Toward a Healthy Society: The Morality and Politics of Health Care
Milton Fisk
Kansas University Press, 249 pages, $35 (hardcover)
ONE OF MANY dubious distinctions held by the United States is that it is still the only industrialized nation without universal, public health insurance. (In the wake of September 11 it has even been discovered that public health infrastructures are woefully inadequate to deal with a possible mass epidemic.)
Many are familiar with the appalling U.S. health care statistics: 43 million uninsured, 21st in life expectancy, 24th-best in infant mortality, abysmally low rankings on hospital and doctor visits per capita.
Poor quality health care corporate style, however, does not come cheap. U.S. health care costs per capita are nearly double those of any other nation, and after a brief period of stability, are again increasing at a double-digit rate.
The successful historic experience of Canada and other industrialized nations with single-payer (i.e. public) health insurance systems is at best ignored by politicians and the mass media; the implicit message is that there is no alternative to a largely privatized system.
How did we get into this mess, and how do we get out of it? Indiana University ethical philosopher and political activist Milton Fisk tackles this difficult and important subject in his recent book Toward A Healthy Society: The Morality and Politics of American Health Care Reform.
For a deep understanding of the political evolution of American profit-driven health care and formulating a successful challenge to it, this is a must read. With eloquence and a calm but unmistakable passion for social justice, Fisk systematically presents a compelling philosophical and empirical case for national health insurance.
Fisk also takes us through the byzantine twists and turns of U.S. health care politics over the last few decades, and discusses at length the formidable barriers that exist to health care reform and how these barriers could plausibly be overcome.
Fisk situates the rise of corporate-dominated health care within the context of the ascendancy of neoliberalism, the ideology and practice of favoring unregulated markets and opposing “big government.” Stagnation of corporate profits during the 1970s led to such cost-cutting and profit-seeking measures as downsizing, lean production, and the like as well as governmental changes such as privatization, deregulation, “free trade” and massive cuts in social programs.
In the late 1980s a variety of forces, including both activists advocating single-payer health insurance and employers concerned about the skyrocketing cost of insuring their employees, began pushing for health care reform to control runaway costs.
Fisk argues that because the reform movement arose in the political context of neoliberalism, a fundamental premise of which is that there is no viable alternative to the market, forces pushing market (attempted) solutions won the tug of war with public health insurance proposals, which were never taken very seriously by mainstream politicians or media.
Fisk’s work is in part motivated, he explains, by dissatisfaction with traditional arguments for social reforms that are grounded exclusively in abstract appeals to individual rights such as a right to receive health care.
Such philosophical approaches presume to have identified universal principles which, through sheer force of reason, will be acceptable to anyone regardless of their point of view. There could be no better refutation of such perspectives than the ongoing existence of a health care system wherein intentional denial of care to millions of people is a fundamental component.
There are obviously powerful individuals who have not been persuaded that health care is a universal right, and Fisk reckons that no amount of logical argument is likely to alter this state of affairs. An ethics of social reform needs to begin not with an abstract, individualistic appeal to rights, but with the identification of social goals on which there is widespread agreement, or potential agreement.
Fisk contends, based on such evidence as the strong majorities favoring national health insurance in several polls, that widespread agreement exists that a healthy society is a worthy goal – but not universal agreement.
There are profits to be made by practices that interfere with this goal – denying health care to those who need it, maintaining unsafe conditions in workplaces, pursuing government policies that exacerbate economic inequality and insecurity, etc. – and those who stand to gain from such practices will be reluctant to forgo them.
Hence, the sort of ethical appeal Fisk is making is not neutral, but is based on what he terms a political morality. A political morality is an ethics that advocates a specific point of view representing particular – albeit widely shared – interests and opposing others. In this instance, the interests represented are those of individuals whose health care needs are underserved by the present system, and those opposed are those of individuals who benefit financially from its perpetuation.
Given the powerful vested interests that benefit from continuation of a system wherein profits take precedence over health (and where accountability is primarily to investors, not the public), the goal of a healthy society can only be achieved, Fisk argues, if health care becomes a public good rather than a commodity.
Only if public control is exercised over the health care system, such as through a single-payer health insurance system, will health care be accessible to all and the social goal of a healthy society within reach.
It might be argued that health care corporations have a financial incentive to minimize costs by emphasizing preventive medicine, spending enough time with patients to ensure correct diagnoses, etc., and that this incentive is consistent with the goal of a healthy society.
Fisk points out, however, that health care corporations can – and do – more than compensate for the cost of having a less healthy society by charging higher premiums and investing the money that denying care up front saves them.
Fisk argues for a broad definition of a healthy society involving general well-being and capacity to function. For a society to be truly healthy, high-quality medical care must be readily and equally available to every citizen. In addition, preventive medicine must be emphasized, and environmental hazards to health such as poverty, toxic waste, radiation, air pollution and so forth must be minimized.
Furthermore, a healthy society is one characterized not only by readily available mental health care (including treatment for alcohol, tobacco, and other drug habits) but also by societal conditions conducive to mental health.
Clearly, even a national health care plan does not by itself suffice to bring about such a society. For starters, a national plan that only guarantees a bargain-basement level of health care, but enables the more affluent to buy the “first-class” health care denied their compatriots (precisely the situation that exists in Great Britain’s system), will fall short.
In addition, promoting a healthy society must go far beyond treating diseases or even strictly medical procedures themselves; ultimately, broader reforms than simply creating a public health insurance system will be required.
However broad the consensus may be that a healthy society is a desirable goal, seemingly insurmountable obstacles stand in the way. First and foremost, of course, are the vested interests that profit from the continued existence of a largely privatized health care system, and of practices that harm public health such as producing toxic chemicals or producing and advertising cigarettes.
Relatedly, Fisk notes, physicians and corporate medicine share a vested interest in “medicalization” of health care that treats public health and preventive measures (let alone environmental or workplace safety laws) as beyond the pale of health care.
Moreover, even defending current universal social programs such as Social Security and Medicare from conservative attack is not easy, Fisk points out. Even moderately affluent individuals pay far more money into such programs than they can reasonably expect to get out of them.
In addition, individuals’ health care needs vary greatly, and subsidizing the Medicare costs of those with expensive health problems (e.g. lung cancer) is not in the (immediate) self-interest of healthier individuals, who tend to assume that they will never experience such problems themselves.
Thus, Fisk concludes, a successful movement for national health insurance cannot arise from self-interest alone; there must be solidarity amongst society’s members – genuine concern for others’ well-being and motivation to take action on their behalf.
In the United States, however, the dominance of market relations and the relative absence of public goods undermines solidarity. People have relatively little opportunity to cooperate with each other to achieve common goals. Instead, they live in a society characterized by inequality, economic insecurity and dog-eat-dog competition.
Psychological research demonstrates that competition undermines solidarity and instead breeds hostility, mistrust and prejudice. Moreover, misfortunes among the relatively more privileged (e.g. a crash in the price of cotton in the post-Reconstruction South) breed a tendency to seek scapegoats (such as a tendency to look for Blacks to lynch).
One of my few quibbles with Fisk’s book is that he does not cite any research regarding these sorts of effects of competition and economic insecurity on interpersonal feelings. Nevertheless, he does make a compelling logical case for such effects.
The competitive atmosphere in the United States does not, of course, do away with solidaristic impulses; political consciousness remains divided between solidaristic and more self-interested impulses.
Rather, Fisk argues, what occurs is that powerful societal institutions, from government to employers to the corporate-owned media, form a united front encouraging self-interested values consistent with acquiescence to the status quo and discouraging or simply ignoring those who would challenge it.
Another barrier faced by any social reform effort in the United States, Fisk notes, is the corrupt, rigged nature of the electoral process. Politicians are bought by wealthy special interests before they are even elected; winner-take-all elections present a formidable obstacle to reform-minded third parties; party platforms are virtually meaningless, as candidates are in no way accountable to them; and numerous other electoral problems have come to light in the aftermath of the most recent Presidential election.
Organized labor is also relatively weak. A relatively small percentage of the workforce is unionized, the leadership is passive and all too willing to cooperate with management, and no labor-based mass political party exists.
One example of the AFL-CIO’s willingness to acquiesce to a corporate agenda is its abandonment of support for single-payer health insurance at precisely the time, in the early 1990s, when the need for health care reform was receiving widespread public attention and labor support could have made a difference.
Aside from isolated locals and a few smaller unions, there is still little support for comprehensive health care reform from organized labor.
A central thread running through many of these problems, Fisk points out, is that there is a relative lack of democracy in the United States. The operative principle of the political system is closer to one dollar, one vote than one person, one vote.
Corporations exert a stranglehold on the mass media. Furthermore, the fact that the vast majority of the economy is in private, corporate hands means that there is virtually no accountability to the general public on the part of most economic sectors (and certainly the health sector) that provide the basic necessities of life.
In short, rather than being widely and equally shared, political power in the United States lies in the hands of a tiny, wealthy minority.
But after enumerating these various obstacles, Fisk nevertheless concludes that successfully challenging the corporate medical establishment and winning deep reforms is possible:
In periods of strong challenges from below ... progressive legislation has been forthcoming despite institutional barriers. In the Depression, the popular challenge was sufficiently strong to allow for labor and social legislation. In the 1960s, the challenge was sufficiently strong to generate civil rights legislation. In the early 1970s, the challenge was sufficiently strong to generate environmental and occupational health and safety legislation. The money spent buying politicians proved ineffective in stopping these initiatives.
Moreover, Fisk notes, national health insurance was won in Canada despite the fact that organized labor was not at the time significantly stronger than in the United States.
Still, in the current neoliberal context in which multinational corporations rule the roost more than ever, the task before us here is more formidable than that Canadian activists faced. What will it take to succeed here?
Fisk argues that, just as corporate health care arose in a more general context of neoliberalism, comprehensive reform can only occur in the United States in the context of a broader movement for democracy and social justice.
This movement must find ways to unite diverse groups (minorities, women, gays, the poor, the uninsured, those most impacted by environmental destruction, etc.) around struggles against many forms of oppression by identifying overarching social goals on which consensus is a realistic possibility.
The overall agenda of this movement, of course, would not be class-neutral or have universal appeal, given the vested interests (primarily corporations and wealthy individuals) opposing radical reforms; however, it would be one around which the vast majority of members of society (loosely speaking, “working people”) could unite.
Fisk argues that a key element in creating the necessary unity in a societal context that encourages distrust and individualism is the creation of a third political party which is able, unlike the Democratic Party, to remain independent of and steadfastly challenge the priorities of corporate America.
Such a party would need to promote open discussion among interested groups suffering structurally similar forms of oppression or injustice. As noted previously, political consciousness is a divided creature even in a society such as the United States where it is at a low level; it contains not only inner-looking attitudes conducive to maintaining the status quo but also the seeds of a more solidaristic outlook conducive to supporting sweeping change.
A third party can play an important role in promoting and building on latent solidaristic values by helping to build support for a broad political platform that addresses the needs of the vast majority of working people, and pointing out how these needs are largely unmet by a neoliberal agenda.
Unlike the Democratic Party, with its allegiances to the very forces promoting neoliberalism as well as vestiges of loyalty to broader public interests, a third party without such divided loyalties would be uniquely capable of putting radical reforms centered around creating public goods, such as a national health system, on the public agenda.
Merely putting such reforms on the agenda and generating widespread discussion about them would be an important advance over current circumstances. Through democratic struggle in all its manifestations (open discussion, political protest, strikes, boycotts, etc.), this agenda could be advanced and at least some reforms won.
The creation of a society more characterized by the presence of public goods and less dominated by market forces would, in turn, create a more solidaristic context that would make it easier to win subsequent reforms.
Fisk’s point, in short, is that the struggle for a healthy society must go hand in hand with the struggle for a more just and democratic society in general, and a force (e.g. a third party able to avoid the hegemony of corporate power) must exist that is capable of uniting working people around this broader agenda.
ATC 96, January–February 2002