The groundbreaking 1970 book American Health Empire reported that health care conglomerates had jelled into a profit-making system notable for inflicting chaos on sick people. Someday, the authors wrote, health-care reformers would be facing off against “the empire at its core institutions.” For authors contributing to the recent Monthly Review Press book Health Care Under the Knife, that someday is now.
Former academician and public health physician Howard Waitzkin, more recently a medical practitioner, edited the multi-author volume and contributed several essays of his own. The book includes essays from Steffie Woolhandler and David Himmelstein, co-founders and leaders of Physicians for a National Health Program, a prominent advocacy group on behalf of universal health care in the United States. They survey the political context of health care reform efforts in the United States and comment on the Affordable Care Act, enacted in 2010.
The title evokes an image of a patient undergoing surgery for the sake of a decisive cure, except that the patient in question is our diseased health care system. The subtitle is “Moving beyond Capitalism for Our Health, which implies that the offending pathology, capitalism, was somehow removed or eradicated. Radical political change is surely on the agenda, if not actual surgery.
This book is about antagonism between the neoliberal form of capitalism and decent health care. On display are capitalist-induced perversions that impinge on the delivery of care, interactions among the various health-care players, and the ideals and presumed mission of health workers. Corporations, institutions, and the state do the dirty work, mainly in the United States, but elsewhere too. A record emerges demonstrating that health care for all won’t happen under advanced capitalism.
Many of the problems catalogued in the book have to do with providers and their dealings with patients, employers, companies, and government agencies. The reader learns that primary care is shortchanged, providers must compete for employer approval, quantitative data replace judgment in determining quality of care, and the electronic record supersedes providers themselves as a medical home for patients.
According to authors Gordon Schiff and Sarah Winch, physicians comply with cost-cutting, document trivialities for the sake of reimbursement, “game the system,” and suffer “burn-out.” Atomized and alienated, they face “prolitarianization.”
Their bosses generally regard health care as a commodity. Insurance companies pursuing “vertical integration” absorb heath-care provider groups. Giant hospitals do likewise. The book refers to an omnipresent “medical-industrial complex.” It’s the creature of monopoly capital funded by debt-funded speculation. The pharmaceutical industry, for example, derives most of its huge profits from financial manipulations rather than from drug production, according to contributor Joel Lexchin.
Academic medical departments collaborate with corporations in carrying out research projects. High-level physicians and researchers, having bonded with corporations, end up hawking their products, pharmaceuticals most prominently. What with collaboration of state entities with corporations, business notions of cost-cutting and outsourcing inform governmental decisions on health care. Pharmaceutical companies have corrupted governmental regulatory processes in the United States and Europe. Drug companies exert control over the dissemination of scientific information, Lexchin reports.
These failings plus others described in the book lend support to the book’s main point: real health-care reform is impossible as long as rules, standards, and priorities of neoliberalism are in charge. The Affordable Care Act is shown to have hugely benefited the private insurance industry; it left 27 million Americans uninsured. Having adopted concepts of managed care, the legislation limits access by allowing pre-authorization, cost sharing, utilization review, high deductible plans, tiered benefit packages, and exclusion of out-of-plan providers. Administrative costs remain high.
Throughout the Global South, multi-national insurance companies have built associations with the social security and health care systems of various nations. In the Eurozone, neoliberal remedies like austerity, deregulation, privatization, and retreat from universal coverage have eviscerated some national health plans. Nations honoring international trade agreements don’t easily recover sovereign control. A chapter in the book cites the painful experiences of Greece, Spain, and England.
Another section says a lot about health care philanthropy in the hands of the very wealthy. The Rockefeller and Gates Foundations (GF) are shown to have emphasized technical, short term solutions for public health problems at the expense of preventative strategies. Concentrating on disease eradication, the foundations deal very little with social causes of ill health. The philanthropies are engaged in what authors Anne–Emanuelle Birn and Judith Richter call “philanthro-capitalism.”
They hold that a “global health plutocracy [has] enabled business interests to obtain an unprecedented role in global health policy-making with inadequate public scrutiny.” They claim that the World Health Organization has lost its once prominent role in studying health strategies and organizing primary and preventative care for the world. It functions less well now, mainly because United Nations member states, especially the United States, have been slow with dues payments. Private donations now account for almost 80 percent of that UN agency’s budget.
A section of the book explains how market- oriented mega-projects with a large ecological footprint have aggravated environmental and social threats to human health. These range from diminishing access to fresh drinking water, to deforestation and consequent proliferation of the Ebola and Zika viruses, to industrial-scale concentrations of food-producing animals that harbor disease-producing microbes.
The various contributing authors attend mainly to problems weighing on health care due to capitalism. But solutions they offer look to be scattershot and more in the category of good intentions than workable methods. They find promise in social movements by means of which community-based initiatives and resistance campaigns might be organized. In their concluding section of the book, authors Waitzkin and Adam Gaffney look to progressive elements within the Democratic Party for reform possibilities. And change may “require creating a new working class party (or parties).” In any case, they say, a “powerful, multicentric coalition” is “urgent.”
Praiseworthy examples appear of resistance to capitalist abuse of power. Among them are: water privatization in Bolivia, privatization of health services and social security in El Salvador, and public health failings in Mexico City. Far-reaching health-care reforms in Kerala, India; Bolivia; and Venezuela are mentioned. Authors Woolhandler, Himmelstein, and Gaffney present a “new vision” of single payer health care.
There’s no discussion in the book of a socialist alternative to capitalism. Dr. Waitzkin, the book’s editor, observes that, “We have chosen not to address the Cuban case here, which is in many ways exceptional, and on which a great deal of previous work exists.”
The imperfections of health care under neoliberalism catalogued in the book are legion, but the listing there is hardly exhaustive. Others include: frequently impaired interaction of U.S. physicians with working class patients due to biases relating to social class, heavy U.S. reliance on foreign trained physicians to fill the ranks of medical practitioners, and skewed implementation of affirmative action favoring middle and upper class entrants into medical schools.(1)
And for a long time U.S. medical educators have failed woefully in preparing adequate numbers of primary care physicians. Without them, transformation of U.S. health care is impossible. Also, the motivations of would-be health workers evidently are of no great concern to U.S. medical educators. Their Cuban counterparts, by contrast, foster ideals of service and solidarity.
Dr. Waitzkin and colleagues, it seems here, would have strengthened their critique of capitalist health care had they introduced data on health outcome. In fact, U.S. mortality data are scandalous. Infants die needlessly in epidemic fashion. African-American infants die at twice the rate of white infants. So many mothers die in association with childbirth as to suggest an underdeveloped nation. Minority citizens living in poor communities have diminished live expectancy. Life expectancy of middle-aged white Americans is falling.
Health Care under the Knife is valuable mainly because it provides reams of information on health care realities under capitalism. Moreover, the authors display contagious enthusiasm for a kind of health care that favors people over profits. They earn extra credit for their evident sympathy for a society heading in a revolutionary direction for the sake of just and effective health care. Regrettably, they did not pursue that lead.
Monthly Review magazine recently published two compelling articles that cover ground similar to that of the book. In an essay titled “Absolute Capitalism” John Bellamy Foster (MR, May 2019) traces the evolution of capitalism from Karl Marx’s version to the neoliberal form, the setting, he thinks, for “social-system failure.” Ian Angus (MR, June 2019) describes an out-of-control proliferation of microorganisms resistant to antibiotics – a “profit-driven plague” – which portends a “social and economic crisis.”
1. W.T. Whitney Jr., “Becoming a Physician: Class Counts,” Nature, Society, and Thought, vol. 15, no. 3 (2002), p. 261.