Category Archives: Medical Insurance

Corporate and “Progressive” Democrats Threaten Medicare Itself

The Democratic Party won a majority in the House of Representatives in the November 2018 elections by making health care one of its top “messages.” Yet events from Bernie Sanders’ bill of 2017 to legislation that “progressive” Representative Pramila Jayapal introduced on February 27, 2019 show that the Party is on its way to destroy Medicare.

For decades activists identified the prize as “single payer health care.” The program would issue a Medicare card to everyone, like the one senior citizens get now. The card would be good at any doctor’s office, clinic, hospital, laboratory, and prescription pharmacy. These largely private businesses would be reimbursed from a public single-payer fund. The fund would receive broadly collected tax revenues; the patient would pay little or nothing at the reception desk, and no monthly premium. This is guaranteed, comprehensive health care.

In other words, single payer is Medicare for all, carried to completion by eliminating Part B premiums and by more comprehensive coverage including prescribed drugs.

Health care activists always agonized over the colorless name “single payer.” A few years ago many of them began to speak of Improved Medicare for All. Actually, it had been in the title of the benchmark bill, H.R. 676, when congressperson John Conyers introduced it in 2003. A few years later he shortened the title to The Expanded and Improved Medicare for All Act. The text remained stable, and although the bill went nowhere in Congressional committees, H.R. 676 became the centerpiece of organizing. It is readable, only thirty pages of double-spaced large type. Hundreds of trade union locals and councils endorsed this model legislation in a steady stream year after year.

The health care industry has enjoyed a long-term phase of expansion, like railroads in the latter half of the nineteenth century. Back then, the new way of moving heavy goods and people was amazing and useful; today, new biological and biochemical understanding makes possible longer life, survival from a heart attack, restored clarity of vision, and so on. In both situations, capital has had strong pricing power and taken fat profits. And just as anger at railroads swelled into a populist revolt against The Octopus (Frank Norris’ novel about the Southern Pacific railroad corporation), people today are angry at insurance corporations, pharmaceutical monopolies, and hospitals, whether or not they call themselves “non-profit.”1

Opinion polls measure growing support for single payer health care for all. Employers continue to raise the employee cost of coverage, or simply not provide a health benefit. Health insurance purchased individually on the so-called exchanges of the Affordable Care Act (“Obamacare”) turns out to be full of exceptions like a slice of Swiss cheese.

Sanders Promotes Health Care for All Then Undercuts Conyers

Popular support erupted into a political force when Bernie Sanders launched his presidential campaign at the end of April 2015. Record-breaking crowds filled his rallies around the country. The top three issues in a Sanders speech rotated – sometimes including inequality of wealth and income, sometimes climate change – but he always revved up on health care for all. It had been the cause of a few thousand health care activists. Now Improved Medicare for All became a challenge to the neoliberal establishment. For the first time in forty years, people were on the verge of a mass campaign for a major gain in their quality of life and their security.

It did not happen. Sanders did not win the Democratic presidential  nomination. He returned to the Senate, making an implicit or private deal with the party: he would speak as a independent progressive, but he will act on all serious matters as an unannounced Democrat.

Doing something about health care for people largely fell out of public view. Health care activists carried on. Policy aficionados spun proposals. Sanders had used the issue in his campaign, but sustained mass organizing for it did not happen.

Then in September 2017, senator Sanders introduced his “Medicare for All Act.” S. 1804 is three times as long as H.R. 676, and the reader must unravel cross-references within the text. Sanders made no mention of Conyers’ H.R. 676 at his press conference. Since then, no one has asked him the obvious question: Why didn’t Sanders simply introduce the text of H.R. 676 in the Senate?

The “Buy-In” Trap

Sanders’ bill would actually undermine Medicare. It would set up a “Transitional Medicare Buy-in Option and Transitional Public Option.” Sanders portrayed it as a four-year period (longer if necessary) to bring people of age 55 or over into Medicare, then down to age 45, then down to age 35, then everyone. This scheme is the very opposite of guaranteed single-payer health care for all.

How is Medicare financed today? Most of the money comes from payroll and income tax revenues, not enrollees’ Part B premiums, by a ratio of 3½ to one.2 We all pay into Medicare. At the moment when someone needs care, she gets it, period – without financial worry. That is the single-payer principle, and Medicare implements it, although not entirely, since enrollees must keep up-to-date on their Part B monthly premiums, and there are some co-payments for services.

Expanded and Improved Medicare for All would eliminate premiums and co-pays. That is what H.R. 676 declared, but in Sanders’ S. 1804 people younger than 65 could “join” Medicare by paying fat monthly premiums (a “buy-in”). People who want to sign up this way would use the notorious Obamacare exchanges.

Trade union campaigners for genuine Medicare for all, H.R. 676, wrote in a December 11, 2018 letter:

Unlike HR 676, S 1804 inserts supposedly incremental steps of public options and Medicare buy-ins for four years prior to arriving at a real single payer plan. Because S 1804 expands care while maintaining the private insurance companies, costs will skyrocket before the savings of single payer kick in. The incremental steps will become a roadblock rather than a path to single payer. Perhaps the worst part of this inclusion of the public option and the Medicare buy-in is the reinforcement of the false notion that there should or must be transitional steps to single payer. Neither the public option nor the Medicare by-in are based on sound policy. To place them in the bill for even a short period of time endangers the single payer goal.

All Unions Committee for Single Payer Health Care, HR 676, Kay Tillow, coordinator

It is a neat trick: under the guise of expanding Medicare, you make it more dependent on premiums. You change it from a public good, like the neighborhood fire station, into a commodity insurance product that individuals buy. You make health care dependent on the patient’s finances.

This perversion of Medicare is not only a fraud upon people of age 55, 45, or 35. It is a threat to Medicare itself. Whenever Medicare seems headed for a financial crunch, real or conjured, the pressure in Congress will be to shift more and more toward a premium- and co-pay-financed program rather than one supported by general and progressive tax revenues – and to take chunks of medicine out of Medicare.

An independent in name but a Democrat, in fact, senator Sanders at his press conference happily introduced several corporate Democrat co-sponsors of his bill. Behind closed doors he had let them write sections of S. 1804! The public option section was written by senator Kirsten Gillibrand of New York. “One part of the bill that I worked with my colleagues to put in was the ability for every American to buy into a nonprofit public option as part of a four-year transition…,” she said during the news conference introducing the bill.

A public option is a competition with insurance corporations rigged in their favor. They know how to repel potential enrollees who are likely to need expensive care. A government health plan cannot and, of course, should not play that game. It can either raise premiums, or it can turn the program into something like its poor cousin Medicaid. Either way, it cannot become improved Medicare for all.

Democratic Party: “Death to H.R. 676!”

Two important bills stood in contradiction to each other: one for Expanded and Improved Medicare for All (H.R. 676), the other a threat to Medicare itself (S. 1804). Conyers’ bill has been the acknowledged model legislation since 2003; Sanders introduced his in 2017.

But words do not move on their own. The corporate Democratic Party soon put H.R. 676 on the chopping block. Representative John Conyers was pushed out of Congress in a #MeToo incident, resigning from a hospital bed, denying the charges but not up to the rigor of a fair hearing if he could get one.

Somehow, sponsorship of H.R. 676 went to new congressperson Pramila Jayapal. 3 She immediately announced that she was in consultations to rewrite it. In the meantime, she surrendered the number 676 that had been reserved for Conyers’ bill since 2003. It was issued to military legislation on January 17, 2019.

After the Democrats won control of the House of Representatives in the November 2018 elections, it became more urgent for them to gut single payer health care for all. Otherwise, they might have to deliver. Representative Nancy Pelosi, during a post-election whirlwind of bargaining to make sure she became Speaker of the House, agreed to help advance the same scheme that senators Sanders and Gillibrand had put into S. 1804: a buy-in to a premium-based option for people age 50 to 64. Jayapal, who also praised Pelosi during her run for Speaker, spoke out of both sides of her mouth. “I would prefer to have a reduction of the age of Medicare so that more people could qualify but not a buy-in, because that continues the problems that we have right now.” She said lowering the eligibility age “would be an appropriate way to go where we’re taking a step forward towards a system that will ultimately cover everybody.”

The Buy-in Trick Again

Representative Jayapal introduced H.R. 1384, her replacement for the Conyers’ model, on February 27, 2019. The 119-page bill is a masterful card trick. On one hand, it maintains the ban on premiums and co-payments, and it specifies a broad list of covered medical services, including some never proposed before in such legislation.

On the other hand, Jayapal copied Sanders’ big step backward – an optional “buy-in” transition period with premiums, only shortened from his four years to two. (After the first year, minors up to age 18 and people 55 and older would move automatically into the new system.) H.R. 1384 states:

The Administrator shall determine the premium amount for enrolling in the Medicare Transition buy-in, which may vary according to family or individual coverage, age, and tobacco status,… (H.R. 1384, Title X, Subtitle A, Sec. 1002 (e)(A))

Since Conyers introduced H.R. 676 in 2003, his bill never had a premium-based buy-in. Why does Rep. Jayapal think a buy-in period is necessary?

With a buy-in transition, the first experience people would have with the new system would be yet another commodity insurance plan with monthly premiums. This is a recipe for political failure. During those two years the tentative new system would soon be under attack as financially unworkable and just not popular enough.

People could buy in if they wished as individuals through the notorious Affordable Care Act exchanges (“Obamacare”). Because of the extensive benefits, the plan would be one of the most costly choices. Unaffordable for most as an individual premium plan, trying to compete in an unreformed health care system with its bloated costs, the buy-in would attract few enrollees. Enemies of genuine universal health care will pounce on the result, demanding that genuine Medicare for All be postponed and turned into a supplement of one kind or another to corporate health insurance.

Only H.R. 676 delivers guaranteed healthcare for all, the equal care for all of which our advanced society is capable. Bernie Sanders and Pramila Jayapal, just like openly corporate yet arguably less devious Democrats, cower before insurance capital, pharmaceutical capital, hospital capital, etc. These parasites demand that healthcare be a set of commodities that some can afford and others cannot. The people or the dollar – that is the inescapable choice.

  1. A nominally “non-profit” hospital today is not the church-run charity that it might have been a hundred years ago. Non-profit simply means that the corporation is tax-exempt. It does not pay dividends to stockholders, but it still makes a profit. Banks share in the loot, and layers of executives are paid millions of dollars. Affiliated for-profit clinics and labs may suck profits out under cover. Examine the Sutter Health and Kaiser hospital chains in California, for example.
  2. Medicare trust fund trustees’ report, 2018, pp. 45 and 78.
  3. Jayapal went to elite Georgetown University, got an MBA after that, worked on Wall Street on leveraged buyouts, switched to executive positions in several nonprofits, sat a mere two years in the Washington state senate, and won election to the House in 2016.

The Movement And The 2020 Elections

The political system in the United States is a plutocracy, one that works for the benefit of the wealthy, not the people. Although we face growing crises on multiple fronts – economic insecurity, a violent and racist state, environmental devastation, never-ending wars and more – neither of the Wall Street-funded political parties will take action to respond. Instead, they are helping the rich get richer.

The wealth divide has gotten so severe that three people have more wealth than the bottom 50% of people in the country. Without the support of the rich, it is nearly impossible to compete in elections. In 2016, more than $6.5 billion was spent on the federal elections, a record that will surely be broken in 2020. More than half that money came from less than 400 people, from fewer than 150 families.

People are aware of this corruption and are leaving the two Wall Street parties. According to the census, 21.4% of people do not register to vote, and in 2018, less than a majority of registered voters voted. According to Pew Research, independents (40% of voters) outnumber Democrats (30%) and Republicans (24%). The largest category of registered voters is non-voters. Yet, the media primarily covers those who run within the two parties, or billionaire independent candidates who do not represent the views of most people.

This raises a question for social movements: What can be done to advance our agenda over the next two years when attention will be devoted mostly to two parties and the presidential race?

Progressives Failed to Make the Democratic Party a Left-Progressive Party

People in the United States are trapped in an electoral system of two parties. Some progressives have tried — once again — to remake the Democratic Party into a people’s party.

We interviewed Nick Brana, a former top political organizer for the Sanders presidential campaign, on the Popular Resistance podcast, which will be aired Monday, about his analysis of the Democratic Party. Brana describes the efforts of progressives to push the party to the left over the past three years and how they were stopped at every turn. They tried to:

  • Change the Democratic Party Platform: The platform is nonbinding and meaningless but even so, the Party scrapped the platform passed by the delegates the following year and replaced it with a more conservative one called the “Better Deal.”
  • Replace the Democratic National Committee (DNC) Chair. They discovered the chair is picked by the DNC, which is made up of corporate lobbyists, consultants, and superdelegates, who picked Hillary Clinton’s candidate Tom Perez, over Rep. Keith Ellison, former co-chair of the Progressive Caucus.
  • Replace the DNC membership with grassroots activists. Instead, at the DNC’s  2017 fall meeting, the Party purged progressives from the DNC, making it more corporate and elitist.
  • Fix the Presidential primary process after it was disclosed that the DNC weighted the scale in favor of Hillary Clinton over Bernie Sanders. The Democrats rigged the Rules Commission to accomplish the opposite; i.e., kept closed primaries to shut out progressive independent voters, kept joint fundraising agreements between the DNC and presidential campaigns, slashed the number of states that hold caucuses, which favor progressive candidates, and refused to eliminate superdelegates, moving them to the second ballot at the convention but reserving the right to force a second ballot if they choose.

Further cementing their power, Democrats added a “loyalty oath” which allows the DNC chair to unilaterally deny candidates access to the ballot if he deems the candidate has been insufficiently “faithful” to the Party during their life. And the DNC did nothing to remove corporate and billionaire money from the primary or the Party, ensuring Wall Street can continue purchasing its politicians.

The results of the 2018 election show the Blue Wave was really a Corporate Wave. Brana describes how only two progressives out of 435 members of Congress unseated House Democrats in all of 2018: Alexandria Ocasio-Cortez and Ayanna Pressley. When Pelosi was challenged as leader of the House Democrats, she was challenged from a right-wing Blue Dog Democrat, not a progressive Democrat, with many “progressives” including AOC and Rep. Jayapal speaking up for Pelosi’s progressive credentials.

In contrast to the failure of progressives, the militarists had a banner 2018 election. The 11 former intelligence officials and veterans were the largest groups of victorious Democratic challengers in Republican districts. Throughout the 2018 election cycle, Democratic Party leaders worked against progressive candidates, for instance pushing them to oppose Medicare for all.

This is an old story that each generation learns for itself: the Democratic Party cannot be remade into a people’s party. It has been a big business party from its founding as a slaveholders party in the early 1800s, when slaves were the most valuable “property” in the country, to its Wall Street funding today. Lance Selfa, in “The Democrats: A Critical History,” shows how the Democratic Party has consistently betrayed the needs of ordinary people while pursuing an agenda favorable to Wall Street and US imperialism. He shows how political movements from the union and workers movements to the civil rights movement to the antiwar movement, among others, have been betrayed and undermined by the Democratic Party.

Social Movements Must Be Independent of the Corporate Parties

The lesson is mass movements need to build their own party. The movement should not be distracted by the media and bi-partisan politicos who urge us to vote against what is necessary for the people and planet. At this time of crisis, we cannot settle for false non-solutions.

Howie Hawkins, one of the founders of the Green Party and the first candidate to campaign on a Green New Deal, describes, in From The Bottom Up: The Case For An Independent Left Party, how Trumpism is weakening as its rhetoric of economic populism has turned into extreme reactionary Republicanism for the millionaires and billionaires. He explains that Democrats are not the answer either, as “they won’t replace austerity capitalism and militaristic imperialism to which the Democratic Party is committed.”

The result, writes Hawkins, is we must commit ourselves “to build an independent, membership-based working-class party.” Even the New Deal-type reforms of Bernie Sanders “do not end the oppression, alienation, and disempowerment of working people” and do not stop “capitalism’s competitive drive for mindless growth that is devouring the environment and roasting the planet.”

Hawkins urges an ecosocialist party that creates economic democracy; i.e., social ownership of the means of production for democratic planning and allocation of economic surpluses as well as confronting the climate crisis. He explains socialism is a “movement of the working class acting for itself, independently, for its own freedom.”

He urges membership-based parties building from the local level that are independent of the two corporate-funded parties.  Local branches would educate people on issues to support a mass movement for transformational change. Hawkins is a long-time anti-racism activist. He became politically active as a teenager when he saw the mistreatment of the Mississippi Freedom Democrats, who elected sharecropper Fannie Lou Hamer as their co-chair. He believes a left party must confront racial and ethnic tensions that have divided the working class throughout its history.

Hawkins points out the reasons why the time is ripe for this. Two-thirds of people are from the working class compared to one-third in 1900. The middle class (e.g. teachers, nurses, doctors, lawyers, technicians) holds progressive positions on policy issues creating super-majority support for critical issues on our agenda. The working and middle classes are better educated than ever. Over the last forty years, their living standards have declined, especially the younger cohort that is starting life in debt like no other generation. Finally, the environmental crisis is upon us and can no longer be ignored creating a decisive need for radical remaking of the economy.

Critical Issues To Educate And Mobilize Around

Popular Resistance identified a 16 point People’s Agenda for economic, racial and environmental justice as well as peace.  Three issues on which we should focus our organizing over the next few years include:

National Improved Medicare For All: The transformation of healthcare in the US from an insurance-based market system to a national public health system is an urgent need with over 100,000 deaths annually that would not occur if we had a system like the UK or France, two-thirds of bankruptcies (more than 500,000 per year) are due to medical illness even though most of those who were bankrupted had insurance, 29 million people do not have health insurance and 87 million people are underinsured.

While many Democrats are supporting expanded and improved Medicare for all, including presidential candidates, the movement needs to push them to truly mean it and not to support fake solutions that use our language; e.g., Medicare for some (public options, Medicare buy-ins and reducing the age of Medicare). Winning Medicare for all will not only improve the health of everyone, it will be a great economic equalizer for the poor, elderly and communities of color. This is an issue we can win if we continue to educate and organize around it.

Join our Health Over Profit for Everyone campaign.

Enacting a Green New Deal. The Green New deal has been advocated for since 2006, first by Global Greens, then by Green Party candidates at the state level and then by Jill Stein in her two presidential runs. The issue is now part of the political agenda thanks to Alexandria Ocasio-Cortez. She and Senator Ed Markey led the introduction of a framework for a Green New Deal, which is supported by more than 50 Democrats including many presidential candidates.

Their resolution is a framework that the movement needs to educate and organize to make into real legislation to urgently confront the climate crisis, which has been mishandled by successive US presidents. The movement must unite for a real Green New Deal.

The Green New Deal has the potential to not only confront the climate crisis by shifting to a carbon-free/nuclear-free energy economy but to also shift to a new economy that is fairer and provides economic security. Remaking energy so it serves the people, including socializing energy systems; e.g., public utilities, could also provide living wage jobs and strengthen worker’s rights. It will require the remaking of housing, which could include social housing for millions of people, a shift from agribusiness to regenerative agriculture and remaking finance to include public banks to pay for a Green New Deal. The Democratic leadership is already seeking to kill the Green New Deal, so the movement has its work cut out for it.

Stopping Wars and Ending US Empire: US empire is in decline but is still causing great destruction and chaos around the world. US militarism is expensive. The empire economy does not serve people, causing destabilization, death and mass migration abroad as well as austerity measures at home. Over the next decade, the movement has an opportunity to define how we end empire in the least destructive way possible.

As US dominance wanes, the US is escalating conflicts with other great powers. The US needs to end 15 years of failed wars in the Middle East and 18 years in Afghanistan. In Latin America, US continues to be regime change against governments that seek to represent the interests of their people especially in Venezuela where the threat of militarism is escalating, but also in Nicaragua, Bolivia, and Cuba. The migrant issue being used by Trump to build a wall along the US-Mexican border is created by US policies in Central America. And, the US needs to stop the militarization of Africa and its neocolonial occupation by Africom.

Take action: Participate in the Feb. 23, 2019, international day of action against the US intervention in Venezuela and the “Hands-Off” national protest in Washington, DC on March 16, 2019.

There will also be actions around April 4, when NATO holds its 70th-anniversary meeting in Washington, DC, on the same day as the anniversary of Martin Luther King, Jr.’s death and his Beyond Vietnam speech.

Join the Spring Actions against NATO in Washington, DC.

While the US lives in a mirage democracy with manipulated elections, there is a lot of work we can do to build a mass movement that changes the direction of the country. This includes building independent political parties to represent that movement in elections.

Medical Ethics Can Only Be Restored With a Single-Payer System

It is the year 2019, and American health care is in a state of profound crisis. While oligarchic parasites from the pharmaceutical industry and health insurance companies make enormous profits, bankruptcy and the fear of being denied care hang over the American people like a sword of Damocles. This diabolical order, predicated on greed and placing profit-making over human life, has stripped doctors of their autonomy and given birth to an inhuman and deeply unjust multi-tier system.

Unless we are able to disenthrall ourselves from the tyranny of privatized health care, Americans will continue to die as a result of avaricious insurance companies denying coverage for needed drugs and procedures, and from treatment which is delayed due to requests for “prior authorizations.” Moreover, medical students and residents are being taught that good health care is a privilege and not a right, and that the oath to do no harm applies, but only to a privileged few. In a world turned upside down, doctors in training are being inculcated with the pernicious notion that the job of a doctor is not to listen to the patient, perform a comprehensive physical, respect the patient’s privacy, get an accurate history, diagnose, treat, and follow up; but rather to help their employer maximize the greatest possible profit. Indeed, the number of patients doctors are expected to see each day has become increasingly unwieldy, and this has gravely undermined their ability to practice good medicine.

Are we to continue to buy and sell health care as if it were a consumer good? The wealthiest can buy a Ferrari, the upper middle class a Lexus, the working class a Toyota, and the poor a used car. The very destitute cannot afford a car at all and have to take the bus. Clearly, it is barbaric to run a health care system in such a manner, and yet this is precisely what we are doing.

From their very first day of residency, doctors in training are being indoctrinated with the following code of dishonor: “This patient has a right to privacy, while this patient doesn’t. This patient has a right to informed consent, while this patient doesn’t. This patient has a right to linger following their surgery, while this patient has to leave immediately following their procedure. This patient has a right to their own room with a view, while this patient will be crammed into a room with a stranger.” The idea that medical ethics can coexist with such an ideology is inane and deeply delusional.

Many institutions have established multi-tier systems which are so egregious that it has resulted in the implementation of a Jim Crow health care system. Indeed, these institutions often place the “humans” and the “subhumans” in physically separate facilities. In this internationalization of the third world model, patients with inferior insurance are regularly arm-twisted into being clinical guinea pigs and used as laboratory animals with which to teach impressionable residents and fellows. This railroading of the “losers” into resident clinics magnifies the innate power imbalance inherent in the doctor-patient relationship a hundredfold, and constitutes a violation of patient privacy, informed consent, confidentiality, and patient dignity all of which fall under the umbrella of the physician’s oath to do no harm.

In an article in Annals of Emergency Medicine titled “Observers in The Medical Setting”, by Joel M. Geiderman, MD, the author posits that:

Privacy is treasured by citizens in free societies around the world, and any infringement on it is considered by many to be an affront to personhood. In the United States, the right to privacy runs deep in the American soul.

Residents that have no qualms about observing office visits without the patient’s consent are likely to go on to violate the privacy of their patients as attendings, and may very well spend their careers mindlessly violating and debasing their fellow human beings, only to periodically vent their frustrations on the Internet over all the “self-entitled” patients that don’t appreciate their diligence and divine wisdom. And while there are undoubtedly some residents that may have misgivings over participating in a clinic which coerces patients with unglamorous insurance plans into being medical models, as we have largely become a nation of careerists, the apelike majority will blindly follow orders.

Geiderman writes:

In addition to informational privacy, or protection of their personal health information, patients are also entitled to physical privacy, that is, a zone of personal space where access is under the patient’s autonomous control. Closely linked is the right to one’s modesty, a human value that is expressed in the Bible in Genesis, as Adam and Eve wished to shield their nakedness even from their Creator.

Should a physician order countless tests and prescriptions which are subsequently vetoed by the insurance companies, assuming they are not vehemently opposed to single-payer, they are unequivocally not to blame for this. However, once a doctor has knowingly participated in a clinic which is predicated on coercing patients with inferior insurance into being clinical guinea pigs for residents and fellows to practice on, they have stepped into a void beyond which lies a wasteland devoid of honor, dignity, integrity and morality. Any participation in such an egregious multi-tier system on the part of a physician threatens the survival of the doctor-patient relationship and constitutes unbridled and unmitigated heresy.

This descent into barbarism is glaringly on display in many dermatology departments, which are able to choose from the crème de la crème of our nation’s medical graduates, dermatology being one of the most competitive and sought-after specialties. These departments often assign patients with inferior insurance to a resident, who in turn has to be supervised. And so through artifice and trickery, the patient is duped and arm-twisted into being a medical model without their consent. The attending arrives and spews platitudes such as “The more eyes the better,” “There’s nothing we’ve never seen before,” and “We’re all professionals here” as if this can mitigate the fact that they are teaching their residents that the have-nots deserve neither privacy nor respectful care. That neither the attending nor the resident would even think of seeking care in such a clinic underscores the fact that in the innermost recesses of their addled brains they are cognizant of the fact that what they do is unethical. To gain admission into MS-13 one would likely have to commit murder. When doing a dermatology residency at an elite Manhattan medical institution, violating the privacy of hundreds of patients is the price of admission into this rather alarming society.

In conjunction with this uncivilized behavior, doctors in training are duly inculcated with the idea that informed consent is a privilege and not a right. Many of these creatures will go on to do practice pelvic exams on anesthetized patients, or even perform forced cavity searches at the request of law enforcement. Indeed, doctors that have no respect for informed consent are a danger to themselves, and a danger to those who place their trust in their care.

Reactionary physicians at elite institutions take for granted having the finest insurance, and delude themselves into thinking that patients go to resident clinics of their own volition, and not because their insurance dictates that they go there. Few realize that if a Medicaid patient sees a doctor out of network they can actually lose their insurance. Restoring physician choice to the American patient is absolutely vital if we are to restore any semblance of democracy to our health care system. For as long as a vast swath of American society is forced to work with doctors that they do not wish to work with, all talk of “patient-centered care” is farcical and absurd.

If a woman with good insurance needs a prescription for birth control, she can leave a doctor who insists on doing a pelvic exam prior to ordering the prescription, whereas a patient with inferior insurance can be bullied into submitting to the unnecessary exam due to the lack of gynecologists that take their insurance. While the pharmaceutical companies, health insurance companies, and hospitals grow fat with the lucre sucked from the blood of their patients, not a day goes by when the underinsured do not experience such indignities. And while the government continues to abrogate its social responsibility to implement a single-payer system, many patients that do have good insurance are a cancer diagnosis or car accident away from losing their job and their superior insurance along with it.

In non-union jobs employers often change insurance plans every year, perpetually searching for the plan which is most affordable. This in turn forces patients to constantly change doctors, and if a patient has a complex medical condition, the consequences of perpetually denying such an individual continuity of care can have disastrous consequences. Indeed, even if a patient is healthy, this can result in reduced health care outcomes over the long-term. And just as the multi-tier education system has come to be accepted without question by millions of our countrymen, the multi-tier health care system has likewise left its mark on the consciousness of millions of Americans, and is increasingly accepted as “normal” by the insouciant and the knavish alike.

Patients that freelance can also see their insurance change while their income fluctuates, and this can likewise force a patient to change doctors. Like a marriage, the doctor-patient relationship is predicated on a sacred trust, and being forced to constantly change doctors disrupts, destabilizes, and destroys these relationships.

The takeover of the medical decision-making process by insurance companies – essentially criminal gangs – has stripped doctors of their autonomy and is a driving force behind physician burnout. For after every treatment plan agreed upon between a doctor and a patient, doctors’ orders are increasingly countermanded by the patient’s insurance company. Not a day goes by without a doctor prescribing a drug which a patient’s insurance refuses to cover. The doctor then calls in a second drug – a variation on the first – and the insurance company may refuse coverage for this as well. Then a third drug is called in – perhaps not even of the same class – and this too may be rejected. Meanwhile, the patient has been examined by their doctor, not by an MD working for the insurance company. Should a physician order a PET or CT scan to determine whether a patient has metastatic cancer following a needle biopsy that has revealed a mass to be malignant, it is not uncommon for the patient’s insurance to declare this request as requiring “prior authorization.” This pervasive undermining of a doctor’s authority is without precedent in American health care, and these delays have caused people to die.

In addition to living paycheck to paycheck, millions of Americans are under the illusion that their health insurance plan is much better than it is, incognizant of the fact that they are a health problem away from financial ruin. The insouciant among us who ask where the money is going to come from should consider why they failed to ask this question prior to the invasions of Iraq and Afghanistan. The money will come from demilitarizing our society and transferring to a peacetime economy. Are the underinsured not victims of terrorism?

As their entire raison d’être is anchored in maximizing the greatest possible profit, hospitals ruthlessly exploit their residents, many of whom work eighty hours a week or more. In an article on KevinMD titled “The secret horrors of sleep-deprived doctors,” by Pamela Wible, MD, a doctor speaks of their training:

I did my internship in internal medicine and residency in neurology before laws existed to regulate resident hours. My first two years were extremely brutal, working 110 to 120 hours/week, and up to 40 hours straight. I got to witness colleagues collapse unconscious in the hallway during rounds, and I recall once falling asleep in the bed of an elderly comatose woman while trying to start an IV on her in the wee hours of the morning.

It is not uncommon for young doctors to accidentally kill patients as a result of being so exploited and sleep deprived, and this has undoubtedly played a role in making hospital errors the third leading cause of death in this country. Wible quotes another physician:

I have made numerous medication errors from being over tired [sic]. I also more recently misread an EKG because I was so tired I literally couldn’t see straight. She actually had a subarachnoid hemorrhage, and by misreading the EKG, I spent too much time on her heart and didn’t whisk her back to CT when she came in code blue. She died.

This is the inevitable result of exploiting residents as if they were fast food workers. Moreover, as has transpired with education, health care is simply becoming unaffordable. In an article for KevinMD titled “The demonization of socialized medicine,” by Matthew Hahn, MD, the author writes, “It’s almost become a ritual now where a patient (who usually has health insurance) is diagnosed with cancer, and then we attend their community fundraiser to help them with the costs of their care.”

Many doctors are compelled to spend countless hours each month filling out electronic medical records which have been foisted on them by the insurance companies. To assist with this onerous task, doctors increasingly employ a nurse or medical scribe to type the required information into the computer during a patient’s office visit. This destroys any semblance of confidentiality and undermines the physician-patient bond. It can also result in the doctor failing to obtain a comprehensive history.

Some physicians feel that the way to regain autonomy is to not take insurance at all, but by doing this they are denying care to patients with low income; i.e., the majority of the country. In theory, doctors take an oath to do no harm. In reality, they are in thrall to rapacious corporate power and are more likely to spend a lot of time violating patients’ privacy, doing mind-numbing data entry, and failing to disclose the risks of extremely dangerous drugs such as opioids and psychiatric medications.

Liberal saints Obama and Hillary had an opportunity to make a push for single-payer, but instead chose to spend trillions of dollars murdering large numbers of people in Ukraine, Iraq, Afghanistan, Yemen, Libya, Honduras and Syria while maintaining nearly a thousand bases all around the world. How many more patients will be forced into bankruptcy? How many more souls will be debased and defiled? How many more human lives will be lost?

Capitalism Is Killing Patients… And Their Physicians

Photo Greanville Post

Physician burnout, depression, and suicide increasingly invade discussions within the medical field. Depression and suicide are more common among male and female physicians, with suicide rates 1.41 and 2.27 times greater than that of the general male and female populations, respectively. Though, the insults to the mental health of physicians begins much earlier in their career.

While the numbers may vary from study to study, some 28 percent of medical residents experience a major depressive episode during their training compared to 6 to 8 percent of the general population. These numbers are important, not only because suffering physicians are suffering humans in their own right, but also because this epidemic leads to poor patient care.

As a recent study out of the Stanford School of Medicine suggests, burnout and depression in physicians can lead to medical error and death. Many have tried to explain the causes of the epidemic, referencing everything from unmanageable workloads and work inefficiency, to lack of meaning in work and lack of work-life balance. Films are now being produced to shine light on the issue. In her TED talk “Why Doctors Kill Themselves,” Pamela Wible points to a medical school culture of hazing and bullying that continues into residency, along with a professional culture that hinders physicians from obtaining mental health treatment.

These factors certainly contribute to the epidemic, but when discussing physician suicide, we ignore the elephant in the room: capitalism. We are unable to recognize how the exploitation and alienation of physicians is integrally connected to this dominant economic system, but nothing could be more poignant, given in the state of the world today.

Ironically, the same destructive system that is driving physicians to extremes is also the main driver of the deterioration of health of the patients and populations, requiring patients to see physicians in the first place. The sooner we realize and confront our own exploitation, the sooner we can join in the fight to address the real driver of disease that is plaguing physicians and patients.

The System Outlined

Busy physicians may not have time to study how the world’s prevailing economic system functions, but doing so could benefit both our profession and the patients with whom we work. To briefly discuss, inside this system the working class that does not own the means of production is forced to sell its labor to an employer to survive.

A few corporations control most of the market for each of the commodities they produce. In these corporations, a very small sector of a board of directors and majority shareholders makes essentially all of the decisions on what to produce, where to produce and how to distribute profits. This puts the working class in a vulnerable position.  With the ultimate goal of profit maximization, decisions are often made by the corporate class which are not in the best interest of workers and negatively affect the health of entire communities.

Outsourcing work, closing factories, creating poor working conditions to cut costs, polluting waterways and the environment–decision after decision may initially increase profits, but in the long term harms health. This harm to health can be more obvious, as when air and water are polluted, or more subtle, for example, when families are put under chronic stress–which eventually leads to various forms of illness– from poor workplace conditions or income insecurity secondary to factory closure and outsourcing.

In this system, certain “costs”–the health of families, and entire communities being destroyed–are “externalized.” This means the business itself does not pay for these costs of poor societal health, which are created secondary to decisions made by business executives to increase profits. Such decisions are made by a small number of wealthy, powerful individuals pursuing their interests for greater wealth and power accumulation at expense of all else.

As economists such as Thomas Piketty have shown by combing through economic records from as far back as the 18th century, capitalism inherently generates inequality, concentrating wealth into the hands of the few at expense of everyone else. Study after study shows us that socioeconomic inequality itself is detrimental to patient health and actually increases morbidity and mortality.

Despite the negative effects, the working class today is more productive than ever, while wages remain flat (or are sometimes even lower) and work hours continue to increase. Workers struggle to put food on the table and meet basic needs, while the ownership class continues to become richer. Workers are exploited and reduced to tools for industry, many times forced to do mundane tasks or assignments over and over. They are alienated, or separated from the control and the product of their labor, each day they go to work. Inside this system workers are ultimately reduced to mechanistic cogs producing profit for large corporations.

This combination of being overworked and lacking true meaning and fulfillment in the work being done, drives more and more throughout both the white and blue collar sectors into despair. As Johan Hari, shows in his recent work Lost Connections: Uncovering the Real Causes of Depression and Unexpected Solutions, workers become separated from loved ones and from things that bring them joy as they work multiple jobs for longer hours as they struggle to make ends meet.

This constant stress leads to anxiety, depression, and various other forms of disease. Meanwhile, all medicine has to offer for them are at best poor attempts–many times with questionable supporting data demonstrating efficacy– to numb the pain that much larger systemic structures continue to create.

Unfortunately, the corporate elite know no limits in this system. They continue to exploit the masses and drive more and more into poverty and desperation while concentrating wealth in ever fewer hands. In America today, the three wealthiest individuals own the same wealth as the entire bottom half of the population, more than 160 million individuals. In order to maintain this system, the elite must ensure that the members of the working class fight amongst themselves rather than direct their rage toward those who are benefiting off of the oppression of the masses.

The capitalist system, born from racism and white supremacy as highlighted in studies such as Edward Baptist’s The Half That Has Never Been Told: Slavery and the Making of American Capitalism, continues to separate members of the working class based on social constructs such as race. At the same time, through a multitude of mechanisms, the system creates a self-loathing, insecure public, driven to constant consumption, leading to the pollution of the earth and poisoning of community after community.

These various forms of structural violence are the true drivers of disease and suffering, of which the health care system sees the results, but has little to no ability to truly address. The health of the majority of the population deteriorates and the elites benefit. Capitalism’s need to endlessly expand and its effect on the earth, has literally lead some scientists to call for the designation of a new geologic era called the anthropocene to describe the effect humans have had on the earth.

Scientists now warn we have moved into the sixth great mass extinction of species seen in our world’s history. A new report by the World Wildlife Fund (WWF) suggests, “Humanity has wiped out 60% of mammals, birds, fish and reptiles since 1970, leading the world’s foremost experts to warn that the annihilation of wildlife is now an emergency that threatens civilisation.” Meanwhile, a new U.N. Intergovernmental Panel on Climate Change (IPCC) report warns us that humanity has only a dozen years to address global warming to avoid increasing droughts, floods, etc., which will inevitably lead to more poverty and illness.

Capitalism does not just threaten the health and well being of every human, but life on this earth as we know it. Capitalism operates as a terminal cancer, knowing no limits to its endless growth and consumption, destroying systems necessary to survival and threatening the continued existence of its host.

Medicine Has Not Escaped

What is outlined above are the underlying causes of the majority of disease and suffering. The prevailing economic system in the world today commodifies every aspect of life including health care. As a result, the health of the public, especially the US public, is subjected to a barrage of market mechanisms.

US medical professionals, while often paid more than the typical member of the working class, are still forced to operate inside of this system that places profits above patient health. We see how this system harms our patients, limiting availability of the care they need, but we tend to miss that we also are damaged by this same system.

As Howard Waitzkin and the “Working Group on Health Beyond Capitalism” state in the book, Health Care Under the Knife: Moving Beyond Capitalism for Our Health,” until the 1980s, doctors, for the most part, owned and/or controlled their means of production and conditions of practice.” This allowed them to have control over things such as their work hours and how much time to spend with patients. As the Working Group references, “loss of control over the conditions of work has caused much unhappiness and burnout in the profession”.

As other members of the proletariat, or working class, have experienced for years, doctors now no longer have control over their labor. Now corporations or other large institutions control such decisions. Physicians have become “proletarianized” and while not members of the traditional working class, they have become tools in the corporate wheel of profit production. This has left us with a health system parasitized by the capitalism that cares more about profit production than it does the care of human beings.

The medical industrial complex, made of a multitude of different institutions–hospital corporations, large insurance companies, or pharmaceutical and device corporations and, more specifically the corporate elite who control these corporations–ultimately governs a majority of the large scale, structural decisions that affect patient care. The elite in these institutions, just like other capitalist organizations, make decisions that affect the lives of the majority with little to no input from those who are affected by these decisions.

They govern the prices of drugs–often leading to the obscene drug prices–and how long a physician should be spending with his or her patients in the clinic. These organizations have the primary goal of maximizing profit (regardless of whether they bear the title of “for profit” or “non-profit”) above all else. Consequently, patient health really becomes secondary in this system.

The metastasis of capitalism’s perverse incentives to even the sector that claims to care for the health of human beings, has given us the ineffective, damaging system we have today. Since profit production is of prime importance, physicians–and really health care providers in general–must be trained to be efficient tools for profit, seeing more patients more quickly, knowing how to bill appropriately, etc.

These incentives limit a physician’s ability to do what he or she actually went into medicine (or should have) for: to help people. Physicians want to help their patients, but are simply not able to truly address patient suffering because addressing the causes, as highlighted above, are outside the scope of a profit based medical system.

To understand how exactly this system creates human tools for health care profit while in the process leaving them physically and mentally broken, we must delve into the medical education and training structure and analyze how medical providers are conditioned to accept their own exploitation.

Training in the Art of Being Exploited

Step 1: Medical School

Medical trainees in the US enter medical school at least generally claiming they have some interest in caring for other human beings. Unfortunately, little do they know they are entering a system designed to prime them for their own exploitation from the second their training begins—one could argue even well before that point–and subsequently throughout their residency training.

During medical school, students are forced to study innumerable hours while being told they have to “lay a good foundation” of knowledge for their future practice. The first 2 years in most medical schools are classroom based, where insurmountable amounts of information are thrown at students as they are told “this is just the way medicine is, get used to it.”

Unfortunately though, much of the information students spend their time studying–or more often mindlessly memorizing–will never be used when caring for patients. This information is absorbed, regurgitated on an exam, and then often forgotten. One thing students do begin to learn–if they hadn’t already through their undergraduate education or their grade school education prior–is to listen to authority figures’ demands if they would like to succeed.

Students have little influence on what they are being taught. Instead, they must accept what they are being told or they may not pass their next exam. Students who entered medicine eager and idealistic, hoping to help others, begin to slowly withdraw from their individual passions and interests simply because tests, rotation evaluations determined by the opinions of supervising providers students must impress, and board exams are deemed more important. They are taught that listening to authority figures at the expense of their own interests and passions, comes first and then they can try to pursue their interests if they have time. This obviously can affect the mood and morale of a training physician.

During their third year, medical students are forced to spend numerous hours in the hospital. They are also required to take “shelf exams” at the end of each rotation, which can often have a large impact on their overall rotation grade. Because slight differences in grades can affect residency opportunities, students spend free-time studying for these exams instead of participating in activities to maintain their own mental and physical well being. While the exam scores offer little insight into the type of a physician the student will become, they serve to add extra pressure on students and ensure that they spend little time actually thinking for themselves while they are out of the hospital.

During fourth year many students are expected to complete sub-internships in the fields they are are interested in going into for residency training. These sub-internships normally require students to work near their 80 hour work limit, congruous to work limits of residents (more on that shortly). Medical students often carry their own patient panels, write notes that can be co-signed, and can even pend medication orders to be approved. The main difference between them and an actual paid intern is that they do not get paid. Instead they must work to “impress” their superiors in hopes of obtaining a positive evaluation. Once again, students are taught that listening to and striving to impress authority is their ultimate goal.

After four years of indoctrination, in addition to a medical degree, most medical students are given one final parting gift on their way into residency: hundreds of thousands of dollars of debt. This debt serves as a convenient way of pushing newly minted doctors into financial constriction when entering their residency.

No matter how they view their new employer or the field they have chosen, they know that they now have hundreds of thousands of dollars that they must find some way to pay back. This makes them much less likely to question or challenge authority in their new positions because doing so could impede completion of their training, sabotaging their career and only chance to escape debt. Along, with the inherent emotional stress of caring for sick patients, these financial difficulties can lead to depression, anxiety and a host of mental health issues in the newly minted physician.

Step 2: Residency

Once medical school graduates enter residency, they have already been primed for their inevitable exploitation, understanding that they need to take direction from authority, curtail their passions to make them more palatable to superiors, and most importantly, suppress any depression or anxiety they feel secondary to an ineffective, exploitative system. They now have few options–or are at least told so–other than to continue through residency. They know that to find themselves at this stage, they have made significant financial and emotional sacrifices, often losing connection with the people and things they love in order to fulfill education requirements.

Unfortunately, the exploitation of these newly minted doctors is just beginning.  During training, residents are forced to work often 80 hours per week doing a large portion of the patient care in hospitals (not to mention the additional hours of preparation outside of hospital or clinic, which are not counted toward this 80 hour limit). Residents are salaried, so they provide a cheap, efficient source of labor for hospitals and clinics. Residents become physically and emotionally exhausted trying to care for maxed out patient loads effectively in understaffed hospitals. Work hours become normalized over time and residents simply expect to be working an unhealthy amount of time in the hospital or at least convince themselves that it is normal to maintain their own sanity. It is no wonder this situation plunges many, who are already at risk, into burnout and depression.

Throughout residency, residents do, admittedly, grow exponentially in their ability to care for patients and become independently functioning physicians. Though, there is another type of growth that occurs during these years, which is seldom discussed.

Residents are groomed to be efficient, effective profit producers once they enter the workforce. For example, over their time in residency, a large degree of emphasis is placed on residents meeting particular “quality measures” for the clinic or hospital settings. Training after training is spent ensuring residents understand how to properly bill and submit insurance claims. Residents learn how to see patients extremely quickly and complete entire patient visits within 15 minutes. As anyone who has even interacted with a health care provider can attest, this is not enough time to actually make any significant interpersonal connection with a patient.

Either during this visit or after, residents must also learn to input information into whichever electronic medical record their training center uses. As Matt Anderson notes in Health Care Under the Knife commenting on EMRs, “most were designed to capture billing and quality information, not facilitate clinical care.” Residents end up spending more time looking at a computer than they do connecting with a patient. In the inpatient setting, a hospitalized patient might only see their doctor for a few minutes each day. This is partially because the rest of the day is spent documenting a coordinating care inside of a completely nonsensical system to ensure hospitals will be able to cash in on patient hospital stays.

This puts individuals, who went into medicine to care for and make connections with patients, torn between still trying to achieve this goal and meeting designated “quality measures.” If they are not able to see patients fast enough in the clinic or inpatient hospital setting they may not be seen as “marketable” to employers. This is clearly an environment that can breed physical, mental, and emotional suffering in the exploited trainee.

Even while studies have shown these grueling hours put both patients and residents at risk, when it comes to actually addressing the problems highlighted above, the onus is consistently put on the provider to maintain “self care.” From the beginning of residency, different “mental health departments” speak with residents about the importance of maintaining self care and “balance,” while at the same time maintaining an exploitative system that overworks its employees and drives suffering. Residents are a cheap form of labor for hospitals or clinics, and actually addressing this problem at a systemic level would be too threatening to the profitable status quo.

How the system’s leaders speak about these work conditions is very telling. For example, in 2016 Dr. Janice Orlowski, the Chief Health Care Officer with the Association of American Medical Colleges (AAMC), stated:

The individual is going to go into a profession where their profession calls on them to work extended hours and to be available at unusual hours […] We need to train individuals who can learn to pace themselves, who can recognize when they have sleep deprivation or when they are stressed.

This is an interesting statement, coming from someone who should know the demands put on residents drastically limits their capacity to “pace themselves.” It is clear that there is much more concern for protecting a public image of medicine and hospital programs than there is for addressing the crisis of physician depression and suicide.

Step 3: Practicing Physicians

Finally, if not already burned out, the physician has escaped residency and now believes that he or she will be able to practice “however one wants.” Unfortunately, any overburdened physician–either fresh out of residency or seasoned–who has worked inside a busy hospital or clinic, can attest to feeling tired, overworked, and often unfulfilled, in part due to their lack of patient connection as they are rushed from patient to patient and progress note to progress note.

Again, citing Matt Anderson in the Health Care Under the Knife’s section “Becoming Employees: The Deprofessionalization and Emerging Social Class Position of Health Professionals,” concepts typically lauded again and again in the health sector–”value, efficiency, quality, and market discipline–are part of an ideology to justify corporate control over the work of physicians and other works providing health services.” He references Marx’s concept of alienation–the separation of worker’s control over his or her labor– and describes how more and more health care providers are separated from what they once truly loved about their work, and now must fill the primary role of profit producer and secondary role of health care provider. If this separation did not occur during residency, there is a good chance it will when outside of training working for an employer.

While practicing, providers are still attempting to treat patients who present with illnesses created by the much larger system of capitalist exploitation referenced above, but their training prior to starting independent practice in no way, shape, or form has actually prepared them to join the communities they serve in combating these larger oppressive systems. On the contrary, what they were taught was to keep their head down, survive, and make it through exploitative residency programs. They are in regular practice and know how to put in a billing code and attempt the near impossible task of making a true connection with someone in a 15 minute clinic visit, but have not remotely learned how to begin to resist a parasitic capitalist system damaging both their colleagues and their patients.

At the same time, even if a physician did want to step outside of traditional boundaries to help challenge the true socioeconomic and structural causes of disease highlighted above, the provider still has a massive amount of student loans constricting their decisions. They may also have started a family or accumulated other financial constraints during residency. This leaves them with few options and many find it easier to get back in the clinic, put their heads down, and tell themselves they are really helping to address patient health. When in reality, they have been indoctrinated into a system based on profit maximization and blunting of patient suffering at best.

This endless process of day after day in clinic, seeing little to no progress at a systemic level, can become frustrating and make one’s work seem futile. Imagine spending over 10 years in training–from college, through medical school, through residency–to find yourself in this position. It is no surprise that more and more physicians are burning out, and feeling so desperate, that harming oneself becomes a viable option to escape.

Recognizing One’s Exploitation and Fighting Back

Capitalism’s parasitic economic structure has infiltrated all aspects of our society, and medicine has not been spared. This results in physicians being trained and conditioned to be obedient profit producers above all else. It leads them to be alienated from their loved ones and from their true passions. Inside our healthcare system, physicians are separated from the things that truly brought them joy and fulfillment. Yet we still continue to question why physicians are killing themselves?

Some maintain hope that there will be action around these issues from residency administrations, hospital working groups, or any number of hierarchical bodies that govern medical education, graduate medical education, or our healthcare system in general. The reality is that these issues will never be solved by any large committees or “task forces” we currently have in place, which continually put the onus onto medical students, residents, and practicing physicians to develop more “resilience” inside of a system that is built to do the exact opposite.

Those who have made it to the top positions of organizations such as the Accreditation Council for Graduate Medical Education (ACGME) or the Association of American Medical Colleges (AAMC) are there because they will continue to support the status quo. As political dissident and linguist Noam Chomsky discusses in reference to elite control of institutions, “an unstated but crucial premise is that the ‘responsible men’ achieve that exalted status by their service to authentic power, a fact of life that they will discover soon enough if they try to pursue an independent path.” These institutions will never consider the best interests of physicians or the patients they serve. Their leaders have been groomed to support the status quo. It is up to us to realize our exploitation and begin to fight against it.

Realizing this fact is easier said than done, as most physicians, due to the filtering mechanisms throughout our educational system, which typically lead to those from the upper classes securing seats in medical school, come from the exploitive classes themselves. Physicians are also paid more than a majority of other employees within our healthcare system such as nurses, technicians etc. They are conditioned to believe that they are somehow different or more important than the rest of the working staff when in reality all members are important in caring for the patient and all members are overworked and exploited by the same system.

Giving one member of an exploited group–in this case the physician–more benefits than others, helps to keep the fighting going between all groups as opposed to collaboration and organizing. We will be able to begin addressing the crisis of physician suicide once we, as physicians, accept that just as this capitalist system exploits our patients and coworkers, it is also exploiting us. And then we organize against it.

Whether it is consciously recognized or not, physicians specifically are also often boosted up with a false sense of elitism from the second they step into the field. This creates a blind spot for them being able to recognize their own suffering and exploitation and organize against it. They are given special white coats, which–besides becoming completely filthy after 80 hour work weeks–distinguish them from other hospital staff and distinguish themselves by the title of “doctor.”

While other staff members, such as nurses, actually have the collectivist mindset to organize against the damage the health care industrial complex causes to the patients they care for and even strike when necessary, physicians–especially those in the US–have been conditioned to believe they are too important to the system to do the same, even while that system is actively damaging them. Their administrators and peers say, “If we aren’t caring for patients, our patients will die.”

Those with a vested interest in maintaining the business as usual hold patients as hostages inside this system, guilting providers into accepting the status quo (inadequate care, inadequate access to care, medical errors, and crushing debt) with this rhetoric. It is despite the fact that physicians around the world have been able to organize and strike effectively while also continuing to provide absolutely necessary care.

Referencing Mark Ames’s 2005 book, Going Postal: Rage, Murder, and Rebellion: From Reagan’s Workplaces to Clinton’s Columbine and Beyond is useful for understanding this current phenomenon. In the book, Ames evaluates the mental anguish caused by Reagan era policies and analyzes how our capitalist system degrades and humiliates workers until they are pushed to harm themselves and others. In the following passage he speaks of how people can often deny their own exploitation until it is too late. He notes:

The middle class persistently denies its own unique pathos, irrationally clinging to an irrational way of measuring it, perhaps because if they did validate their own pain and injustice, it would be too unsettling–it would throw the entire world order into doubt. It is more comforting to believe they aren’t really suffering, to allocate all official pathos to the misery of other socioeconomic groups, and its more comforting to accuse those who disagree of being psychologically weak whiners. Despite its several hundred million strong demographic, the white bourgeoisie’s pain doesn’t officially count–it is too ashamed of itself to sympathize with its own suffering.

Until physicians are willing to accept the fact they they are being exploited by the same system that harms their patients, there will be no progress made in addressing physician depression and suicide. At that same time, until health care providers generally accept that it is our current capitalist system which puts profit production above the well being of every living thing on this planet–including themselves–we will not be able to effectively address true social and structural causes of disease and suffering.

Capitalism exploits, damages, and destroys us all. History shows us, large scale systemic change has never come from the beneficence of those in power and, frankly, it never will. As historian Howard Zinn writes speaking about public activism, the rights of the citizenry only come when “citizens organize, protest, demonstrate, strike, boycott, rebel, and violate the law in order to uphold justice.”

As physicians, if we truly care about the well being of our coworkers and of our patients, we must begin to organize, unionize, and rebel inside our practices, residency programs, etc, resisting business as usual, and finding ways to threaten the profits of capitalists if we want to see systemic change. We must begin to organize with communities and populations resisting oppression from a parasitic capitalist system as physicians in the past have done with groups such as the Black Panthers and Young Lords.

Once physicians can begin to view the dynamics of our capitalist system more clearly–and view the dynamics of our healthcare system as just one microcosm of how capitalism harms us all–it will become clear what needs to be done. We must put down our fancy white coats and begin to organize with our fellow healthcare staff–and, more importantly, with our patients–against a system that exploits and damages us all. Only then will we be able to begin developing a new system that actually cares about both people and the planet.

• First published in Popular Resistance