The noisy, controversial and increasingly confrontational ‘debate’ in the USA over the Obama administration’s proposed healthcare reforms has received a good deal of attention in the UK, especially after a series of speeches, articles, email circulars and TV ads began making outlandish claims about both the contents of the proposals and the UK NHS, which is supposedly about to be emulated in the US.  Former vice presidential candidate Sarah Palin, not someone known for thoughtful analysis, chipped in with a comment which would be entertainingly absurd if it wasn’t representative of the level of debate: “The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama's "death panel" so his bureaucrats can decide, based on a subjective judgment of their "level of productivity in society," whether they are worthy of health care. Such a system is downright evil.” Some of the more focussed claims have been just as detached from reality. Senior republican senator Chuck Crassley claimed that the 77 year old Ted Kennedy would have been denied treatment for his brain tumour in the UK due to his age. Though the falsehood of the statement was quickly pointed out, similar claims have been made, with one circular email claiming that those over 59 are ineligible for Heart Disease treatments and the US paper Investor’s Daily stating that if Stephen Hawking was British ( which he is) he would be dead (which he isn’t).

Much of the rhetoric plays on deep-seated fears about “socialism” which have been ingrained into the American psyche since before the beginning of the cold war. References to creeping tyranny, the erosion of liberties and ballooning government are easy enough to find in the literature and placards of protestors against the plans, alongside references to Nazi Germany and its “euthanasia” policies.

However, party political manoeuvring, rather than any genuine concern over ‘big government’ or ‘liberty’ lies behind the origins of the current campaign. The US right has been dealt a bloody nose over the last year, as Obama (who it should be remembered is to the right of many European conservatives) made a stronger case to both corporate power and a large section of the population in the US that he was better posed to manage capitalism in that country and globally. The failure of the McCain/Palin campaign and the deep unpopularity of the Bush administration in its final years have put the Republican section of the ruling class on the back foot. Capitalising on sixty years of anti-communist propaganda and whipping up hysteria over “Orwellian” “socialised” healthcare is an opportunity to put a dent in their rivals’ popularity that they can’t afford to miss. High profile republicans have made as much clear, with Senator Jim DeMint of South Carolina claiming that Healthcare reform would be Obama’s “Waterloo”. Rightwing forces are coalescing around the issue accordingly.

At the forefront of the campaign has been the rightwing organisation ‘Conservatives for Patients Rights’ (CPR), founded by Rick Scott. That the rights of patients are at the bottom of Scott’s list of priorities is observable in his history of corruption and mismanagement in healthcare. In 1987 he founded a hospital which would grow into the financially successful healthcare company Columbia/HCA. Ten years later, the FBI raided HCA hospitals across the country following evidence that the company had been overcharging one of the existing government health programs, Medicare, and passing on the difference to doctors in exchange for patients being sent to HCA hospitals. Scott was ousted by the board, but HCA was still found to be responsible for what the Department of Justice called the “largest health care fraud case in U.S. history.” CPR has hired the PR firm responsible for the notorious “Swift Boat Veterans for Truth” attack ads during the 2004 elections, and similarly scaremongering ads have been produced for the current campaign.

There are clearly significant concentrations of private power behind the attacks. However, there are concentrations which are even more significant behind Obama. We should not fall into the trap of seeing the controversy as one where “corporate interests” are clashing with the popular will. Universal healthcare has had wide popular support in the US for many years, and the emergence of plans to put in place something with a family resemblance to it during the last presidential elections were not due to any change in public opinion. That the resemblance is familial is important, as the Obama administration is proposing to allow a government healthcare option for everyone, whilst at the same time avowing its commitment to “competition”. Healthcare options already exist for the elderly, those on low income, members of congress and members of the armed forces, amongst others. What the administration is not proposing is the wholesale replication of the NHS. According to Noam Chomsky1, “the opposition, who regard themselves as free market advocates, charge that the proposal would be unfair to the private sector, which will be unable to compete with a more efficient public system. Though a bit odd, the argument is plausible.” Chomsky goes on to quote the economist Dean Baker’s observations that on the Open Market, medicare has outcompeted private alternatives.  However, Chomsky goes on to note that 85% of the population support the government negotiating drug prices with pharmaceutical corporations, a proposal not on the agenda. The Obama-backed plans look set to create, in Baker’s words “the largest tax increase in the history of the world - all of it going into the pockets of the health care industry."

Significant concentration of capitalist power look set to do pretty well from healthcare reform, and support it accordingly. It is for this reason that it is even on the political agenda. The US healthcare system is a disaster by comparison to those of similar countries, with the cost of healthcare per head being twice that of the UK despite life expectancies being lower. Though demands for healthcare reform have been consistently popular with much the population for many years, the effects of the crisis on private capital have been the motive for the move to reform the system – according to General Motors Chairman and Chief exec  G. Richard Wagoner Jr, "Failing to address the health care crisis would be the worst kind of procrastination, the kind that places our children and our grandchildren at risk and threatens the health and global competitiveness of our nation's economy."2

Ordinary working class people are therefore being drawn into a faction fight between sections of US capital in which their needs and requirements are secondary to profitability. However, it is undeniable that healthcare is of vital importance to the lives of ordinary people, forming part of what we can call the “social wage” – the range of social provisions which on the one hand are vital to both the reproduction of the workforce for capitalism and to the quality of life of the majority of the population. The fact that under capitalism these will be cut back when the system requires it (for example with likely cuts to the NHS following the banking bailout here) while the popular need and demand for them continues makes them a site of class struggle in their own right. The question is how to approach the issue without being drawn into the false dichotomies of capitalist politics, or capitalist faction fights.

Likewise, healthcare in the UK is by no means “socialised”, as critics in the US claim. Though healthcare in the UK is undoubtedly better than healthcare in the US - just as other countries have better healthcare than the UK - it is still subject to the pressures and dynamics of capitalism, existing as it does in a capitalist society. It has also been increasingly marketised over recent decades, with attacks on both social provision and NHS workers coming under the cover of “privatisation” – the introduction of payment by results has introduced a market in health services, many non-frontline services have been privatised or contracted to companies like DHL, the introduction of wholly privately owned and operated “NHS treatment centres”, the rollout of Private Finance Initiatives etc all represent part of the same project of “rationalising” social provisions to the benefit of the overall capitalist system. Even the NHS in its classic form, as the centrepiece of the postwar welfare state came as part of the attempt to stave off prewar-style class conflict and integrate the working class more closely into the state following the end of the war, as well as from the needs for capitalism to stabilise itself after the turbulence of the 1920s, in a change of tactic well-known as the postwar settlement.

The question then is how we, as working class people, go about defending our immediate living conditions. This must be an issue of asserting our needs, independent of faction fighting inside the capitalist class. Clearly, in the US, free access to quality healthcare is paramount and should be fought for on its own terms – and that fight for quality will have to include the fight against the distortions produced by capitalism alongside “responsible” attempts to keep the costs of our quality of life down. Though quality of life may be improved in one sector – through access to universal healthcare - it may be attacked in another – through tax hikes and the like. To avoid getting drawn into the question of how to successfully and “responsibly” manage the capitalist system, making “sacrifices” in one area in order to make gains in another, we must consistently struggle in our interests for our needs, whether that means fighting for better services in “privatised” systems or “socialised” ones.