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Sick and Sicker: Two Models of Medical Rationing

by Susan Rosenthal

Everyone knows that Canadians live longer and have lower infant mortality rates than Americans. In Sicko, Michael Moore suggests that a Canadian-style medical system would solve this problem. Surprisingly, the evidence indicates that it would not.

A cross-border team of 17 researchers (including high-profile supporters of the Canadian system) examined a variety of medical problems, including cancer, coronary artery disease, chronic illness and surgical procedures. With the single exception of end-stage kidney disease, where Canadian patients fared better, they found no consistent difference in patient outcomes between the two nations.(1)

As I have argued elsewhere, the United States has the worst health statistics in the industrialized world because it is the most unequal society in the industrialized world.(2)

Although Canada’s medical system does not produce generally better patient outcomes, it is more fair and far more economical. In 2003, the average American spent almost twice as much for medical care as the average Canadian. Exorbitant medical bills are a constant worry and a major cause of personal bankruptcy.

Profit-taking is responsible for the high cost of American medicine. However, the Canadian system is also subject to market forces.

Contrary to popular belief, Canada does not have a single-payer medical system. Government pays about 70 percent of medical costs, including most hospital and physician care. Individuals and private insurance companies pay the remaining 30 percent for prescription drugs, dental and vision care, ambulance, medical devices, home care and other services.

To contain costs, both the United States and Canada ration medical care, but they do this in different ways. In the U.S., more than 45 million people have no medical insurance at all. The Institute of Medicine estimates that 18,000 people die every year as a result.

In Canada, lack of access is more equitably spread across the population in the form of long waits for assessment and treatment. We don’t know how many Canadians die while waiting for treatment, because no one is counting the bodies.(3)

The Canadian model of rationing is sick, and the American model is sicker because it unfairly discriminates against those who cannot pay. Neither is good enough. Medical care is a human right and should not be rationed at all.

Disgust with the American medical system has built support for HR 676 – The United States National Health Insurance Act – a single-payer system where medical care would be publicly financed and privately delivered. Winning HR 676 would be a tremendous victory. However, the Canadian experience shows that private delivery of medical care opens the door to parasitical profit-taking.

The Canadian experience

Until the 1960's the American and Canadian medical systems were nearly identical. Those with the highest incomes obtained the lion’s share of medical services even though those with the lowest incomes experienced the most illness. The logical solution was a government-run system to provide medical care for all, but doctors and private insurers rejected what they called "state medicine and socialism."

During the upturn of the 1960s, the pressure grew for universal health care. To contain demand, the federal government launched a Royal Commission to "study" the problem. The Canadian Labour Congress (CLC) made its preference clear.

"We favor a system of public health care that will be universal in application and comprehensive in coverage. We favor a system that will present no economic barrier between the service and those who need it. We are opposed to any provision which will require some people to submit themselves to a means test in order to obtain service. We look to a system of health care that will be regarded as a public service and not as an insurance mechanism."(4)

The public-service model, where government is both payer and provider, was rejected. Instead, the Medical Care Insurance Act of 1966 established a publicly-financed system to be administered and delivered by the private sector, "free of government control or domination."

The province of Quebec took a different route. Pressured by workers’ demands that culminated in the 1972 General Strike, Quebec incorporated medical services into a broad social benefits system, paid for and provided by the provincial government. The Quebec working class is rarely credited for producing the most comprehensive medical system in North America.

The assault on Canadian medicare

The ink was barely dry on the Medical Care Insurance Act before the federal government began cutting funds for health and social services. The 1974 recession and the recessions of the early 1980s and the early 1990s were followed by deeper cuts. As the cost of medicare was downloaded from the federal government to the provinces, the principle of equal access was eroded.

Private corporations rushed into the breach created by under-funding. The more medical services were removed from the public realm, the more individuals had to pay out of pocket, purchase insurance to cover the gap or go without.

To reassure nervous Canadians that medicare was safe, the Canada Health Act of 1984 guaranteed universal and equal access to medical services, but provided no funds to make this possible. Behind the scenes, government was committed to "growing" the private medical industry.

In 1994, the Ontario government concluded, "To have the effective launching pad it needs, the health industries sector must expand its share of its own home market. Steps must be taken to ensure that, as in other countries, the domestic market supports the development of globally competitive companies."(4) One of these steps was to eliminate regulations mandating a minimum level of daily care for Ontario nursing-home residents.

In 1997, the federal government declared "Promoting Canadian companies as global health-keepers is the main objective driving the strategies and plans of the government for the medical devices, pharmaceutical and health-services sector."(4) In support, Canada’s Supreme Court stated in 2004 that, "The Canada Health Act [does] not promise that any Canadian will receive funding for all medically required treatment."

Behind the mask of "health-care reform" and "restructuring," the Canadian medical system has been handed, piece-by-piece, to private industry in a manner similar to the dismantling of Britain’s National Health Service — publicly-provided health care is under-funded to the point of crisis, then denigrated for its inadequacies. The private sector is proclaimed the only possible savior, and opponents are ridiculed as old-fashioned and sentimental. When the market fails to deliver, we are told we must adapt to "the new reality."(5)

The strongest opposition has come from organized health-care workers. Canadian hospitals, which by law must be non-profit institutions, became a battleground as unionized workers resisted wage cuts and contracting-out of housekeeping, information systems, food preparation, laboratory and other services to private, non-union companies.

In 1981, Ontario hospital workers launched a province-wide strike, defying back-to-work legislation and the jailing of union leaders. Unwilling to broaden its challenge to neoliberal social policy, the union caved and the strike was defeated. Many small, local hospitals were closed. Others were merged into giant conglomerates managed by business consultants.

Privatization has decimated services. Families stagger under the burden of sick, injured and frail relatives who were previously cared for in hospital, rehabilitation and chronic-care facilities. In-home nursing care is scarce or pricey.

Tens of thousands of hospital nursing jobs have been eliminated at the same time that average hospital stays have been cut, so that fewer nurses care for much sicker patients. Hospital food lacks nutrition and infectious diseases plague hospitals that are no longer clean.(6)

As hospital out-patient clinics closed, patients were sent to family doctors (GPs) for follow-up, creating a crisis at the primary-care level. By 1998, 62 percent of Canadian physicians reported that their workload was too heavy, and more than half said that their family and personal life were suffering. By 2000, only 39 percent of Ontario GPs were accepting new patients. By 2006, fewer than 10 percent were accepting new patients. People typically wait months to see a specialist and more months for treatment. Patients grow sicker and die while they wait.

Quebec’s model health-care system has been damaged severely by funding cuts. In 2005, Canada’s Supreme Court ruled that lack of timely access to treatment in Quebec was serious enough that the province could no longer prohibit private funding for medically necessary services. Similar legal challenges are expected in the other provinces.

Unless the public system is resuscitated with a major transfusion of funds, it’s only a matter of time before private hospitals begin servicing those who can pay to go to the front of the line. Ironically, while Americans long for a Canadian-style medical system, that system is disintegrating under the pressure of market forces.

Why ration medicine?

The capitalist class will pay anything to defend and extend its power. No ceiling has been set on spending to win the war for Middle-East oil. In contrast, there is fierce resistance to funding any services for workers beyond the minimum required to keep them productive.

As the competition for capital increases, most governments are reducing their investment in health, education and social services — robbing the public sector to boost the profitability of the private sector. No nation and no medical system are immune to the relentless drive for profit.

The American medical system will be reformed. Ordinary people want medical services. Business complains that the cost of medical benefits is hurting their profits and global competitiveness; they want to transfer these costs to the public sector. Because Americans pay almost 90 percent more per-capita on medical care than Canadians do, rationalizing the medical system would offer fantastic cost savings. The real question is how it will be reformed.

The key demand is for affordable medical care. With almost 60 percent of the American workforce making less than $15 an hour, affordable care would have to be free. That shouldn’t be a problem. A nation that find the money to pay for war can find the money to pay for universal health care — in theory.

In practice, capitalism prioritizes cost-efficiency over human need by "industrializing" social services. The work of medicine is dissected into components that are individually priced and parceled out. The profitable parts are handed to the private sector and the unprofitable portions remain in the public realm or are abandoned altogether.

While applying industrial methods to medicine is cost-effective from a business point of view, it fragments health care. Planning health services to meet population needs and integrating prevention and treatment, hospital and community care become impossible.

Winning HR 676 would be a definite step in the right direction. However, we need to go further. Eliminating profit from the medical system requires public financing and public delivery of services (socialized medicine). More than that, all health and social services must be provided as a human right — fully funded, fully integrated and with no rationing. If capitalism cannot meet these basic needs, then we need to construct a socialist society that can.

References

1. Guyatt, G.H. et. al. (2007). A systematic review of studies comparing health outcomes in Canada and the United States. Open Medicine, Vol. 1, No. 1 http://www.openmedicine.ca/article/view/8/1

2. Rosenthal, S. (2007). Illness and inequality: What's missing from the health-care debate. Counterpunch. http://www.counterpunch.org/rosenthal05252007.html  Also, Rosenthal, S. (2006). POWER and powerlessness. Vancouver: Trafford. www.powerandpowerlessness.com

3. According to the Canadian Institute for Health Information publication, Health Indicators, 2007, the mortality risk for patients who waited longer for [hip] surgery was 22 percent higher than for those treated within two days of admission to hospital. www.cihi.com

4.Cited in Fuller, C. (1998). Caring for profit: How corporations are taking over Canada’s health care system. Ottawa: Canadian Centre for Policy Alternatives.

5. Pollock, A.M. (2004) NHS plc: The privatization of our health care. New York, NY: Verso.

6. Valiquette, L., Low, D.E., Pépin, J. & McGeer, A. (2004). Clostridium difficile infection in hospitals: a brewing storm. CMAJ, July 6, Vol.171, No.1. http://www.cmaj.ca/cgi/content/full/171/1/27

Defining Class

by Susan Rosenthal

How do you define class? According to the 2006 General Social Survey, most Americans view society like a giant football, with a small group of rich people at one end, a small group of poor people at the other end, and the majority filling out the middle.

While class is commonly defined on the basis of income, wealth, education, and occupation, these individual characteristics tell us nothing about people’s social relationships.

A social definition of class would measure two variables: the control that people have over their work and the control that they have over other people’s work. Using these criteria, society can be divided into three classes: the class that rules (the capitalist class); the class that obeys (the working class); and the class in between (the middle class).

This definition would structure society like the typical workplace — a pyramid with a boss at the top (the capitalist class), a layer of middle-managers or supervisors (the middle class), and the majority who do the actual work and are unemployed from time to time (the working class).

The class that rules

The capitalist or ruling class has the most power because it owns or controls the natural resources required to create wealth, the process of creating wealth, and the wealth that is created. Because it controls all these things, the capitalist class decides the overall direction of society, determining what will be produced, how it will be produced, and who will have access to the resulting goods and services.

The capitalist class includes CEOs of the largest corporations, presidents and directors of the largest universities and banks, and the highest-ranking politicians, government bureaucrats, judges, and military officers. Each nation has its own capitalist class, and together they form a global capitalist class.

Capitalists compete constantly for capital. Larger corporations swallow up smaller ones and grow larger. Stronger nations dominate weaker ones and grow stronger. Ceaseless competition has caused the ruling class to shrink in size while it grows in wealth and power. By 2005, one percent of people at the top of society owned one-third of America’s financial wealth.

The class that obeys

The capitalist class controls the means of production, but the working class sets it in motion. The working class creates all the wealth in society, yet has the least power. People in the working class own no land, no factories, no machines, no businesses, nor any other means of making a living. (They can, of course, own personal property such as homes and vehicles.) Workers survive only by selling their ability to labor in exchange for a wage. They have no control over how they produce and what they produce. They have no control over the labor of others.

While the ruling class has shrunk over time, the working class has expanded. More than half the global population is now urban working class (with the next largest group being small farmers who are middle class because they own a little land). In the U.S., about 80 percent of the population is working class — the vast majority.

Rising productivity has made it possible to accumulate more surplus from fewer workers. Some of this surplus has been used to expand the service sector — finance, transportation, communications, hotels, restaurants, and the education, medical, and penal systems. While the working class as a whole has continued to expand in size, the proportion of industrial workers has declined while the proportion of service workers has increased.

The class that obeys has the option of not obeying, of taking collective control of production and reshaping society to meet human needs.

The class in the middle

The middle class is the second largest social class. Forming about 20 percent of the North American population, the middle class sits between the two other classes, blending into the capitalist class at one end and the working class at the other end.

People in the middle class have an intermediate level of power, having some control over their own work and some control over the work of others. The middle class owns or controls some means of production: the small farmer owns some land; the self-employed artisan owns some tools: the corner-store retailer buys and sells some produce. Sections of the middle-class employ and exploit workers — on a small scale.

The 18th-century middle class was composed of small farmers and fishermen, artisans, entertainers, lower-level clergy, traders, and owners of small businesses. The process of capital accumulation obliterates the traditional middle class. Agricultural corporations swallow family farms and fast-food chains replace family restaurants.

While squeezing out the traditional middle class, capitalism creates a layer of middle-class managers to supervise the working class. The capitalist also needs middle-class financial, legal, scientific, design, and technical experts to find ways to increase profits. While ordinary workers are micro-managed, salaried professionals are encouraged to think creatively and act independently, within the limits set by the boss.

Middle-class managers and professionals can be distinguished from waged workers by the amount of control they exercise in the workplace. A unionized electrician on a construction site could be more educated, more skilled, and make more money than the site supervisor. However, the supervisor tells the electrician what to do.

The grey zones

An indeterminate number of people inhabit the two grey zones on either edge of the middle class. The zone between the middle and ruling classes includes members of the ruling class who perform upper-level managerial functions, and upper-level managers who are occasionally invited to make big decisions.

There is a much larger grey zone between the middle and working classes. At the one end are middle-class professionals whose degraded working conditions resemble industrial assembly lines. Physicians working for Health Management Organizations (HMOs) are permitted to order only those tests and provide only those treatments that the employer approves. By removing their decision-making functions, HMOs force doctors into working-class conditions. In response, thousands of doctors have joined unions and organized collective bargaining units recognized by the National Labor Relations Board.

At the other end of the zone between the working and middle classes are waged workers with small businesses on the side and blended-class families that form when middle- and working-class people marry. Changes of fortune also create blended-class families: the disbarred lawyer takes a job at the post-office and the steel-worker’s daughter goes to medical school.

The grey zone also includes workers who perform managerial functions — salaried social workers, nurses, grade-school teachers, low level government workers, and prison guards. All are working class because they have little or no control over their own working conditions. At the same time, their jobs give them some control over other people.

Ordinary soldiers are working class because they have absolutely no control over the conditions of their work. At the same time, the soldier has a middle-class function — to control others. Soldiers are not in the same class as police officers. The working-class soldier is drilled to follow commands without thinking, while the police officer is a middle-class professional who is trusted by the higher-ups to know who to target, who to charge, who can be roughed up, and whose life has less value.

When it is difficult to decide if someone is middle or working class, that person probably inhabits the grey zone.

This material was excerpted from POWER and Powerlessness, Chapters 13 & 15. Available at www.powerandpowerlessness.com. For a class analysis of unions, see "Class-Divided Unions," March 23, 2007

Cindy Sheehan Unmasks the Democrats

by Susan Rosenthal

Cindy Sheehan is the Founder and President of Gold Star Families for Peace. When her son Casey was killed in Iraq in the spring of 2004, she threw herself into the campaign to end the war.

Sheehan became a thorn in the side of President Bush, following him wherever he went. She camped outside the White House and established "Camp Casey" next to the Bush ranch in Crawford, Texas. Her challenge to the president was simple and heartfelt:

"You tell me the truth. You tell me that my son died for oil. You tell me that my son died to make your friends rich. You tell me my son died so you can spread the cancer of imperialism in the Middle East. You tell me that."

Democrats and liberals loved Sheehan when she attacked Bush and the Republicans, but they turned on her when she held them to the same standard.

The Democrats were swept into Congress on a wave of popular revolt against the war. Despite their anti-war posturing, they gave Bush billions more dollars to continue the war. Outraged, Sheehan condemned the Democrats as heartless hypocrites:

"How can you even go to sleep at night or look at yourselves in a mirror? How do you put behind you the screaming mothers on both sides of the conflict? How does the agony you have created escape you? It will never escape me...I can’t run far enough or hide well enough to get away from it."

The Democrats have proved to be just as committed to ruling the Middle East as the Republicans. In 1998, Democratic President Bill Clinton signed the Iraq Liberation Act to force regime-change in Iraq. Barely two months later, he ordered the bombing of Baghdad. And it was Clinton who presided over the deadly UN embargo against Iraq.

Neither of the two Bush presidents could have invaded Iraq if the groundwork had not been laid by Democrats. And the war could not continue if Democrats did not support it. Both parties serve a capitalist class that is determined to dominate the world, and controlling the Middle East is central to that domination.

We expect to be attacked by our enemies. We don’t expect to be betrayed by our friends. Back-stabbing Democrats accomplished what Bush and his supporters could not — they brought Cindy Sheehan to her knees. On Memorial Day, she announced that she was too depleted to continue fighting.

Sheehan urges us to "figure a way out of this two-party system that is bought and paid for by the war machine." However, sections of the anti-war movement will continue to back the Democrats, no matter how often this proves to be a dead-end, because the only real alternative is to reject capitalism altogether.

We owe Cindy Sheehan a tremendous debt. She shouted the truth in a world full of lies. She confronted the war mongers and unmasked the hypocrites. In her exhaustion, she confirms that none of us can change the world alone.

Now, it’s up to us. We must step up the fight to bring an immediate end to the war.

For more on this subject read POWER and Powerlessness, Chapter 15, "Beware the Middle Ground." Available at www.powerandpowerlessness.com

Equality and Universal Health Care

by Susan Rosenthal

Human health is not a commodity that can be churned out by the right kind of health-care system. The key to winning better health and universal health-care is to fight for equal rights — for a sharing, socialist society.

As I explained last week, growing inequality is generating America’s deepening health crisis.

In egalitarian societies, people share social resources and use any surplus to raise living standards, thereby improving health. Under capitalism, an elite accumulate profit by holding down living standards for everyone else, thereby generating illness.

When workers win more of the social surplus, inequality decreases and health improves. When capitalists win more of the surplus, inequality increases and health declines. America’s position as the dominant global super-power has been achieved at the cost of increased inequality and illness.

The current health-care debate sidesteps the fact that capitalism makes people sick and concentrates instead on the best way to manage this sickness. Even so, the push for profit gets in the way.

Corporate America is caught between a rock and a hard place when it comes to matters of health. Raising productivity requires a basic level of fitness within the working class; however, paying for this in the form of higher wages, employee benefits or higher taxes decreases productivity.

The conflict between the desire for higher productivity and the need to control costs is expressed in the demand for a more effective health-care system and the failure to provide one. Simply arguing that the current system is unfair, ineffective and overly expensive will not be enough to break this stalemate.

Universal health-care programs are based on the principle that everyone has an equal right to health care. However, capitalism prefers to provide goods and services only to those who can pay. The kind of medical system we have is shaped by class conflict, with the working class pushing for a service-based medical system, and the capitalist class pushing for a profit-based medical system.

When the capitalist class is stronger and more confident, the medical system is run on the business model. As popular rebellion grows, the capitalist class will concede health and social services in order to save the system.

Germany established the first European national medical plan in 1883 to avoid a revolutionary upheaval like the one that shook France in 1871. In Britain, the 1911 National Insurance Act was rushed through Parliament during a mass strike wave.

In 1943, a Conservative member of the British Parliament warned, "If you don’t give the people reform they are going to give you revolution." The British NHS was part of a social welfare program designed to restore social stability after the war. Canadian unions won a national health plan in 1972, the year of the Quebec General Strike.

In the U.S., the Congress of Industrial Organizations and the American Federation of Labor pushed for a national health program after World War II. The ruling class preferred to build a bigger military machine. America’s Cold War with Russia provided the opportunity to attack the unions and gut them of militants. That defeat explains why there is still no labor party in the U.S. and no national health plan.

As capitalists become more confident, their drive for profit accelerates, and they roll back wages and benefits. Today, Britain, Canada and the European Union are dismantling and privatizing their own national health-care programs in order to compete more effectively with the U.S.

At the Cannes screening of Sicko, Michael Moore states, "The bigger issue in the film is, ‘Who are we as a people?’" Human sickness is a product of sick social relationships, and human health is a product of healthy social relationships. The quality of our medical system is a result and a reflection of those relationships.

For more on this subject, read POWER and Powerlessness, Available at www.powerandpowerlessness.com