Sunday, November 2, 2008

Marx, McCain and Health Care

Back in the second Presidential debate, a question was asked of the candidates which I found very penetrating and revealing. A woman asked, "Do you believe that health care should be treated as a commodity?" Barack Obama's answer was standard, nondescript fare, and I really can't remember a whole lot from it so I won't bother discussing it.

McCain gave a long-winded answer about consumer choice and a national medical records database and the like. However, his answer could have been a lot simpler and to the point if he had simply replied, "yes." I say that because basically his answer revealed that he thinks health care should be treated like a commodity.

Thus, the title of this post.

Karl Marx wrote extensively on the nature of "commodities" in Das Kapital, even dedicating an entire chapter to them (The Fetishism of Commodities). The subject of Marx also recently came up in email exchanges I had with a friend of mine in reference to Barack Obama (whom he does not trust as a candidate). I certainly can come up with many criticisms of Obama's economic plans, but calling it "Marxist" is nowhere near the truth -- it is a bugaboo paraded around by the right wing to scare and divide people that we are moving toward some kind of dictatorship of the proletariat, as if a candidate backed by significant Wall Street interests is somehow surreptitiously leading that charge.

Let me be clear -- I do not believe that Karl Marx provided a realistic template for social or economic change. However, I do believe that he provided one of the best critiques of industrial capitalism that was ever written. The tendency of capitalism to commodify all areas of life is central to this critique, and I think it is one that deserves further attention.

On the surface, Marx's criticism of commodities focuses on the way in which the purchasers of "commodities" (anything that is a manufactured good and has labor-added value is defined by Marx as a "commodity") are insulated from exploitation at every step along the way of the process. At first glance, this may appear that Marx is simply outlining the way in which people should be aware that exploitation exists in the supply and manufacturing chain, and try to avoid supporting such behaviors in pursuit of profit. However, historical perspective is necessary in truly analyzing what is being said here.

Marx developed these ideas in the midst of the industrial revolution, and although he wrote extensively about the industrial proletariat, he traveled in circles of craft artisans. It was this class with whom he most identified. Therefore, it is imperative to consider the plight of craft artisanry during the industrial revolution in order to unpack what Marx is really saying here.

Prior to the industrial revolution, anything that could be considered a "commodity" was produced by artisans. These artisans were members of guilds that set prices and maintained standards for quality and production. Typically, they labored in small shops and created goods from start to finish. Artisans made up the backbone of a growing middle class -- not the middle class of literacy and bureaucracy that we recognize today, but one of skilled labor that produced manufactured goods. In this sense, Marx was probably expressing a somewhat narrowed class interest that he and his contemporaries criticized in the bourgeoisie.

The industrial revolution eviscerated the artisan class. Goods that previously had to be made by hand, from start to finish, were instead manufactured by unskilled workers and industrial machinery in piecemeal fashion. Perhaps most distressing in this turn of events to Marx, however, was the destruction of the social fabric.

When goods were made by artisans, economic exchange for those goods had an added social dimension. The artisan was, at most, one step removed from the economic exchange if he was a journeyman laboring for wages in a master's shop. Since prices were largely set by the guilds, the practice of different shops undercutting each other by better exploiting their labor force was not really an option. Sure, goods were much more expensive and there were less of them -- but the social dynamic at play ensured that all parties involved were not subject to the whims of the market.

As Marxist historian and philosopher Juergen Habermas pointed out, the development of bourgeois capitalism was based upon two primary assumptions that were a reaction against the feudal system it eventually replaced. The first of these was the notion of free competition -- the idea that all commodities were exchanged according to their "value." The second one -- and perhaps more important one -- was that all producers would have equal access to the means of production. This assumption in itself implies an economy based upon small producers -- the artisan's shop.

By Marx's time, it was painfully apparent that at least the second one of these presumptions was no longer valid. A journeyman artisan could reasonably gain access to the old means of production -- tools -- because they did not require a great capital outlay. However, the vast majority of artisans could not afford to buy their own factory, and as the industrial revolution took hold, this is what was required in order to have equal access to the means of production.

Where Marx focuses his critique, however, is not so much upon the change in control over the means of production, but rather on the effect of this transformation upon social relationships. To reference Habermas again, the development of bourgeois capitalism meant that even these social relationships themselves were transformed into commodities. I believe that this is to what Marx is referring when he outlines the layers of exploitation inherent in industrial capitalist production. At every step of the process, what previously was an economic exchange with a social foundation is transformed into a narrow focus on leveraging economic advantage devoid of any social consideration. I am not saying that the old world of artisans did not have exploitation, nor that economic advantage was ignored in these exchanges. I am simply saying that there was an attendant dynamic at play in these exchanges that highlighted broader social considerations.

Back to McCain and health care. The basic relationship in health care should be between a doctor and a patient. This is primarily a social relationship. The patient has a vested interest in seeing that the doctor is not taken advantage of, otherwise he or she could no longer continue to practice. Likewise, the doctor has an interest in providing quality treatment, otherwise he or she will lose his or her client base. However, the introduction of health insurance for profit has no concern over these relationships. It is removed from the level of social interaction and instead interested only in maximizing its profit from the patient while minimizing the payment to the doctor. If the patient suffers due to lack of coverage or the doctor's care degrades in quality due to being squeezed by the insurer, it matters not. What matters is profit, pure and simple.

Customer "choice" has nothing to do with helping customers, because the entire exchange is devoid of social utility. The providing of health insurance is treated purely as a commodity -- except in this instance it is a labor-added service that has "value" only in the sense that people in modern society need health care, and the insurers have exploited a niche in which they can turn a buck.

The question I inevitably come back to in this consideration is, "Is this really the best way we can do things?" I readily admit that I am a fan of a government-administered, single payer system for a few reasons. The first is purely economical -- it actually costs less to administer a single-payer plan because the government is interested in breaking even, not turning a profit. The second, however, is social. The removal of insurer profit from the system pushes it more in a social direction. The focus of the system can once again be on doctors and patients, and the expression of their mutually-beneficial self-interest.

Blind faith in "market solutions" assumes that capitalism always provides the best way for doing things. In the arena of health care -- a sector of economic activity more concerned with social interaction than the manufacture of goods -- I'm not certain that is the case.

2 comments:

Jeff, Kristi and Sophia said...

Do you think the government or insurers are going to provide the best service in terms of :providing the best medicines; access to the best technologies; timeliness of treatment?

If the government is going to set plan policies and payments, do you think doctor's or hospital pay will remain competitive?

Chris said...

With regards to your first three questions, I think that the example of pretty much all other industrialized nations of the world demonstrates that quality of care remains high under a single-payer system, and since profit is written out of the "insurance" equation (I think it's more of a parasitic role played by corporate insurers) it can be ultimately delivered at a lower per capital costs. In fact, a piece by Michael McCally MD, PhD at the University of Williamette (Oregon) demonstrates this to be true (http://www.willamette.edu/centers/publicpolicy/projects/oregonsfuture/PDFvol3no2/F2Mccally20.pdf)

If doctors didn't think their pay would be competitive under universal health care, then the AMA probably wouldn't be endorsing it, either (http://www.pnhp.org/news/2008/october/ama_position_on_sing.php). By doctors' pay being "competitive," what exactly do you mean? Evidence from other countries with single-payer plans shows that doctors remain one of the highest-paying professions, although probably not quite as high in the United States. If there is one group that will probably see their salaries go down, it's specialists.

I believe in FDR's statement, "The test of our progress is not whether we add more to the abundance of those who have much, it is whether we provide enough for those who have little." I think that health care is an issue that falls into this realm. For me, it really is about recognizing a "common good" rather than embracing Margaret Thatcher's view -- "There is no society. There are only individuals."