An Anarchist Vision of Universal Health Care: Mutual Aid through Self-Managed Health Cooperatives
This work is an edited version of one section of the extensive Anarchist FAQ (frequently asked questions), by The Anarchist FAQ Editorial Collective: Iain McKay, Gary Elkin, Dave Neal, and Ed Boraas, with assistance from a virtual team of anarchists from across the world, www.infoshop.org/faq. The purpose of the piece is to sketch one vision of how universal health care might be achieved in a society not dominated by profit-seeking hierarchal corporations or run by coercive states, but organized into self-managed communities, workplaces, and cooperatives.
Most anarchists argue that a privatized health care system is only able to meet the requirements of those who can afford to pay for it, and so is unjust and unfair. The need for medical attention is not dependent on income, and a civilized society would recognize this fact. Under capitalism, profit-maximizing medical insurance sets premiums according to the risks of the insured getting ill or injured, with the "riskiest" consumers unable to find insurance at any price. This is hardly a vision to inspire a free society, or one compatible with equality and mutual respect.
Capitalist Healthcare is Inefficient
Social anarchists point to what happens under capitalism when discussing the benefits of a socialized system of health care in an anarchist society. Competition, they argue, harms health care provision. According to Alfie Kohn:
"More hospitals and clinics are being run by for-profit corporations; many institutions, forced to battle for 'customers,' seem to value a skilled director of marketing more highly than a skilled caregiver. As in any other economic sector, the race for profits translates into pressure to reduce costs, and the easiest way to do it here is to cut back on services to unprofitable patients, that is, those who are more sick than rich...." [No Contest, p. 240]
As Robert Kuttner notes: "By their nature, universal systems spend less money on wasteful overhead, and more on primary prevention. Health insurance overhead in the United States alone consumes about 1 percent of the GDP, compared to 0.1 percent in Canada.... Remarkably enough, the United States spends the most money on health care, but has the fewest hospital beds per thousand in population, the lowest admission rate, and the lowest occupancy rate -- coupled with the highest daily cost, highest technology-intensiveness, and greatest number of employees per bed." [Everything for Sale, pp. 155-6]
Therefore, most anarchists are in favor of a socialized and universal health care system for both ethical and efficiency reasons. Needless to say, an anarchist system of socialized health care would differ in many ways from the current systems of universal health care provided by the state.
Such a system of socialized health care could be built from the bottom up and based around local communes (self-managed communities or cooperatives). In a social anarchist society, "medical services . . . will be free of charge to all inhabitants of the commune. The doctors will not be like capitalists, trying to extract the greatest profit from their unfortunate patients. They will be employed by the commune and expected to treat all who need their services." Moreover, prevention will play an important part, as "medical treatment is only the curative side of the science of health care; it is not enough to treat the sick, it is also necessary to prevent diseaseÉ." [James Guillaume, Bakunin on Anarchism, p. 371]
How might an anarchist health service work? It would be based on self-management, of course, with close links to local communes and federations of communes. Each hospital or health center would be autonomous but linked in a federation with the others, allowing resources to be shared as required while allowing the health service to adjust to local needs and requirements as quickly as possible.
Anarchist Health Care in Practice
The Spanish Revolution of the 1930s provides us one example of an anarchist health service in practice. In rural areas local doctors often joined the village collective and provided their services like any other worker. Where local doctors were not available, "arrangements were made by the collectives for treatment of their members by hospitals in nearby localities. In a few cases, collectives themselves built hospitals; in many they acquired equipment and other things needed by their local physicians."
For example, the Monzon federation of collectives in Aragon maintained a hospital in Binefar, the Casa de Salud Durruti. By April 1937 it had 40 beds, and departments which included general medicine, prophylaxis, and gynecology. It saw about 25 outpatients a day and was open to anyone in the 32 villages of the district. [Robert Alexander, The Anarchists in the Spanish Civil War, vol. 1, p. 331 and pp. 366-7]
The socialization of health care took on a slightly different form in Catalonia but was organized on the same libertarian principles. People were no longer required to pay for medical services. Each collective, if it could afford it, would pay a contribution to its health centre. Building and facilities were improved and modern equipment introduced. Like other self-managed industries, the health service was run at all levels by general assemblies of workers who elected delegates and hospital administration.
Thus, all across Spain, the workers in the health service re-organized their industry along libertarian lines and in association with the local collective or commune and the unions of the Confederacion Nacional del Trabajo (the anarcho-syndicalist National Confederation of Labor).
[Editors' note: Recent examples of anarchist health care provision in the United States include: the Chicago-based Jane Collective, which provided safe abortions to women from 1969-1973 while abortions were banned; the Common Ground Collective (their slogans: Solidarity Not Charity - social justice is the foundation of community health) , which sprung up to provide health care in the wake of Hurricane Katrina (see "Military in New Orleans Requests Help from Anarchist Relief Project," Peacework, October 2005), and the Anarchist Black Cross, which provides health care to demonstrators (see "How to Deal with Pepper Spray at Protests," Peacework March 2008).]
In a future anarchist society, workers in the health industry would organize their workplaces, federate together to share resources and information, and formulate plans to improve the quality of service to the public. The communes and their federations, the syndicates (self-managed workplaces) and federations of syndicates, would provide resources and effectively own the health system, ensuring access for all.
Ultimately, the public services that exist in a social anarchist society would be dependent on what members of that society desire. If a commune or federation of communes desires a system of communal health care, then they will allocate resources to implement it. They will allocate the task of creating such a system to, say, a special commission based on volunteers from the interested parties such as the relevant syndicates, professional associations, consumer groups, and so on. The running of such a system would be based, like any other industry, on those who work in it. Functional self-management would be the rule, with doctors managing their work, nurses theirs and so on, while the general running of a hospital would be based on a general assembly of all workers, who would elect and mandate delegates to decide the policies the hospital would follow.
Non-workers who took part in the system (patients, for example) would not be ignored and would also have a role in providing essential feedback to assure quality control of services and to ensure that the service is responsive to users' needs. The resources required to maintain and expand the system would be provided by the communes, syndicates, and their federations. For the first time, public services would truly be public - not a statist (or corporate) system imposed upon the public from above.
Any system of public services would not be imposed on those who did not desire it. They would be organized for and by members of the communes. Therefore, individuals who were not part of a local commune or syndicate would have to pay to gain access to the communal resources. However, it is unlikely that an anarchist society would be as barbaric as a capitalist one and refuse entry to people who were ill and could not pay. And just as other workers need not join a syndicate or commune, so doctors could practice their trade outside the communal system either as individual artisans or as part of a co-operative.
However, given the availability of free medical
services, it is doubtful they would grow rich doing so. Medicine
would revert back to what usually initially motivates people to
take up this profession - the desire to help others and make a
positive impact in people's lives.