Nursing assistants often resent their clients.

I worked in assisted living. My co-workers would complain about residents who blew up if they got breakfast at 8:10 instead of 8 – never mind that each of us had 8 or 9 other residents also demanding breakfast at 8. Sometimes, they did worse than chew us out. For most people, getting hit by clients from time to time isn’t “just part of the job.” For CNAs, it is.

However, the residents who lashed out had cause to feel isolated and powerless. Social programming for long-term care residents is inadequate in many facilities (if it’s offered at all). Facility life is profoundly lonely; worse, facilities rarely treat their clients as adults with a right to dignity and bodily autonomy. And, of course, plenty of them don’t even meet their residents’ bare physical needs.

Was that the CNAs’ fault? We did the best we could under conditions not of our making. But, frustrated residents still took out their grievances on us, the only representatives of the facility with whom they had any regular contact. It made sense for them to blame us for their situation, just as it made sense for us to blame them for mistreating us.

But management decided how the place was run. They created a situation in which mutual scapegoating was a logical decision for both CNAs and residents. Meanwhile, the company could cut costs and accumulate profit, at the expense of clients and workers both.

Residents and their families were rarely the ones who paid. Assisted living costs thousands of dollars per month; few can afford it out-of-pocket. So, most residents at most facilities are there only because their health insurance covers it. If insurance doesn’t pay, the resident doesn’t stay.

That gives management an incentive to keep residents healthy enough to live for a long time, but never so healthy that they need a less intensive level of care (since that would mean less billable treatment). From a patient’s point of view, the best-case outcome is to recover enough to require less intensive care. But for the facility, the best case is that the resident never stops having more health problems to treat, so insurance never runs out.

At its 2017 convention, the Democratic Socialists of America (DSA) declared Medicare for All (M4A) its highest priority.

Single-payer healthcare has long been a leftist and liberal priority. While Democrats tend to view M4A as an end in itself, socialists approach it as a springboard to a fully-nationalized, UK-style system. As Timothy Faust wrote in Jacobin:

In other words, a single-payer program is not the goal. Single-payer on its own cannot be the goal. Single-payer does not solve the biggest sin of commodified health care: that taking care of sick people isn’t profitable, and any profit-driven insurance system thus disregards the most vulnerable. … Single-payer alone does not solve these problems. But it gives us a fighting chance to square up against them.

Further, given that Bernie Sanders made it a key campaign promise, many leftists view M4A as the ideal “winning issue.” What could be better than a “universal public good” that enjoys majority support in the polls and already gets significant media coverage?

So, is there a leftist critique of M4A to be made? What socialist would oppose universal healthcare?

M4A, though, isn’t universal healthcare access in the abstract. Medicare is a specific program. M4A calls for it to be expanded in specific ways. M4A is not the general principle of a right to healthcare. It’s a concrete policy proposal and should be evaluated as such, just as criticizing a particular play doesn’t mean condemning the theatre in general. In critiquing M4A, I am not attacking the principle of universal healthcare. Rather, I am arguing that this particular reform campaign is flawed to the point that socialists shouldn’t take part in it.

Neither lack of access nor commodification is US healthcare’s deepest problem.

It’s more than how it’s paid for or to whom it belongs. The issue is in its bones: how people get diagnosed, how treatments get prescribed, and how care gets delivered. US healthcare serves two primary purposes: it keeps workers healthy enough to go to work, and it warehouses disabled people as cheaply and expeditiously as possible. Those imperatives aren’t simply imposed by individual corporations. After all, the process of diagnosis, prescription, and treatment works no differently in a state-owned or nonprofit clinic than in a private one. When the process itself artificially pits patients and workers against each other, neither more comprehensive insurance nor nationalization deals with the root cause. It’s not about who gets healthcare. It’s not even about who owns healthcare. It’s about what healthcare is for.

Why else is long-term eldercare is so often institutionalized neglect (or worse), even if it’s state-run – especially if it’s state-run? Why else is inpatient psychiatric care rife with organized physical, emotional, and chemical violence? M4A demands greater access to something that, in certain situations, is actively harmful. For instance, a former EMT in Washington recently told me:

Many of the psychiatric facilities our ambulance visited were understaffed, filthy, and frequently spared little regard for patients’ wellbeing. Staff members often referred to patients with contempt and disgust (sometimes within their hearing). I observed that patients’ medical needs were often neglected for days at a time, which was frequently the reason for our visits. On multiple occasions I had reason to suspect that facilities were manipulating their documentation in order to maintain patients’ involuntary commitment status. (I only had limited interactions in my capacity as an EMT because we were only there when they called us.)

In those cases, the only way out of institutional abuse is for someone’s insurance to run out. What happens when M4A guarantees it never will?

Now, DSA’s fifth M4A demand – “job training/placement assistance for people currently employed by the private health insurance industry” – already looks beyond simply expanding insurance access. However, nothing in the campaign even implicitly critiques the process of healthcare provision itself.

If M4A requires a jobs program, shouldn’t it also require that people in long-term care and people with mental health diagnoses get the right to refuse unwanted treatment? After all, other categories of patients have the legal right to decline care, even if that means the patient’s death. A psychiatric diagnosis, however, means that police can detain a person and physically force them to receive treatment against their will – and at least a quarter of police shooting victims have a mental health condition, while involuntary psychiatric commitment rates exhibit a racial bias.

Shouldn’t M4A demand an end to abusive and eugenicist practices? For instance, guaranteed coverage of Applied Behavioral Analysis isn’t a good thing for autistic minors – ABA applies physically and emotionally punitive techniques developed for anti-gay conversion therapy to suppress common autistic mannerisms, such as hand-flapping and avoiding eye contact.

Shouldn’t M4A call for healthcare workers and patients to exercise control over their facilities, rather than bureaucratic managers (either private or state-sector)?

Instead, M4A demands universal healthcare without those reforms. Sure, some individual supporters of M4A support them as well. But, M4A the campaign does not make reference to them. Neither DSA nor any other M4A organization is pushing for them, even in a non-M4A context. They aren’t part of the M4A package. Even if M4A is the first step on the road to a national healthcare system, that doesn’t address the issue – every one of these problems is embedded in government-run and nonprofit healthcare facilities, not just for-profit ones.

Is a “winning issue” so worth pursuing that there’s no need to address the key contradictions it contains (except with a jobs guarantee)? Socialism depends on leadership across differences, not lowest-common-denominator single-issue coalitions.

The state isn’t neutral.

Every state belongs to a class. In medieval Europe, the state belonged to aristocratic landowners. In ancient Rome, it belonged to slave-owning patricians.

The US government belongs to the capitalists – that is, the owners of the physical and organizational machinery that workers use to create goods and services.

It doesn’t belong to them because politicians are corrupt. This isn’t a matter of “money in politics” – it’s the way the state itself is set up. No matter who holds office, the structure of the state means that it can’t help but enforce capitalist class rule. From the day-to-day activities of municipal civil servants to the highest levels of the Executive Branch, everything the government does in some way contributes to that task. It makes sure that contracts are enforced, infrastructure carries goods and services, markets operate smoothly, threats to private property are neutralized, and – above all – that workers keep going to work every day. The state uses force to defend the “public order” of capitalism; in practice, that also means white supremacy, empire, and patriarchy. It regulates businesses to protect the business class’s long-term stability. It runs social services to keep the working class healthy enough to be exploited. It allows radicals to participate in elections to pre-empt their inclination to build revolutionary institutions of their own. It grants concessions to movement demands to de-fang their revolutionary potential and coax them into patronage politics.

This is an inherently capitalist state. Changing that would mean completely redesigning and restructuring it, bottom to top, from the Constitution to common law to the bureaucracy. In other words, it would have to be smashed. A new system would have to be built in its place.

Revolutionary socialism, both Marxist and anarchist, begins by recognizing that. Government socialism begins by denying it. Government socialists, like conservatives and liberals, treat the government as a “public sphere.” Supposedly, it does (or at least could) belong to “the people” in general, not just the ruling class. It can act in the “general interest.” Socialism, therefore, just means more government! State universities are socialist. Roads and sewers are socialist. Parks are socialist. According to a few government socialists, the NSA, the NYPD, and the United States Marines are, too. And “universal public good” redistributive programs – like an expanded Medicare – are the most socialist things of all.

The problem, of course, is that the institutional machinery of the US government can’t be divorced from its role in defending white supremacy, imperialism, and the ruling class. To expand that machinery, even if it does some good in some people’s lives, necessarily strengthens those things.

It is one thing to set up a day care centre the way we want it, and demand that the State pay for it. It is quite another thing to deliver our children to the State and ask the State to control them, discipline them, teach them to honour the American flag not for five hours, but for fifteen or twenty-four hours. It is one thing to organise communally the way we want to eat (by ourselves, in groups, etc.) and then ask the State to pay for it, and it is the opposite thing to ask the State to organise our meals. In one case we regain some control over our lives, in the other we extend the State’s control over us. –Silvia Federici

Until the government disbanded it in 1954, the Communist Party ran a group called the International Workers Order. The IWO provided its nearly 200,000 members with health, dental, and life insurance, and its 19,000 branches ran clinics and summer camps of their own (all in addition to a wealth of cultural and educational activities). The Communists built it all during the Great Depression, when working-class people had far fewer resources than they do now. A generation later, the Black Panther Party and its allies followed the IWO’s lead, establishing clinics and social services of their own.

The state didn’t establish the IWO. It didn’t run the Panthers’ clinics. Revolutionaries created those services themselves. They operated them on their own terms, under their own control.

The point of socialism is mass power, in every sphere of life. It’s not a bigger federal government.

Therefore, we repeat, state ownership and control is not necessarily Socialism – if it were, then the Army, the Navy, the Police, the Judges, the Gaolers, the Informers, and the Hangmen, all would all be Socialist functionaries, as they are State officials – but the ownership by the State of all the land and materials for labour, combined with the co-operative control by the workers of such land and materials, would be Socialism. Schemes of state and municipal ownership, if unaccompanied by this co-operative principle, are but schemes for the perfectioning of the mechanism of capitalist government-schemes to make the capitalist regime respectable and efficient for the purposes of the capitalist … –James Connolly

Don’t campaign for M4A.

Address healthcare like any other issue: organize the workers in that industry. Use mutual-aid programs to grow revolutionary capacity. Government socialists claim that for something on the scale of healthcare, mutual aid just isn’t a workable approach. But even setting aside the IWO and other counter-examples, mutual aid is still more workable than M4A.

M4A can’t happen without a Democrat in the White House, a filibuster-proof Democratic majority in Congress, and (most of all) those Democrats’ willingness to actually make it policy. Now, all of the Democratic 2020 presidential hopefuls recently co-sponsored an M4A bill. That’s only symbolic. It’s red meat for primary voters, but they don’t intend it to ever actually lead to policy. It’s no different than the millionaires’ tax that the New Jersey Democrats supported in opposition, but oppose now that they’re in power.

DSA has the numbers (if not the will) to launch an IWO-style mutual-aid health program. But do they think they’ll be able to win over the federal leadership of the Democratic Party – the same people who made sure that the most popular politician in the country lost his primary fight to one of the least popular, who couldn’t even stomach Keith Ellison as DNC chair, and who just spent eight years in office administering war and neoliberalism? What do they think the Democratic Party is?

The US working class doesn’t yet exist as what Marx called a “class-for-itself” – it isn’t an autonomous political force in its own right, organized through its own base of institutions and capable of contesting for social power against other classes. The most important job for revolutionaries right now is to help it become a class-for-itself. Government-socialist and left-populist reforms can’t do that. Organizing the unorganized, building up the institutions through which an independent base can exist, can.

That won’t come from Medicare for All.

Sophia Burns

is a communist and polytheist in the US Pacific Northwest. Support her work on Patreon: https://www.patreon.com/marxism_lesbianism