By R.L. Stephens, DSA National Political Committee & Editor-In-Chief of DSA Weekly
Last month, Seattle writer and organizer Sophia Burns put forward an article titled “The Socialist Case Against Medicare for All.”
The central claim of the article is that a campaign for a Medicare for All reform “is flawed to the point that socialists shouldn’t take part in it.”
I disagree with this thesis, as a matter of general principle.
On principle, the inadequacy of a reform doesn’t invalidate the tactical imperative to fight for it. I believe Burns would generally agree. For example, affirmative action–which was (and is) necessary for expanding Black employment access in public and private sector job markets–was inadequate for addressing the crisis of the racial subjugation of Black people. However, affirmative action did in fact facilitate the mass expansion of a Black middle class and created a whole new set of opportunities and contradictions, which was not in itself a bad outcome. Even flawed reforms can be generative.
I also disagree with Burns’ specific call for socialists in DSA to reject participating in a campaign to win Medicare for All. Expanding access to healthcare services by shifting the way they’re funded will improve many people’s lives, even if the underlying quality and purpose of those services remain unchanged. Though I disagree with Burns’ position, I find the questions she poses to DSA to be productive starting points to help us clarify what socialism is and what socialists do.
Burns’ article can be broken down into three key questions. What relations govern healthcare? What is healthcare for? Where do the Medicare for All reform movement’s politics reside?
What Governs Healthcare?
First, Burns contends that the public/private distinction in payment method does not resolve the capitalist character of healthcare because “no matter who holds office, the structure of the state means that it can’t help but enforce capitalist class rule.” Drawing on autonomist Marxist Silvia Federici, Burns argues that socialism is not simply a question of redistribution, but redistribution under what/whose governance.
Governance is a key question for us to navigate as we attempt to clarify just what socialism is. In its simplest definition, governance refers to the manner of managing the structure of a set of social relations and the practices therein. Governance is a continuous process. Though I disagree with her conclusions and some of her analysis, Burns is certainly onto something by pushing us to think about the governance of healthcare.
In a 2015 academic article for Critique Peter Kennedy compares health systems in the U.S. and U.K. Kennedy, writing, “The US system emphasises the governing role of the private sector and the UK emphasises the role of the public sector. However, the differences are quantitative rather than in kind. We should not conclude that one is governed by capitalist relations and the other is in some way non-capitalist.” In other words, Kennedy is arguing, much like Burns, that the public sector funding of healthcare, for example Medicare for All or even the National Health Service, is not in itself an expression of socialist governance and that capitalist relations remain dominant.
At present, the public sector accounts for 48% of all health expenditures in the United States, compared with 83% in the UK and 70% in Canada. There are meaningful distinctions in the care offered across those systems. For example, healthcare being free at the point of use makes a huge difference in people’s lives. However, Kennedy argues that this difference is not “the historic struggle between capitalistic and socialistic organisation” because “the difference in real terms between the US and UK is in the relationship between how the capitalist state and economy merge in maintaining a healthcare system conditioned by the limits of the system to resource it and the competing needs of capital and labour.”
What Do Healthcare Services Do?
Next, Burns draws a distinction between how healthcare is paid for and “what healthcare is for,” positing that healthcare under capitalism “keeps workers healthy enough to go to work, and it warehouses disabled people as cheaply and expeditiously as possible.” She holds that this tendency to “keep the working class healthy enough to be exploited” is not eliminated by the government paying for health services.
To Burns’ point, Peter Kennedy concludes that irrespective of the public/private distinction in payment method, “the focus of the healthcare labour process [is] to reproduce a use value not a commodity: use value in the sense of repairing, maintaining and if possible enhancing the use value labour has for capital.”
Burns is pushing us to consider that it is not simply that we need our present healthcare covered, but that we need to radically alter what healthcare does because capitalism dominates not just at the point of delivery but in the very nature of the health service that is delivered. Kennedy argues that the dominance of capitalist relations over healthcare is facilitated by the body of science known as biomedicine, which “reduces disease to visible lesions within and on the surface of the body, while at the same time it atomises both cause and cure of illness to the individual.”
Kennedy argues healthcare’s biomedical regime operates as an ideological scaffolding for “narrowing the definition of health to ‘absence of illness’, ‘fitness for work’ or, if unemployed, to degrees of ‘employability.’” Though he recognizes biomedicine’s medical utility with regard to treating numerous diseases, nonetheless Kennedy observes that biomedicine “offers the state and capital an ideological shield obscuring the social context of health, particularly the involvement of capitalist society in creating, compounding and sustaining illness and disease.”
In the final analysis, it should be simple to acknowledge, as Burns does, that Medicare for All is not socialist governance in practice. I think it’s also fair to say that most socialist proponents of Medicare for All do in fact want a substantive transformation of healthcare. However, does the fight for Medicare for All inherently preclude a broader and deeper struggle for a transition to quality healthcare under socialist governance?
Who Has the Power?
In her final passage, Burns argues that the only viable path forward for achieving Medicare for All is through the Democratic Party. She contends, “M4A can’t happen without a Democrat in the White House, a filibuster-proof Democratic majority in Congress, and (most of all) those Democrats’ willingness to actually make it policy.” The obvious implication here is that Medicare for All can only occur through the Democratic Party and long-term activism within it. As a result, political leadership is ceded to the Democratic Party apparatus, leaving proponents of Medicare for All dependent on the efficacy of the party and its apparatchiks.
Burns concludes that socialism is “mass power, in every sphere of life,” which cannot be facilitated through the Democratic Party. Thus, for Burns, the struggle for the Medicare for All reform cannot make the working class “an autonomous political force in its own right, organized through its own base of institutions and capable of contesting for social power against other classes.”
Burns is concerned with building autonomous power among the working class, a laudable aim and one she rightfully concludes is not likely to be established through the Democratic Party. Not only is the party not democratic, but it is primarily a twisted amalgamation of demographic constituencies, political machines, and operatives captured by the party apparatus and the wealthy financiers who dominate its funding. This party is then grafted onto the state, ultimately as a legitimizing force for the dictatorial dominance of capitalist relations.
I appreciate Burns’ concern that Medicare for All enhances the dictatorial power of the capitalist class and undermines autonomous working class power. After all, in 1883 German ruler Otto Von Bismark created the world’s first universal health insurance system, and he did so in an explicit bid to recoup the impoverished masses and prevent the working class from continuing to organize for power. However, even popular power generated through base-building methods like mutual aid, as Burns proposes in her piece, can be captured by the state or otherwise absorbed into capitalist governance. The medical mutual aid campaigns of the Black Panthers and Young Lords demonstrate that fact. Neither mutual aid tactics nor abstention from the Medicare for All reform struggle resolve the essence of the question of socialist governance.
Furthermore, we should not underestimate the significance of the friction within the Democratic Party and the intra-party warfare occurring within in its bounds. Among the amalgamation of forces cobbled together as the Democratic Party, there exists a crisis of leadership and coherence. The alignment of the party, that is the party’s dominant coalitional axis and ideological orthodoxy, is in flux. Medicare for All is not socialist governance in effect, as Burns rightfully points out. However, Medicare for All is proving quite useful as a means for creating a frontal political battle within the party.
Alexandria Ocasio-Cortez, the recent Democratic primary-victor and presumptive congresswoman from New York, articulated her support for policies such as Medicare for All as “asserting the minimum elements necessary to lead a dignified American life.” While these minimum elements do not constitute socialist governance, it’s entirely possible that among the groups competing within the Democratic Party, the insurgent forces anchored by what Ocasio-Cortez calls the “minimum elements” could win out and deliver Medicare for All. Such a development would be positive in a world where basic dignity is denied to so many and the stakes are life and death.
Moving Towards Socialist Governance
We live in an era of global rupture, as the old ways of living and ruling crumble and new forms take shape but it remains to be seen under what governance. The spectre of reactionary nationalism is surging from nation to nation, and even European social democratic parties are failing to overcome it.
I believe in socialism because I believe socialist governance of society actually solves the problems of the crisis we are facing, from reactionary nationalism to climate catastrophe. Today, people are pulling whatever levers are available to them. Socialist governance cannot be established by abstaining from where the action is simply because the levers people pull are inadequate.
I agree with Sophia Burns, building durable autonomous power among the working class is the primary duty of socialists today. However, this autonomous power is not advanced by abstention from reform struggles like Medicare for All; rather, it rests on our ability to develop the governing capacity of the people. The friction generated by frontal political conflict within the Democratic Party can motivate people’s willingness to take on questions of governance themselves; DSA’s explosive membership growth after the Democratic Party’s failure to defeat Trump is proof. This same friction can also recoup and neutralize people, as has happened to electoral reformers time and again.
The immediate test before socialists in matters such as the fight for Medicare for All is whether we can clarify what socialist governance is and lead through methods of doing reform struggles that build the capacity of the people to govern society, or will we cede political leadership? To rise to the challenge, we must unite those among the masses who are active on a whole range of issues, Medicare for All being one of them, and move towards establishing socialist governance of society. If socialism is the people in power, as Burns suggests, then we cannot constitute socialism by avoiding where the active people are.