Healthcare: For Patients or Profits?

(In India, the UPA Government is on the point of enacting a National Health Bill that promises health care ‘reforms’. Will the ‘reforms’ ensure access to healthcare of a uniform standard to all, irrespective of wealth? Or will it take us a step closer to a US model of health care – with the poor left at the mercy of the markets? Interestingly, the US too has recently passed a Health Reform Bill after intense debate. Padma looks at the recently enacted US Health Bill to see if it offers any substantial ‘reform’ of the privatised and unequal healthcare model prevailing in the US; while Indira Chakravarthi looks at the UPA’s Draft National Health Bill to assess its agenda. Dr. Debashish Dutta, President, People’s Health (a W Bengal-based organisation of health activists) shares the experience of the impact of privatisation of health care in West Bengal. While history is witness to the fact that existing healthcare provisions have been won by Left-led working class struggles the world over, and countries like Cuba, in spite of their economic weakness still boast better healthcare than their mighty superpower neighbour, it is unfortunate that West Bengal ruled by the CPI(M)-led Left Front has also capitulated to the neoliberal prescriptions as have most other Indian states.- Ed/-)

Draft National Health Bill:

Health ‘Reforms’ for Markets, Not People

Indira Chakravarthi

In January 2009 the Indian government put out a working draft of a National Health Bill “to provide for protection and fulfilment of rights in relation to health and wellbeing, health equity and justice, including those related to all the underlying determinants of health as well as health care; and for achieving the goal of health for all; and for matters connected therewith or incidental thereto”.

The Preamble admits that the persisting inequities, denials and violations in the matter of health in the country are cause for concern to all. Hence “the need to mandate, enable, authorize, guide, and where necessary, limit, health policies and actions (emphasis added) by all the relevant stake-holders, including the communities/ civil society, within a rights based approach, so as to lead to actualization of right to health for all”. According to the draft Bill there is also the need to (i) set a broad legal framework for providing essential public health services and functions, ……… principally through the State and local public health agencies, in collaboration with others in the public health system….; (ii) to have an overarching legal framework and a common set of standards, norms and values to facilitate the Governments’ stewardship of private health sector as a partner (emphasis added).

Section II lays down several general obligations of central and state governments towards realization of health and well-being. Such as the general obligation “to provide free and universal[1] access to health care services and ensure that there shall not be any denial of health care directly or indirectly, to anyone, by any health care service provider, public or private….”. However, the nature of healthcare services that will be “free and universal” is not clearly defined anywhere. If one were to go by the mention in the preamble of the need for a legal framework to provide essential healthcare services, one can assume that it will be only these essential services that will be free and universal. This is an area of grave concern, because the Bill will end up institutionalizing, making irreversible the ideological shift that has taken place since the 1980s in provision of welfare services by the state. There has been a shift from provision by the state of comprehensive health services[2] through a publicly funded, universal, national health system, to free provision of just a minimum, essential package of services only to those identified as poor by the state.

Historical Significance of Comprehensive Healthcare & National Health Services

Since the early 20th century, when medical care began to be provided as a public service on a large-scale[3], the provision of such services has been characterized by a debate on the role of the state - should it directly provide the services, or should it only finance the provision, or should it only address the needs of the poor leaving the rest to be provided for by the private providers? Only few countries (such as UK and Cuba) adopted the National Health Service (NHS) system of the then Soviet Union – namely direct provision by the state of as complete a health service as possible[4]. It is the working class struggles of the late 19th-early 20th century that made profound contributions towards this concept of collective responsibility for provision of basic welfare services, and especially regarding the provision of health services.

In India, around 1947 many eminent doctors and planners for health were influenced by the Soviet and British National Health Systems (NHS). The oft-quoted Bhore Committee of 1946 framed a blueprint for provision in the country of comprehensive health services through a national health system. Given the need then for a vast health service for the vast rural population and the difficulty faced in attracting medical practitioners to the countryside, it concluded that “the most satisfactory way of meeting the situation was to provide a whole-time salaried service, which would enable government to ensure that doctors are made available where their services are most needed”. These were the recommendations that were adopted in the post-colonial period by the Indian state. Several other Committees later made valuable recommendations to achieve these goals. These were implemented to an extent, and some progress made in terms of creation of infrastructure in the initial five year plan periods.

However, the public health services in India did not grow as envisioned due to factors such as lack of political will; inadequate budgets; pressure from international agencies such as WHO to implement vertical[5] programmes for population control and against specific diseases such as malaria; corruption; and reluctance of doctors and specialists (trained in urban medical colleges oriented to western standards) to work in the rural health facilities. At the same time the private healthcare sector in India got subsidies and concessions, and conditions favourable for its unimpeded, unregulated growth, giving rise to a ‘passive privatization’ process.

Several events of the 1960s and 1970s, including the failures of vertical programmes, led to the Alma Ata Declaration of 1978 and the goal of achieving Health for all by 2000 AD[6]. The Alma Ata declaration, to which all WHO members including India were signatories, re-incarnated the importance of national health systems, although in a tortuous manner through the concept of comprehensive Primary Health Care (PHC). Implementation of PHC had socio-political implications, where governments had to address the underlying social, economic and political causes of poor health, and also build their national health systems.

Many governments, including India, did not implement it seriously. Instead a ‘selective PHC’ approach was advocated by the group of World Bank (WB), Ford and Rockefeller Foundations, USAID, and UNICEF. These institutions argued that the comprehensive PHC of Alma Ata was too unrealistic and costly[7]; if health statistics were to be improved, high risk groups must be targeted with carefully selected, cost-effective interventions for a limited number of diseases; that, until health care systems are adequately resourced and organized, it is better to deliver a few proven interventions of high efficacy at high levels of coverage, aimed at diseases responsible for the greatest mortality. ‘Selective PHC’ also promotes a biomedical orientation to disease & ill-health: it relies on delivery of ‘medical technologies’ amenable to vertical programmes. Just as smallpox was eradicated through a concerted global effort, for instance, it is argued that diarrhoeal disease, malaria and other common diseases can be tackled in a similar way. It is such ‘selective’ interventions that are largely being delivered as the minimum, essential package of services.

Health Sector Reforms – the Trojan Horse

The inefficiencies of the public sector healthcare system, arising largely from its deliberate neglect, have been used to justify imposition of a series of health sector reforms (HSRs) by many governments, as part of conditionalities of WB loans. The WB has been advocating that governments in poorer countries should focus their scarce public resources on providing a free ‘basic’ or minimum package of preventive and curative services for the poor, while withdrawing from the direct provision of other services. It argues that by encouraging the relatively rich sections of society to use the private sector, the public sector will be able to redirect its resources to those most in need. The assumption is that it is more efficient and equitable to segment health care according to income level – a public sector focused on the poor and a private sector for the rich. This is a major departure from the concept of universal, comprehensive healthcare services.

There is no evidence that such a system is better, more equitable or efficient. On the contrary, the private sector draws on a limited pool of health professionals, and takes away more health care resources than it relieves the public sector of workload[8]. Segmentation is attractive to private investors, as they can provide health care as a profitable, commercial product to those who can afford it. This is true especially for countries like India, where there is a huge private healthcare sector, as well an upper- and middle-class market to sustain the development and financing of the private health sector.

One finds that the draft National Health Bill intends to provide a legal framework for such a segmented system of healthcare services, thus re-inforcing the inequities and inequalities. Nowhere in the draft is it mentioned that the deficiencies of the existing public healthcare system will be rectified, and that it will be transformed into an universal, efficient, effective and accountable system as envisioned, catering to needs of all sections.
It is not surprising that the National Health Plan (NHP) 2002 shall be one of the plans guiding the National Health Act until other policies and plans are specially notified.

The NHP 2002 is quite emphatic about the need to move towards private provision of health services. According to this policy, “The health needs of the country are enormous and the financial resources and managerial capacity available to meet them, even on the most optimistic projections, fall somewhat short……….. In the context of the very large number of poor in the country, it would be difficult to conceive of an exclusive Government mechanism to provide health services to this category. It has sometimes been felt that a social health insurance scheme, funded by the Government, and with service delivery through the private sector, would be the appropriate solution”. It welcomed the participation of the private sector in all areas of health activities – primary, secondary or tertiary, and said that “The contribution of the private sector in providing health services would be much enhanced, particularly for the population group which can afford to pay for services”. The Policy also encouraged the setting up of private insurance for increasing the coverage of the secondary and tertiary sector under private health insurance packages. In keeping with the selective PHC concept, it prioritized TB, Malaria, Blindness and HIV/AIDS, and called for separate schemes to cater to health needs of women, children, tribals and other socio-economically under-served sections.

The National Health Bill provides for a National and a State Public Health Board (Sec IV) for implementing and monitoring of the Act. The functions of the State Board include: developing mechanisms for initiating public-private partnership in implementation of public health programmes that ensure equity and quality of health care services. Thus, while the centre will continue to deliver certain minimum services for the poor, through the existing infrastructure of peripheral institutions (sub-centres, primary health centres (PHCs), and community health centres (CHCs), the state governments can deliver other services through public-private schemes. The private sector, through direct provision and insurance, will cater to the affluent. Once again, the draft Bill, like the NHP 2002, holds out promises of regulation of this sector.

Questions to be asked

The government’s claims that finances, infrastructure and managerial capacity are insufficient are not very convincing. Is there actually a shortage of financial resources? Or is the ‘shortage’ due to the abysmally low allocations to health in the central and state budgets, despite promises to increase it? Secondly, since the mid-1990s loans were availed from World Bank for health system strengthening (Health Systems Development Programmes -HSDPs), in nearly a dozen states – Punjab, Andhra Pradesh, West Bengal, Karnataka, Maharashtra, Uttar Pradesh, Orissa, Uttaranchal, Rajasthan, and Tamil Nadu. In almost all states the loan amount is of several hundred crores rupees, repayable at 11-12% interest. The loans were exclusively for: constructing / improving infrastructure at secondary levels; development of management skills; policy reforms; and improving the performance of the healthcare system. What is the outcome of these programmes?

Several irregularities have been reported by the Controller Auditor General (CAG) of India in the HSDPs in almost all the states. Apart from corruption in states like Orissa, what is of major concern is that while the buildings and equipment are there, they are not being utilized due to lack of human resources, shortage of doctors and other staff, and acute lack of specialists, such as surgeons, anaesthetists, and paediatricians. Why are state governments not employing doctors and utilizing this infrastructure effectively? On one hand, we actually have a large number of doctors passing out each year and either leaving the country or joining the private sector. On the other, there is no genuine effort to create favourable conditions to recruit and retain doctors for the public health services. Under the reform measures and WB prescriptions, many appointments are either contractual or ad-hoc, or under specific programmes, or specialists are contracted in as and when required. The general policy of cuts in staff and freeze on recruitments has severely affected public health services in several states. Thus, loan money is being wasted and not utilized for the purpose for which it is being taken.

Together, all this raises questions about the sincerity of the government’s intentions to fulfill (and protect) people’s rights regarding healthcare, and about the objectives of the reforms it is implementing with assistance from WB and other international agencies. While public health services are in dire need of improvement, the on-going HSRs and the proposed National Health Act are ‘reforming’ it, not with interests of the common people in view, but that of commerce and markets.

Notes :

1 Services for all on the basis of citizenship, rather than ability to pay or insurance scheme criteria.

2 Services covering and meeting all kinds of healthcare needs, from infancy to old age; and not just for specific illnesses or physical illness only, but also preventive and curative.

3 Initiated in Russia in the 1860s through district assemblies.

4 In this system medical and public health services are provided by salaried physicians and other health personnel who work in government hospitals and health centres, the entire population is covered by such services, practically all services are included, and provided free of charge

5 Vertical programmes refer to exclusive programmes for specific diseases, with separate planning, management and implementation structures.

6 The Alma Ata Declaration has to be seen also in the context of the Cold War politics. It was an attempt to deflect the proposals by USSR in the early 1970s that WHO should support developing countries in developing their national health services, instead of supporting vertical programmes.

7 The Cuban health system belies such arguments.

8 The US experience of public funding and private provision shows that it actually increases administrative expenses.

Privatisation of Health:

A Letter from West Bengal

Dr. Debashish Dutta

The Left Front Government of West Bengal published a document “Public Private Partnership” (PPP) on 6th October, 2004 in its official website www.wbhealth.gov.in boldly announcing its intention to privatise the government health sector step by step. It set up the target of attracting 80 per cent of the total health budget as investment from private business houses in the coming ten years. However, the preparation for this paradigm shift started way back in November 1992 when it introduced fees for outdoor tickets in government hospitals, levied charges for diagnostic investigation, reduced the number of free beds etc. This was done to show allegiance to the conditions laid down by the World Bank for its loan of amount Rs. 701 crore which started coming from the year 1995. In accordance with the second phase of structural adjustment for which DFID provided a loan of Rs. 745 crore, the user fees increased in amount and free services became more and more restricted. Supply of free medicines and other appliances were also constricted.

In the next phase of privatisation, government hospitals are being transferred to private investors in the name of PPP. Already a specialised TB hospital at Jadavpur, Kolkata (having 750 indoor beds in a sprawling area of 200 bighas) has been leased to a private group for just Rs. 1 to build up a private medical college. Incidentally, it is the first private medical collage of West Bengal and has already gained a reputation for underhand dealing, capitation fees and other irregularities in admission of students along with doubtful teaching standards.

Three more hospitals, at Kamarhati, Dhubulia and Dubrajpur, are in the pipeline for sale. The hospital at Kamarhati was all prepared to be handed over to Apollo Gleneagles when a protest by the local residents and workers led by our party stalled it for the moment.

Recently, the government has planned to set up a West Bengal Medical Service Corporation Ltd. as per the Companies Act, following in the footsteps of the Tamil Nadu government. At present, the corporation will procure medicines and other equipments for government hospitals along with construction and budgetary provisions. It is apprehended that gradually, recruitment of staffs will also be taken up by this corporation. Already, low-paid contractual staff is replacing regular staff in all spheres, important programme components of DCH II, NACP III, RNTCP II, NLEP etc. are being assigned to NGOs and all district level health activities have been transferred to the District Health & Family Welfare Samity which is controlled by the Zila Parishad Sabadhipati, DM, representative of MP etc. In a survey done in 2007 it was seen that among the 922 health centres of West Bengal, 111 centres have no doctor, 257 centres have no lab-technician and 66 centres have no pharmacist. Amongst the nursing staff, 8 posts are vacant and 2486 new posts required to be created.

On the whole, though a huge extra budgetary transaction was noted, the State Health System Development Project II which intended to develop middle-tier hospitals (rural to district hospitals) and a proper patient referral system turned out to be a flop. The common people failed to achieve any benefit from this project due to lack of proper planning, fragmented approach, lack of coordination among various departments, reluctance on part of service providers etc. On the other hand, a group of corrupt party leaders, corrupt administrators, contractors, a section of doctors and health staff siphoned off funds into their pockets.

The government health system in West Bengal is being systematically and deliberately paralysed to pave way for the boom in the private health sector. Private hospitals, nursing homes, clinics, diagnostic centres are now lucrative investment proposals. The quality of treatment in these institutions is questionable, yet the huge expense is pauperising the patient. Moreover, unethical and corrupt practices like false billing, unnecessary investigations, irrational use of ICU, ventilator etc. are routine. The government is reluctant to curb these corrupt activities through prompt and proper implementation of Clinical Establishment Act. There is also people's resentment against the Medical Council for their failure to take the grossly negligent doctors into task. Further, the West Bengal Legislative Assembly has passed a bill (now awaiting the Governor’s approval) – “Medicare Service Persons and Medicare Service Institutions – Prevention of Violence and Damage to Properly – 2009” to protect these private institutions from the wrath of the patients and their family members.

Unhealthy Medicine:

Health Care in the United States and the Debate for ‘Health Reform’


Unhealthy Facts:

The population of the United States (U.S.) as per the U.S. Census Bureau is slightly above 300 million (July 2008). 47 million Americans do not have any kind of medical insurance. In 2006, 108 million Americans had insufficient coverage or were underinsured. The definition of underinsured varies but includes individuals who spend more than 10% of their post tax incomes on medical expenses. 62 percent of all bankruptcies filed in 2007 were linked to medical expenses. Research released in September, 2009, in the American Journal of Public Health estimates that 45,000 deaths per year in the United States are associated with the lack of health insurance. The researchers examined government health surveys from more than 9,000 people aged 17 to 64, taken from 1986-1994, and then followed up through 2000. They determined that the uninsured have a 40 percent higher risk of death than those with health insurance because of inability to obtain necessary medical care. A 2007 report ranked the U.S. 42nd in the world for life expectancy and 41st in infant mortality rate – worse than most of Europe and even Cuba.

Health Insurance - Private and Government:

Having viewed the grim statistics above, what exactly constitutes the health care system in the richest country in the world? The health care system in the U.S. has been described as ‘highly decentralized and fragmented’ and there is no Ministry of Health. There are 3 types of health care facilities - government facilities which include federal (central), state and local, private non-profit and private for-profit health facilities. Although the private sector dominates the health care delivery system, it is the government-funded programmes and facilities that treat the mentally ill, native Americans living in dire poverty in reservations, short and long term care of the elderly, those with end-stage kidney disease on dialysis, patients with AIDs etc.

There are about 1,300 private health insurers. The government insurances are Medicare, Medicaid and the Veterans Administration (VA) hospitals that treat the veterans (those who have fought in the innumerable wars that American imperialism has waged in the last 100 hundred years). A research team at Harvard just released a study which reported that over 2200 veterans died in 2008 from lack of insurance. The VA covers all veterans with illnesses related to the wars and poor veterans for other illnesses as well. It does not cover illnesses in those with mid- and higher level incomes which are not war-related. Medicare was established in 1965 during the peak of the civil rights and anti-Vietnam War movements in the US. Medicaid, established at the same time, provides some medical coverage for poor people. It is supported both by federal and state taxes and benefits vary by the states. A 2007 study by Public Citizen’s Health Research Group reported that 60% of poor Americans are not covered by Medicaid. The Federal Agency for Healthcare Research and Quality estimates that the government pays for two-thirds of the nation’s health care, the private health insurances cover two-thirds of the population and pay for a third of the total health expenditures. The private health insurance companies are known to ‘cherry pick,’ insuring only healthy people and refusing to insure those who were unhealthy or are likely to become unhealthy.

Health Care Debate

CBS News/New York Times poll found in June 2009 that 72% of Americans supported a government-sponsored health care plan. Most also thought the government would do a better job than private industry at keeping down costs and believed that the government should guarantee health care for all Americans. The mood of the working class and the middle class has been increasingly angry in response to the economic recession and the trillions of dollars doled out to Wall Street. The ‘change’ desired by the vast majority of Americans which led to the ‘historic’ election of Obama has been missing in action. Whether on immigration policy, on national security or on the bail outs to banks and corporations the two ruling class parties have been united. Health care became the most controversial issue in 2009 as millions were forced into unemployment. The Taft Hartley Act established in 1947 forced the workers to get health care benefits through collective bargaining agreements at the place of employment. Workers who lose their jobs lose not only wages, but also health benefits for themselves and their family. The lack of universal health care has resulted in important U.S companies like the big automakers like Ford and General Motors closing factories in the U.S. because of huge health care expenditures for their employees (Ray O. Light Newsletter, July 2007). Interestingly, corporations like Walmart known for extremely unfair labour practices have supported health reform as they would like some sort of public health insurance for their employees. The Democratic Party which has traditionally been supported by organized labour and other ‘progressive’ and liberal groups in its election campaign had promised to bring changes to the health care system. President Obama who vociferously supported universal health care during his campaign changed his position in deference to the health care industry from universal care to ‘health reform’.

After months of debates and intense lobbying by the ‘medical industrial complex’, the House of Representatives (the lower house) on November 7 passed a health care bill by a vote of 220-215. The 1,990-page bill will fail to deliver even any real ‘reform’. While a small proportion of people will have improved access and that too in 2013 when they will be offered a public health insurance option, private insurance’s grip on the healthcare system will increase as uninsured Americans will be mandated to buy private insurance or else pay a hefty fine. There will be little assistance for individuals and families who presently have employer-sponsored health plans and face frequent erosion of their coverage and health security. According to California Nurses Association (CNAO, with no effective limits on the insurance industry's price gouging, out-of-pocket costs for premiums, deductibles and other fees may eat up from 15 to 19 percent of family incomes.

Senator Max Baucus of the Democratic Party who has been prominently involved in the health reform bill had reached agreements with his colleagues in the Republican Party (the so called ‘right’ wing of the ruling class) in private on the health bill. The Montana Standard a paper from the Senator’s home state reported that he received more campaign money from health and insurance industry than any other member of Congress in the past six years. Nearly 25% of the money raised by Baucus and his political action committee has come from groups and individuals associated with drug companies, insurers, hospitals, medical supply companies, and other health professionals.

At the peak of the heated discussions over national health insurance in June,2009, when the Democrats and Republicans appeared to be at loggerheads, a deal was struck between the Pharmaceutical Research and Manufacturers of America (PhRMA), the White House and Senate Democrats. As detailed in a memo first published by The Huffington Post, the Obama administration agreed to oppose congressional efforts to use government leverage to bargain for lower drug prices. This will result in a net gain of more than $137 billion dollars in total market sales over the next four years.

The pharmaceutical and health insurance industry have used lies and propaganda in the last several months to create hysteria about the Obama administration’s efforts to bring in health reform. United Healthcare and WellPoint, two of the largest health insurance companies in the country, sent memos to their employees to take part in the town hall meetings. They are both under government investigation in California for these activities. (Los Angeles Times, Sept. 3) The fascist section of the ruling class has worked with these groups to fan chauvinism. Town meetings where Obama and other democrats addressed people over health issues have been attacked and disrupted. Stories have been spread about how universal health care will affect health care for the elderly and how it will benefit illegal immigrants and other dregs of the society like poor people and people of colour at the expense of good hardworking whites. Obama has been called a socialist for supporting a health plan which has been described by progressive health care activists as a gift to the private health industry! While there are differences and internal conflicts between the two ruling parties in the U.S which manifested in the debates over the health care system the bill that passed will continue to further the profits of the medical industrial complex that serves both parties.

Health Care as a Right – A Brief History

In the late 19th century largely middle class professionals called ‘Progressives’ created a reform organization American Association for Labour Legislation (AALL). AALL campaigned for compulsory health insurance plan for all. The American Federation of Labour (AFL) teamed up with organization of business leaders and defeated the implementation of the plan. Samuel Gompers the president of AFL described compulsory health insurance as ‘a menace to rights, welfare and liberty of American workers”. The AFL union leadership felt that social insurance would lower wages as the contributions would have to come from the wages of workers. The AFL was in direct conflict with the Socialist Party which endorsed the national health insurance.

After the end of the World War afraid of the influence of the Soviet Union, imperialist countries made concessions to their working class which included national health care. In the U.S too national health care began to assume a central place in the discussions. The communists and their sympathizers had organized large numbers of the working class into unions. This period became infamous for the witch hunts of communists and their sympathizers in an organized fashion by the American state. The American Medical Association (AMA) and its supporters ardently opposed national health insurance. They succeeded in linking socialism with national health insurance. They had one pamphlet that said, “Would socialized medicine lead to socialization of other phases of life? Lenin thought so. He declared socialized medicine is the keystone to the arch of the socialist state.” The anti communist propaganda of the government and the efforts of the AMA helped to defeat the plan to have universal free health care. Private insurance systems expanded and provided enough protection to prevent any great agitation for national health insurance in the 1950’s and early 1960’s.

In the mid 1960s the civil rights movement was at its peak. Two thirds of people over 65 had no coverage for hospital treatment. There was militancy in the air with leaders like Malcolm X and Martin Luther King posing serious challenges to the system. The Black Panther party, a revolutionary party with its goal of real economic, social, and political equality across gender and color lines, was becoming popular with the youth. Against this background Medicare and Medicaid were established in 1965. However, universal health care remained elusive.

Medical Industrial Complex

Vicente Navarro, Professor of Public Policy at the Johns Hopkins School of Public Health, describes the private health insurance companies, for profit health care facilities and the pharmaceutical companies as the medical industrial complex. In 2002, the ten most profitable drug corporations earned about 36 billion dollars more than the other 490 corporations on the Fortune 500 combined! In 2007, insurance industry profits reached $12 billion, and pharmaceutical industry profits $49 billion, the highest in the U.S. and in the world. The top executive of United Health a powerful private health insurer makes 37 million dollars year and has billions in stocks. All this comes from hardworking Americans with many going without adequate coverage even after paying premiums! The health sector contributed $54.5 million to Democrats and $46.1 million to Republicans in the 2008 elections. Contributions linked to manufacturers of pharmaceutical and health care products were split about evenly between the parties.

The Struggle for National Health Care Now

California Nurses Association (CNA) and Physicians for National Health Program (PNHP) are two organizations which have been in the forefront of the struggle for implementation of universal health care in the form of single payer health care or ‘Medicare for All’. Healthcare-NOW! is a coalition that has been mobilizing a large community of advocates composed of organizers and activists in more than 300 cities in all 50 states. There have been many rallies, sit-ins and voluntary arrests in front of large private insurance companies this year. Thousands of unionized workers have supported these actions. American Federation of Labor and Congress of Industrial Organizations (AFL-CIO), the largest federation of unions in the United States and Canada representing about 10 million workers and Service Employees International Union (SEIU) a labor union representing about 1.8 million workers have supported the health reform bill. They have not gone all out for a national health insurance/single payer as demanded by other health care activists.

When Health Care is Not for Profit

In 1932 Sir Arthur Newsholme of the Local Government Board of England and Wales, and John Adams Kingsbury, former commissioner of public charities for the City of New York, travelled to the Soviet Union to examine that country’s health care system. Their observations were published in 1933 as “Red Medicine: Socialized Health in Soviet Russia.” Among their conclusions is the following… “It has surpassed all other countries in its socialization of medicine. It has removed the doctor almost entirely from the field of monetary competition…. it has made medical service of an astonishingly complete character promptly available for the vast majority of urban populations, a service which is being rapidly extended to rural Russia; and it has given the whole of this service an admirable turn in the direction of social as well as medical preventive measures”. In China after the revolution, life expectancy doubled from 32 years in 1949 to 65 years in 1976. One of the important achievements at the time in China was community participation and people taking responsibility at the grass roots over health issues.

Cuba’s achievements in providing free quality health care at all levels are very well known. The New England Journal of Medicine, a premier U.S. journal reported, “Cuba has engineered a national medical apparatus that is the envy of many developing nations. For some of these nations, it is not Boston, but Havana that is the centre of the medical world.” This small country has approximately 28,000 health professionals now providing care in 68 countries.


The example of the ‘health reform’ bill in the U.S. shows that the so called public-private enterprise is really about putting the profits of the private corporations over people’s health. With the struggle for “Medicare for All” in the U.S., the struggle for health care can become part of the larger struggles for economic and social rights.

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