Reviewed by Mark Anderson
May 30, 2018
Health Care Under the Knife: Moving Beyond Capitalism for Our Health by Howard Waitzkin and the Working Group on Health Beyond Capitalism. New York: Monthly Review Press, 2018. Softcover, $27.00. Pp. 336.
This valuable collection of essays examines many facets of contemporary capitalism’s harmful impact on health and health care in the United States and, to a lesser extent, worldwide. It also contains suggestions for how capitalism’s toxic, for-profit influence in health care can be curbed and ultimately eradicated.
The 16 authors, most of whom live in the U.S., are health policy experts, physicians, activists, and scholars in global health, medicine and medical ethics. Several hail from Canada; one lives in Australia.
Howard Waitzkin, a U.S.-based physician, sociology professor, and longtime observer of heath care in the U.S. and Latin America, coordinated the effort.
Waitzkin writes that while most of the book was written before Donald Trump’s election to the presidency, the authors found that after he was elected, “we actually needed to change very little in the analysis. … Capitalist health care became further entrenched under Obama, has persisted under Trump, and would have differed little under Clinton.”
The book is divided into five parts.
Part 1 looks at the changing class position of health professionals, particularly doctors, in a system that’s increasingly dominated by giant private corporations; the degradation of medical labor and deterioration of quality standards under the corporate drive for ever-higher profits; and the growing alienation among health care workers who find themselves confronting management’s unproven “pay for performance” schemes, billing-focused (vs. clinical health-focused) electronic medical records, and mindless metrics – all at the price of undermining patient care. Part 1 also contains an interview with two prominent physician advocates for a single-payer national health program, David Himmelstein and Steffie Woolhandler, who offer their own perspectives on the development of health care in the U.S. over the past four decades.
Part 2, titled “The Medical-Industrial Complex in the Age of Financialization,” looks at the evolution of the “medical-industrial complex” since the term’s coinage in 1969, and the relentless encroachment of private enterprise, and particularly financial corporations, into all aspects of U.S. health care. Pharmaceutical companies come in for special treatment in a second essay.
Part 3 focuses on the impact of neoliberal policies on health reform, taking an in-depth look at the origins of the Affordable Care Act (“Obamacare”), including an examination of a similar scheme in Colombia in the mid-1990s (in addition to its more recent predecessors, e.g. the Massachusetts plan under Gov. Mitt Romney). The authors contrast such schemes with alternative models of reform, including national health insurance plans (e.g. in Canada) and national health service (NHS) plans (e.g. in Scotland, Wales or Sweden), and suggest the NHS model deserves more serious consideration in the U.S. than it’s received. An essay titled “Austerity and Health Care” discusses the destructive impact of corporate-inspired austerity plans on the health systems of Greece, Spain and the U.K.
Part 4 examines “imperialism’s health component,” U.S. health policy toward other nations as mediated through “philanthropic foundations, international financial institutions, organizations that enforce trade agreements, and international health organizations.” The authors assess the historic role of the Rockefeller Foundation and more recently the Gates Foundation in shaping global health initiatives; the impact of GATT, NAFTA and other trade pacts in undermining public health programs in other countries; and how the World Bank and Gates Foundation, taking advantage of the World Health Organization’s financial difficulties, stepped in and are now steering WHO in a pro-corporate direction. A related chapter looks even more deeply at the role of “philanthrocapitalism” in global health care policy.
Part 5 is titled “The Road Ahead,” and opens with a piece by Rebeca Jasso-Aguilar and Howard Waitzkin on successful campaigns by people in El Salvador, Bolivia, and Mexico in resisting the privatization of public health systems and resources. Subsequent chapters detail the failures of Obamacare (and a corresponding increase in public support for single-payer reform) in the U.S., and more general observations about the prospects for “moving beyond capitalism” in health.
For all the strengths of these essays, there are a number of noteworthy shortcomings.
The intense drive by for-profit interests in the U.S. to further privatize Medicare, Medicaid, and the Veterans Health Administration receives surprisingly little attention. Similarly, institutional racism, which pervades U.S. health care and is a major social determinant of health, is mentioned only in passing. The same can be said of income inequality.
The concept of “moving beyond capitalism” is itself problematic, inasmuch as (1) the next rung on the ladder is merely described as “non-capitalism,” or “the construction of non-capitalist economic systems”; (2) the historical experiences, both positive and negative, of the Soviet Union, China and Cuba are not discussed (the USSR, in fact, is cited in one article as having been a “social imperialist” country; and socialist Cuba, whose achievements in public health and health care have won worldwide acclaim, is skipped over because its successes have been described elsewhere, they say); and (3) all of the examples of successful resistance to privatization that the authors cite took place in nations that remain capitalist.
Granted, it’s possible to speak of health systems in capitalist countries that are publicly owned or operated and based on the principle of human solidarity (rather than the commodification of care) as having, in a very broad sense, moved “beyond capitalism.” But again, most activists associate “moving beyond capitalism” as synonymous with achieving some form of socialism – including the kind of social revolution that Cuba underwent.
Why the hesitancy exists to “name the system” of socialism in this context is a bit of a mystery. It’s not as if a specific discussion of health care under socialism would be stepping beyond the bounds of acceptable discourse. The rising support for socialism in public opinion surveys in the U.S., especially among young people, is an indication that many would welcome such a discussion.
The result of this omission is a fuzziness about the ultimate goal.
In fairness, the concluding essay does get more concrete about strategy by making reference to the need for “a powerful, multicentric coalition – including unions and labor campaigns, organizations centered around the health professions, racial justice groups, and other grassroots activist organizations – that can offer a vision of change, while at the same time shaping, prodding, and supporting progressive political actors and parties.”
And, importantly, the authors say “moving a bold progressive health care agenda forward, including instituting a national health program, may additionally require a new working-class party (or parties), a process that imposes unique challenges. This process will require a broad, potent, multi-focal popular movement pushing for change from below.”
It’s reasonable to predict that in the course of building such a popular movement, the historic working-class battle cry for equitable, high-quality health care for all is likely to become even louder – as will the popular cry for a more fundamental restructuring of the whole of society, i.e. socialism.
In sum, this latest addition to Monthly Review’s booklist on health care (notably preceded by the Socialist Register’s “Morbid Symptoms: Health Under Capitalism,” in 2009, and “Dangerous to Your Health: Capitalism in Health Care,” in 1993, by Vicente Navarro, the latter being among the clearest on the need for taking class approach to analyzing health care issues), makes a valuable contribution to a much-needed dialogue on the state of U.S. health care and the need to put people’s health before profits.
At the same time, the door remains open for further writing on what it will take to move beyond capitalism in health care – and how such a move is urgently needed.