Image from The Washington Post

On Thursday October 12, Donald Trump signed an executive order clearing the way for insurance companies to sell short-term plans that offer bare-minimum services at discounted rates. If implemented, the measure is expected to cause the flight of low-risk patients to cheap “junk insurance” plans, effectively disbalancing the risk pools that form the base of the Affordable Care Act (ACA). The impact of the order will be higher fees and deductibles for sicker patients, while healthier patients choose less comprehensive, cheaper plans.

Later in the day, the White House announced it would cut off subsidies for premiums, another pillar of the ACA. Trump’s decision comes on the heels of yet another failed repeal of Obamacare with the recent Graham-Cassidy bill.

Forget About Obamacare

Despite grand promises, Republicans have been unable to overturn the program simply because the ACA is what some of their big business allies actually want.

Touted as a path to expanding the number of insured Americans, the ACA was in fact most successful in protecting profits and maintaining the viability of the corporate healthcare sector. It did so by mandating millions to purchase insurance from a marketplace of private plans – advertised, promoted, and subsidized by public funds. This does not mean we shouldn’t defend critical gains of the ACA that are currently under attack – notably, the expansion of Medicaid. But we need to move beyond the defense of the ACA.

Congress would like the healthcare debate to remain narrow, with majority of Democrats and Republicans staking out a position in defense of or against the ACA, ultimately unified in their attempt to keep the demand for “Medicare for All” on the fringes. Mainstream criticism against Medicare for All largely centers on its financial feasibility, attacks that ring hollow in the wake of the recently-passed defense budget amounting to 700 billion dollars.

Rallying to save the ACA serves as a deflection from engaging with a more expansive and politically-viable demand of health care for all.

What We Have: Insurance Industry Vultures Profit Off of the Sick

It is outrageous that in the 21st century, in one of the wealthiest countries on the planet, there are still millions who die from preventable diseases or suffer irreparable damage to their health because they can’t afford to get medical assistance.

Frontline healthcare workers know first hand that patients delay going to the doctor when they are uninsured or underinsured, leading to a patient population that is sicker than ever by the time they seek emergent care. Once admitted to hospitals and urgent care clinics, patients bear the burden of additional anxiety on top of managing their illness, often worrying about extensive medical costs, hidden fees, and gaps in insurance coverage. It is not surprising that medical expenses are the first cause of individual bankruptcy in the U.S.

Meanwhile, funds are siphoned from trillion dollar health budgets to pad corporate management salaries, supporting thick layers of administration and bureaucracy. At the same time, wages of hospital workers remain stagnant and labor conditions deteriorate in an environment driven by efficiency and profit, above safe patient care.

A recent study published by the Annals of Internal Medicine shows that, exposed to the same health issues such as hypertension or cystic fibrosis, the uninsured have higher mortality rates than patients with health insurance. All the while, insurance companies, private hospitals, and Big Pharma continue reaping massive profits.

What We Need: Free Universal Healthcare for All

We need a system that guarantees access to high quality healthcare for everyone, regardless of one’s nationality, immigration status, state of employment or their income. This means that we need to get rid of the leeches that conceptualize health and disease as an opportunity for profit-making. Healthcare should not be treated as a commodity – it’s not like buying clothes you like or going out for drinks; it’s not about preferences or individual choices.

The right to health care is a basic human right. Limiting access to health care or offering a lower quality health service based on one’s ability to pay is indefensible. The only way to accomplish universal access with quality health care is by decommodifying it – that is, taking it out of the market. To put it in different terms, no one chooses to get heart surgery or a treatment for cancer; treatments are prescribed when the patient needs them (unless market and profit-making logic interfere). This is why health care cannot be submitted to market rules. Eliminating all profits and speculation is the only way to accomplish this. In this perspective, the profit-driven medical care is only one sector that we need to dismantle. The highly profitable production of drugs as well as the development of health-related technologies (diagnostic and therapeutic) need to be wrested from the hands of capital and put toward the collective needs of the whole of society.

Public health is much more than the treatment of diseases, but rather addresses the social determinants of health. These can be understood as the social conditions that put individuals at higher risk of becoming ill, and they range from lack of access to preventative healthcare and a healthy diet (usually linked to poverty and food deserts), to occupational hazards, to unsafe housing (poor heating, lead paint), to unemployment and poverty wages. It should come as no surprise that there can be no solution to the social and economic determinants of health under capitalism – the system relies on unemployment, poverty and inequality to function. And the reverse can be stated too. It would be only under a socialist society, where everyone’s needs are fulfilled, that the human potential will blossom in full.

Bernie Sanders’ Medicare for All Bill

Although Bernie Sanders’ Medicare for All is a far cry from decommodifying health care, it would still be a major improvement for the working class and the poor in the U.S. The plan eliminates the stranglehold of the corporate insurance sector by replacing it with a single-payer, government-run health insurance, which would negotiate the costs of health services with providers.

The bill proposes comprehensive coverage, including dental and vision care, and would be phased in over four years starting with people 55 and over and children under 18. It would also remove the private addendums to Medicare that it currently exists, such as Medicare Advantage, a premier tier of supplemental care and coverage exclusive to seniors who can afford to pay out-of-pocket.

Markedly absent from Bernie Sanders’ plan is any guarantee that undocumented immigrants and DACA recipients would qualify for the benefit. The bill state all residents would be covered, but leaves the definition of who is and who is not considered ‘resident’ in the hands of the Secretary of Health and Human Services, i.e. whoever sits at the Oval Office. It is possible that Bernie Sanders chose to leave this question open in order to secure the support of the Democratic establishment. This politically-expedient compromise is unacceptable and shatters the possibility of a broad class-wide push for universal health care. Socialists can’t lend support to this bill as it is. Furthermore, any discussion around single payer or Medicare for All should explicitly criticize this ambiguity and push for real universal health care. A considerable amount of confusion comes from advancing, instead of the political goal, the funding mechanism: single sayer. For this reason, we think “Free Universal Healthcare” is the demand socialist should put forward.

Under Bernie’s plan, the delivery of health care would still be overwhelmingly in the hands of private providers and pharmaceutical companies. Healthcare costs are expected to fall since the government, being the only “payer” of health services, would be in a much stronger position to negotiate the rates than insurance companies today. One can wonder, however, if the government officials in charge of this task will actually be invested in lowering healthcare industry costs or, instead, would be eager to strike profitable deals for the companies that fund their campaigns. Remember that Hillary Clinton got paid more than any other politician by the health insurance industry, while Cory Booker, one of the main supporters of Bernie Sanders’s bill, received over $250,000 dollars from Big Pharma in the past year. The pharmaceutical industry was the most profitable industry in the U.S. in 2016, and everything indicates that they won’t let go of their profits easily.

The Political Viability of Medicare for All

A growing coalition has formed behind the fight for Medicare for All that includes The Labor Campaign for Single Payer Healthcare (National Nurses United, New York State Nurse Association and others), along with Healthcare-NOW, Physicians for a National Health Program and political organizations such as the DSA (Democratic Socialists of America). Perhaps more surprising is that 16 Democratic senators, including high-profile politicians like Kamala Harris and Cory Booker – who are speculated to run for presidential office in 2020 – endorsed Sanders’s bill last month. It matters little whether they are paying lip service or are sincerely supporting the proposal: the bill is dead upon arrival in the GOP-dominated congress.

There is no chance to get the bill passed in Congress with the current configuration of seats in place. If only there was a Democratic Party majority, they will tell us. But Democrats held the White House and majority in the House and the Senate in 2009, when Barack Obama tabled single payer and passed instead the ACA, while gutting progressive measures from its initial draft, including a “public option” and regulations on insurance companies. The Democrats winning back control of the Congress is no guarantee that any resemblance of a single payer bill will get passed. The electoral path is a dead end.

The only possible way to win free universal health care is through mobilization, protests and disruption. When Congress feel that things are getting out hand and that they need to address a demand that has overwhelming support, the chances of getting such a bill passed will dramatically increase.

The Journey Ahead

The movement for single payer will have to be large-scale, energized and persistent in order to win public control of healthcare. We need the whole of the labor movement on board. Like the Democratic representatives in Congress, union bureaucrats will only bring themselves to endorse single payer if they feel enough pressure from below. The force behind this movement will be in the rank-and-file, whose organization can expand across unions in order to strongarm the leadership to take up the campaign for universal healthcare. This type of labor mobilization would be a welcome departure from the failures of U.S. union leadership to advance class-wide workers’ solidarity, particularly in its historic pandering to racist and nationalist divisions.

The struggle for universal health care, provided it actually is universal is in the interest of the whole working class. The dividing line here would be between those who have a full-time job with health benefits and all the rest – including the unemployed, the undocumented, and precarious and part-time workers. The result will be an immediate and inevitable strengthening of workers’ bargaining power overall.

The U.S. Left can play a pivotal role in organizing this drive. The DSA membership has shown great interest in the fight for Medicare for All (over 80% of its members voted it as a national priority in a pre-convention poll) and there have been attempts to build a movement around this demand, like the campaign in California or the push for a March on Washington. After the the plan for a March on Washington was abandoned, the efforts to build a nationally-coordinated campaign receded.

However, this discussion is still vital. If the DSA decided to throw its weight behind a militant, national campaign to win Medicare for All, with its members bringing the issue to their workplaces and pushing for their unions to take up the fight, it could have a significant impact on the outcome of the struggle.

A Stronger Footing for All Workers

Winning universal health care would increase workers’ independence to confront the bosses. Today, when workers organize on the job, whether for higher pay, better working conditions, or to form a union, they not only risk losing their jobs, but also risk losing health care for themselves and their families. The stakes are too high, and thus the task of rallying people together for a collective fight becomes extremely difficult. Although it’s not the only mechanism, the level of coercion that employers exert today through the provision of health care is astounding.

How many people do we know who have made the decision to keep a job they hate, or who work full-time against their wishes, for the sole reason of not losing their health insurance? How much less likely is a worker to go on strike if he has a child with asthma, or she herself has a health conditions that requires treatment, be it diabetes, hypertension or a kidney disease?

Since its creation and later its consolidation at the end of WWII – with the full support of labor unions – the employer-sponsored health care model represents a yoke that workers can’t escape. It’s a sword of Damocles continually hanging over their heads. Breaking this system of coercion is a primary task for workers today.

Four Points on the Fight for Single Payer

In lieu of a conclusion, let us stress some points we need to keep in mind in the fight for winning a single-payer healthcare system like ‘Medicare for All’:

1. The Democratic Party is heavily invested in keeping the for-profit character of our healthcare system intact. The public endorsements of Sanders’s bill are only a measure of the popularity of a plan to provide universal health care – and a feeble attempt by Democratic senators to demonstrate a progressive veneer.

2. Bernie Sanders’ bill can’t be supported as it exists now. Socialists must not lend support to a bill that leaves the door open for anti-immigrant discrimination and, once again, perpetuates divisions among workers.

3. The profits snared by the insurance companies are enormous. The only viable strategy for getting rid of this entrenched industry is through the pressure exerted by mass mobilization. Unions can play a prominent role by advocating for a unifying demand that can cut across traditional divisions in the working class with far-reaching impact.

4. Winning a single payer program that includes all people living in the U.S. would be a victory for the working class, but it’s a far cry from what we need. Under private ownership and market rules, health clinics and institutions will continue to squeeze healthcare workers and rip-off patients and kick them out when they’re no longer a source of profit. The drug industry will continue to make millions from over-priced treatments, and people will continue to suffer from job-related injuries and a myriad of diseases closely linked to the capitalist mode of production. The level of health that we can achieve under capitalism is pitiful in comparison with the potential of prevention and maintenance of health under a socialist society. Nevertheless, having health care guaranteed regardless of age, health, income, employment, or immigration status would dramatically increase workers’ bargaining power nationwide and would likely foster an uptick in organizing, militancy and struggles at the workplace.