By J. Abreu

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This text was written as part of the LSC Pamphlet Program. It reflects only the opinions of the author(s) and not the consensus of the Libertarian Socialist Caucus.

At the most recent Convention of the Democratic Socialists of America (DSA) in August 2017, hundreds of delegates established the campaign for "Medicare for All" (M4A) as one of the pillars of DSA's national strategy. Accordingly, new and existing DSA chapters have adopted the campaign, anchored by a clear and popular objective. Arguably, the centerpiece of M4A is Bill S.1804: The Medicare for All Act of 2017 introduced in the Senate by Bernie Sanders and currently cosponsored by 15 senators.

DSA national leadership enthusiastically endorsed the bill while adding:

...there are still ways the bill can be improved. Our job as socialists is to keep pushing the envelope and raise expectations of what's possible under a Medicare for All system. Namely, we should to fight to eliminate co-payments on all medications, outlaw misleading pharmaceutical advertising, and drive out the profit motive in health care by banning all for-profit health facilities.

It can be argued that the passage of the bill would constitute a revolutionary act in and of itself. Language in the M4A bill would guarantee access to health coverage from any eligible provider, universal and automatic enrollment, and non-discrimination on any basis including: "race, color, national origin, age, disability, or sex, including sex stereotyping, gender identity, sexual orientation, and pregnancy and related medical conditions (including termination of pregnancy)" (S. 1804, s 104).

Sure, the objectives are laudable enough, but the method leaves something to be desired. In the statement above, there is an emphasis on improving the bill–a process mostly involving elected officials and economic actors who wouldn't even accept the limited reforms which the bill entails.

In the interest of delivering on the promise of pushing further, we need to critically assess the language of the bill itself and point to post-capitalist alternatives that could only be achieved through building power from below, of building movements rather than winning elections. Beset by civil war and with limited means, anarchists in Spain managed to build a health system which might inform a more revolutionary approach to the discussion on M4A.

Libertarian Socialism and Collective Healthcare in Spain, 1936-1937

"The socialisation of medicine was becoming everybody's concern, for the benefit of all."
- Gaston Leval

Though the goal of universal healthcare is traditionally understood to be a social democratic innovation within the confines of the nation-state, anarchists have long fought to broaden the horizons of healthcare access. In 1932, Spanish anarchist Dr. Isaac Puente summarized his views on healthcare as: "Health to health professionals" (Alexander 47). The most opportune moment to build a model of healthcare based on libertarian socialist ideals came amid the military and political chaos of the Spanish Civil War beginning with the attempted invasion and takeover of Spain by right-wing elements of the military led by Francisco Franco in July 1936.

Resistance to Franco was led in many places by workers and militants affiliated with the newly created alliance of the Confederacíon Nacional de Trabajo with the Federacíon Anarquista Iberica (CNT-FAI), or anarchist ideas more generally. Workers under the CNT-FAI banner moved quickly to form self-managed workers' collectives in industrial areas such as Barcelona as well as in agriculture. CNT-FAI and other political factions opposed to Franco constituted the Popular Front, a coalition of left groups forming the basis of Spain's republican government. Controversially, the CNT-FAI decided to participate in the Popular Front by taking roles in government ministries such Justice, Economy, and Health.

CNT-FAI activist and anarchist Federica Montseny assumed the role of head of the newly created Ministry of Health and Social Assistance in November 1936. This was not without controversy, and Montseny herself had significant misgivings about leaving Catalonia–the main theater of revolutionary struggle–to act as a bureaucrat (Alexander 868). Not only did Montseny become Minister of Health, but she also took on a newly created agency with responsibilities previously assigned to more than one agency (Barona and Perdiguero-Gil, 106-107). As head of the Ministry, Montseny had to tackle a number of wartime problems, but managed to reduce administrative positions, stating: "I suppressed almost all of the high posts" (Alexander 893; Barona and Perdiguero-Gil 107). While sweeping changes were being made at the local and national level, health indicators remained steady among "stable populations" in Republican Spain up to late 1937 (Barona and Perdiguero-Gil 115).

Part of the CNT-FAI success in organizing the healthcare system was its ability to mobilize resources among its own varied members in different sectors of the economy, reflecting work that began long before 1936. In Catalonia, textile workers in Badalona enjoyed access to healthcare through agreements between their union and unions representing doctors and pharmacists, all of which were affiliated with the CNT (Alexander 619). This was possible because the CNT embraced a philosophy of "one big union." Reaching this point in the contemporary U.S. would be a monumental task to say the least, but would reflect a level of workers' power that no legislation could accomplish or initiate.

Though the CNT created healthcare networks independently of state power, it did not organize a union of healthcare workers until the Civil War was well underway, with the Sindicato de la Sanidad representing thousands of healthcare workers including doctors, nurses, dentists, and veterinarians. A larger federation of CNT healthcare unions was established in February 1937, numbering about 40,000 healthcare workers (Leval 487).

Meeting in Valencia, this federation was poised to extend a healthcare model based on federative principles, patient access, and workers' control throughout the parts of the country not under Francoist control. In addition to these broad ideals, the meeting also demonstrated a holistic understanding of health that included physical education and sporting facilities while also taking into account immediate concerns such as infectious diseases (Leval 507-510; Barona and Perdiguero-Gil 107).

Robert Alexander describes a healthcare system that is extensive while also being organized on an egalitarian basis (Alexander 675):

Those who were in charge on the various levels of the system were elected by the appropriate general assemblies of workers. Once a week the central committee of the sindicato met with delegates from the nine primary subdivisions of the system, to coordinate activities.

However, it should be stressed that this system coexisted with, and received support from, existing state structures. In Catalonia, for instance, the regional government provided limited funds to health initiatives that were otherwise organized along libertarian socialist lines. This can be described as a sort of "dual power" in healthcare (Alexander 675). As Leval puts it (Leval 491-492):

The C.N.T. could, thanks to its contact with the working masses, and its constructive and organising spirit, be a valuable and even necessary aid, though the government, or whatever was in its place, held the advantage of disposing of the financial resources which those on the revolutionary side lacked.

To the extent that anarchist implementation of healthcare drew from Ministry of Health resources, other groups within the Popular Front such as the socialist Unión General de Trabajadores (UGT) objected to the decentralization of healthcare and role of unions in independently establishing healthcare facilities (Barona and Perdiguero-Gil 108). The Ministry of Health also supported the legalization (albeit with numerous limitations) of abortion in late 1936 (Barona and Perdiguero-Gil 110). The Ministry, along with the anarchist women's association Mujeres Libres distributed information on birth control and facilitated the participation of female medical workers (Willis 164-165).

Many institutions were organized independently of state resources. In eastern Spain, anarchists presided over the creation of the Mutua Levantina, a mutual aid network for healthcare consisting of doctors and other healthcare workers representing different specialties that survived well into the Franco era (Leval 488).

In centers of revolutionary activity such as Catalonia, the collectivization of health was carried out largely by libertarian socialists using state resources, drawing administrative divisions for healthcare in such a way that rural and remote areas had access to medical services. Each individual medical facility was also managed jointly by municipal committees and unions representing healthcare workers (Leval 496). The application of federal principles allowed the union to provide towns and villages with medical workers based on local need (Leval 498-499).

Though increasing tensions between CNT-FAI activists and other segments of the Popular Front–which no doubt worsened as anarchist initiatives encountered bureaucratic obfuscation and divergent political priorities (Alexander 893)–led to the purging of CNT-FAI members from positions of influence in 1937, there are numerous examples above that point to a popularly managed system of universal healthcare. Though social and political conditions in the U.S. are currently far different than Spain in 1936, I will use some of the libertarian socialist ideals highlighted above to evaluate specific sections of the Sanders M4A bill in order to highlight areas where we can push further as our Spanish comrades did.

A Libertarian Socialist Approach: Medicare for All, by All

SEC. 402. Consultation.

The Secretary shall consult with Federal agencies, Indian tribes and urban Indian health organizations, and private entities, such as professional societies, national associations, nationally recognized associations of experts, medical schools and academic health centers, consumer groups, and labor and business organizations in the formulation of guidelines, regulations, policy initiatives, and information gathering to ensure the broadest and most informed input in the administration of this Act. Nothing in this Act shall prevent the Secretary from adopting guidelines developed by such a private entity if, in the Secretary's judgment, such guidelines are generally accepted as reasonable and prudent and consistent with this Act.

The language here is quite vague about the composition of outside contributors to how M4A would be implemented: Note the inclusion of "business organizations" and "nationally recognized associations of experts" as a part of the consultation process. How often would such consultations take place, or would that be completely up to the Department of Health and Human Services (HHS)? Keep in mind that previous HHS Secretaries don't inspire confidence as delegates of working class power.

We should reject a technocratic approach to healthcare and embrace a federative system of decision making comprising representatives of all sectors of healthcare workers. This is not something that can be accomplished by legislation. This is not something that can be accomplished by mobilizing as voters. This is not something that can be accomplished within our present political system.

But this is also not a project that can be delayed. We should build networks of mutual aid around healthcare and we should also organize among healthcare workers, even those who already have union representation.

SEC. 403. Regional administration.

a) Coordination with regional offices.—The Secretary shall establish and maintain regional offices to promote adequate access to, and efficient use of, tertiary care facilities, equipment, and services. Wherever possible, the Secretary shall incorporate regional offices of the Centers for Medicare & Medicaid Services for this purpose.

Again, we must reject the idea that healthcare is something which can only be administered by technocrats in a top-down fashion. This means that medical training, access to healthcare, and the location of healthcare facilities must be determined by community need, addressing the existence of "healthcare deserts." This can't be done by a federal bureaucracy with no direct accountability to patients or healthcare workers.

SEC. 613. Office of primary health care.

(a) In general.—There is established within the Agency for Healthcare Research and Quality an Office of Primary Health Care, responsible for coordinating with the Secretary, the Health Resources and Services Administration, and other offices in the Department as necessary, in order to—

(1) coordinate health professional education policies and goals, in consultation with the Secretary to achieve the national goals specified in subsection (b);

(2) develop and maintain a system to monitor the number and specialties of individuals through their health professional education, any postgraduate training, and professional practice;

(3) develop, coordinate, and promote policies that expand the number of primary care practitioners, registered nurses, midlevel practitioners, and dentists; and

(4) recommend the appropriate training, education, technical assistance, and patient advocacy enhancements of primary care health professionals, including registered nurses, to achieve uniform high quality and patient safety.

These very nice objectives have been locked within a Russian nesting doll of bureaucracy – an office (Office of Primary Care), within an office (Agency for Healthcare Research and Quality)…within an office (HHS). Oh yes, and it is responsible for coordinating…with other offices (Health Resources and Services Administration). To belabor a point already made here, none of these entities are directly accountable to workers or patients.

SEC. 614. Payments for prescription drugs and approved devices and equipment.

(a) Negotiated prices.—The prices to be paid for covered pharmaceuticals, medical supplies, and medically necessary assistive equipment shall be negotiated annually by the Secretary.

While the power to negotiate with pharmaceutical companies is a step up from current policy, this still does not rule out the possibility of graft under current political conditions. If healthcare providers, pharmaceutical companies, and producers of medical supplies remain as capitalist entities, then there are two possibilities under a scenario where M4A passes:

1. Companies compensate for tighter profit margins through some combination of capital flight/capital strike, layoffs, and speed ups imposed on workers at all levels.

2. Companies strike sweetheart deals resulting in consistently high profits, perhaps even as they vociferously protest M4A. This could easily result in M4A becoming fiscally "unworkable," creating an easy pretext for later defunding and privatization.

Either scenario would make something which might seem impossible–building workers' control in all these sectors within a short timeframe­–an urgent necessity.

SEC. 1002. Establishment of the Medicare transition plan.

(3) PARTICIPATING PROVIDERS.—

(A) IN GENERAL.— A health care provider that is a participating provider of services or supplier under the Medicare program under title XVIII of the Social Security Act (42 U.S.C. 1395 et seq.) or under a State Medicaid plan under title XIX of such Act (42 U.S.C. 1396 et seq.) on the date of enactment of this Act shall be a participating provider in the Medicare Transition plan.

(B) ADDITIONAL PROVIDERS.— The Administrator shall establish a process to allow health care providers not described in subparagraph (A) to become participating providers in the Medicare Transition plan. Such process shall be similar to the process applied to new providers under the Medicare program.

Michelle Chen touches on an important issue when she writes: "there's surprisingly little discussion on how an overhaul of our health-care system would affect the people delivering our care." The precarity of labor conditions for healthcare workers should be a serious concern–not a passive one for technocrats and pundits, but for workers organized at the workplace and community level.

The present M4A legislation must make provisions for labor standards among participating healthcare providers. Even within the confines of this legislation, there is an opportunity to ensure better wages and representation for entire categories of healthcare workers, including many who are not traditionally considered as such. This is the real potential of M4A, a shift in the political terrain beyond simply "streamlining" and "cutting out the middleman" from the healthcare process.

What might seem like the "next" battle after M4A should really be thought of as part of a continuous process to achieve Medicare for All, by All–with power in the hands of communities, workers, and patients.

References

Medicare for All Act of 2017, S.1804, 115th Cong. (2017)

Elizabeth A. Willis, "Medical Responses to Civil War and Revolution in Spain, 1936–1939: International Aid and Local Self-organization," Medicine, Conflict, and Survival 24(3) (July-Sept. 2008): 159-173

Josep L. Barona and Enrique Perdiguero-Gil, "Health and the War. Changing Schemes and Health Conditions during the Spanish Civil War," Dynamis 28 (2008): 103-126

Gaston Leval. 1975. Collectives in the Spanish Revolution. Accessed March 21st, http://libcom.org/files/Gaston%20Leval%20Collectives%20in%20the%20Spanish%20revolution.pdf

Robert J. Alexander. 1999. The Anarchists in the Spanish Civil War. Westport, CT: Praeger.