ABC News responded that, “the government should institute and operate a national health program.”17 Now with exposés like Moore’s Sicko and Sered and Fernandopulle’s Uninsured in America confirming the day-to-day experience of millions, it is common knowledge that the United States stands alone among industrialized nations in refusing to guarantee health care for all, preferring instead to squeeze profits from patients. It is common knowledge that tiny, impoverished Cuba, able to spend far less on the nation’s health services, delivers better care to more people. Even free-market cheerleader Nicholas Kristof was forced to concede after surveying international health statistics the “wrenching fact: If the U.S. had an infant mortality rate as good as Cuba’s, we would save an additional 2,212 American babies a year.”18 As for the predictable smear campaign launched by the for-profit health industry to discredit Sicko, it was astonishingly feeble. When CNN “fact-checked” Sicko, for instance, their own report was riddled with obvious errors. “The bottom line,” writes New York Times columnist Paul Krugman, “is that the opponents of universal health care appear to have run out of honest arguments.”19
At the same time, grass-roots champions of single-payer health care have been finding their voices, pushing real reform back into the political spotlight for the first time in well over a decade. With Sicko’s release, members of the California Nurses Association (CNA) rallied on the red carpet, riding a red bus cross-country to thirty premieres where they were joined by members of Physicians for a National Health Program, state and local nurses’ unions, steelworkers, telephone workers, and more. In Hartford, Conn., twenty-two health-care activists and union members staged a sit-in at the state capitol building, demanding a meeting with the governor to discuss a single-payer bill for Connecticut. But perhaps most suggestive of the deep vein of anger and mounting expectation that Moore’s film taps into is this account from blogger Josh Tyler of what followed an afternoon screening in a Dallas/Fort Worth metroplex:
The theater was in chaos. The entire Sicko audience had somehow formed an impromptu town hall meeting in front of the ladies room. I’ve never seen anything like it. This is Texas goddammit, not France or some liberal college campus. But here these people were, complete strangers from every walk of life talking excitedly about the movie. It was as if they simply couldn’t go home without doing something drastic about what they’d just seen.20Understandably, the thousands of people stirred to action last summer are unsure about next steps. About the Dallas/Forth Worth moviegoers, Tyler writes: “Suddenly everyone was scribbling down everyone else’s e-mail, promising to get together and do something…though no one seemed to know quite what.”21 Explains CNA’s Jan Rodolfo, “[S]omething great will happen in one city and then in another city, but there isn’t a connection between them.”22 Nevertheless, Rodolfo emphasizes, such “explosion of activity,” points to “the potential for a true national movement.”23 HR 676, a bill introduced in the House by Rep. John Conyers (D-Mich.) that would eliminate private insurance in favor of a government-administered, single-payer plan—“Medicare for all”—provides one point around which a national movement could coalesce.
Who’s trying to kill single-payer?
Instead of helping to galvanize such a movement, however, some professed champions of health care for all are advising activists to curb their expectations. In Vermont, for example, activists first turned to Senator Bernie Sanders (I-Vt.) as most likely to introduce a version of Conyers’ “Medicare for All” in the U.S. Senate. Sanders, after all, enjoys the support of Vermont’s Progressive Party, whose platform calls for replacing private insurance with single-payer. In a recent op-ed, Sanders seemed at first poised to answer the call: “The time is long overdue for Congress to pass a national health care program which, finally, guarantees health care to all as a right and not a privilege.” By the op-ed’s end, however, Sanders didn’t promise to sponsor “Medicare for All” in the Senate. Instead, he’s promised to introduce a bill providing “federal assistance and waivers for those states interested in establishing universal health care.” Waivers? Assistance? How does Sanders justify this retreat mere sentences after thundering that a national health program from Congress is “long overdue”? By reasoning that a federal program will never pass until a handful of states “demonstrate that universal and non-profit health care works and is the cost effective and moral thing to do.”24
This conclusion taps into two common arguments about why the United States has not yet won a national health program: the argument that, preferring private to public solutions, Americans still need to be convinced that government-administered health care can work and that, with power diffused across the states and the private insurance industry now so deeply entrenched, state reform is the more realistic goal.25 Through these two arguments, health-care activists are urged to scale back their expectations. Yes, free-market medicine has been thoroughly discredited; yes, a solid majority are clamoring for change; yes, Sicko has made it public, popular knowledge that by every measure universal, non-profit health care works and works better, more equitably, and less expensively all around the world; and yes, indeed, national legislation delivering public, non-profit health care for all is at least sixty years overdue. But no, we should not expect to win single-payer, not nationwide. Too many people still need to be convinced. The insurance industry is too strong.
Sanders’ particular retreat probably has less to do with an “anti-government” mindset of the American people or a sober assessment of what’s needed to take on the two-trillion-dollar-a-year health industry and much more to do with providing election-year cover for Senators Hillary Rodham Clinton and Barack Obama and former Senator John Edwards. (All three have announced their opposition to single-payer; instead, they are peddling still more market solutions—what Himmelstein and Woolhandler sum up as the “‘buy it yourself’ variety” of health-care reform.)26 Nevertheless, such arguments against single-payer as “too much, too soon” can disorient seasoned and new activists. At one recent panel, a nurses’ union president, who’d traveled on the red bus with the CNA, explained that she was reluctant to call on her local to rally around single-payer; too many nurses, she worried, would be wary of a government-run system. Other audience members speculated that unions themselves are responsible for—and far prefer—employment-based insurance or that no national movement could make a difference until there is campaign finance reform to cut politicians off from the coffers of industry lobbyists.
Do these arguments hold grains of truth? Do we need to first win single-payer in a single state to bolster activists’ confidence? If yes, why do all of the “universal coverage” models debated and adopted by states so far move away from single-payer: expanding the role of private insurance and, by mandating residents to purchase high-deductible, low-coverage policies, exacerbating inequality in health-care delivery? Is this what we’re stuck with because Americans are too wary of government solutions, too duped by glossy insurance-industry campaigns, or too averse to struggle? What about the other common, and compelling, argument that we cannot hope to win national health care because we have no labor party, only two parties of capitalism—the Republicans and the Democrats—who are bought and paid for by health industry lobbyists? What’s the truth about why Americans have not—not yet—won national health insurance? For these questions we need to turn to a largely hidden history of U.S. workers’ struggles for fundamental guarantees, including the right to retire and the right to health care. It’s this history of struggle that can help activists sort through facts and myths—including the myth that we don’t have national health insurance because U.S. workers have not wanted it. In fact, at peak moments in the twentieth century, workers ardently fought for it.
Labor: “The critical force”
What Vicente Navarro calls the “medical-industrial complex”—private insurers, for-profit hospitals, medical supply and imaging corporations, the pharmaceutical giants, and many more all joined to transform health care from a universal right to a profitable commodity—did not develop in the United States until the second half of the twentieth century. Yet growing with capitalism over the past 250 years has been an expanding need for health-care insurance, resulting in sharp clashes between ruling and working classes over private versus collective solutions.
Health care first became a public problem under capitalism as new production arrangements undercut people’s means to survive when they could not—due to illness, age, disability, or a scarcity of jobs and a surplus of available workers—sell their labor. While in pre-industrial society, the self-provisioning family could care for its sick and a feudal master might lessen the load (and pay) for an aging worker, such a “paternalist approach,” explains political economist Robin Blackburn, disappeared with production line methods.27 Industrialization had stripped the feudal family of land and tools for self-provisioning, scattering its members across industrial districts. At the same time the production line shifted the balance of favor from the skills of older workers to the speed of the young—provided, that is, they managed to stay able-bodied and find work. No worker was genuinely secure since, as Ernest Mandel describes, capitalism “throws out of the production process a section of the proletariat: unemployed, old people, disabled persons, the sick”—all bearing what Marx termed the “stigmata of wage labor.”28 Unemployed and elderly workers had slim means for support—right at the same moment when expanded production was also bringing increased longevity. 29
While some workers formed mutual benefit societies and bourgeois families could purchase annuities from insurance houses against the death of a patriarch, a revolutionary argument for universal provision was advanced with the French Revolution as one of the “Rights of Man”—a notion quickly swept away in anti-Jacobin reaction. By the middle of the nineteenth century, Thomas Paine’s call for a public pool created through progressive taxation of the wealthy had been supplanted by pitiless Malthusian sermons on the economic necessity of misery’s “killing frost.”30 The misery of working-class districts—where fevers ravaged a population recently driven from their English and Irish countryside homes—was captured in harrowing detail by Engels in The Condition of the Working Class in England and chronicled too by Charles Dickens in such popular novels as Hard Times and Little Dorrit. Although a class of skilled physicians was also developing, Engels points out, their prices were out of reach: “English doctors charge high fees, and working-men are not in a position to pay them.”31 England revised its Elizabethan era poor laws but in a punitive direction: sentencing to workhouse labor any able-bodied person unable to support herself or himself. In the United States, the dogma of self-reliance, mid-nineteenth century religious revivalism (which held that the elderly and sick weren’t suitable candidates for salvation anyhow), plus Southern planters’ resistance to federal intervention all joined to deter the ruling class from advancing even punitive, demeaning “workhouse” and “poorhouse” solutions for those unable to support themselves through wage labor.32
The usual story of how public programs finally emerged, writes Navarro, is that as industrialization expanded and workers’ insecurity deepened, governments finally had to respond with social insurance. In the usual telling of the tale, for instance, the Great Depression threw millions into misery and Franklin D. Roosevelt responded with the New Deal. But such a voluntarist formulation, Navarro points out, neglects “the critical force behind the birth of health and other social insurance programs”—“the political and economic strength of the working class.”33 Germany’s Bismarck, the first to introduce social insurance in the early 1880s, was moved not by workers’ growing immiseration but by demonstrations of their radicalism and ability to organize. In the previous decade, desperate conditions and radical ideas had combined to ignite the Paris commune, the breathtaking moment in which a working class had seized and, for two months, held power. Although Versailles had put down the commune with a bloody massacre and mass deportations, the ideas of social democracy continued to gain a widespread following. By guaranteeing health insurance, death benefits, retirement, and other basic social provisions, Bismarck proposed to “take the wind” out of revolutionary “sails.”34 Similarly, Britain’s Lloyd George sought to “outflank the Left” with pensions for the elderly introduced in 1908 and a meager national insurance program offered in 1911 (subsequently expanded, through the agitation of workers following the two world wars, into the British Health Service).35
For the eleven European countries winning national insurance by the start of the twentieth century, Navarro argues, the degree of unionization, the number of unions organized on an industrial rather than craft basis, the unity provided by a national trade federation, and the launching of working-class parties were all prime determinants. In Germany, the founding of the Socialist Workers Party in 1875 was followed by the uniting of workers into a trade-union federation in 1868 and the establishment of social insurance in 1883. In France, the creation of a trade-union federation in 1895 preceded the winning of national insurance in 1898, followed in 1905 by the launching of a socialist party.36 In the United States too, an unprecedented explosion of industrial militancy was the critical force in pressing the Roosevelt administration into finally delivering, with the Social Security Act of 1935, retirement and welfare rights.
The U.S. working class: Militancy betrayed
But why didn’t the Social Security Act include a national health program? Why, at the dawn of the twentieth century or at least by the 1930s, don’t we find in the United States the launching of a labor party, the knitting together of workers into a mighty trade federation, and the victory of public, universal health care? Social commentators most often answer this question with arguments about American “exceptionalism,” theorizing that the promise of upward mobility, the steam-release valve of westward expansion, and language barriers between immigrant groups all worked to diffuse and pacify the U.S. working class. These arguments by themselves, however, set aside astounding evidence of mass working-class struggle even in the post-Civil War decades of westward expansion and mass immigration: 7.5 million workers went on strike between 1881 and 1905, including the 190,000 workers who walked out for the eight-hour day in mid-May 1886, the 150,000 workers who united in the 1894 Pullman strike, and the New Orleans General Strike of 1892 that joined 25,000 Black and white workers to deal a double blow against capital and white supremacy.37 In fact, writes Sharon Smith, theories of American exceptionalism “describe temporary, not permanent features of American society,” which by the 1880s U.S. capitalism was already fast outgrowing.38 With Western lands gobbled up and gates closing against further immigration, capitalism now expanded by extracting greater wealth—through slashed wages and boosted productivity—from labor. Its combativeness growing in turn, the U.S. working class came to be regarded as exceptional not for any sort of complacency but for a militancy still commemorated around the world on May Day and International Women’s Day, both born of U.S. strikes.
“Supply-side” explanations for why U.S. workers didn’t win national insurance programs alongside their European counterparts just don’t hold up. Workers did raise their demands—for an eight-hour day, a living wage, and benefits for the victims of horrific (and horrifically commonplace) on-the-job accidents—with a ferocity admired around the world. Far from living comfortably and well, U.S. workers were driven to fight by desperate conditions. For instance, in a single year in one Pennsylvania county, accidents in steel, railroad, and mining killed 526 workers.39 Hence prosperity arguments don’t hold up either. Instead, we need to turn to the specific areas that Navarro points to as decisive for European workers winning rights in this period and that appear to have been decisive, too, in delaying and limiting the rights won by U.S. workers. Here are weaknesses we need to examine—though without allowing examination to overwhelm our recognition of the considerable force and significant gains of U.S. workers’ actions for change.
To begin with, a weak political tradition (in part attributable to the fact that white, male U.S. workers did not have to organize for universal suffrage) set America’s nineteenth century working class some years behind in seeking to form a party in their own interests. When workers in the 1880s and 1890s did begin flexing their muscles both through mass strikes and organizing populist parties, they were ill-prepared for the political as well as military means deployed against them. The New Orleans General Strike of 1892, for instance, was answered not only with brutal repression but also the establishment of Jim Crow laws, which divided members of the Louisiana’s People’s Party, and new property requirements for voting, which suppressed voting rights for both Black and white propertyless workers. As a result, writes Smith, “[T]he Black vote in Louisiana dropped by 90 percent and the white vote dropped by 60 percent, leading to the collapse of the Populists.”40 Further hampering the formation of a workers’ party and the unity of workers across craft, skill, and racial divisions was the dominance of the craft-based American Federation of Labor (AFL). Under the foully racist Samuel L. Gompers, the AFL shut out unskilled (Black, women, and immigrant) workers, undermined key strikes, and entrenched labor in the Democratic Party, with Gompers and company enjoying the largesse of machine politics. Infamous too is Gompers’ opposition to national insurance for U.S. workers as a “menace” to “liberty.”41
It shouldn’t be imagined that Gompers spoke the minds of rank-and-filers or of all AFL unions. Against Gompers’ opposition, miners and garment workers organized for national health care during the Progressive Era. The United Mine Workers also bucked the AFL’s unofficial color bar, building a multiracial industrial union with 20,000 Black members.42 In the century’s opening decade, the Industrial Workers of the World (the “Wobblies”) rose to challenge the AFL’s exclusionary craft unions, aiming to bring all workers, regardless of race, nationality, gender, and skill, into “one big union.” Yet because they also rejected the idea of building a workers’ party or making a bid for leadership in the Socialist Party of America, the Wobblies were unable to withstand the repression unleashed by the U.S. government against them, repression that intensified from the red scare through the 1920s.
It was in the 1930s that U.S. labor finally became a force able to push forward its demands for living wages, pensions, and health care. The decade began with a working class devastated by the previous decade’s unrelenting assault on labor rights and wages compounded by the mass misery that followed the 1929 stock market crash. As puritan arguments about the rewards of thrift and hard work collapsed, the decade’s opening years were also replete with ingenious examples of, in Howard Zinn’s words, “self help in hard times.” Billing themselves the Bonus Army, First World War veterans marched on Washington to demand cash payment to feed themselves and their hungry families. In Chicago, schoolteachers rallied for back pay, their placards proclaiming “Give Us Cash or Buy Tombstones.” In Harlem women marched into grocery stores and, armed with rolling pins and skillets, demanded lower prices. Councils of unemployed workers brought half a million people into the streets for a national day of action. They also reconnected shut-off utilities and, by simply picking up the furniture and moving it back in, reclaimed apartments for evicted families.43 The vicious response of the U.S. ruling class—Detroit police in 1932 answered hunger strikers with machine gun fire, killing four and injuring more than sixty—spurred still greater rebellion. Months before Roosevelt tried to restore some peace with the National Industrial Recovery Act (NIRA), workers were discovering their power at the point of production. In a harbinger of things to come, Hormel meatpackers in Austin, Minnesota, struck and won with what would become the decade’s favored tactic: the sit-down.44
It might seem then—certainly by the decade’s midpoint—that U.S. workers had finally achieved the critical combination of elements that helped European workers win national insurance programs. Union density and combativity grew exponentially following the passage of the NIRA with some 1.5 million workers participating in nearly 2,000 strikes in 1934. U.S. labor was also at last breaking from craft unionism with the Congress for Industrial Organization (CIO) rapidly organizing one million members, including those leading the most militant strikes. This dramatic upswing in labor struggle was also provoking a renewed and vigorous debate about national health care, pensions, and unemployment insurance—pressing the question at the precise moment when capitalism’s usual pieties held no water and radicalism was on the rise.
Still missing, however, was a party in the interests of the working class. True, the Communist Party (CP) of America led in nearly every pivotal struggle of the decade. Party membership swelled as it built the CIO, and the militancy, creativity, and anti-racist dedication of CP rank-and-filers won them leadership on shopfloors and in neighborhoods nationwide. The CP was very far, however, from the independent workers’ party needed in 1935 to prevent the jettisoning of national health care from the Social Security Act. As Smith details, the party used its hard-won leadership to serve instead the foreign policy needs of Joseph Stalin. As labor struggles were surging forward, the CP took a chapter from Gompers’ book and withheld support from key strikes so as to ease mounting pressure on Roosevelt, now Stalin’s declared ally against Hitler. As tens of thousands of increasingly confident workers expressed readiness to break from the Democrats, the CP urged a vote for Roosevelt. And as the Democrats dropped health care from the Social Security Act, opted for funding through payroll rather than a progressive tax on wealth, and—in the decade’s most devastating betrayals—struck deals with Dixiecrats to exclude most Black and women workers from minimum wage and retirement guarantees,45 the CP stood by. Their reward for applying the brakes on the class struggle and delivering unions ready to sign no-strike pledges and march their workers off to the Second World War?46 From Roosevelt’s Smith Act in 1940 to Truman’s Loyalty Oath and Taft-Hartley Act in 1947, an emboldened ruling class responded with the campaign—later known as McCarthyism—to rid unions of communists and secure federal laws against such a radical idea as national health insurance.
From “security through bargaining” to social insecurity
By the time, twenty years later, U.S. workers had in the AFL-CIO a united trade federation, it was a federation purged of radicals and operating under the fist of Taft-Hartley, whose provisions included not only a ban on solidarity and wildcat strikes but also set in law that collective bargaining, not the government, would determine the U.S. worker’s path to health-care coverage. “Security through bargaining” became labor’s promise to the one-third of U.S. workers who now belonged to private-sector unions, and indeed it was primarily through collective bargaining that the number of insured mushroomed from 6 million in 1940 to 75 million by 1966.47 Although it would be a mistake to conclude (as one social policy researcher does) that U.S. labor thus expressed its preference for “a private alternative to state-run welfare programs”48—contradicting such an interpretation is the AFL-CIO’s dedication in this period to winning social insurance for the disabled; further, the AFL-CIO and Truman’s Democratic Party both promoted national health care immediately following the Second World War, until the red-scare flames they also fanned subsumed the argument—at labor’s helm were officials disposed to buckle down under the dictates of Taft-Hartley. On the hostile terrain of McCarthyism and settling into the comforts of business unionism, the labor officials exchanged the fundamental principle of universality when it came to health care for the principle that membership has its privileges.49
Today, what Steffie Woolhandler describes as the “slow-motion collapse” of employer-funded health care50—mandated by Taft-Hartley and uncontested by union officials for decades following the war—is moving into fast-forward with General Motors winning its bid to ditch responsibility for the health and disability benefits won in bargaining for more than 400,000 retirees. As the bond between employment and health care dissolves, it is replaced not by the too long delayed public program that would guarantee health care regardless of job status, but instead punitive mandates requiring people already drowning in debt to purchase a policy that provides less coverage than they need at a price they cannot afford. In reality, the health-care reforms touted by major politicians and praised in the mainstream press really amount to Robin Hood in reverse. Explain Woolhandler and Himmelstein about the Massachusetts Health Plan:
[T]he health reform law has buoyed our state’s wealthiest health institutions. Hospitals like Massachusetts General are reporting record profits and enjoying rate increases tucked into the reform package. Blue Cross and other insurers that lobbied hard for the law stand to gain billions from the reform, which shrinks their contribution to the state’s free care pool and will force hundreds of thousands to purchase their defective products. Meanwhile, new rules for the free care pool will drastically cut funding for the hundreds of thousands who remain uninsured, and for the safety-net hospitals and clinics that care for them.51
Similarly, writes the CNA’s Rose Ann DeMoro on the Huffington Post Web site, Hillary Clinton’s just-unveiled health-care proposal “will generate hundreds of millions of dollars in additional profits for the insurance giants.” “It’s probably not a coincidence,” DeMoro adds, “that she is also the top recipient of health-care sector contributions to her presidential campaign.”52
National health care’s true champions will look at this picture and understand, once and for all, that it’s not because of deep-seated antipathy for government programs that people in the United States lack public and universal coverage. Social Security, the GI Bill, Medicare: All are examples of enormously popular and successful public programs. In fact, the efficacy of single-payer health care, its efficiency and popularity, doesn’t have to be proven to anyone. It was already proven when Medicare and Medicaid were launched in the mid-1960s. At the time, Woolhandler and Himmelstein point out, 47 million elderly and poor Americans were going without insurance.53 It takes no leap of faith for people to consider that expanding Medicare would best solve the problem of 47 million uninsured today. No leap of faith is needed either for people to agree that we can pay for expanded Medicare by prohibiting any further price-gauging by hospitals, the drug companies, and private insurers—all of whom have banded together to fight price caps, their greed creating health-care inflation. There’s no mystery either about how the United States could pay for full coverage for many millions more: by ending the $12 billion-a-month wars in Iraq and Afghanistan. Fear of reforms like these doesn’t come from ordinary people, who in poll after poll have called for health care and an end to the war, but from the members of Congress and their corporate sponsors whose faux reforms further enrich and more deeply entrench the for-profit health industry.
What happens to a dream deferred?
Gradualists would tell us that we can’t take on such a mighty system and that state legislation, despite the sorry record of such reforms so far, is where we can realistically focus our hopes instead. Of course making demands at state houses, outside hospitals and insurance headquarters, and on any employer looking to cut or dump benefits is a good thing. In advance of Roe v. Wade, when state legislatures took up the question of reforming or repealing anti-abortion laws, women packed hearings—or, when excluded from giving “expert” testimony, held and publicized their own hearings—in a press for full abortion rights.54 The Connecticut workers who recently refused to end their sit-in until state house guards dragged them away also had the right idea. These are ideas that come straight from labor and civil rights history where the combination of grass-roots action and big demands created national movements powerful enough to win Social Security (a universal entitlement that the U.S. capitalist class had held out against longer than any other) and smash Jim Crow (its complex of laws, institutions, and custom far more deeply ensconced than that of today’s private health insurance industry, which has only developed into the profit-extracting and care-rationing bureaucracy in the past thirty years). “In notable instances when ordinary citizens defeated elite stakeholders,” argues Jill Quadagno, citing labor and civil rights victories, “they coordinated their efforts through organizations that mirrored the federated structure of American government.”55
What happens in the absence of organizations with the strength to rival Corporate America and stand up for rights across state lines is evident in the rapid rise of that medical-industrial complex since the mid-1970s. It’s a rise aided at every turn by Congress: The Bayh-Dole Act, which handed over drugs developed in publicly-funded research labs to drug companies to market and sell for big profit; the Hatch-Waxman Act granted monopoly rights for brand-name drugs and keeps lower cost generics off the market; the Medicare Modernization (read Privatization) Act of 2003 included that infamous “doughnut hole” in drug coverage, which is, in fact, a gift to the HMOs, to whom seniors must turn if they want help fill in this manufactured for-profit gap. It will take a national movement to halt, and reverse, this Capitol Hill giveaway. It will take the return of the kinds of movements—like the ones against Vietnam and the draft, for Black Power, women’s liberation, and gay liberation—that in the early 1970s, propelled a bona fide single-payer bill so far in Congress that the Washington Post opined, “The question is not whether the United States should have national health insurance, but what kind it should have.”56
There remains the question of whether it will take—not only to advance but win a national health-care bill—a labor party that’s declared its independence from the Democrats and big business. History suggests that the answer to the question is yes. We can see this in the experience of workers worldwide who won national health insurance through their own parties as well as in the defeat of the question for U.S. workers when they did not form a labor party in the 1930s. Another version of this defeat came in the 1970s and 1980s as former activists were absorbed into the Democratic Party, becoming champions of neoliberal “free market” measures, including the repeal of welfare, a major piece of the Social Security Act of 1935. The 1970s opened with a Republican president considering a health security bill (which would have set a budget for hospitals and doctors’ practices and replaced private health insurance with single-payer) and closed with a Democratic president promising support for a national health-care bill only “if it preserves a role for the insurance companies.”57 This suggests once again the incredible vibrancy of U.S. social movements and the price we have paid for not organizing an independent political party.
Yet a too-exclusive focus on the labor party question obscures the prime ingredient for winning expanded rights: struggle. It was through struggle that labor activists wrested from the federal government a major victory for U.S. health care in the mid-1960s with the creation of Medicare and Medicaid. To lead this campaign, the AFL-CIO turned to the generation of workers who had built the fighting unions of the 1930s who were preparing to organize themselves into the National Council of Senior Citizens. Bearing no resemblance to today’s American Association of Retired Persons (AARP), which operates as an arm of corporate health care, the council brought 14,000 members to march on the 1964 Democratic National Convention in Atlantic City. When a Florida Democrat and chair of a key committee declared opposition to the Medicare and Medicaid bills, the council sent busloads of seniors through the state, holding public hearings to “educate” him. Although the American Medical Association launched a counter-campaign, including recordings of actor and anti-communist Ronald Reagan denouncing the evils of “state-sponsored medicine,” they were no match against the popularity of the council and the rising tide of civil rights, antiwar, and anti-poverty agitation.58
In fact, as Navarro’s historical sketch shows, the relationship among trade unions, workers’ parties, and gains in social programs has been dynamic. In France, workers’ agitation for national insurance ran ahead of their organizing a socialist party. In the Depression-era United States, hunger strikes and unemployed marches—demands for basic provisions—spurred the phenomenal growth of trade-union numbers and strength; the demands for social insurance and burgeoning consciousness of the need for an independent party rose in tandem. In the mid-1960s the escalating civil rights movement and simmering discontent with the war in Vietnam combined not only to deliver national health care for seniors and the poor, but to exert federal authority to desegregate Southern hospitals. The lack of a labor party is big reason why these two pivotal periods did not deliver national health insurance—but that historical fact doesn’t doom our present moment to the same result.
…Or does it explode?
Today, we are looking at what one activist following a screening of Sicko summed up as a “perfect storm” with the power to demolish for-profit health care. Mainstream opinion runs strong for a national health program and against the war in Iraq. The insurance industry has been exposed and is reviled. With employers shedding the costs, and health care a leading cause of personal bankruptcy, the urgent need for a government program is evident to all. (Save the major presidential candidates who continue to admonish workers to shop around or argue that children may be entitled to a patchwork of health care benefits but their parents are not.) The major spring 2006 demonstrations by immigrant workers carrying banners announcing, “We produce, we demand!” announced that the radicalism that won Social Security in the mid-1930s has not been eradicated. The nearly 100 labor councils that have so far endorsed HR 676 suggests too the intimate link between organizing for health care and rebuilding a grass-roots labor movement. Although leadership in this movement isn’t likely to come from the top. As political economist Sam Gindin points out, United Auto Worker leaders are “too cautious, too much a part of the history of defeats” to imagine transforming attacks on retirees’ health care into a campaign for national health insurance. Yet the sparks set off by Sicko suggest Gindin is right in speculating that with health-care agitation could come the “long-awaited revival of the moribund American trade-union movement.”59 Activists who know their history and who understand the prime role of mass struggle in every gain they’ve made are needed.
We especially need the stories of those past struggles. For instance, anyone who worries that labor today is too dispersed and too weakened by contingent employment to be a critical force should read the story of coal truck drivers of Depression-era Minneapolis who built strikes from the bottom-up strong enough to defeat the trucking industry and the National Guard, despite their dispersion in yards across the city and the precariousness of their seasonal employment.60 If most of us think that the AARP is the official (mis)representative of Americans over sixty-five or that the AFL-CIO has never openly challenged a Democratic Party position, it’s because we haven’t heard of the radical retirees who descended on Atlantic City in 1964 to give Johnson and the Dixiecrats a piece of their minds. When Sered and Fernandopulle in their otherwise excellent Uninsured in America use “caste” and “untouchables” to describe today’s uninsured—aiming for these terms to jolt people out of what they argue is widespread acceptance of the rhetoric of “personal responsibility”61—they miss a crucial opportunity to connect with a class history of fightback in earlier eras when the ruling rhetoric likewise failed.
In the 1960s there was the collision course of the civil rights movement and the Vietnam War, the lie of the U.S. government fighting for freedom abroad exposed by its brutal suppression of rights at home. At the start of the Depression when, as bank failures wiped out life savings and more than a quarter of the population was thrown out of work, the fundamental truth about capitalism was laid bare: What counts is not what you do but who you are, into what class you were born. As the rate of mortgage foreclosures today begins to rival the worst of the Depression years and still the major Democratic presidential candidates—every bit as out of touch as Herbert Hoover—talk of compulsory insurance, we can turn again to the story of Harlem women marching through grocery stores. We can go on the march too—maybe not with rolling pins and skillets, but with scalpels and paper shredders.
Nancy Welch is Professor of English at the University of Vermont. Her short story collection, The Road from Prosperity, was published by Southern Methodist University Press. She is also a frequent contributor on health care to Socialist Worker.
1 Susan Starr Sered and Rushika Fernandopulle, Uninsured in America: Life and Death in the Land of Opportunity (Berkeley: University of California Press, 2005.) 1.
2 Stephen Ohlemacher, “U.S. lags behind 41 nations in life span,” Associated Press, August 11, 2007.
3 “One in three: Non-elderly Americans without health insurance,” Families USA, June 2004, 3, http://www.familiesusa.org/assets/pdfs/82million_uninsured_report6fdc.pdf.
4 “One in three,” 6.
5 “Overall infant mortality rate in United States largely unchanged: Rates among Black women more than twice that of white women,” Centers for Disease Control and Prevention, May 2, 2007, http://www.cdc.gov/od/oc/media/pressrel/2007/r070502.htm
6 “Key facts: Race, ethnicity, and health care,” Henry J. Kaiser Family Foundation, January 2007, 11, http://www.kff.org/minorityhealth/upload/Key-Facts-Race-Ethnicity-Medical-
7 Insuring America’s Health: Principles and Recommendations, Institute of Medicine (Washington, DC: National Academy Press, 2004).
8 David U. Himmelstein and Steffie Woolhandler, “Mayhem in the medical marketplace,” Monthly Review 56 (7): December 2004.
9 Himmelstein and Woolhandler, “Care denied: U.S. residents who are unable to obtain needed medical services,” American Journal of Public Health 85 (3): March 1995.
10 Cited in Vicente Navarro, “The inhuman state of U.S. health care,” Monthly Review 55 (4): September 2003.
11 Jill Quadagno, One Nation, Uninsured: Why the U.S. Has No National Health Insurance (New York: Oxford, 2005), 3.
12 Sered and Fernandopulle, 17–19.
13 Tim Grieve, “Poor kids don’t vote,” July 17, 2007, http://www.salon.com/politics/war_room/2007/07/19/schip_veto/index.html.
14 Bill O’Reilly, “Socializing with socialism,” July 12, 2007.
15 CNN/Opinion Research Corporation Poll, May 4-6, 2007, http://www.pollingreport.com/health3.htm.
16 “Californians and their government: PPIC statewide survey,” Public Policy Institute of California, January 2007, 23.
17 Cited in Vicente Navarro, The Politics of Health Policy (Cambridge, Mass.: Blackwell, 1994), 36.
18 Nicholas Kristof, “Health care? Ask Cuba,” New York Times, January 12, 2005.
19 Paul Krugman, “The waiting game,” New York Times, July 16, 2007.
20 Josh Tyler, “Sicko spurs audiences into action,” July 1, 2007, http://www.cinemablend.com/new/Sicko-Spurs-Audiences-Into-Action-5639.html.
22 Jan Rodolfo and Elizabeth Lalasz, “Sicko: The movie and the movement,” International Socialist Review 55, September–October 2007, 24.
24 Bernie Sanders, “We need health care for all—now,” Burlington Free Press, August 31, 2007.
25 For further examination and critique of the major explanations for why the United States does not have a national health insurance program see Quadagno.
26 Himmelstein and Woolhandler, “Health reform failure,” Boston Globe, September 17, 2007.
27 Robin Blackburn, Banking on Death Or, Investing in Life: The History and Future of Pensions (London: Verso, 2002), 33.
28 Ernest Mandel, Marxist Economic Theory, Vol. I (New York: Monthly Review Press, 1962), 151.
29 Blackburn, 33.
30 Ibid, 39–41.
31 Frederick Engels, The Condition of the Working Class in England (Moscow: Panther Edition, 1969), http://www.marxists.org/archive/marx/works/1845/condition-working-class/ index.htm.
32 Blackburn, 42–44. Blackburn further notes that we should not imagine the U.S. ruling class as “wedded to individualism”: Pieties about self-reliance notwithstanding, government had no qualms about giving away Mexican and Indian lands or loaning police and soldiers to robber barons to put down strikes.
33 Vicente Navarro, Dangerous to Your Health: Capitalism in Health Care (New York: Monthly Review Press, 1993), 89.
34 Blackburn, 46.
35 Ibid, 46-47.
36 Navarro, Dangerous to Your Health, 88.
37 Sharon Smith, Subterranean Fire: A History of Working-Class Radicalism in the United States (Chicago: Haymarket Books, 2006), 4; see also Chapter 1, “Are American workers different?” and Chapter 2, “The peculiarities of American capitalism.”
38 Ibid, 7–8.
39 Roy Lubove, The Struggle for Social Security 1900–1935 (Pittsburgh: University of Pittsburgh Press, 1935), 46.
40 Smith, 40.
41 Florence Calvert Thorne, Samuel Gompers, American Statesman (New York: Philosophical Library, 1957), 63.
42 Smith, 35–36.
43 Vibrant accounts of these and other forms of “self help in hard times,” as historian Howard Zinn puts it, can be found in Howard Zinn, A People’s History of the United States (New York: HarperCollins, 1999); Howard Zinn and Anthony Arnove, eds., Voices of a People’s History of the United States (New York: Seven Stories Press, 2004); and Mark Naison, The Communists in Harlem During the Depression (Urbana, IL: University of Illinois Press, 2005).
44 See Smith, “Depression decade: The turning point,” in Subterranean Fire and Jeremy Brecher, “Depression decade,” in Strike! (Cambridge, MA: South End Press, 1997).
45 Although Social Security was subsequently expanded, the NIRA’s exclusions continue to haunt home health-care workers, restaurant wait staff, farm workers, and many others still denied even a paltry minimum-wage guarantee.
46 Smith, 123–35,142–51.
47 Quadagno, 49.
48 Quoted in Quadagno, 49.
49 See Quadagno, 44–52, for an account of the postwar period in which the CIO moved to expel the unions under communist leadership, the labor militants of the 1930s were supplanted by “policy experts with calculators.”
50 Steffie Woolhandler and Nancy Welch, “What kind of health care reform?” Socialist Worker, September 14, 2007.
51 Woolhandler and Himmelstein, “Health reform failure.”
52 Rose Ann DeMoro, “Hillary learned the wrong lesson from 1994 health care fiasco,” Huffington Post, September 18, 2007.
54 See Leslie J. Reagan, When Abortion was a Crime: Women, Medicine, and Law in the United States, 1867–1973 (Berkeley: University of California Press, 1997) and Ninia Baehr, Abortion without Apology: A Radical History for the 1990s (Boston: South End Press, 1990).
55 Quadagno, 213, my emphasis.
56 “The health insurance debate,” Washington Post, May 26, 1974, quoted in Quadagno, 122.
57 Quadagno, 124.
58 Ibid, 69–71.
59 Sam Gindin. “One-sided class war: The UAW-GM 2007 negotiations,” The Socialist Project E-Bulletin 62, October 6, 2007, http://www.monthlyreview.org/mrzine/gindin051007.html.
60 That story, chronicled by Farrell Dobbs in the classic Teamster Rebellion (New York: Pathfinder, 1972), shows too how much can be won with even just a handful of socialists operating with the class’s—not Roosevelt’s or Stalin’s—interests in heart.