‘Hospital and Emancipation’, By Nadja Rakowitz

We translated this article from the German magazine ‘JungleWorld’ for the general debate…

Left politics, which claims to represent a democratic perspective that goes beyond capitalism, cannot be satisfied with the goal of merely redistributing the social wealth generated under capitalist conditions.It must at least strive to liberate labour from the form of wage labour and thus from its coercive character, to pose the question of property as one of capital relations, and to put an end to the violent dynamics of capitalist compulsion to accumulate. For the inequality that necessarily characterises capitalist class societies stands in principle contradiction to a conception of democracy as the form of a society of equals and free people, in which production must be self-determined, free of domination and thus must be democratically organized.

With the example of health care, one quickly learns to bid farewell to simple notions of emancipation.

It is easy to formulate in such abstract terms. But what does that mean for the health care system? This can be discussed using the hospital sector as an example. Until the mid-1980s, hospitals in the German Bundesrepublik were not organized in an entirely capitalist way, due to a legal ban on profits and to the way they were financed. That has changed thoroughly since then. More recently, since the red-green federal government introduced the system of flat rates-per-case in 2004 and expanded market mechanisms, hospitals have been fully subjected to capitalist operation. This applies to both privatised hospitals and those that continue to be in public or not-for-profit ownership, for example, those run by church organizations. Just how dysfunctional it is to organise the hospital sector in this way, is evident to any contemporaries who are not completely narrow minded, in the Covid 19 pandemic.

The reform proposals for this sector can be used to illustrate what the difference is between a social-democratic and a left-wing but intra-capitalist policy, and to sketch out what a left-wing policy that points beyond capitalism and aims at a self-organization of society might look like.

Almost all [German] parties except the Linkspartei [Left Party] hold essentially liberal economic positions on the hospital sector. Although they now want to improve the financing of hospitals’ maintenance costs, they want to centralise the sector and privatise it further. They hardly express any doubts about market mechanisms.

The SPD at least claims to have recognised that the so-called economisation of the hospital sector is a problem. However, it does not mention that it was itself involved in the profit-oriented restructuring of this sector. Their concrete proposals consist of making small corrections, but not changing the fundamental mechanisms.

The SPD’s election program for the 2021 federal election states: “Profits generated from funds of the solidarity community must flow back into the health care system, at least for the majority.” The system of flat rates per case will be “put to the test, the flat rates will be revised and, where necessary, abolished”. Of course, “where necessary” does not mean Germany, but individual specialties, such as paediatrics or obstetrics.

Similar positions can be found in the Green Party’s Bundestag election program: “The common good orientation in the healthcare system should be strengthened and the trend toward privatization reversed. The concentration on profitable services must come to an end. In the future, hospitals should therefore be financed not only according to case numbers, but also according to their social mission.”

For employees and patients, this would be entirely desirable. In view of the interests of the healthcare companies operating in Germany, however, it is questionable whether the cautiously formulated will to somewhat contain the capitalist constitution of the healthcare system will be sufficient to achieve this. There seems to be no desire to take on the real opponent, the capital factions that want to invest and make profits in the healthcare system in this country. The coalition agreement between the SPD, the Greens and the FDP confirms this assumption.

The Left Party takes a left-wing parliamentary position in its Bundestag election program: it is wrong that hospitals should be run on a profit-oriented basis. Private hospitals and nursing homes should be transferred to public ownership. They would have to be organized according to need and public welfare. We want to replace the system of flat rates per case with needs-based financing. “We want to replace two-tier medicine with a solidarity-based health insurance system into which everyone pays.”

Of course, this would not abolish capitalism, but at least capitalist mechanisms would be explicitly excluded from the hospital sector again and private ownership would be transferred back to common ownership – which could open up possibilities for further considerations. The fundamental distributional questions are posed in health insurance: A solidarity-based citizens’ insurance system should include all incomes and income types equally. All this would be possible and make sense. At least with regard to patent protection for Covid-19 vaccines, an internationalist perspective is also made clear in the program: “The pandemic in particular shows that pharmaceutical research is a public good. The licenses for the Corona vaccines must be released.”

But what would a left perspective on health care that points beyond capitalist conditions be? What demands would result from this with regard to ownership in the hospital sector? Should private hospitals, for example, be handed back to the municipalities, or should they be organized as cooperatives? How should medical needs be determined and who should plan to meet them? Should a central body be responsible for planning, or should it be democratised by involving employees, patients and local politicians? In which bodies could this be done? How should the mediation between these and a central planning body, which is unlikely to be dispensed with, take place? In short, how does one democratically determine the need for medical care?

The assumption that this need would simply result from the sum of individual needs and demands, and that everyone could therefore get what they need, ignores possible supply problems, because it is a matter of what is medically necessary. In the disputes and strikes in the hospitals, employees and political activists ask themselves such questions: Which services in the hospital merely serve profit, and which are medically justified? The former can be dispensed with.

Practical experience gained during strikes in the hospital sector could also be linked to a transformational perspective: Strikers in hospitals now often no longer allow union representatives to conduct collective bargaining alone, but each ward or team delegates one person to participate in the negotiations. These units of action of self-organization have been experienced by many strikers as collective self-empowerment.

In the example of health care, one quickly learns to abandon simple notions of emancipation. A radical left perspective cannot assume that in a society that no longer produces in a capitalist mode, everyone can do what they want. Even under communism, people will have to work day and night in health care, and this highly complex work will have to be planned and organized. The question of which services are to be provided by society will also arise. Not everything that is technically possible will be socially useful. Here, too, it cannot be assumed that everyone will get everything they want. We can therefore look forward to conflict-ridden democratic disputes between equals and free people.

Marx describes this freedom as the “realm of necessity”. It can “only consist in the socialised man, the associated producers, who rationally regulate their metabolism with nature, bringing it under their communal control instead of being dominated by it as by a blind power; carrying it out with the least expenditure of force and under the conditions most worthy and adequate to their human nature.” This also applies to health care.


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