Imagine your doctor or nurse practitioner or midwife hard at work, talking with patients and doing exams, comforting the sick, and delivering babies. It seems like a rewarding and well-respected career with great autonomy. In the first few chapters of Health Care Under the Knife, this image is torn asunder and the reader is given a peek into a world I know well—a world of endless paperwork and meaningless trainings, billing and coding requirements, and patient reviews that determine your hospital’s reimbursement. It’s a stark difference from the almost antiquated view that most have of what health care work looks like.
Health Care Under the Knife is a collection of essays edited by Howard Waitzkin, a professor of sociology and internal medicine. In five parts, the contributors—who range from physicians to public health policy workers (including David Himmelstein and Steffie Woolhandler, public health professors and primary-care physicians who co-founded Physicians for a National Health Program)—detail how broken the American health system is and what it might take to win health care for all.
Part 1, “Social Class and Medical Work,” asks readers to move beyond their familiar conception of physicians as part of the professional class and shows through a moving essay on the frustrations of practicing modern medicine that physicians are becoming aware of their own role in the working class. Howard Waitzkin opens the book detailing his personal battle against inane rules for coding and compliance along with “meaningful use” measures that interfere with his ability to use clinical judgement to practice the best medicine he can.
From here, we move from a discussion of what it is like to practice medicine on an individual level to a discussion of how physician-owned medical practices have been supplanted by giant hospital systems that employ hundreds or even thousands of physicians. Health Care Under the Knife details the incredible bureaucracy now intertwined with all medicine and the history of the rise of health insurance corporations and the control they have on how health care systems operate today.
In parts 2 and 3, the authors break down in incredible detail the ins and outs of healthcare reform, including the Affordable Care Act (ACA or Obamacare), and offer helpful criticism of the way in which the ACA further entrenched a for-profit healthcare system, instead of being a step towards a single-payer system, in which private health insurance is replaced by a government-funded guarantee of healthcare for all. The Medicare program in the US already provides such a guarantee for people sixty-five and over—a single-payer system that should be extended to the whole population. Waitztkin and Ida Hellander detail the crisis of underinsurance and the principles of neoliberalism and austerity that have been implemented under the ACA, pushing more costs onto individuals and families as well as employers. They write, “due to high deductibles (…$10,000 for a family bronze plan, and $6,000 for a silver) and co-payments, coverage under Obamacare has become unusable for many individuals and families.”
After the authors lay bare that our current health system is structured to make profits rather to serve human need, they turn to other countries that have instituted healthcare reform that falls short of single payer, or that have implemented some form of universal coverage but have nevertheless fallen back into rationing care and creating chaos because of the pressures of the wider capitalist system. Greece, for example, has suffered extensively under the immense austerity imposed upon it by the European Central Bank and the IMF. In 1983, the social democratic PASOK government passed laws that started to implement a single-payer system as part of Greece’s National Health Service, but overall this law did not regulate private practice. Many parts of this law went unimplemented, and by 2010, there was still no functioning single-payer system. In the aftermath of the global financial crisis, the harsh spending cuts imposed on the Greek people and their health system left nurses caring for four times as many patients as was safe and creating weeks-long waiting lists for surgeries that should have been treated as emergencies.
The last few chapters offer some glimmers of hope into how we can fight for a humane, rational health system. Waitzkin, who is an expert in the movements against privatization of healthcare in Central and South America, offers us some examples of healthcare providers joining massive social struggles for health reform. By pulling examples from El Salvador, Bolivia, and Mexico, Waitzkin offers a glimpse of what kinds of social pressures it will take to win healthcare for all.
While I applaud the efforts of leaders of Physicians for a National Health Plan, in their writings on how to make change in the US health system, the authors make a glaring error by completely ignoring the role of nurses in this process. In the countries that Waitzkin and other contributors look to for physicians leading in struggles, they are always doing so alongside the nurses they work with. Physicians in Britain, El Salvador, and Mexico are also largely unionized, and have the ability to play a different role in mass struggle than physicians in the US currently can. Especially given the recent strikes led by nurses all over the country and the prominence and power of National Nurses United—whose demands always incorporate safe staffing ratios and offers a deep critique of for-profit healthcare—it makes no sense to me why the authors would by and large ignore nurses. Nurses are one of the last major sectors of US labor that are highly unionized, and they will have to play an integral role in toppling for-profit healthcare.
Overall, Health Care Under the Knife offers an in-depth look at the chaos of our health system and the lengths to which capitalism will go to protect profits, even when it means literally killing people. Some chapters seem unnecessarily dense and read more like health policy reviews rather than underlining the central point of the book—that capitalist health care is an inhumane and irrational system. What Health Care Under the Knife does well, though, is explain the need for mass mobilization to push for policy change, and gives the reader a glimpse into other countries that have fought and won this battle already, showing what it might take to win Medicare for all here in the United States.