Thursday, 20 August 2009

US Healthcare, The NHS and The Left

To the vast majority of people, in Europe, the current debates, in the US, over Healthcare Reform, appear bizarre. There again, a lot of US politics appears bizarre to Europeans. Although there have been fairly recent times, when, in various European countries, the Catholic Church has had a powerful influence on politics, there is nothing like the kind of relationship between fundamentalist religion and politics that exists in the US. Not even the Catholic Church denies the theory of Evolution, or clings to the idea that the Earth is only a few thousand years old and was created in just 6 days! As rich Capitalist states, money plays a big part in open political activity, but nothing like the almost flagrant buying of votes that occurs in the US. You might also think that, given the almost complete identity of the politics of the Democrats and Republicans, the US State apparatus and the ideological apparatus of the media, which is an integral part of it, could afford to be that much more objective in its analysis; instead, the mainstream US media appear crude in the extreme, compared to Europe. The most glaring example being Murdoch’s US media empire, and Fox News in particular, which is grotesquely partisan. Not even Murdoch’s British outlets, like the Sun, or Sky News, would resort to the kind of activities that Fox engages in, including the recent stories about the NHS, about their being “Death Lists” for patients in the UK, administered by Government bureaucrats.

Faced with the unbelievable comments that Republican backwoodsmen, and the right-wing media, in the US, have been making, on the NHS, and European socialised healthcare in general, its understandable that the first reaction of socialists is to counter these lies with a defence of the NHS. Understandable, but largely wrong. There is a difference between defending the principle of socialised healthcare, of the principle that healthcare should be free at the point of use, and uncritically defending the NHS, or any other State Capitalist health provision. What is somewhat hypocritical is the fact that some of the organisations, which uncritically defend the NHS against privatisation or against these recent attacks from the Right, are themselves Third Campist organisations, who argue/d that State Capitalist property in say the USSR or Cuba, COULD NOT/CANNOT be defended, because it is no more progressive – in fact, possibly less progressive – than the “democratic” imperialist states, and their capitalist property relations, that confront/ed it!

Some time ago, I had a discussion on this, on the AWL website, in relation to Cuba. The argument went like this. AWL: We will not defend Cuba as a State Capitalist economy, but we will oppose foreign intervention as we would for any other small state. Me: So if attempts other than foreign intervention were made to overthrow Cuba’s healthcare system you would not defend it? AWL: Yes, we would because it is progressive like the NHS. Me: Why is a State Capitalist hospital progressive, but a State Capitalist Pharmaceutical Company, or Steel Works, Not? AWL: No answer. Me: If insurgents were attacking would you only put your forces around hosp[itals and not factories? If the Cuban State sent troops to defend the hospital too, would you join them in defending it, or also fight them as the State Capitalist class “enemy”? AWL: No answer.

In fact, the logic, of the Third Camp position, is to offer no opposition to the privatisation of State Capitalist enterprises, because the basis of their argument is that if anything State Capitalism or its twin Bureaucratic Collectivism are, if anything, more reactionary than bourgeois democratic, market Capitalism! The fact, they do so simply demonstrates the petit-bourgeois, Opportunist nature of Third Campism, which basis itself, not on principle, but on tailing the working class.

The Marxist position is clear. State owned property is historically progressive for the reasons Engels sets out in Anti-Duhring. Not because, it is more efficient, not because it offers workers better conditions etc., but simply because it represents the more mature form of Capital, and is thereby closer to its own demise. As Engels puts it, in “Anti-Duhring”, State Capitalism exposes clearly the exploitative relationship, as the Capitalists are reduced to a class of “Coupon Clippers”. For that reason, just as Marxists oppose measures to limit Monopoly, Marxists oppose attempts to turn the clock backwards, to convert Capital to more primitive forms. But, defence against attempts to turn the clock back, does not at all imply refraining from attempts to turn the clock forward. On the contrary, the Marxist position has always been that the best means of defeating such threats is to attack, to set out why the existing set-up is inadequate and why only a more socialist, a more democratic solution can be successful.

In setting out his argument for Defence of the USSR, Trotsky was not at all committed to defending Stalinism. He set out clearly, that the Stalinists were not capable of providing a real defence of the USSR, and that it was necessary in order to provide that defence, to remove the Stalinists, to replace the existing bureaucratic structures, with real workers democracy, and so on.

The same is true with the NHS. A progressive alternative to the NHS does not lie in a return to private Capital, and Marxists should oppose every attempt to bring that about. But, the best way to prevent such a change is not to give uncritical support to the current State Capitalist regime, but to argue the need for a wholesale “political revolution” within it, to remove the top bureaucrats, and to bring it under some form of working class democratic structure.

The reality is that some of those critics of the NHS do have a point. The NHS, like all State Capitalist enterprises, is massively top heavy and bureaucratic. However well-meaning the vast majority of its staff, they work in an authoritarian, highly structured regime, in which the top bureaucrats are driven like all bureaucrats to build their own internal empires in which the number of highly paid staff beneath you, the impressiveness of the buildings you control etc. are the indicator of the extent to which you have scaled the greasy pole. This is one reason that investment is directed heavily towards new sexy, large hospitals rather than towards the far more effective use of resources in Primary Care. It is why this kind of huge investment stands in contrast to the lack of hygiene, and other necessities, and which leads to thousands of workers dying from MRSA, and C-Diff etc. Infection rates in UK private Hospitals are much lower than in the NHS, and one reason for an increase in the number of people taking up Private Medical Insurance. Other Socialised Healthcare systems in Europe, which often work on the basis of a National Insurance scheme, but with actual provision undertaken by private hospitals and clinics, provide generally better levels of healthcare, and at lower costs. In many of these countries, waiting lists are pretty much unheard of.

The history of all State Capitalist enterprises in Britain has been one in which the industry is run by, and in part for the benefit of, its bureaucratic top management, drawn from the private sector and retaining close links with it. Not surprisingly then, there is also a history of such enterprises also being run for the benefit of Capital as a whole at the expense of the enterprise’s workers, and non-business consumers. State Capitalist energy suppliers systematically overcharged domestic consumers, whilst subsidising large Capitalist users of energy. Nationalised industries were required to set their prices equal to their Marginal Costs, whilst, for British Capital as a whole, prices were, on average, around 10% above Marginal Costs. This can be seen again with the NHS, which is widely regarded as being ripped off on a big scale by the pharmaceutical companies. A look at the prices for many drugs, that individual patients have to buy for themselves, in Europe, shows them to be a fraction of the prices charged for exactly the same drugs provided on prescription in Britain. The reason is simple. In Europe the individual patient either will not, or is unable to pay high prices for drugs they require on a regular basis and so, prices are set accordingly. In the UK, the Government is seen to have an almost bottomless pit, with which to buy drugs, and the pharmaceutical companies know that, if it refuses to provide them, their will be a Public outcry. Of course, in reality it is not the Government or the NHS that buys the drugs, but the individual worker who pays for them along with the bloated bureaucracy of the NHS and Department of Health in high taxes.

Anyone who has worked in the State Capitalist sector, knows how this works. Let me give an example from my own experience. One day, I was asked, by a Manager in my Department, how much the Maintenance Contract for his PC cost. I told him that all PC’s were covered under a General Maintenance Contract, dealt with by the Central IT Department, and along with all Central IT costs were recharged to all other Departments. He said there must be a figure for his particular PC, and he’d like to know it. So, I went to ask, and was amazed at the answer, despite the fact that my previous dealings, with the IT Department, had demonstrated waste on a massive scale. The Council had a Maintenance Contract for all its PC’s with ICL. For this PC the cost was £150 per quarter or £600 a year. This was around 1995, and the value of this particular PC was probably only about £150! Given that their were several hundred PC’s in the building, this amounted, on my calculation, to around £120,000 a year that was being spent for Maintenance Contracts on PC’s that were worth only a fraction of that cost. Had each individual Department had control over its own IT expenditure it would never have done that, because it would have been much cheaper to simply have a few replacement PC’s on hand to replace any that were faulty! I could give many similar examples, some of which are even worse than this.

Nor can you imagine that, if workers actually had direct ownership and control of such activities, they would allow their money to be wasted in this way. In fact, in regard of the NHS, things have moved backwards not forwards. At least with the old local elected Health Boards, and the more recent elected Health Authorities there was some semblance of Public democratic control and oversight, even if it was more appearance than reality. The creation, instead, of Primary Care Trusts, made up of Health professionals, is rather like asking the poacher to work part-time as the Gamekeeper. There is no reason why, at least, some semblance of democratic control could not be exercised by transferring this responsibility to Parish and Town Councils, and by beefing up those bodies in order that they could undertake this task. In addition, one of the selling points, of establishing Foundation Hospitals, was that they should be run by a democratically Board – though like with democratically elected School Governors the whip hand would remain with the hospitals top doctors and bureaucrats – but, why should this only apply to Foundation Hospitals? There is no reason, here and now, why all hospitals should not be run by democratically elected Boards made up of the hospitals workers, at all levels, and patients elected within a given radius of the hospital.

No reason, that is, other than that I have pointed out in relation to calls for Workers Control appended to demands for nationalisation by the Capitalist State; it has no reason to concede such demands, other than in a completely neutered form – and there is no way under present conditions that the working class could force the State to accede to such a demand. That is why, although such demands can be raised, Marxists should point out why the State will not accede to them, and why, instead, workers have to look to the development of their own healthcare systems directly under their ownership and control. Ironically, the organisations like BUPA, which are the bette noir of the Left, show that such developments are well within the possibility of workers and their organisations to create.

In the 19th century, workers not only created Trade Unions, to defend themselves in the workplace, but also developed a wide range of other social institutions to cater for their wider needs as workers. They developed Friendly Societies, through which they were able to make provision for Unemployment, Sickness and Old Age, (out of which the various Provident and Mutual Associations like BUPA emerged) they developed various educational institutions and so on, demonstrating clearly that workers could build on their natural inclinations towards solidarity and self-reliance to posit their interests in opposition to the Capitalist Class and its State. It is perhaps, then, no coincidence that, at the very time when the prosperity of the Long Wave Boom, that began around 1890, meant that workers' rapidly rising living standards could put real resources into these worker owned and controlled institutions, the Capitalist State intervened to draw off these funds with the establishment of National Insurance, bringing nearly all of these functions under the dead-hand of the State. Of course, the role of Lasalleanism and Fabianism, which ideologically dominated the political wing of the workers movement, including those organisations which claimed to be Marxist, played its part in undermining the workers own independent development, and instead pushed them into a belief in the power of the bourgeois state, which was to create a relationship of dependency much akin to that of the medieval serf and his master.

Under these conditions, of misleadership of the movement, by the Lassalleans and Fabians, the potential, for independent working class organisations, withered and died. The only remains were the Mutual organisations such as the Building Societies, which, in a culture of reliance upon the State, which undermines independent working class activity and self-reliance, came to simply mirror their private Capitalist equivalents in the Commercial Banks. The Provident Associations like BUPA, became the mirror-opposite of what they started out as. Instead of being workers organisations, they became the instruments of private Capital, reliant on, and determined by the large employers who filled their coffers in order to provide for the needs of their Managers.

But, that fact should not be an impediment for Marxists learning the real lesson of that experience, nor for workers to once again build their own organisations, through which they can exercise their own interests, and control. After all, the same thing could be said, of other workers organisations – the Trade Unions and the LP. Only when it has to does the bourgeois state come out in open class warfare against the working class and its organisations. Its method, from the inception of bourgeois democracy, at the end of the 19th Century, has rather been to subvert the workers' organisations, to infuse them with the dominant bourgeois ideas, to incorporate them into the State, and thereby to neuter them. That does not lead us to abandon the idea of Trade Unions, or the Workers Party! It does teach us that workers have to remain as separate from the State as they possibly can be, and that Marxists have to teach the workers that the State is their mortal enemy on which they should place no reliance, and whose role and influence in society they should try to diminish at every opportunity. Not, of course, in the way that the Right advocate, by postulating a crass individualism, but, instead, by postulating that which makes the working class strong, that which makes it the revolutionary class, its solidarity, its innate need to co-operate, and its need to liberate society by liberating itself from all oppression, not least that imposed upon it, by the crushing weight of the Capitalist State, which controls and shapes its daily life, in order to make it a fit collective servant of Capital.

In that context, I’ve been interested to hear that one option being discussed in the US Healthcare debate is that of establishing Co-ops. But, there are Co-ops and Co-ops. As I have said before, there is nothing automatically socialist about a Co-op. The billionaire swindler Bernie Mahoff, lived in a housing Co-op in Manhattan. I doubt there was anything particularly socialist about that. There are many peasant distribution Co-ops in Southern Europe, but if anything they can tend to reinforce typical peasant, petit-bourgeois ideas and values. If I understand the proposals correctly, the suggestion is for the establishment of Purchasing Co-ops. That would mean that people could come together to create their own collective fund, which they control and administer to then buy healthcare from the private sector. There are a number of problems I can foresee with this.

Theoretically, there could be a problem that such a Co-op could be dominated by the wealthier, middle class members if it were successful. I doubt that would be the case, because those sections of society already tend to have good healthcare insurance. But, the obverse of that is the case. If those who join such a Co-op are only those who currently have no insurance and are not covered by Medicaid, then it is unlikely to be able to acquire the necessary resources to be able to buy healthcare from the private sector on decent terms. Only if large numbers of workers could be won to the idea of a large Co-op, probably established on the basis of local federations, each under effective, working class, democratic control, could the necessary resources and efficiencies be established, which would enable it to bargain, with private healthcare providers, on a reasonable basis. As the demonstrations at Town Hall meetings across the US have shown – though clearly much of this seems to have been orchestrated by the Republicans and other Right-Wing organisations – the fact that a large number of US workers DO have Health Insurance, provided by their employers etc., is a major obstacle in bringing that about. The more the big employers ditch Health Insurance for their workers, the less that will be an obstacle, but that could take some time.

Of course, that is no reason why the Trade Unions could not organise a drive to establish a Co-operative Insurance scheme in competition with the private insurance companies, and simply demand that employers switch their payments in to that. That would provide the financial resources necessary, and be a means of then winning over other workers to join. But, such Purchasing Co-ops inevitably face the same kinds of problems that the NHS faces when dealing with private companies. Only if this culture were transferred into a drive to also establish Co-operative provision of healthcare – a start would be to copy the example of the UK’s Co-operative Pharmacies – and to infuse these with a real local working class democracy could a real progressive alternative begin to develop. But ultimately, the power of the big drug companies pose a major problem, especially in the US where Protectionist legislation defends the profits of US drug companies, by making it almost impossible to buy imported drugs. Creating new worker owned drug companies is not feasible. But, US workers, like their European counterparts, have huge amounts of savings accumulated in their Pension Funds, and 401K’s. A systematic campaign by the Trade Unions for control of those funds, and their mobilisation to buy up, and gain control over one or more of the large drug companies, could begin to undermine that stranglehold, as well as demonstrating the way that Labour can begin to challenge, at a fundamental economic level, the power of Capital. That would be to do what Marx spoke about when he said that,

“They (the workers) ought, therefore, not to be exclusively absorbed in these unavoidable guerilla fights incessantly springing up from the never ceasing encroachments of capital or changes of the market. They ought to understand that, with all the miseries it imposes upon them, the present system simultaneously engenders the material conditions and the social forms necessary for an economical reconstruction of society”

Whilst workers, in Britain and Europe, have the task of defending socialised healthcare against a return to more primitive forms of Capital, whilst attempting to establish a more progressive worker owned and controlled healthcare system, that more adequately meets their needs, in a way that present systems cannot, workers, in the US, have the opportunity to counterpose, to the current private capitalist healthcare system – which is effective for many, ineffective for many more, and non-existent for perhaps a majority – a real independent, working class solution, based upon the establishment of worker owned and controlled Healthcare Co-operatives. No Marxist would have advised workers in Russia that they had to struggle for a deformed Workers State, let alone a State Capitalist or Bureaucratic Collectivist State, only then to try to redeem it. Nor should workers, in the US, be advised to settle for the kind of State Capitalist systems that exist in the UK or Europe, for their healthcare, simply as some kind of stop-gap short of socialism. Creating the Socialism of tomorrow entails fighting for it today, in establishing worker-owned property, and independent working class organisation in militant opposition to the bosses state, not in deference to it.

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