28 March 2017

Monarchy, medicine and social solidarity

At the Hospital, by Nicholas Bogdanov-Belsky

It is worthy of note, and by no means an accident, that the earliest adopters of universal health insurance were all monarchies. Universal health insurance was adopted in stages, by Germany under Kaiser Wilhelm I and Otto von Bismarck in 1883 and 1884 with the Sickness Bill and the Accident Bill; by Russia under Tsar Saint Nicholas II of Russia in 1912; and by Norway around the same time under King Haakon VII. The United Kingdom also adopted a national insurance law – less extensive, but an insurance law all the same – in 1911.

The standard critique of these measures from the left (and some portions of the right), is that they were adopted piecemeal in this way, precisely in order to stymie and confuse the development of a genuine socialist movement, and forestall revolution by bolstering the working class with state-funded handouts. And that is certainly a true part of the story. Otto von Bismarck was explicitly concerned with preventing a proletarian revolution in Germany, and he did this by blunting the effects of capitalist exploitation on the workers through workmen’s compensation, mandatory paid sick days and other measures. At the same time, the critique goes, they left the old class structures in place and did nothing to fundamentally change the exploitative relations between the classes.

To a certain extent, these critiques are fair and justified – though I cannot agree with them entirely. Certainly the marriage of the great machines of big business to the bureaucracies of government – no matter whether it is a monarchical or a republican government – is something to be lamented and resisted.

At the same time, I am sceptical (to say the least) of violent political revolution as a remedy. Clearly Diderot’s preference for strangling the last king with the innards of the last priest to guarantee freedom for the rest has not worked. Have either France or America truly thrown off the shackles of exploitation or imperialism, in a way which would make their psychotic episodes of fratricidal bloodletting worthwhile? For that matter, have Russia or China? If revolutions make society more equal, then how comes it that some of the most income-equal societies in the world – places like Sweden, Denmark, Norway, Canada, the Netherlands, Belgium, Japan, Czech Republic, Slovakia, Belarus, Kazakhstan, Slovenia, Serbia and Montenegro – are either social-democratic constitutional monarchies or post-communist republics, which have resisted revolution and generally placed a higher priority on social stability and gradual reform? And how comes it that China under the Qing (however technologically-‘backward’ and repressive toward women) was œconomically more egalitarian than under either the Nationalist or the Communist regimes which followed?

Clearly these reformist societies with monarchical or post-communist governments seem to be doing something correct in creating and maintaining a level playing field and ensuring that certain outcomes are fair. I would argue, indeed, that these monarchical or quasi-monarchical societies have a firm sense of civic order in which the welfare of the poorest is considered a responsibility of the powerful. Furthermore, I would argue that the impetus for fair œconomic policies in these countries comes not purely from a cynical desire to buy off the goodwill of the working-class and stave off revolution, but from a genuine (if sometimes attenuated) sense of obligation to the poor.

As for the policy of universal health coverage itself: it should be a no-brainer that healthcare is a basic good which ought to be made available to all at a low cost – or, as the Basis of the Social Concept puts it, ‘the criterion of “vital needs” should prevail over that of “market relations”’. At the same time, I find myself agreeing more with the distributist critics of our current system, that the question of who pays for insurance is neither the only nor even the most important question that needs to be asked. Instead, the question of the role of insurance itself is at issue – and the solution that John Médaille proposes to the problem of insurance (the reestablishment of guilds, or mutual aid organisations, of healthcare providers) is intriguing. Perhaps a mixture of mutual-aid networks (both among consumers and among healthcare providers) to control costs, and a ‘public option’ to keep the guilds honest and to guarantee that the poorest and least-connected patients don’t fall through the cracks (in the same manner that the state provides the service of a public defender to low-income defendants in the legal system), would be ideal.

No comments:

Post a Comment