The health sector of the United States is in profound disarray. Even though the United States spends more on health care (14 percent of its GNP) than any other country, we still have problems that no other developed capitalist country faces. Let me list some of them. The first and most overwhelming problem is that no less than forty-four million of our people have no form of health benefits coverage whatsoever. The majority of them are working people, and their children, who cannot afford to pay the health insurance premium that would enable them to get care in time of need. Many of them work for small companies that cannot or will not pay their part of the health insurance premium. Because these individuals cannot pay for insurance, they do not get needed care, and many die as a consequence. The most credible estimate of the number of people in the United States who have died because of lack of medical care was provided by a study carried out by Professors David Himmelstein and Steffie Woolhandler (New England Journal of Medicine 336, no. 11 [1997]). They concluded that almost 100,000 people died in the United States each year because of lack of needed care—three times the number of people who died of AIDs. It is important to note here that while the media express concern about AIDs, they remain almost silent on the topic of deaths due to lack of medical care. Any decent person should be outraged by this situation. How can we call the United States a civilized nation when it denies the basic human right of access to medical care in time of need? No other major capitalist country faces such a horrendous situation.
But the problem does not end here, with the uninsured. An even larger problem is the underinsured, that is, people whose health benefits coverage is inadequate. Most people find, at a crucial moment in their lives when they really need care, that their health insurance coverage does not include the type of medical problem they have, the type of intervention they need, or the type of tests or pharmaceuticals they require—or, that it covers only a minute portion of what must be paid for the services. We, as Americans, are the citizens with the least amount of health benefits coverage in the western world. Even the federal programs, such as Medicare (which in theory should cover all care for the elderly), are very insufficient. In every European country and in Canada, the elderly do not have to pay for the pharmaceuticals they need. Not so in the United States, where many elderly must cut back on necessities in order to pay for the drugs they need. In the United States, 35 percent of the elderly cut back on their food purchases so they can afford their medications. But where the cruelty of the system reaches its utmost is among those who are dying. Among the terminally ill, 39 percent indicate that they have “moderate to severe problems” in paying their medical bills. No other major capitalist country comes even close to this level of inhumanity.
The overwhelming majority of people living in the United States are faced with such inhuman prospects due to inadequate health care. You may have seen the movie John Q, which shows the anger and frustration of a manufacturing worker who suddenly finds out (as do millions of Americans every day) that treatment of his son’s life-threatening condition is not covered by the family’s health insurance.
Obviously, the problem in the United States is not lack of funds. As I mentioned before, we spend much more on health care than any other country. What, then, is the cause of this situation?
The Distribution of Power in the United States
In order to answer this question, we have to understand how power is distributed in the United States. Indeed, the health care sector of any society is the best mirror of the power relations existing in that country. In the United States, most people would agree that race is a category of power. In general, whites have more power than blacks or Hispanics. And the mortality statistics reflect this. A black man with a cardiovascular disease is 1.8 times more likely to die of it than is a white man with the same disease.
Also, it is generally agreed that men have more power than women. Gender and race are indeed categories of power. But these factors by themselves cannot explain why we have the type of health services we have. Needless to say, racism and sexism have an enormous influence on the health conditions of people living in the United States and on the characteristics of the country’s medical care sector. But, they alone do not go to the root of the problem, which is class power. The most important variable that predicts people’s type of work, education, housing, consumption, and standard of living, and the types of diseases they have and how long they are likely to live, is the class they belong to. Of course, within each class, race and gender play a significant role. But in today’s United States, class is the most important category of power. A blue-collar worker with cardiovascular disease is 2.4 times more likely to die of the disease than is a corporate lawyer. Class mortality differentials are, indeed, the largest mortality differentials in the United States (V. Navarro, ed., The Political Economy of Social Inequalities: Consequences for Health and Quality of Life).
I am aware that class is almost an un-American category. It is widely assumed in the media that we are a middle-class society, with the majority of our people in the middle, a few at the top—the rich—and a few at the bottom—the poor. This is the most commonly referred to class structure in the United States: rich, middle class, and poor. Also, in polls people are frequently asked to define themselves by the group to which they belong. Time Magazine regularly asks people, are you upper class, middle class, or lower class? Not surprisingly, most people respond “middle class.” Actually, I have always admired the tolerance and patience of average folks. I must admit that if someone were to ask me whether I am a member of the lower class, I would respond “your mother also!” “Lower class” is clearly an offensive term. Yet large sectors of our working people are frequently referred to as the lower classes. Classism is as prevalent in the language as are racism and sexism, if not more so.
This perception of our class structure—rich, middle, poor, or upper, middle, lower—is heavily ideological and profoundly wrong. Actually, our class structure is remarkably similar to that of most of the capitalist developed countries of Europe. At the top we have a group that in Europe is called the bourgeoisie. We don’t use that term since it sounds too French. We call this group the corporate class, since most of its members are the top brass of corporate America. These are the individuals whose incomes derive primarily from property. It includes, among others, top executives of insurance companies and the CEOs of large corporations—groups that play a key role in the health care sector of this country
Next we have what Europeans call the petit bourgeoisies, but what we call the upper-middle classes, which include owners of mid-size enterprises and highly trained and paid professionals, among others. Below this, in terms of power, is the middle class, which includes craft workers and artisans, self-employed people, and technical and administrative personnel. Then we have the working class, which includes clerical, manufacturing, and service workers, individuals who are supervised, who work at repetitive jobs, and are paid by hourly wages. The working class represents around 60 percent of our population—the majority of the U.S. population.
Power in the U.S. Medical Care Sector
How does class power explain the U.S. health sector? Very easily. The United States is alone among the developed capitalist countries in not having a national health program, a universal health care program funded by the government or by social security. The United States is also the only country in the developed world where most people get their health benefits coverage through their employer. This unique situation is rooted in the Taft-Hartley Act, which basically legislated that the working people of this country should have their health benefits coverage through highly decentralized collective bargaining agreements. This explains why the steelworkers in Baltimore, who have strong unions, have fairly comprehensive health benefits coverage, while the clerks in the local supermarket, who don’t have a union, have pretty lousy health benefits coverage or no coverage at all. Let me point out, though, that even those sectors with the best coverage, like the steelworkers, have much less coverage than their fellow workers in all other developed capitalist countries. Moreover, in the United States, even these workers are losing their coverage in today’s anti-union climate. Today steelworkers pay 32 percent of all their medical care costs as out-of-pocket expenses, a 50 percent increase over just five years ago. The deterioration of the economic situation is having an enormous human cost. More than one million people (mostly workers and their families) lose their health insurance every year, and another sixty-two million see their health benefits coverage reduced or their premiums increased.
Notice, too, that if your health insurance benefit is dependent on your job, then when you are fired, you lose not only your salary but also the health benefits coverage for yourself and your family. This is why workers think twice before making trouble, since getting fired has a higher human cost in the United States than in any other country. And this was precisely the intention of the Taft-Hartley Act: to discipline labor. The employers knew the value of work-related health benefits as an instrument to discipline labor. The Taft-Hartley Act also forbids the working class of the United States to act as a class. It forbids sympathy strikes, which is why steelworkers cannot strike in support of, for example, coal miners. This inability to go out on sympathy strikes weakens labor dramatically. Again, no other country has this type of legislation. Not even Prime Minister Thatcher was able to put such a law, as she intended to, through the British Parliament. If the working class could add pressure as a class (as do workers in other countries when they call a general strike to make their voice heard), then it could have enormous power, certainly enough to force the government to provide health benefits through progressive taxation.
You may well ask why this situation continues and is reproduced. The answer is, again, because of class power, that is, because the corporate class, such as insurance bosses and large employers, has enormous power in our political system. This class power manifests itself in many different forms. One of them is the class composition of the top decision-making bodies of our government: 84 percent of cabinet members, 78 percent of the Senate, and 62 percent of the House over the last forty-two years have been members of the corporate class. The remainder have been members of the upper-middle class. There are very few from the lower-middle class or from the working class. One of these is a senator for Maryland, Barbara Mikulski, who was a social worker before being elected to the U.S. Senate. Politicians of working class backgrounds tend to be the most progressive. But there are remarkably few of them in the U.S. Congress.
Let me stress that the same class composition we see in these decision-making bodies of our government also occurs in our health care institutions. For one example, look at who sits on the Board of Trustees of the Johns Hopkins University and of the Johns Hopkins Hospital. You will see that they are the CEOs of some of the most powerful insurance, banking, and manufacturing corporations in Maryland. Actually, there is not one hospital in the entire Baltimore region that has on its board a member of the working class—which happens to be the majority of the Baltimore population.
These points need to be made, because in our country you may have been encouraged to check for the presence of minorities and women in positions of power, and to denounce institutions as discriminatory when you see very few minorities and women in them. I encourage you to continue doing this. But I have to stress that if your concern is—as it should be—to improve the representativeness of our institutions, then class plays a key role. You should ask not only about the race and gender of the members of boards, but also about what class they belong to, pressing for changes in the class composition of those boards. If you press for that, you will soon encounter an enormous resistance—much, much larger than when you ask for an end to race or gender discrimination.
Another way that class power is reproduced in our political system is through the privatization of the electoral process. Here again, we in the United States are quite unique. In no other country does money play such a key role in the electoral process. As Senator Mikulski said recently, “money is the milk of politics.” And most of that money comes from the corporate class: in 2000, 92 percent of the soft money that went to the key members of Congress who make decisions about health care and financial matters came from large insurance, banking, and employers associations, hospital corporations, pharmaceutical firms, and professional associations, such as the AMA. Indeed, it is an alliance of corporate and upper-middle-class interests that pays for those politicians, paying with the aim—successfully achieved—of defending their corporate and professional interests. The profits of the medically related industries, such as the health insurance industries, have reached an all-time high during the administration of George W. Bush, the most class-conscious U.S. president since Hoover.
Let me stress here that this situation is often reproduced in the way progressive forces choose to operate. Indeed, we have the most divided progressive community in the developed capitalist world. We tend to focus on gender or on race or on age, or on specific groups or issues. The United States is indeed the country of social movements. I of course applaud this diversity, but it is dramatically insufficient. For example, the United States has a very powerful association of the elderly—the AARP—but our elderly are less taken care of than those in any other developed capitalist country. They don’t even have their medications included in their health benefits. We see the same with women. We have a very strong women’s association, NOW. But American women have very limited maternity leave: just four weeks without pay. Sweden, which does not have a very strong women’s organization, provides a year’s maternity leave with pay.
Why this difference? Class power is the explanation. If you establish a spectrum of capitalist countries, listing them from very “corporate friendly” (like the United States) to very “worker friendly” (like Sweden), you will find, where the capitalist class is very strong, very poor health benefits coverage (in the public as well as in the private sectors), highly unequal coverage, and very poor health indicators. This is, indeed, the U.S. case. But in countries where the working class is very strong, with a strong labor movement (as in Sweden, which has been governed by a labor party for forty-eight years since the end of the Second World War), you will find very comprehensive health benefits coverage, a more equal distribution of resources, and better health indicators. The lesson here is clear: it is important that we help to strengthen the labor movement in the United States, and in doing so we should also capitalize on the diversity of the social movements, helping those movements to see the basic commonality of their struggles to unite rather than divide working people. This is, indeed, the best thing you can do to improve the health of our people.
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