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 British Labour Party’s 2019 Manifesto: More Social Democracy and More Social Reformism, Part Two

The following is the second of a two-part series of posts, providing a critical assessment of some of the views expressed in the 2019 British Labour Party’s Manifesto, It’s Time For Real Change.

The section on public services is typical of the social-reformist or social-democratic left: what is needed is mainly a quantitative expansion of existing conditions rather than a qualitative change in such conditions. For example, in education it is proposed (page 38):

We will reverse cuts to Sure Start and create a new service, Sure Start Plus,
with enough centres to provide a genuinely universal service, available
in all communities, focused on the under-2s.

Labour will radically reform early years provision, with a two-term vision
to make high-quality early years education available for every child.

This is the dream of all social democrats–provision of equal opportunity (especially in education), so that all can compete on an even-level ground. Of course, such competition will lead to inequality, but such inequality, it is implied, is healthy and justified.

Nowhere does the Manifesto address the question of whether the education system itself is adequate to the task of providing quality education on a different basis than the typical academic curriculum. Indeed, in a typical reformist fashion, it proposes to merely add on to the existing curriculum arts and other programs to supplement the existing curriculum (page 39):

The narrowing curriculum is denying many children access to modern languages, arts and music, or technical and engineering skills that will be essential in a world shaped by climate change.

The proposed educational system might then look like what the Chicago Teachers’ Union proposed–an inadequate model for the educational needs of students (see my publication “A Deweyan Review of The Chicago Teachers’ Union’s Publication The Schools Chicago Students Deserve, found on the Publications and Writings link on this blog).

On the issue of social justice, the Manifesto is vague and contradictory. It states (page 64):

For Labour, the true measure of fairness is not social mobility but social justice.

Implicit in the notion of social mobility is the idea that poverty and inequality are acceptable provided some people can climb the social ladder.

Social justice, on the other hand, demands that we end poverty, reduce inequality and create a society in which the conditions for a fulfilling life are available to everyone.

It is claimed that it is possible to end poverty. What is meant by poverty remains unclear. It probably is measured by level of income, with those below a certain level of income being in a state of poverty and those above it not being in a state of poverty. Hence, if everyone had a certain level of income that was above a defined poverty line, then poverty could be eliminated–according to social democrats.

I criticized the adequacy of such a view before (see “Capitalism needs economic coercion for its job market to function” (Ontario Coalition Against Poverty: OCAP)), so I refer the reader to that post.

The issue of inequality, in all likelihood, also refers to level of income rather than the source of that income. The same problem arises with such a definition of inequality as the definition of poverty.

In addition to the problems with such a definition of poverty (and inequality) as pointed out in a previous post, the following demonstrates the limitations of the Manifesto (pages 60-61):

We will give working people a voice at the Cabinet table by establishing
a Ministry for Employment Rights.

We will start to roll out sectoral collective bargaining across the economy, bringing workers and employers together to agree legal minimum standards on a wide range of issues, such as pay and working hours, that every employer in the sector must follow. Sectoral collective bargaining will increase wages and reduce inequality. This will also stop good employers being undercut by bad employers.

This distinction between “good employers” and “bad employers” is a typical social-democratic tactic of avoiding to address the power of employers as a class. I have addressed this issue, briefly, in another post (see The Contradictions of Unions: Reformist and Radical Assessments), so I will not belabor the point here.

The Manifesto’s social-democratic message also becomes clearer when it refers to the police. On page 42, we read:

The primary duty of government is to keep people safe. Our communities were
endangered when the Conservatives took 21,000 police officers off our streets.

If the primary duty of government is indeed to keep people safe, the Canadian federal government should commit suicide–in 2010, there were about 550 murders and 1000 workers who died at work (in addition to over 600,000 injuries).

On page 43, we read:

A Labour government will invest in policing to prevent crime and make
our communities safer, and we will enforce the laws protecting police
and other emergency workers from violent assault.

We will rebuild the whole police workforce, recruiting more police officers, police community support officers and police staff. We will re-establish neighbourhood policing and recruit 2,000 more frontline officers than have been planned for by the Conservatives. We will work with police forces to invest in a modern workforce to tackle the rise in violent crime and cybercrime under the Tories.

There is little recognition that police themselves are sources of oppression and violence in the context of a society characterized by the dominance of a class of employers (see my post Socialism, Police and the Government or State, Part One) for an elaboration of this point.

It is unnecessary to further analyze the Manifesto. The purpose of the Manifesto, evidently, was designed to gain votes by jumping on the bandwagon of climate change, anti-neoliberalism (not anti-capitalism) and the fear of personal crime and the idealization of the police.

Such are some of the limitations of the social-democratic left not only in the United Kingdom but in Canada, the United States and elsewhere.

What is needed–and what has been needed for a long time–is a political party whose aim is to free workers from the power of the class of employers. What is needed is a class party that addresses directly the power of the class of employers as a whole by challenging its power in its various forms, whether at work, in schools, in hospitals, at home, in the malls and in government.

What is not needed is just more of the same–the skirting of the power of employers as a class, the domination of that power in the associated economic, social and political structures, and the creation of solutions that never question the basic power of employers to dictate to workers what to do, how to do what they do, how much to produce and whether what they do is satisfactory or not.