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:


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.

The Radical Left Needs to Call into Question Existing Social Institutions at Every Opportunity, Part One

Before I obtained a so-called permanent teaching position (I will explain in a much later post why I use the word “so-called”), I worked for a number of years as a substitute teacher (with short periods of term teaching positions). I became an executive member of the Winnipeg Teachers’ Association (WTA) (in the province of Manitoba, Canada), representing substitute teachers.

The WTA had an education fund for the executive, where each member, if approved by the executive, could access up to $3,000 for educational purposes. A condition for obtaining such funds was a summary of the educational experience and its publication in the WTA newsletter.

I used this situation as an opportunity to criticize the limitations of the educational experience.

Of course, representatives should not limit themselves to such criticism but rather perform their representative function in order to enhance the democratic nature of the union or association to which they belong. To that end, I and others on the Substitute Teachers’ Committee created a survey for substitute teachers and used the results of such a survey to criticize the policy of the WTA of permitting only permanent teachers the right to apply for permanent positions (substitute teachers paid association dues and consisted of usually 700-900 paying members of around 4000 members, but they did not have the right to apply for permanent positions).

Below is a copy of the draft (written in 2007) as well as the critical summary of my educational experience.

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To the Negotiations Committee

As members of the same organization, all should be treated in the same way unless there are sufficient differential grounds for distinguishing the members and for thus treating them on a differential basis. However, that does not mean that substitute teachers should necessarily all have the same rights as permanent contract teachers.

A basic principle of political philosophy is that all should be treated the same unless there are differential conditions for treating some differently from others. There are differential conditions, at least in the case of substitute teachers who are relatively new. Would it be fair, for instance, that permanent contract teachers, who by definition generally expect to work for the same employer for years, be reduced to the same rights as a beginning substitute teacher? Attachment to a particular employer for an increasing length of time forms the basis for privileging permanent teachers over substitute teachers, just as the principle of seniority does in unions.

However, as substitute teachers are engaged in employment with the same employer for an increasing length of time, the grounds for differential treatment become less and less valid.

Of course, the reported statistics from the survey of substitute teachers do indicate that there is a substantial percentage of substitute teachers who have been employed by the Division for a number of years. Their exclusion from any consideration of whether they can apply for positions is less valid than the exclusion of shorter term substitute teachers. Of course, the exact cut off line is not easy to define, but the issue is first of all whether all substitute teachers should be banned from applying for positions. Perhaps there are counterarguments which justify such exclusion, and I would like to hear such arguments. Lacking such counterarguments, substitute teachers with a certain period of employment with the Division should have the right to apply for positions as they arise, just like permanent contract teachers.

Addressing now the issue of those with a shorter period of employment with the Division, the Division may agree to allow them to apply for positions once the third round of blue sheets have been distributed.

In other words, there would be two sets of substitute teachers, those with sufficient length of service to be able to apply for positions immediately, and those with less service, who would be able to apply for positions on the third round of job postings.

Although this two-tier system of selection may be preferable, it may not be possible during the 2009 round of bargaining; a collective agreement involves two parties, and it may be impossible to negotiate the “best” scenario in any particular year of bargaining. Consequently, there are two alternative proposals: a “bottom-line one,” and a preferred (but perhaps unrealistic) one at this stage. The important point is to have substitute teachers’ concern about the right to apply for job postings addressed.

Proposed “bottom-line clause”: All substitute teachers shall have the right to apply for job postings during the third round of postings of the blue sheets.”

An alternative would be as follows: Substitute teachers who have substituted for the Division for at least ten (10) years shall have the right to apply for job postings. Substitute teachers with less than 10 years of substitute teaching shall have the right to apply for job postings during the third round of postings of the blue sheet.”

Of course, the exact wording is irrelevant at this stage. It is the concept that matters.

Fred, chair, Substitute Teachers’ Committee

The critical summary of my educational experience (

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The Double-Bind of Teachers as Employees

On September 21 [2007], I attended a seminar on Employment Law Essentials. It covered various topics, including the difference between an employee and an independent contractor, pre-employment inquiries, employment standards and workplace harassment policies.

There were two areas of most relevance to teachers: a discussion of the nature of an employee and the issue of the age at which people can become employees.

Let us start with the last issue first. The age at which people can become employees is relevant for teachers since the age at which students can become employees then arises. Generally, it is very difficult for students under the age of 12 to become employees. On the other hand, it is less difficult for students between the ages of 12 and 16 to obtain a permit. Four people must be in agreement if those between 12 and 16 are to become employees: the student, the parent, the principal and the employer. Since being an employee may affect school work, teachers who are concerned about some of their students working as employees may consult with the principal since the latter needs to agree to such employment.

Addressing now the first issue—the nature of an employee—there are four criteria for determining whether a person is an employee or has her or his own business (is an independent contractor): lack of control over the work performed (how, when and where the work is to be performed), the ownership of tools, possibility of loss or gain and the extent to which the person is integrated into the employer’s operations. The criterion of loss or gain is inapplicable to the situation of teachers. The criterion of integration is only used in borderline cases. Hence, the question of the status of teachers is reduced to the two criteria of control and ownership of tools.

In the seminar, we briefly discussed whether teachers are employees. Although teachers may control the order in which the curriculum is presented, it is the Division, generally, which determines standards of performance for teachers. Another aspect of control is whether the employer determines where and when work is done. Teachers work for the Division and not for specific schools. The collective agreement may modify the power of the employer, but it does not fundamentally alter the situation—as teachers in low-enrollment schools may discover when they are transferred to other schools. In terms of control, teachers are employees.

The other criterion for determining who is an employee is the ownership of tools. In the case of teachers, although the latter may personally purchase items for use in the classroom, it is the Division which owns the buildings, the things in the building and so forth. The fact that the Division may represent the vague public because of the payment of taxes does not change the situation.

Since the situation of teachers satisfies the two major criteria for determining whether teachers are employees, it can indeed be concluded that they are employees.

The collective agreement does not change the status of teachers as employees; it modified the conditions of employment—certainly an important characteristic—but it does not fundamentally alter the employer-employee relationships as such. For example, employment standards are such that judges will take into account length of service to an employer when considering notice required, but the judge will not take it into consideration when the issue of dismissal arises. Arbitrators of collective agreements, on the other hand, do take into account length of service when considering the issue of dismissal.

The issue of control is full of interesting sub-issues. One of the issues that were brought up was whether employees who are under the control of employers are extensions of the will of the employer. They are. This situation, however, has major social implications. If employees are extensions of the will of the employer, then employees are means to the ends specified by the employer.

Immanuel Kant, a German philosopher, argued that it is a categorical ethical imperative to treat all human beings as ends in themselves. If we apply the philosophical principle of the unity of the ends in the means and the means in the ends, then to treat human beings as ends in themselves is to have them participate in the process of defining their own ends. They need to be able to contribute to the formation of the ends toward which their activity tends: living democracy rather than formal democracy.

Being an employee, however, which involves being an extension of the will of the employer, clashes with the principle of treating human beings as a unity of both means and ends in the same process. Human life is split, with teachers being extensions of the will of the Division. Their personhood is suspended to the extent that they cannot formulate the ends of their own activity in conjunction with the activity of other teachers.

This clash applies to other employees in other domains, such as waiters and waitresses, bus drivers, factory workers, office workers and so forth. In the specific case of teachers, though, there is an added contradiction. Teachers are supposed to treat students as ends in themselves: the formation of character. To do so, they need to have students learn to unify the ends in the means and the means in the ends. If, however, part of their function is to prepare students for their status as employees, then their educative function clashes with their function within the school system. This is the double bind of teachers: being an employee, on the one hand, and being an educator within an economy dominated by the employer-employee relation on the other.

Are teachers in a double bind? What do other teachers believe?

Fred Harris, executive member