How to Make Friends and Influence People – Bringing a Left Vision to the Health Care Reform Struggle

Posted November 5, 2009

The battle over health care reform has engaged most of the progressive activist forces in the country, including unionized workers in the “labor for single payer” movement, with the left lining up behind single payer while liberals are demanding a public option. Anticipating that even a public option is unlikely to be enacted, thanks to the power of conservative and monied interests, many progressives and the entire socialist left have decided that the outcome can be nothing less than disaster, squelching possibilities for true health care reform for years to come.

This essay argues for a different assessment.

First, the struggle is far from over and there are proposals worth defending in the Obama/Congress plans. If these reforms survive even in a watered-down form, they will considerably benefit working people.

Second, the movement for single payer is not going away, has gained strength in the current struggle, and has great potential for mobilizing and radicalizing working-class activists. The health care system has now become an arena for public policy-making and will remain a field of contest well beyond this round of reform. And that contest offers great opportunity to challenge capitalist “common sense” about how health care is organized and delivered, a vital set of issues that have been obscured by near exclusive focus on winning single payer or the public insurance option. Just as the fight for single payer challenges neo-liberal ideologies about the superiority of the market over public systems, ideas about reforming, in fact transforming, how health care is actually provided challenge the superiority of elitist, hierarchical organization and assert the effectiveness and power of democratically organized healthcare delivery.

The Opportunity

Even without single payer or a robust public insurance option, the multiple bills voted out of the various House and Senate Committees have some saving graces. Thus they all envision a major expansion of Medicare and Medicaid to the considerable benefit of maybe 50 million people. Some of the versions include a surtax on the wealthy and taxes on the health care companies to pay for much of the expansion. All include considerable regulation of the insurers, including a minimum benefit package and requirements to cover all costs of approved treatments, which will eliminate benefit ceilings and greatly reduce medical bankruptcies. And all include money for fraud detection as well as for research and action on best practices, which provisions if conscientiously implemented would likely drive out the worst profiteers and improve medical practice.

These of course are half measures likely to be weakened in the Congress’s Conference Committee, and at their best would not adequately challenge the fee for service core of the system that generates such poor outcomes at such enormous costs. Yet if enacted and implemented, if not entirely compromised and weakened, the proposed reforms will guarantee regular care to many millions of people, relieve some of the insecurity that haunts working class life, and save many lives and relieve much misery. The possibilities for meaningful change calls for the left to adopt a “reform and revolution” strategy supporting efforts for real if limited reform, like parts of the Obama/Congress plans, yet also pointing out and critiquing the limitations of these half-measures, and simultaneously introducing and legitimating radical ideas and solutions, thus putting constant pressures on the system and building movements for the system reconstruction that is necessary. Because some key aspects democratically organized health care delivery are already operating in the best clinics around the work, the fight over health care provides an unprecedented opportunity to build widespread appreciation for a feasible, persuasive radical alternative, one that could be projected toward other workplaces and industries.

Some “Reform” Looks Likely, If for the Wrong Reasons

Of course the devil’s in the details. The better bills coming out of Congress may amount to a wish list for liberal members whose proposals will effectively operate as “bait and switch.” Any final enactment will arise in back room negotiations, driven first and foremost by corporate demands for cost controls, secondly by the political calculations of conservative Democrats, and only finally by a recognition that the medical and health care system must be drastically improved. And in the final negotiations, the provisions most favorable to working people will likely be pared back.

Except for the health predators, US business elites are committed to rationalizing the health care industry and putting the brake on the 5-10%/year cost increases that are eating up an expanding share of corporate profits. Of course, these forces will not tolerate a direct public takeover, because they rightly fear the threat of a good example, which could provide momentum to additional social democratic reform, such as regulating finance and particularly the system of stock options and bonuses that so enrich all top executives. Thus, their favored strategy is regulation and insurance reform.

The industries in the health care system – hospitals, big pharma, most of the physician specialists, and especially the insurers – are running scared, and feeling isolated, increasingly distrusted by the people, and abandoned and pressured by the rest of the corporate/government establishment. And the health care predators are especially worried about action in the bluest states towards reform that could really make life difficult for them. Seeing the writing on the wall, many top health care executives appear willing to accept considerable constraints on their company and industry in return for large short term profits, and thus even larger salaries and bonuses until they retire billionaires at age 50 to enjoy the pleasures of being baked alive on sailboats and golf courses. (Ah the folkways of the best and brightest.) Note all current Obama/Congress plans guarantee the health industry this short term bonanza.

And supporting a health care bill may well be politically advantageous, indeed appear necessary, for the Democrats. If the propaganda “”We have the best medical care in the world” has had some success, especially among those with a good employer paid insurance plan or Medicare, working people also know the system doesn’t work for many, that their family’s share of the costs keep rising, that many employers are bailing out, and that they, like people they know, face threats of arbitrary denial of care and bankruptcy if any family member develops a serious protracted illness. As the battle has proceeded, the just say no right wing has made a lot of noise and sometimes, like when attacking at the Congressional town halls, captured immense attention and the debate itself; still popular opinion continues to favor health care “reform,” though perhaps not in the districts of the conservative Democrats.

The Democrats, still branding themselves the party of minorities, women, and workers, have moved way to the right, basically renounced social democracy, and cannot even imagine raising taxes on corporations or even increasing capital gains taxes beyond its current 15%, thus privileging rentier over earned income, one reason why Warren Buffet’s secretary pays a higher percentage of her income in taxes than the second richest man in the world (though in some years Buffet beat Gates). Still, in the final negotiations over the health care bill (as the many versions are integrated into a final product to be enacted by the House and Senate), the slender majority of Congressional Democrats who actually remain committed to improving health care, especially for the poor, will have some weight. And the utterly conservative Democrats, mindful of business support for cost control, will likely accept a compromise, as long as some of the more controversial lightening rod sections are removed from the bill. (Indeed the robust public insurance option, near dead for a while after Obama declared it unnecessary to his plan, was likely revived for this purpose, so that the conservative Democrats can take credit for its defeat.)

And all Congressional Democrats fear failure of the Obama/Congress health care effort will undermine grass roots loyalty and decimate their party in the Congressional elections of 2010, as happened when Clinton’s health care initiative collapsed early in his first term. Desperate to avoid humiliation at the hands of the right, desperate for something they can call a legislative victory, a Democratic Congress is likely to give Obama a modest reform bill – with large short term gains to the big predators but also with some real gains for working people – which he will sign in a triumphal ceremony featuring the entirety of the Democratic leadership as well as many titans of capital and the health industry, all repeating a common theme: “This is profoundly important and only the first step.”

The Virtues of Critical Support

Certainly any enactment of the current struggle will be a messy dirty compromise, and will lead to endless battles in the regulatory and implementation process with the lobbyists in best position for influence. Thus the expansion of Medicare and Medicaid could be very limited. The mandate for all to be insured could amount to a tax on workers, depending on the funding mechanism. Surely the surtax on high income earners could be jettisoned. Substantial cost shifting to working people is always threatening, as are limitations on treatment and intensification and indeed official authorization of a multi-tier system. The many regulations on insurers now contemplated in current bills could be festooned with loopholes that effectively negate the provisions. Without doubt attempts will be made to insert in late night deals at the very end several terrible provisions, including: increased subsidies to the companies; weakened regulation with lesser enforcement and longer periods to comply with it; federal preemption nullifying the power of the states to enact stricter controls; and of course that perennial conservative demand for “medical malpractice reform” discouraging law suits for negligence. At best the bills provide means for the regulatory agencies to push harder for best practices, and the final bill will do little to curtail “fee for service” medical care that encourages endless costly often injurious treatment. Thus costs could well keep rising for a system that works hard to keep people alive but constantly sick. And with health costs continuously rising, few companies will resist shareholder demands to cut health care costs, either by limiting care or just eliminating the benefit and forcing employees into some public plan.

It’s conceivable that the final enactment could turn out worse than nothing. (Kuttner) As many single payer advocates fear, a failed, complex, incomprehensible, and very expensive “reform” could further sour the public on the capacity of government and thus generate opposition to what is really needed, a profound public reconstruction of the system. Still right now, with so many beneficial proposals supported in the Congress and the final package still up in the air, and with the campaign for the November 2010 election already begun and the Democrats and Obama desperate to claim some legislative success, it is now premature and morally indefensible to conclude that the emerging plan is either bound to be an improvement or on the other side so fatally flawed that the better features could not be aggregated and modified to constitute a meaningful set of reforms, with of course more to come.

So rather than declaring “real” health reform a dead letter, the left would do well to pay more attention to those points of entry in the current struggle where it can gain respect and audience and contribute to movement building. Surely those working people and reform movement activists who are watching carefully (and many have been energized by single payer organizing to examine the entire near impenetrable mess of detail and propaganda) would be far more inclined to respect a socialist left, even look to them for information and analysis, even read their material and come to their educationals, if that left found a way to combine support for provisions that people desperately need while also being thoughtfully critical of the whole package where it deserves criticism, and also present that feasible inspiring alternative. Rather than pronouncing health reform dead, the left would do well to turn our attention to the ongoing battles that will shape not only this round, but future debates on health care reform.

Proving the Necessity and Feasibility of Radically Democratizing the US Health Care System – Best Practices Are Democratic Practices, Especially for Chronic Diseases

In fact the current health care struggle offers a tremendous opportunity for gaining activist and public attention to ideas that legitimate and validate the fundamentals of the democratic and sustainable, dare one say socialist, society we want to live in and seek to build. We can in fact credibly and thoughtfully, using the best of mainstream health care research, promote and put on the table the kind of radically democratic reconstruction that has inspired socialist activism for two centuries.

Though not making the headlines and surely not claiming ancestry to any left tradition, health care organizations are adopting democratic forms – in the US primarily in clinical services, not in management or remuneration systems. This democratization is occurring, because it has far superior outcomes. Just type “Teaming in Health Care” or “Democracy and Health Care” in your search engine, and you’re inundated in articles, books, research works, descriptive work, conference proceedings, promotions for best practices, and how to prescriptions on the democratic redesign of health care delivery. Indeed these “best (democratic) practices are now being researched and in some cases mandated by the US Center on Medicare and Medicaid Services (CMS), which is by far the best funded and most thorough operation on this planet for evaluating medical services and writing standards and guidelines for services entitled to public funding. And the Obama/Congress legislative proposals, so far, do fund and encourage further research and the mandating of best practices by the CMS.

This democratic turn is particularly visible in chronic disease treatment, that is in controlling diabetes, asthma, quite a few cancers, congestive heart failure, lung, liver, and kidney decline, deep depression, digestive problems, some neurological degenerations, and many others, that now represent an estimated 50-70% of health care costs. Until recently treatment for chronic diseases in the US went something like this: after a bout of extreme illness and stabilization in the hospital, the chronic disease patient gets a short pep-talk from a nurse or social worker, and is then, after sincere handshakes and wishes of “good luck,” sent home with a few booklets complete with phone numbers to call in an emergency. Basically on their own, to live as they had, the patient often in a matter of weeks returns to the hospital in crisis for more treatment. With their illness poorly controlled and continuously worsening, patients can for decades suffer repeated hospitalization, at great expense to themselves, their families, and the rest of society. US fee for service medical care by and large operates to keep people alive but constantly sick. For most chronic disease patients doctors and hospitals are paid for providing services, not for keeping people healthy. And provide services they do, in abundance, often injuring or killing the person in the process.

Today this model of “care” is being challenged by a democratized “teaming” collaborative approach to chronic disease management, greatly improving life for patients and greatly reducing treatment and hospitalization. In this emerging model, the collaborative treatment teams consisting of doctors, nurses, social workers, and other staff maintain relationships and contact with the patient and family, inspiring and teaching them toward better self-care. The treatment team shares information with one another and with the family, develops with the family plans for disease management, visits with the person and family out of the hospital, introduces them to others who have succeeded in controlling the disease, and responds quickly to requests for help. This model generally replaces fee for service with a yearly lump sum payment, thus removing the fee for service system’s current incentive to concentrate on endlessly treating the disease while providing little to help the patient on the path to control and health. Team members are generally on salary, to be sure not equal, but much less unequal than in private fee for service practice. And with a lump sum payment, team members can concentrate on health care, no longer spending endless frustrating hours filling out forms to justify every service and then negotiating with the insurance company about that treatment.

To be sure managers in many industries have appropriated “teaming” for their own purposes. No attractive idea, no strong human emotion, no human pleasure or desire can escape exploitation in capitalist marketing and labor control. And employers have come to recognize that reorganizing the shopfloor or service delivery area into work teams permits them to sweat out more work at reduced costs. They can trim supervisory staff and generate higher levels of supervision as team members come to train and discipline one another, and on top of that improve staff morale, at least for a time, because team work is often more satisfying and fulfilling. That employers exploit popular hunger for better, more democratic, and more productive useful work poses a strategic challenge for worker activists. The solution is not to oppose teaming but, as contended by the Labor Notes book Working Smart: A Union Guide to Participation Programs and Reengineering, rather to organize for and involve workers in the planning of teamed work and to create structures that actually empower workers, offer more time for education and creative labor, and give workers added responsibility and control but with enforceable democratic ground rules and higher pay. Of course management, especially in manufacturing, have refused these bargains; still proposing authentic democracy alerts workers to the potentials of self-organization and self-management and puts the workers and unions on higher ground when they reject exploitative teaming proposals.

Similarly today in the current struggle the left will not convince either the political or industrial decision makers to thoroughly reshape and democratize the health system. The medical/hospital/insurer/pharma establishment by and large likes things as they are, and have been very slow to change, even in diabetes care where failure to reorganize has become grounds for malpractice suits. But they are being pushed hard, by patients’ organizations (especially for all the chronic diseases), health policy advocates, and most medical professional groups and their unions, who support this model of system change. Though the doctors are badly split. The American Medical Association, while officially supporting the Obama/Congress plan, is strenuously lobbying against any mandate to adopt best practices. But the AMA now represents less than a quarter of physicians, primarily specialists who grow rich in a fee for service system. On the other side, many physician groups, including the emerging organizations of salaried and primary care physicians, are supporting system overhaul. Having found voice in the prestigious New England Journal of Medicine, they are calling for the end to fee for service, great restrictions on the insurers, and system reconstruction towards best practices, particularly teamed care for the chronic diseases.

Today the specialty doctors remain in control of the CMS. Though the Obama/Congress legislation calls for a more independent active CMS, it’s many permanent committees are full of conservative physicians over whom industry lobbyists exert great influence. The CMS will likely remain slow to require best practices. Still the democratic challenge is gaining, and the industry will likely be forced to modify chronic disease treatment, though to be sure they will attempt to narrowly structure and confine teaming, as do manufacturing industries when they reorganize, to maintain effective top-down control.

Still all these developments make for great opportunity for the democratic socialist left in promoting radical reconstruction of the health care system, that contributing to reinvigorating the socialist project. This could be done by presenting and aggregating all the good examples into a working model. Those good examples include the many health care systems around the world – some single payer, others socialized medicine – that provide superior care at half or less of US expenditures. And US Medicare, a single payer system, is much beloved by those over 65 and the disabled who are eligible. US Veteran’s Administration (VA) health care amounts to downright socialized medicine in both funding and clinical practice; having gotten a bad reputation when defunded after the Viet Nam war, with funding restored it became a model system. And its policies – salaried staff, treatment teams, emphasis on communication with patients and prevention, and other best practices – characterize this country’s best clinics and group health plans (parts of Kaiser, the Mayo Clinic, the Group Health Cooperative of Puget Sound, and quite a few others).

Whatever the outcome of this intense current spasm of health system struggle, many emerging forces are organizing for system reform/reconstruction; thus the health policy advocates, the leading clinics organized along democratic lines, the nurses and professional organizations, the primary care physicians, and the single payer advocates particularly the fast growing “labor for single payer” forces, could provide the core of a very powerful coalition carrying highly democratic ideals and proposals.

Conclusion – On Building the Movements: The Many Benefits for the Left of a “Reform and Revolution” Practice

This deepest capitalist crisis since the Great Depression of the 1930s will be long and protracted, with the current health care battle the first in a series of intensifying struggles over the whole of national functioning, and coming next a big energy battle. The energy and health care battles will have many similarities: There will be a lot at stake, and the many involved capitalist industries will be fractured and struggling among themselves. The mainstream policy debates over both goals and means will be very limited, though not without possibilities for some meaningful action, and there will be considerable room to push radical, democratic, and workable solutions that actually meet real needs, and to demonstrate why the existing powers resist them. And with the continuing crises provoking great public attention, popular reform movements will organize and grow.

In this long protracted series of struggles, the reform and revolution strategy and organizing offers many benefits for the left. Thus in today’s health care struggle, instead of savaging Obama and the proposed reforms because they fall so short of our respective ideals, a left, actively demonstrating support and solidarity for desperately needed and meaningful reform, would gain a more sympathetic audience, friendship, and solidarity in return. Thoughtfully critiquing the reforms and showing the way forward, it could gain the respect and confidence to be taken seriously, especially from the many people with radical sensibilities who volunteer and work in reformist organizations. Building confidence and hope in superior, feasible, and democratic alternatives will not only inspire demands for deeper reforms but will also strengthen radical commitments and contribute to rebuilding the left.