Health Care: Socialist versus Capitalist Nationalization

Since the coronavirus and health care are undoubtedly on the minds of many people throughout the world, I thought it appropriate to do a bit of research on socialist health care versus present capitalist health-care systems.

Health care even in a nationalized context can easily be an expression of oppression and exploitation. The idealization of nationalization often goes hand in hand with an argument  that we need to extend public services in health and education (as Sam Gindin has argued). However, nationalized health care can easily become an oppressive experience for workers (as well as patients). From Barbara Briggs (1984), “Abolishing a Medical Hierarchy: The Struggle for Socialist Primary Health Care,” pages 83-88, in the journal Critical Social Policy, volume 4, issue #12, page 87:

GPs AND SOCIALISM

Socialists have traditionally argued for state control of key areas of the economy and of the provision of welfare services such as health and education. Socialist health workers have argued for general practitioners to become salaried employees of the Area Health Authorities, along with the ’ancillary workers’, instead of continuing to enjoy the independent self-employed status that they insisted on to protect their status when the NHS [National Health Service of the United Kingdom] was set up.

But the NHS, the largest employer in the country, has shared with nationalised industries the failure to demonstrate any evidence of ’belonging to the people’: because of the backing of the state it has proved a ruthless and powerful employer, keeping the wages of unskilled and many skilled workers also at uniquely low levels; time and again, union members seeking improvements in pay and amelioration of very poor working conditions have been defeated. Nor has the NHS shown any kind of effective accountability to its users. Public spending constraints have hit the NHS not only by causing a decline in working conditions and in the services provided, but also by imposing even more centralised planning priorities based on the need to save money whatever the cost.

This situation likely characterizes the Canadian public health-care system as well.

A word about the Canadian health-care system. One inadequate view on the Canadian health-care system is the social-democratic or social-reformist perspective, which certainly exists in Canada. One definitely inadequate view considers the Canadian health-care system to be socialist (Mary E. Wiktorowicz, pages 264-262, “Health Care Systems in Evolution,” in Staying Alive:  Critical Perspectives on Health,
Illness, and Health Care (2006), page 243):

In many ways, national health insurance symbolizes the great divide between:
liberalism and socialism; the free market and the planned economy (see Box 10.1).

Nationalized health care in no way represents the great divide between liberalism and socialism. An apparently critical form of the analysis of health care–but in reality a variant form of social democracy or social reformism–looks at the inequality in access to health care, according to level of income. Thus, in the edited work Health Promotion in Canada: Critical Perspectives (2007), Denis Raphael, in his article (pages 106-122) “Addressing Health Inequalities in Canada: Little Attention, Inadequate Action, Limited Success,” refers to levels of income as the major social determinant of the level of health. Since income inequalities in Canada are increasing, it follows that health inequalities are also increasing. However, this view defines a social determinant purely in terms of level of income–a typical social-democratic or social reformist method (I will deal with this issue in another post). As Glenn Rikowski (2001) points out (“After the Manuscript Breaks Off: Thoughts on Marx, Social Class and Education”, though, level of income is used instead of social class, or rather level of income is often used as a substitute by the social-democratic left:

… we witness the virtual abandonment of the notion of the working class…. Most people who analyse social class today do no such thing; rather, they have social inequality and stratification in view.

This use of the level of income to evaluate access to adequate health care is useful to a certain extent, but if it is the prime definition of class and inequality, it is far from adequate. It ignores entirely the source of income and exaggerates differences within the working class rather than a shared economic and social situation of being employees (or unemployed or temporary employees) and subject to a hierarchy of power at work (of course, managers are also subject to control from above, but in general it can be safe to assume that they form part of the middle class if not subordinate members of the ruling class).

The situation of the British NHS is typical of what happens when so-called socialist principles are realized in a capitalist context. Two socialist principles in particular fall by the wayside. From Bob Brecher (1997), (pages 217-225), “What Would a Socialist Health Service Look Like?,” in the journal Health Care Analysis,  volume 5, issue #3, page 219:

These principles are: (a) that there by a reasonable degree of equity in respect of outcome concerning the distribution of basic resources, and (b) that people treat each other as ends and not merely as means. The first may perhaps be understood as a political and economic dimension of socialism, while the second constitutes a moral and social element.

The first principle considers that social equity is itself a good in itself or an end at which we should aim. The second principle considers that people deserve to be treated as people in all circumstances and not just outside work or as “consumers.” This second principle, of course, can never be realized in a capitalist society since human beings are necessarily treated as things or objects to be used as means by a class of employers (see The Money Circuit of Capital).

Health care would be just that: health care–not health service. From Brecher, page 221:

‘Service’ implies server and served; consultant and client; provider and consumer. But none of these describes the sort of relationship between carer and person carefd for that the two principles outlined suggest. To take the example of the NHS again: despite the intentions of its founders, it was the connotations of service–by turn beneficently providing for patients and ‘servicing’ them as though they were objects–which helped provide amply justified dissatisfactions with the resultant shortcomings of the NHS treatment: and these have been used to undermine its founding principles. The combination of professional paternalism, especially in respect of senior doctors; an inability or unwillingness to treat people rather than their symptoms; and an attitude of ‘servicing’ and being ‘serviced’ all helped alienate people from what was supposed to be ‘our’ NHS, enabling successive conservative governments to turn what was at its inception at least a ‘social’ health service into an expliictly anti-socialist one. … these are not accidents of the British context: such terms and the attitudes and mores they describe are inimical to a socialist structure, based as that must be on considerations of equity and respect.

It is important to emphasize, as Brecher points out, that the assumption that nationalization is somehow socialist without further ado itself contributes to the Conservative backlash and the emergence of neoliberalism. By indulging the social-democratic or social-reformist left, with their talk of “decent work,” “fair contracts,” “fair share of taxes,” “$15 Minimum Wage and Fairness,” and the like, the so-called radicals have in reality contributed to the neoliberal backlash. What is needed is not indulgence of such talk, but continuous critique of such talk. What is needed is a critical attitude towards the so-called “left” and its associated idealized institutions.

What is needed is critical and hence democratic analysis and discussion of health-care systems. What is absolutely unnecessary is the defense of flaws in various social systems. If we are going to create a socialist society worthy of human beings, we need to be honest about the inadequacies of current social structures and systems.

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