Capitalist Crisis in Healthcare (1998)

 Introduction (Citations at the end)

California residents are facing a medical emergency, caused by the greed and anarchy of capitalism in health care.   There is  a dangerous shortage of emergency and critical care beds because of massive closings of hospitals over the last five years.  These hospital closings, job eliminations, and patient care cuts were deliberately done to increase profits.   The cuts have produced untold misery for patients and healthcare workers.   They have also produced obscene profits for health maintenance organizations  (HMOs). But healthcare is no longer profitable.   Capitalist healthcare has produced its own downfall.   Hospital closings, job eliminations, and patient care cuts are one-time-only savings that cannot be repeated, and other healthcare costs have continued to rise.  At the same time, the HMOs are in a dog-eat-dog struggle to steal each other's members, so they have kept their premiums down to undercut each other. The result is that after six years of record-breaking profits, HMOs have had two years of huge losses.

Their  immediate solution will be simply to raise premiums, but this is already causing a crisis.    HMOs and employers are refusing to pay hospitals higher rates, and hospitals are refusing to cover patients without the higher rates.  The health industry's  long-term solutions will be more consolidations, a new round of massive hospital closings,  a whole new form of managed care with more "teeth" to severely ration patient care, and abandoning the poor and the old.

As international financial crisis spreads and worsens, and as war over oil and world resources approaches, a major battle over healthcare is developing between two groups of capitalists. Some capitalists in private healthcare want to renew their profits by cutting their own costs more. But the more dominant capitalists have a more long- term outlook, and are more concerned with   reasserting the US as a world power. These capitalists  need overall health care drastically curtailed "in the national interest," and don't trust the marketplace to do this.Hard as this may be to believe, it is quite possible that the rulers of this country will move healthcare away from the for-profit HMOs, and turn it over to "non-profit" health care like Kaiser, which will become centralized and quasi-governmental.   This sounds progressive, but it is not.  "Removing profit from health care" will mean the rulers have decided real healthcare is too expensive and should be abandoned so they can make greater profits elsewhere or rebuild their factories and military.  "Single-payer" will mean the rulers have decided to use the government to enforce healthcare rationing.

Like so many of the "reforms" offered by capitalism in crisis, this restructuring of health care will actually be fascism with a liberal cover.   Any attempt to make meaningful improvements in healthcare directly challenges the needs late-20th century capitalism. Capitalist healthcare cannot be "fixed" without challenging capitalism itself and finally smashing it.
PROGRESSIVE LABOR PARTY envisions a communist future where workers control society.    We would work to supply each other's needs, not to make profits for an elite. Health care will exist to improve the quality of our lives rather than making money. This would make our work and our lives much richer and more integrated. There would be no reason for the horrors of racism, sexism, poverty, or managed care. Our fights against our downward spiraling wages, working conditions and standard of living can develop into a movement to unite, to act, and take power as a class. That is the purpose of PLP.
Read our newspaper CHALLENGE/DESAFIO about the day-to-day struggles to make this dream a reality.

   a dangerous shortage of emergency and critical care beds ...

In January, 1998, it became obvious that there is a healthcare emergency in California. The shortage of beds in Emergency Rooms and Critical Care units threatens everyone, whether they have medical coverage or not.
  • In the second week of January, there were times when no critical care beds were available from San Francisco through San Jose. The shortage of pediatric critical care beds was so severe that one Oakland hospital prepared backup plans to transport pediatric patients to Los Angeles. (personal communications)
  • At San Francisco General Hospital (SFGH), the Nursery was closed to new patients for the first time in years. Non-emergency surgery was canceled because no beds were available for recovering patients. (Personal communication) Severely ill patients could spend 12-24 hrs in the Emergency Department, waiting for critical care beds. Emergency Room (ER) workers were having to care for both gunshot or heart attack victims and critical care patients waiting for beds. In the first two weeks of December '97, SFGH diverted critical ambulance patients to other hospitals 56% of the time. (SF Examiner, 12-17-97)
  • For half of the month of January '98, city officials in San Francisco told Emergency Rooms that, no matter how busy they were, they could not divert new patients to other ERs, because all the other ERs in the city were just as busy. (SF Examiner, 1-27-98) In the last year, diversions were suspended in four of the last 12 months, more than in the last 10 years. (SF Examiner, 12-16-97)
  • Kaiser Richmond's stand-by emergency department had thirteen-hour delays in transferring critically ill patients; a patient died there waiting for a critical care bed. At Kaiser Walnut Creek's ER, a child with extreme fatigue and shortness of breath waited more than 5 hrs to be seen. "I saw people lying on the floor in the emergency room; it was disgusting," the child’s mother said. (SF Examiner, 1-27-98) Kaiser was giving its ER patients fliers saying they would wait an average of six hours. (California Nursing Association,CNA, press release, 1-8-98)
  • For the first two weeks in January, Washington Hospital in Fremont pitched a tent outside the ER for families of patients waiting for treatment. (SF Examiner, 1-27-98)
  • Los Angeles County already is facing a serious undersupply of ER capacity, which will worsen by 2005. According to a May 1997 report by the National Health Foundation. In the mid-1980s there were 102 acute-care hospitals with basic ERs. Now there are 81 basic emergency rooms, and not all of those provide the full range of services for ambulances responding to 911 calls.  (Modern Healthcare, 7-20-98) 
  • The San Francisco Emergency Services administrator said hospital and ER patients are 25-50 percent above projections.  (SF Examiner, 1-27-98) Kaiser is seeing 10 percent more ER patients than this time last year. Davies Medical Center is seeing 25 percent more. (SF Examiner,12-16-97) This increase in ER visits is a reflection of fewer people having medical coverage.
  • Emergency Room patients are much sicker than before. Thousands of people have lost medical coverage. 30% of San Francisco residents who were eligible for Medi-Cal managed care a year ago are no longer on the rolls, either because of intimidation of legal immigrants or because of losing welfare. (SF Chronicle, 11-18-97) Those who have lost Medi-Cal now have no coverage at all. They must use county hospital ERs when they get so sick they can no longer postpone care. By then, they are seriously ill, and often come into emergency rooms needing critical care.

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hospital cuts deliberately done to increase profits ...

This crisis is the result of a  policy of increasing profits by closing beds, units, and entire hospitals, and by laying off thousands of hospital workers.

In the San Francisco Bay Area, Kaiser's new Richmond hospital, where the ICU was never opened and where the ER was recently closed, is located in a predominantly black industrial city, with four times the poverty rate of Walnut Creek, where Kaiser is keeping its hospital open.   The now-closed Martinez facility, where the stroke victim waited eight hours because of a broken CAT machine, is in a working-class part of Contra Costa County with 1.5 times the poverty rate of Walnut Creek.  The flagship hospital in Oakland targeted for closing is in the middle of a majority black city with low average family incomes and four times the poverty rate of Walnut Creek.

In Los Angeles County, the May 1997 report on emergency room access by the National Health Foundation divided the county into 10 hospital regions. It found a shortage of emergency capacity in seven regions largely working-class and minority. It found a surplus in middle-class San Fernando, and Glendale areas and the wealthy West Side. (Modern Healthcare, 7-20-98)


In November 1997, the LA County Supervisors voted to decrease County-USC Medical  Center from 960 beds to 600 beds.  County-USC Medical Center is the biggest public hospital in the US, in the midst of the biggest unsured population in the US, 2.8 million and expected to grow by 25,000 per year.   Nearly a third of the population under age 65 is uninsured. (LA Times, 10-30-97)   The former head of the LA County medical Association said "They are going to be dying in the hallways, dying waiting to get into the operating room."  (LA Times, 11-13-97)  A family practice doctor predicted that private hospitals in the vicinity of County-USC would close their own ERs, rather than risk begin "stuck" with indigent patients who could not be transferred out because County-USC had no room to accept them.  (LA Times, 11-12-97) 

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  . untold misery for patients and healthcare workers ...
 
The effects of these hospital closings, job eliminations, and patient care cuts have been catastrophic.  They have produced untold misery for patients and healthcare workers.

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obscene profits for health maintenance organizations ...
 
The cuts have also produced obscene profits for health maintenance organizations.

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But healthcare is no longer profitable..

Those glory days of gigantic profits are gone with the wind.   Having gutted health care, the financial geniuses of the "health industry" are looking around in disbelief, wondering where their profits went. "I don't think anyone knows where we are going," said Marilyn Moon, a health economist at the Urban Institute in Washington. "This is a wacky period in health care." (NY Times, 1-5-98)
 
With all respect to Ms Moon, it's not "the period" that's wacky. It's the greed and anarchy of capitalism that's wacky. The savings from hospital closings, job eliminations, and patient care cuts, are one-time-only savings that cannot be repeated, meanwhile healthcare costs continue to rise, particularly pharmaceuticals. At the same time, HMOs have been in a dog-eat-dog struggle to capture each other's members, and have had to keep their premiums down to undercut each other. The result is that after six years of record-breaking profits, HMOs have lost large amounts of money for the last two years.
 
The tendency to self-destruct is built into capitalism; there is no way it can escape. On one hand, capitalists must expand their business and get more customers, because if they do not, their competitors will force them out the market: it's grow or die. On the other hand, in order to grow, capitalists, must sink more and more money into buildings and machinery, and interest on the necessary loans, so their profits-per-dollar-invested decrease. Inevitably, the system crashes. Because workers are enmeshed in capitalism's machinery, our lives become part of the wreckage. What's happened to healthcare is an illustration of this.
  • Kaiser Foundation Health Plan, the biggest HMO in the country, lost $270 million in 1997, its first loss in its 50 years. Only last year its profits were $265 million. Its first quarter 1998 losses were $92 million. (SF Chronicle, 5-2-98) Kaiser traces its problems to its own success in attracting new members in California. Kaiser was then unprepared to handle additional members and had to pay to have them treated elsewhere.   Standard & Poor's credit-rating service placed Kaiser's debt on "credit watch with negative implications." (LA Times 2-14-98) Kaiser had a 20% growth in membership last year. It has 8.9 million members nationally, including 1/3 of Northern California residents with coverage. It has $12 billion in assets. (SF Chronicle, 2-14-98)
  • "HMO (patient) ranks continue to grow, while profits continue to sink. ... Profits at the nation's HMOs fell 60 percent last year, from $1.8 billion in 1995 to $700 million in 1996," according to a recent report by Weiss Ratings Inc. in Palm Beach Gardens. The rating agency looked at 344 managed care companies nationwide, which insure nine out of 10 HMO members. "This was the second year of declining profits after six years of steady profit growth," said Martin Weiss, the agency's chairman. "The reason is health care expenses went up, but HMOs were unable to raise premiums accordingly, due to increasing competition in the managed care industry." As a result, Weiss believes that HMOs now are under pressure to either raise rates, cut services or do both. (South Florida Business Journal, 9-1-97)
  • "Many other health care organizations and major insurance companies like Aetna, the Cigna Corporation and the Prudential Insurance Company of America are suffering losses this year or acute erosions of their profits." (NY Times, 10-19-97)
  • "Despite a 3.2 percent increase in enrollment during the second quarter, overall profits for Florida's health maintenance organizations plummeted by 72 percent, with more than half of the health plans losing money." (Orlando Business Journal, 9-23-96)
  • "Combined first-quarter net income for the 10 health plans with the largest local enrollment was down 21 percent from the first quarter last year. PacifiCare Health Systems saw its stock tumble in June after preliminary reports that second-quarter earnings will come in far below initial projections." (Sacramento Business Journal, 7-21-97) PacifiCare's fourth quarter 1997 profits dropped 53% from a year before. PacifiCare blamed losses in the Utah operations of FHP International, which PacifiCare acquired last year. PacifiCare said it would close the Utah operations down if it could not sell it. (LA Times, 3-5-98)
  • "Shares of Oxford, the biggest health maintenance organization in the New York area, fell 62.4 percent in Nasdaq trading. Oxford's announcement was only the latest in a string of disastrous financial reports in the managed health care industry, as Aetna, Cigna and other companies said that higher costs would reduce their profits, too." (NY Times, 10-28-97)
  • "Six of the seven largest HMOs in Georgia saw their profits plunge in the first half of 1996. The six companies' net incomes dropped anywhere from 28% to 95%. Three of the seven -- Cigna, United and U.S. Healthcare of Georgia Inc., registered losses in the second quarter, according to the filings." (Atlanta Business Chronicle, 9-2-96)
  • Some critics of managed care say the savings from restrictions like limiting access to specialists and tests can be realized only once. "We may have squeezed what we can out of the health care system," said Assemblyman Alexander B. Grannis, a Manhattan Democrat who is chairman of the Insurance Committee. (NY Times, 1-11-98)
  • "Many analysts in New York state say the primary reason (for HMO losses) is that managed care companies had kept prices artificially low for years to encourage reluctant New Yorkers to sign up and are only now coming to terms with the actual cost of care." (NY Times, 1-11-98)
  • "The competitive landscape has shifted. There are a lot of HMOs competing for a finite amount of business. The upshot has been that HMOs have not been able to raise premiums like they used to." (CNN financial services 1-17-97)
  • HMOs are complaining that Kaiser deliberately undercut rivals' prices to grab market share, then found itself unable to make money on the new business. California Nurses Association Executive Director Rose Ann DeMoro claimed that Kaiser has diverted funds from patient care to pay for advertising and marketing, management consultants and mergers and acquisitions "for the sole purpose of dominating the HMO market." (LA Times, 2-14-98)
  • Stuart H. Altman, a Brandeis University professor who is chairman of a council studying changes in the health system for the Robert Wood Johnson Foundation said it all: "In the early days, the HMOs extracted fairly substantial profits. Those days are over." (NY Times, 1-5-98)

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 The HMOs' immediate solution will be simply to raise premiums. ...
 

The  immediate solution will be simply to raise premiums 5-15%, but this is already causing a crisis.   Health insurance buyers and employers are refusing to pay higher rates, and hospitals are refusing to cover patients unless the rates are raised.

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But the HMOs' long-term solution will be more consolidations and ...
 

The long-term solutions will have to be more consolidations, a new round of massive hospital closings, and a whole new form of managed care with more "teeth" to drastically restrict patient care.  This will include abandoning Medicaid and Medicare coverage for expensive or unprofitable paitents such as the poor and the elderly.  The devastation of health care over the last five years is not enough!

 


 


 


 

Part of this is due to government cutbacks to Medicaid and Medi-Care.  The 1997 Balanced Budget Act reduces federal Medi-Care spending by $115 billion over the next five years.  (NY Times, 9-9-98)  "The economics of serving people on Medicare make it virtually impossible to make money," said Karen Korn, a health care services analyst at Putnam Investments in Boston. "The government has approved rate increases for Medicare managed programs of about 2 percent while medical costs are rising at 4 percent or higher. "There's no way that translates into OK margins," Ms. Korn said. (NY Times, 7-6-8)     Meanwhile, Washington is still pushing to force even more Medicaid and Medi-Care recipients into managed care plans.  (NY Times, 9-9-98)

Most of the withdrawals from Medicaid care have come in the most populous states with large  pockets of urban poverty. The  Massachusetts Blue Cross and Blue Shield Association and the Tufts Health Plan dropped out  dropped out of the Massachusetts Medicaid program.  (NY Times, 7-6-8)  Oxford Health Plans has canceled its contract to cover 33,000 Medicaid managed care recipients in Connecticut, raising questions about its commitment to cover 42,220 more in New York City.  In early February 1998, U S Healthcare withdrew from the New York City Medicaid managed care program, where it was to cover 24,000 recipients. In August 1998, U S Healthcare announced that it was absorbing a  $900 million charge  to be able to back out of Medicare plans in 35 counties, an announcement that made Wall Street wonder whether any profits could be made off Medicare patients.  (NY Times, 8-7-98)  Over the past year, eight organizations, including Aetna U.S. Healthcare and Prudential, have  dropped Medicaid programs in New York state. Both states have cut back their Medicaid reimbursement to participating HMOs. (NY Times, 2-26-98)    In March, Kaiser Permanente, the biggest HMO, quit  Medicaid care in Charlotte, N.C., and last year Humana did so in St. Louis.  Pacificare, the nation's third largest HMO and which was supposed to have been SFGH's partner in Medi-Cal managed care,  has decided to drop all Medicaid services, closing programs in California, Oregon and Utah. In California, Blue Cross, the designated private HMO for half of the Medi-Cal managed care population in San Francisco and Contra Costa counties, does not want the business any more, since California's Medi-Cal rolls have been greatly reduced. (SF Chronicle, 11-18-97)

In a similar way, economic pressures force  HMOs out of Medi-Care markets where old and sick people are concentrated.   On the average,  managed care companies get $5,700 per year per Medi-Care patient.  90% of these patients are healthy and cost about $1,200 per year.  10% are not healthy and cost about $37,000 per year.  This should make it easy to make profits, but the problem is that healthy patients live in non-urban areas where there are fewer hospitals, and therefore less incentive for hospitals to cut rates they charge to the managed care companies.  (NY Times, 9-9-98)  The only HMOs that have made money from Medi-Care are PacifiCare and Humana, which pay doctors a fixed amount of money per month per patient (physician payment on a capitation basis), thus passing the financial risk onto the individual provider.  (NY Times, 9-9-98, LA Times, 8-12-98)   Despite this, even Humana is dropping some it its Medi-Care markets.  (LA Times, 9-16-98)

Instead, public and county hospitals are taking over Medicaid and Medi-Care patients.  This is a recipe for disaster.  On one hand, federal and state reimbursement for these patients is dropping, up to 20% since the mid-90s.  On the other hand, public and county hospitals are already drained by serving indigent patients, and have no rich patients to shift Medi-Cal/Medicare patients’ costs onto.  As the Times says, "Advocates for patients say they fear the retreat will mean a return to crowded 'Medicaid mill' clinics delivering inferior care."   (NY Times, 7-6-98)
 

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A major battle over healthcare is developing between two groups of capitalists. ....
 

In respnse to this crisis in healthcare,  an intense struggle between two different modes of managed  care has developed.

In one corner are the free-market, for-profit HMOs, typified by the giant hospital chain Columbia/HCA.

In the other corner are the giant "non-profit" HMOs with their own chains of hospitals and doctors, typified by Kaiser-Permanente.

One sign of the struggle between the giant for-profit HMOs and the giant non-profit HMOs  is their positions on federal regulation of HMOs.   Let's be clear on this:  neither the Democrat or the Republican plans challenge the basic premise that the rich and powerful have the right

 to restrict our medical care.

All of these plans are restricted to workers with health benefits from their jobs, an estimated 168 million.  But 40% of jobs has no health coverage; these workers are excluded.  Medicare and Medicaid (Medi-Cal) recipeints are excluded.  Indigent people with no coverage at all are excluded. The Senate Republican plan is further limited to workers in companies that self-insure their employees, an extimated 48 million. (SF Examiner, 7-20-98)

In fact, as we saw above, both for-profit and non-profit HMOs are abandoning care of Medicare and Medicaid patients.

As Bill Clinton says, "Our job ... is not to abolish managed care. Our job is to restore managed care to its proper role in American life, which is to give us the most efficient and cost-effective systems possible,"  (LA Times, 7-16-98)

Nevertheless, the non-profit HMOs and for-profit HMOs still have radically different outlooks about government regulation:

The non-profit HMOs are for government HMO regulation:  Approximately 18 Kaiser HMOs and HMOs and Kaiser affiliates (9 million covered) and an equal number of other HMOs that are also non-profit and have their own hospitals and staffs of doctors have formed THE HMO GROUP to lobby and promote their interests. This group is pushing to have HMOs governed by all of the federal regulations proposed by the Clinton and the Democrats, with the important exception of allowing HMOs to be sued. (See below.)  (NY Times, 7-14-98)

 In fact, as we will see, the non-profits helped draft the regulations.
 
The for-profit HMOs are vehemently against government regulation:  Eight of the largest for-profit HMOs, many offshoots of insurance companies, have united with business lobbiests like the US Chamber of Commerce, the National Federation of independent Business, and the National Association of Manufacturers to form the Health Benefits Coalition.     The HMOs are  Blue Cross/Blue Shield Assn (18 million), United Healthcare/Humana (10 million), Cigna (6million), Aetna-USHealthcare (5 million), New York Life/NYLHealthCARE, Premier, and Prudential HealthCare.  Other members are The American Association of Health Plans (1000 managed care companies, 140 million covered) and Health Insurance Association (commercial health insurers).   (HBC webpage) (Coverage figures from Modern Healthcare, 6-1-98)  The Health Benefits Coalition is pushing to have no federal regualtion of HMOs at all.  (NY Times, 7-14-98, SF Examinier, 7-13-98)

What are these plans for HMO regulation?

As of mid-July 1998, there are three major legislative HMO reform plans: a Democrat Senate/House proposal (Kennedy,Mass/Dingell, Mich), a Republican House proposal, (Gingrich, GA), and  Republican Senate proposal.  These are the highlights:

Health plan liability in case of death or injury:
DEMOCRATS: Allows plan members to sue under state malpractice laws by removing ERISA shield.
HOUSE REPUBLICANS: Expands penalties for health plans for inferior care, $250,000 cap on medical malpractice awards.
SENATE REPUBLICANS: No provisions

Appeals process for patients denied particular care by an HMO:
DEMOCRATS: Requires an internal appeals process and a government-certified company for external.
HOUSE REPUBLICANS: Requires internal appeals process through HMO-appointed arbitrator, non-binding.
SENATE REPUBLICANS: Requires internal appeals process and external appeals board selected by the health plan, for "medically necessary" procedures over $1000..
 
Patients' access to specialists:
DEMOCRATS: Allows the chronically ill to consult specialists to get adequate care. Allows women to choose an OB/GYN as primary care provider.
HOUSE REPUBLICANS: Allows children to choose a pediatrician and women to choose an OB/GYN as primary care provider.
SENATE REPUBLICANS: Allows women to choose an OB/GYN as primary care provider and children to see a pediatrician without a referral
 
Continuity of care if patient or doctor is dropped from health plan:
DEMOCRATS: Requires up to 90 days of coverage after primary care doctor is dropped from plan or coverage is ended.
HOUSE REPUBLICANS: No provisions.
SENATE REPUBLICANS: Similar to Democrats' plan
 
Coverage of services by Emergency Rooms not part of patient's HMO: 
ALL PLANS: Must be covered if a reasonable person would have concluded such care was needed. Doctors right to discuss treatments not covered by HMO ("gag rule")
ALL PLANS: gag rules prohibited

Length of hospital stay following mastectomy
DEMOCRATS: Allows 48-hour hospital stays.
HOUSE REPUBLICANS: No provision.
SENATE REPUBLICANS: No provision.
 
Medical Savings Account
DEMOCRATS: No provision.
HOUSE REPUBLICANS: Some expansion of medical savings accounts.
SENATE REPUBLICANS: Vast expansion. Allows tax-deductible contributions to medical savings accounts instead of comprehensive insurance.

Disclosure of information to patients and potential patients:
DEMOCRATS: includes drugs covered and patient outcome/satisfaction information
REPUBLICANS: limited to what is covered and appeals process.

(data from LA Times, 7-15-98, 7-16-98,  SF Examinier, 7-13-98, SF Examiner, 7-20-98) 

Part of this struggle between the for-profits and the non-profits is a simple dogfight between two competing groups of capitalists. But this is not simply a struggle over immediate profits. These two competing groups of capitalists have completely different sources of money and power, and completely different national agendas and needs. Increasingly, they cannot co-exist.


 


 

For example, in healthcare,  the Health Benefits Coalition (see above), representing the largest for-profit HMOs and insurance company related HMOs, also contains Citizens for a Sound Economy (CSE), which called managed care reform "the road to socialized medicine."  (American Federation of State, County, and Municipal Employees, AFSCME, bulletin, 1-23-98)

Citizens for a Sound Economy is associated with Congressman Dick Armey, who promotes Steve Forbes' flat tax, and with Congressman BillyTauzin, who promotes a national sales tax.

CSE received  $9.3 million from foundations of the Koch family, the largest family owned business in the US, from domestic oil, gas, coal, and chemicals. The Koch foundations considered CSE "an important weapon in the assault on government interference in business." (Nation, 8-26-96, and the CSE webpage)

For example, in healthcare, The HMO Group (THMOG), representing non-profit HMOs with their own hospitals and staffs of doctors, has as a goal "to coordinate national health priorities through collaboration between public agencies and private sector HMOs,"   THMOG has close ties with the Robert Wood Johnson Foundation, the largest US think tank and philanthropy devoted to health care issues.  Much of the Johnson Foundation's work has been helping states get "waivers" from the federal government, excusing states from federal requirements of providing medical and welfare assistance to poor people.  Even before the Clinton/Gingrich welfare reform program,  Clinton's Health and Human Services Department granted waivers to 2/3 of the states in the country.  Many of the Medicaid waivers put together by the Johnson Foundation involved public/private partnerships in the sense of forcing Medicaid recipients into private HMOs.

THMOG recently received a 5 year multi-million dollar contract from the federal Centers for Disease Control and Prevention's National Centers for Chronic Disease Prevention and Health Promotion (NCCDPHP)  to assess the linkage between private providers of health care services and the CDC and other Public Health Service agencies. According to THMOG;s press release, "The HMO Group shares CDC's vision of fostering bridges between public and private health partners that benefit the entire community."
 

 The Rockefeller agenda of extracting billions for rebuilding the manufacturing base and the army means limiting the profits of their domestic rivals, and severely limiting the amount of money that workers get for healthcare. The Rockefeller capitalists cannot afford to spend as much heath care money as the for-profit HMOs use, and they cannot afford to let profits go to their "new money" rivals. The stakes are huge, health spending accounts for one-seventh of gross domestic product. As international financial crisis worsens and as war over oil and world resources approaches, many economists are deciding health care costs must be drastically slashed "in the national interest," and free-market economics cannot be depended on to do this.

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The rulers of this country may well move healthcare away from the for-profit HMOs ...
 

Hard as this may be to believe, it is quite possible that the dominant capitalists of this country will move health care away from the for-profit sector, and turn it over to "non-profits" like Kaiser, which will become quasi-governmental. They will probably use people's anger at for-profit health care as an opportunity to make this move in the guise of reform. To many, this move will look progressive, but it is not.

A recent NY Times article (6-1-98) shows how trying to reform healthcare through the proposed Patients' Bills of Rights will strongly favor large HMOs with their own doctors, so-called Group Practice HMOs, like Kaiser.   The reform legislation mandates that HMOs must publish extensive and detailed statistics about their quality of care.    In theory, the patient can then choose HMOs and doctors with good statistics.  But this theory ignores the reality of who controls health care.  Only the large HMOs with their own doctors charting on their centralized computer patient records  will be able to meet the requirements of the reform legislation.   In this way,   patients' justifiable demand for accountability will speed up the monopolization  of hospitals and insurers, and open up patients to more coercion and worse medical care in the future.  In more detail, the article says:
 

"But the experts also know something the politicians won't say. These bills of rights, the product of a consumer backlash against restrictions imposed by the HMOs, are almost certain to do the opposite of what consumers say they want. Rather than expand consumer options, they will drive patients into restrictive types of HMOs that limit patients to a small roster of doctors. The bills could also wipe out old-fashioned fee-for-service health insurance, which puts medical choices completely in the hands of doctors and patients."
 
Patients' rights have broad support among health policy experts who say they will make insurance companies accountable for the quality of care they provide. The idea is that if every plan reports clear data on mortality, morbidity and patient satisfaction, consumers can reward the best plans with their business.

The patients' rights bills would demand substantial record-keeping. how many of its youngsters receive vaccinations,... how many diabetics are checked for high blood pressure and how many coronary patients take beta blockers ...How many of the plan's asthmatics return to normal work schedules without repeated visits to hospital emergency rooms?... How many of the plan's diabetics successfully control their blood pressure?
 
HMOs can handle demands for extensive data collection, typically by steering patients to a small roster of doctors and by using "gatekeepers" to intervene between patients and specialists. They also provide the plan a single place to find any patient's complete medical record. That makes tracking outcomes possible. By comparison, looser forms of managed care, like Preferred Provider Organizations, allow patients to see nearly any doctor, but require them to pay more for those who are not members of the plan. There is no one place to find a patient's complete record so plans must sift through claims submissions to figure out which treatments their patients received.
 
The bills would tighten the grip of managed care because they impose elaborate record-keeping requirements on the health plans, aimed at making them publicly accountable for how well they prevent, treat and cure illness. What the politicians won't yet admit is that accountability clashes with something else something else patients prize: choice.
 
 

This restructuring of health care will actually be fascism with a liberal cover ...
 

 
When we talk about turning health care over to quasi-governmental "non-profits" for a much tighter, more centralized rationing of patient care, we are talking abut fascism. Fascism can exist years before world war, or concentration camps. Capitalism inevitably leads to periodic crises of decreased profits. And when this happens capitalism switches from "democratic" mode to fascist mode to regain its profitability at any cost.

"Removing profit from health care" will mean the rulers have decided real healthcare is too expensive and should be abandoned so they can use the money saved to make greater profits elsewhere or rebuild their factories and military.  "Single-payer" will mean the rulers have decided to use the government to enforce healthcare rationing.

Fascism involves (among other things) three elements, all of which can be seen in the US and US healthcare:

 

 Fascism is collaboration of unions with the dominant capitalists, and the co-optation of  unions and opposing groups to confuse and then obliterate class consciousness of workers. 

 

Let's try to look at these elements separately.
 

 
Fascism is using force and threat of economic ruination to wring more profits from workers:

 
For the past twenty years, the rulers of the US have been setting the stage for using force and threat of economic ruination to extract more profits from workers, through huge cuts in wages and services, especially health.
 
  •  In the same period, a leading hospital management magazine wrote, "Though some corporations make money as (health care) costs increase, the majority (of corporations) lose money because costs for health benefits, which they share with employees and unions, cut into their profits. Given the competition for markets with foreign firms, US corporations can no longer afford to leave health care politics to the usual participants -- professors, bureaucrats, physicians, and hospitals. .... Whether or not a hospital cost control bill is passed, or is passed but found inadequate, the big corporations are here to stay. They will work for federal and state attempts to control costs, preferably keeping the impetus in the private sector, but controlling costs by all means, at all costs. (Hospital Progress, 12-77 p 49-50). (Setting the stage for major cuts in health care, possibly using the government. Also setting the stage for increased monopolization, by suppressing health-care corporations whose interests conflict with the dominant corporate interests of the US.)
  •  Another speaker at the same 1980 Cost Containment Conference described a 3-year program at UCSF to discourage residents (doctors-in-training) from ordering mechanized blood tests, blood clotting time tests, stat orders, X-rays, vital signs, weights, fluid Intake-and-Output tracking, and medicines administered four times daily. He advised doctors not to worry about malpractice suits, because residents, as students, were not legally liable. When asked why the program trained residents instead of doctors, he explained that there are two levels of healthcare. There is private health care, used by the wealthy, where decisions are made by doctors, and there is public health care, used by the poor, where decisions are made by the residents. "Therefore, it is the residents who need to be taught cost-containment, not the doctors." (Personal observation) (Again, enforcing the rationing of healthcare, particularly healthcare of the poor. Also justifying inequities in healthcare)
 "Persons will be recognized as in need of, and then denied, benefits that the medical care provision system is capable of providing. ... These decisions (to withhold treatment) are likely to be made when any of the following conditions are met: (1) the treatment is determined to be futile, (2) the patient declines treatment, (3) the quality of the patient’s life is unacceptable, or (4) the cost of providing care is too great. ... Only when society is fully able to come to grips with death and dying is it likely that policies and procedures for decisions not to treat will not only will be formulated, but will also be followed. This period is likely to be hastened as financial constraints force the issue." (Health Care Technology and the Inevitability of Resource Allocation and Rationing Decisions, Journal of the American Medical Association 4-22-83 p 2208) A cost-benefit analysis showing that care of very low birthweight babies is not economically justified, based on the expected lifetime earnings of the infant. ("Economic evaluation of neonatal intensive care of very-low-birth-weight infants", New England Journal of Medicine 308:1330-1337, 1983) (Setting the stage for denying care to those who are not "economically productive.") A survey of patient deaths in Seattle extended care facilities, showing that doctors were willing to withhold antibiotics to 40% of patients with fever, the majority of whom died. "Physicians have been accused of prolonging life at any cost. However, surveys of health professionals have found that many (50 to 70 per cent) are disposed to withdraw or withhold life-prolonging treatment." The question of whether the patient expressed a desire to continue living is never even mentioned in the article. ("Nontreatment of Fever in Extended-Care Facilities, New England Journal of Medicine, 5-31-1979, p 1246 (Popularizing the idea of killing unproductive people who might use up resources.) A prominent British neurologist wrote in 1975 that "no person with severe handicaps is likely to be able to earn his living in competitive employment, unless his IQ is at least 100." He developed a set of rigid criteria to determine which newborns with spina bifida should receive aggressive therapy. These criteria include consideration of the infant’s "social condition" (economic resources of the parents.) (J Roy Coll Phys, 10:47, 1975) (Popularizing the idea of letting economically unproductive people die without treatment.) 
  •  Very recently, many economists are deciding that the marketplace cannot be depended on to adequately ration health care. "The HMO industry has lost a lot of clout," said Uwe Reinhardt, an economist at Princeton University. (NY Times, 10-28-97) "Managed care companies do not manage care," said Kenneth E. Raske, president of the Greater New York Hospital Association, a trade group. "Instead they manage price, the prices they pay to providers. There are really few good examples of any sound managed care in New York." "Medical costs are going up," an HMO representative said. "Utilization is going up. They are not managing care." (NY Times, 1-11-98) (Calling for more severe rationing of care. This passage also sets the stage for increased monopolization, by suppressing health-care corporations whose interests conflict with the dominant corporate interests of the US.) This bring us to the next characteristic of fascism: monopolization.

Return to "fascism".
 

Fascism is increased monopolization of the economy ...

The federal government has allowed, and even encouraged, monopolization on the part of "non-profits," particularly Kaiser, which are associated with the dominant Rockefeller-based capitalists. It has allowed them to form bigger and bigger conglomerates. At the same time, the government has attacked for-profit HMO conglomerates associated with the "new" capitalists, forcing them to break up.
 
  • On the other hand, Columbia/HCA has come under huge attack from the government, allegedly for Medi-Care fraud. Federal agents seized thousands of documents, have indicted high-ranking officials, and have forced a complete reorganization of Columbia/HCA in which they are losing a third of their hospitals and their entire home care operation. No one doubts that Columbia/HCA committed massive fraud, but Medicare fraud is very widespread, practically built into the system. (NY Times, 12-18-97) What's behind the attack on Columbia/HCA is an attack on new money. (Direct attack of the upstart capitalists by the dominant capitalists, which will lead to more monopolization.)

 Return to "fascism".
 
 

Fascism is merging business and government ...

Kaiser and other "non-profits" have made moves to integrate themselves with government-supplied health care. They have involved themselves in movements to federally regulate healthcare delivery by HMOs, and in a federal initiative to extend healthcare to more children.  The money  for these "non-profits" comes largely from bonds issued by state health facilities financing authorities, which charge no interest to the HMOs.
 
  • In September, 1997 Kaiser's three non-profit arms (Kaiser itself, Group Health Co-operative of Puget Sound, and Health Insurance Plan of New York) announced an agreement with the American Association of Retired People (AARP) and Families USA (a health reform advocacy agency) on instituting standards in 18 areas of health consumer concern. According to Kaiser's 9-24-97 Press release, "the (joint) group will urge policymakers and President Clinton's Advisory Commission on Consumer Protection and Quality in the Health Care Industry to consider the 18 principles for national standards in their recommendations."
 In a letter to be sent to the Presidential Advisory Commission, the health plans and consumer organizations say they are advocating legally enforceable standards to protect consumers and to achieve fair, consistent and efficient regulation, and greater accountability by health plans."  Remember, this is the same Kaiser whose members are dying in its Emergency Rooms waiting to be seen!   Non-profits calling for federal regulation is a turnaround:   Kaiser and Health Insurance Plan of NY were two of the most prominent HMOs that pressured the federal Health Care Financing Administration (HCFA) to abandon similar federal regulations for HMOs receiving Medicaid (Medi-Cal) and Medicare in July, 1996. (NY Times, 7-8-96) (Movement toward merging business and government; and co-optation of opposing groups.)

The Presidential Advisory Commission itself was tilted toward non-profit HMOs including representatives from Service Employees International Union (SEIU) and the AFL-CIO, which have entered into a partnership agreement with Kaiser (see below), Henry Ford Health Systems (another non-profit HMO on the Kaiser model with its own hospitals),  and Families USA.
 
 

    • Many of the same Presidential Advisory Commission members are forming a pubic/private coordinating group charged with "ensur[ing] that consumers have a consistent set of standards so they can choose health plans based on quality--not just cost", according to vice-President Gore. (LA Times, 6-18-98)  Several of the HMO reform bills being debated require HMOs to divulge detailed information on their programs of patient care. (NY Times, 6-3-98)

    But if Kaiser's children's healthcare initiative is only a token remedy, it is a significant foot in the door to becoming an official provider of health care. Kaiser is pushing legislation to increase coverage of children by Medi-Cal and simplify enrollment. It plans to work with schools to identify 630,000 children presently eligible for Medi-Cal, but not enrolled. It also plans to work with schools and the California Managed Risk Medical Insurance Board to identify uninsured children. It plans to form a coalition with other health care providers, insurance plans, and employers get them to make financial contributions. (Kaiser press release, 6-23-97 and SF Chronicle 6-24-97) Kaiser plans to have its initiative go nation-wide in 1999.

    The Kaiser initiative is part of a network of public-private partnerships to provide children's health insurance coverage. The largest is the Caring Program for Children, which operates in twenty-six states and pools Blue Cross and Blue Shield administrative services and matching funds with private and philanthropic donations. The Colorado Child Health Plan receives funding through corporations, pharmaceutical companies, private donations, and Medicaid teaching funds to the University of Colorado Hospital. (National Governors' Association Fact Sheet, on world wide web)  These three-way partnerships between non-profit HMOs, state governments, and corporate donors are the mainstay of many state's plans for extending children's' healthcare.(Movement toward merging business and government.)

           
     
     

    Return to "fascism".

     

     
    Fascism is collaboration of unions and co-optation of opposition groups ...
     

    The third hallmark of fascism, particularly in its early stages, are collaboration between unions and the dominant capitalists, co-optation of opposing groups, and manipulating things to confuse and obliterate class consciousness of workers.
     

    •  SEIU has been preparing for this partnership for years. Years ago, SEIU International wrote in its pamphlet Keeping Public Hospitals Competitive:
      " ... as beds empty, private hospitals are competing head-on with public hospitals for privately-insured patients and even Medicaid (Medi-Cal) patients. ... The SEIU Research Department has identified the key conditions for keeping these institutions competitive: strong political and community support, stable funding, a well-developed clinic structure, recognized specialties, and a competitive cost structure. It's clear that keeping costs competitive will be key to the survival of public hospitals. For SEIU healthcare workers, this means working with management to address the future of public hospitals -- while defending worker's rights and protecting the quality of care." And just in case anyone doesn't understand what "competitive cost structure" and "working with management" means, SEIU spells it out in Findings About Healthcare Industry Restructuring and Implications for Our Union: 
    "In order to maintain a patient base, public hospitals will be forced to compete with private hospitals. ... Implication: Many public hospitals will need to change to survive/prosper in the new marketplace. These changes will involve cost cutting often in the staffing area ..."     Kaiser wrote in its Southern California Regional Business Plan for 1995-1997, which calls for massive layoffs, deskilling and job restructuring that it intends to "mitigate any potential harmful actions on the part of the labor unions" by continuing to develop "strong relationships with its union leadership." (The Link, CNA Kaiser Interfacility Newsletter, 9-95) (#3, Collaboration between unions and rulers) 

    Nigeria's economy is based on oil; it is one of the richest deposits in the world, producing $12 billion/year, 40% of which goes to the US.  Five companies rule the roost: Shell (Dutch), AGIP (Italian), Elf-Aquitaine (French), and Mobil and Chevron (old-money US, aligned with Citibank and Bank of America.)  The country has been ruled by a succession of military dictatorships for 28 years, which gets half the oil profits in the guise of the state-run Nigerian National Petroleum Company.

    In 1994 Nigeria's two oil workers unions led a strike trying to force the military to recognize an election the year before. The strike paralyzed the oil industry, and the leaders of the unions were arrested. There were worldwide protests, emphasizing the collaboration of the US with the military dictatorship.

    At Mobil's May 98 annual meeting, the Oil, Chemical, and Atomic Workers union (OCAW) forced a resolution onto the floor demanding Mobile review its investments in Nigeria.  The resolution was quashed by institutional shareholders Franklin Research and Development, New York City Pension Fund, and SEIU.

    SEIU  told its members to cross the picket lines of northern California RNs who are striking against patient care cutbacks and hospital closings. Kaiser's position is that it will "bargain" with AFL-CIO unions over patient-care-quality issues, but not with the California Nurses Association. (#3, union-boss collaboration, obliterating class consciousness) 
         On February 5, 1995 the San Francisco Chronicle ran an article claiming that CNA claims of deteriorating patient care at Kaiser were false, citing figures from a liberal business think-tank which purported to show that Kaiser nursing care was actually improving. (Kaiser has repeatedly refused to show patient care statistics to the CNA.) The Chronicle writer, Carl T. Hall, is an AFL-CIO shop steward on his job. (personal communication) (#3, union-boss collaboration, confusing the class consciousness of workers.) 

    Kaiser has already opened a hospital in the Los Angeles suburb of Baldwin Park where the entire theme of the hospital is physician-union co-operation. "Kaiser said the opening will involve an unusual degree of union-management cooperation. Nursing, technical, maintenance and other employees will be closely involved in the planning." (personal communication and LA Times, 2-6-98)

    Northern California Kaiser is planning to open its long-vacant Roseville Hospital in Fall '98, with SEIU Local 250 and 535 participation in planning of staffing models, health care delivery and other aspects of hospital operation. (union-corporation collaboration)(from SEIU Local 250 press releases, 3-5-98 and 3-23-98) (Kaiser seems to have changed its mind and decided not to close all its hospitals.)

    •  The main body of physician opposition to managed care is now taking the position that for-profit HMOs are the enemy, not managed care itself. Describing The Ad-Hoc-Committee to Defend Health Care, composed of some of the leading critics of managed care in the past, Managed Care Magazine (8-29-97) says: "The physicians are not anti-managed care per se, but critical of what they view as undue corporate influence in medical care. Their most specific goal is a moratorium on for-profit takeovers of hospitals, insurance plans and physician practices."

    While acknowledging that, in practice, there often is little difference between not-for-profit and for-profit organizations and hospitals, Steffie Woolhandler, M.D., one of the physicians spearheading the group, said, "The problem is profit-driven health care." Woolhandler said non-profits are forced to compete with, and behave like, for-profit companies. (Ad Hoc Committee's state in JAMA, 12-3-97) (#3, co-optation of opposing groups and confusing the class consciousness of workers.)

    This is exactly the same rationalization the AFL-CIO uses to justify its partnership deal with Kaiser: we must help "non-profit" healthcare against for-profit healthcare. Promoting the "non-profits" by saying "Pursuit of corporate profit and personal fortune have no place in caregiving, " sounds good, but it ignores the fact that as capitalism goes further into crisis, its government will use "non-profit" health providers to severely restrict the flow of health care and make much greater profits for the class that runs the government. Whatever its intent, this babble about eliminating profit from healthcare has the effect of spreading passivity and setting us up for the kill. There is no way to escape profits under capitalism; only communism can give us life without profit. 

     Return to "fascism".

     

    PROGRESSIVE LABOR PARTY:  a communist future where workers control society.
     

    What does Progressive Labor Party mean by communism?

     

    Our vision is a society run by the working class, with no profits, and no money. We produce the things we need and give them to each other. With no economic basis for racism, sexism, or elitism, we could struggle to develop our real human potential.

    Under capitalism, the 1% that rules society has more wealth than the rest of us put together . They have built an entire apparatus to legitimatize, legalize, and secure this system of theft. This apparatus includes the government, the schools, the media, the universities, and the police and prisons. You can add many more parts yourself. Communists call this apparatus "the state".

    These capitalists are not about to hand us control of society on a silver platter. Quite the contrary, the disaster of capitalist healthcare is a reflection of the entire economy. Capitalism is now in a world-wide crisis of inability to sell its goods; its high-flying global economy is rapidly crashing into depression and conflicts of major capitalists over markets, cheap labor, and raw materials, chiefly oil. The fascism we see being imposed on us in health care, the murder and massive jailing of our youth by the "justice" system, the forced labor of welfare recipients and prisoners, all this is being imposed to force more work out of us for less money, to take away our services, and to gear up to fight in world war. We seem very weak.

      On the other hand, the rulers’ hospitals, factories, schools, and armies are all staffed by workers like us. We have no interest in killing ourselves for our bosses on the job or in battle. And we have every interest in overthrowing our bosses. We believe that inspired by a vision of a communist future, we can fight all the aspects of fascism in a way to develop our ability to unite, to act together, and to forcibly take power as a class. That is the purpose of Progressive Labor Party.

     

    What would healthcare be like in a communist society? Here is some of what we want:
     

    Healthcare would exist to improve the quality of life, not make profits. This means we, the working class, would make healthcare decisions based on OUR needs. For example:
     

    WE will decide how many hospitals and clinics were enough in our city or area.

    WE will decide when our patients need to see specialty doctors.

    WE will decide our staffing levels.

    WE will decide when our patients are ready to go home.

    WE will decide how much training was necessary for our different activities.

    WE will decide whether it's better to treat a particular condition at home.

     
    But would "WE" always agree with each other on what's best for all of us?

    Probably not! Our existence has both collectivity and individuality; we all have our individual strengths and weaknesses to contribute. What's important is that the basis for making decisions would be our collective good, and that a mass communist party would exist as a framework to discuss questions and carry out our decisions.

    For example, in the mid-60's, when millions had communist aspirations in China, some providers and patients preferred traditional medicine while others preferred western medicine. People argued over which form should be the medicine of the new society, until they realized there weren't enough practitioners of either type, and they needed to use everyone that was available. The communist party developed a plan to integrate the two disciplines. Traditional and western providers worked together in each clinic and hospital, discussed patients together to make sure all were getting the best care possible, learned from each other, and often devised new treatments based on both methods. (Joshua Horne, Away with All Pests)

     

     

    There would be equality .  No one owning hospitals, food stores, or housing, to enrich themselves.

     No one to force sending patients home or onto the streets while they’re still sick. No one with power over us who would try to bribe us to scrimp on patient care. We wouldn't all have the same tastes, and people's needs would be different, but we would all have the same standard of living. At times this would mean sharing adversity, too. For example, as the working class begins to win in armed revolution, we can be sure the present rulers will try to destroy the nation's infrastructure, including hospitals, rather than let us take possession of it. During the rebuilding phase, there's no doubt about it: things will be difficult. We believe in an environment of collectivity and equality, people's best aspects will come forth. Even under capitalism the spark of this spirit flashes: In the huge 1993 Mississippi River flooding when urban black prisoners from Chicago prisons were sent into rural white downstate Illinois towns to repair levees and save towns, strong suspicions and antagonisms melted away, and strong attachments developed in many cases. (NPR news programming) 

    Mental and manual labor would not be separated as they are now. Each person's work would involve both mental and manual labor. Elitist stratification would not be allowed.
     During the mid-60s striving for true communism in China, a local reporter looked for the captain of a Chinese ship docked in Canada. The captain was found setting tables in the dining room. The reporter asked the captain why he was setting tables. The captain said, yes, it is true he had navigational and nautical skills and was the leader while the ship was at sea, but those skills were no longer needed in port so he was just like everyone else.

     During this same period in China, huge resources were put into healing workers injured during the rapid industrialization. Huge advances were made in microsurgery, and surgeons from many countries came to study the new techniques of repairing hand trauma. These advances were the logical outgrowth of striving for communism, which values manual labor as much as mental labor, and makes each nourish the other. Communist merging of mental and manual work can make healthcare work a smooth continuum of skills where everyone can develop their potential.  Think about the awkward working relationship between nurses and new medical residents: As doctors-in-training, the residents are supposed to give the orders, but the nurses have to prompt the new residents on what orders to give.  It's not the new residents' fault, they've had very little patient contact. Think how much easier it would be to learn to be a doctor, if you'd already been a nurse for years, and an aide for years before that. Better yet, think of how these jobs could be combined, so clinicians could smoothly increase their skills, instead of hitting barriers where you can't get a "better" job, or the only "better" jobs are management, so you become clinically useless. The only reason for the capitalist boundaries between Aides, Nurses, and Doctors is to enforce aclass-based pecking order. We would be able to prevent and treat disease in entirely new ways if people's work involved both manual and mental labor, and both are given respect and validity. Once again in mid-60's China, liver cancer was very common in a large area where there was lots of hepatitis because of frequent fecal contamination of water supplies by flooding rivers. From the village level up there was huge campaign to drill thousands of wells each day to provide safe drinking water. Hepatitis was drastically reduced, very quickly. Cancer scientists said, "Now in 20 years, we'll know whether hepatitis causes liver cancer." Combining mental and manual labor, combining theory and practice, gives "epidemiology" a whole new outlook. (report of Stanford Medical School dean returning from China, early 1970s) Contrast this with capitalist cancer research, where it is almost impossible to use population studies to tell whether a substance causes cancer, because nothing has been done to eliminate the known carcinogens like cigarettes and industrial pollution. Cancers from known carcinogens swamp out cancers from the substance you would like to investigate. 
     

    We would do our work for free, and get our needs free also.
     

    If you were to ask nurses, or other health workers what we would really like, the vast majority of us would say we want to be able to provide good health care for our patients without interference from the hospital, and we want to know we will have food, shelter, medical care, education, and free time for our families and our friends. So the time we're conscious that we need money isn't while we're working, it's when we need food, shelter, clothing, transportation, etc. We need the money because the bosses who own the farms, the apartments, the clothing factory, the bus line, etc have stolen what "their" workers have produced, and we need money to buy it back from those bosses. A hospital worker wrote up an experience on the question on money and wages:
      I went into an operating room in our hospital to adjust some equipment.
    The room was filled with stainless steel and hard tile, but the nurses
    had dimmed the lights, and were moving quietly and speaking in soft voices.
    A delivery was in progress.

     
    "When you feel a contraction coming, press against my hand."
    "That’s good. Now breathe deeply, and let’s get ready for the next one."
    "Very good!   Each time, you’re opening up a little more."
    What quiet intensity!
    What incredible focus!
    What a privilege to work where life is being born!

     
    No matter how much they try to make us forget it,
    WE ARE THE ONES WHO HELP LIFE HAPPEN!
    The administrators, with their power suits and spreadsheets and efficiency reports,
    are completely foreign. They haven’t a clue. They’re just feeding off us.

     My friend works at a different hospital.
    She nursed a preemie as small as a Cornish game hen into a thriving baby.
    She worked with the whole family.
    Later, she called the parents at home to see how the baby was doing.
    They read her the letter they’d sent the hospital about her.
    It was very touching.

     Later, my friend got a letter at work on midnight blue stationery with gold stars:
    "Thank you for co-operating with our Customer Relations program."
    "Please accept this coupon for a free yogurt in our cafeteria."

    How dare these parasites think they can bribe us with yogurt!
    Plying us with trinkets for what comes from our best nature!

     
    But isn’t the whole wage system like the yogurt?
    No amount of money can equal the work we do,
    whether it’s resuscitating a baby,
    or stopping the spread of disease by collecting infectious waste.

    As far as we’re concerned, we work for each other.
    The nurses don’t pay me to fix their machines.
    The parents don’t pay the nurses for delivering their babies.
    Why can’t we run all of society like this?
     
     

    Finally, we would like to include a letter from Progressive Labor Party's newspaper, Challenge. It is the grandmother of a baby who was born at the hospital where a reader works.
     "She is the lay-midwife in a village near Guadalajara Mexico. She told the Labor and Delivery nurses how she takes women into her house for three days, delivers their babies, feeds them, does their laundry, takes care of the baby, helps the mom with breast-feeding, collects baby clothes from neighbors if the mom has none, and often treats them with medicines she makes from barks and leaves, or if necessary transports them to the hospital, about ninety minutes away. Her small house has two beds; if more than one woman is in labor, she and her husband sleep on the floor. She has been doing this for about twenty years, having learned from giving birth to fourteen children herself, taking a month's formal training, and continued reading.

     Her "fee" is the equivalent of three dollars, if people have it, or a chicken or a promise of some favor if they don't. Several times, she emphasized, "The money means nothing, it's all for love!" When asked if this was common in her village, she said "Of course, nobody has any money. We just help each other." The nurses and I were moved and inspired to hear health care described in such a completely different light.

    At first it seemed an amazing co-incidence that we met this woman the same week as Challenge published an article on how humanity worked for free for much of history. But as an earlier article had pointed out, examples of working-class heroism are all around us. We have good reason to trust that our class can create a society where money means nothing, it's all for love.

     

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