Workers Vanguard No. 1019

8 March 2013


Working Families Foot the Bill

U.S. Health Care and the Elderly: Capitalist Cruelty

The squabbling by the Obama administration and Congressional Republicans over how to implement spending cuts—including the recent “sequestration” of funds for everything from the Pentagon to national parks—has dominated headlines. While Social Security and Medicaid were exempted from this round of cuts, there can be no doubt that these programs are in the sights of both the Democrats and Republicans. Barack Obama’s health care “reform” of three years ago slashed Medicare payments by over $700 billion, and in the recent deficit negotiations the president reportedly pushed for further cuts of $400 billion to Medicare and other social programs. Both capitalist parties at bottom agree that the budget ax must fall primarily on society’s most vulnerable: the aged, the poor, the disabled and the chronically ill.

Obama has repeatedly proposed cutting $100 billion from Medicaid—the federal assistance program for the poor—which has become the main source of aid for the long-term care of the elderly and disabled. With encouragement from the White House, both Democratic- and Republican-controlled statehouses have been massively rolling back Medicaid benefits, eliminating coverage for many medical conditions and striking tens of thousands of people from the states’ rolls. To cap spending on long-term care, 26 states—among them New York, California and Illinois—have petitioned Washington for approval to turn millions of Medicaid recipients over to private “managed-care organizations.” Those outfits would be paid a fixed sum for providing a lifetime of (grossly inadequate) care.

These and future cuts in social programs will add enormously to the already crushing burden on families as they try to cope with providing care for aging parents or disabled family members. The Elder Care Study (2010) by the non-profit Families and Work Institute found that during the five years preceding the study, fully 40 percent of the country’s workforce had provided elder care to family members. On average, such care represents the equivalent of a part-time job and typically lasts for over four years. Although family caregivers often perform medical tasks such as administering IVs and injections, caring for wounds and operating dialysis or other specialized equipment, they normally receive no help from anyone except other relatives—no home visits by nurses, medical assistants or other health care professionals.

The percentage of adults providing personal care and/or financial assistance to an aged parent has more than tripled over the past 15 years, reflecting the rapid increase in the country’s elderly population. According to the 2010 census, the number of those 85 years and older increased by 30 percent during the previous decade. Many studies have documented the dramatic toll that the stress and anxiety of caring for aging parents takes on adult children’s health, from higher mortality risks and rates of hospitalization to greater incidence of chronic disease.

Overall, two-thirds of caregivers are women. As they marry and give birth at an increasingly later age, more are becoming part of the “sandwich generation”—adults who are responsible for the care of both young children and elderly parents at the same time. Today, nearly 40 percent of women caring for elderly relatives are still raising children of their own, with many of those women also holding down a full-time job. In this capitalist class society, the enormous costs of providing elder care, which should be borne by society as a whole, fall on individual working-class and poor families and, above all, women.

For Free, Quality Health Care for All!

A 2007 study, Family Caregivers: What They Spend, What They Sacrifice, by hospice provider Evercare estimated that caregivers incurred out-of-pocket expenses averaging over $5,500 per year. Low-income families in particular can scarcely hope to recover from such costs. The study noted: “The lowest income family caregivers have the highest burden of care in terms of both the number of hours they spend helping their family member and in their actual proportion of income spent on care.”

In fully one-third of working families faced with the demands of elder care, one or both parents are forced to reduce the number of hours worked—or to quit working entirely—thus deepening their financial distress. The impact on caregivers leaving the workforce is devastating, as it means not only lost wages but also diminished Social Security benefits for their retirement years. Various studies have estimated the average lifetime financial loss to be from $300,000 to over $650,000. A downward spiral is unfolding: As the current generation of caregivers forego opportunities to save for retirement, they increase the financial burden that they likely will impose one day upon their own children.

The total monetary value of unpaid work that family members perform in caring for the elderly far exceeds the amount that the U.S. spends on home health care and nursing home care. In short, the responsibility for caring for the country’s aging population is overwhelmingly borne by working people. If families are unable to provide that care, then the aged have no choice but to just hurry up and die!

That cruel calculus makes perfect sense in terms of the functioning of the capitalist system. For the owners of banks and industry, government spending on caring for the aged is an unnecessary overhead expense that ultimately lowers the overall profit rate. As Karl Marx explained, profits derive from the exploitation of labor: Workers, who have to sell their labor power to survive, add value to what they produce, but they only get paid a sum that allows them to continue to toil and to raise a new generation of workers. The difference between the value added by the workers and what they actually get paid ends up in the capitalists’ pockets in the form of surplus value. However, the aged and infirm do not labor and therefore do not generate surplus value. In the interest of maximizing profits, the engine that powers the capitalist system, public spending on the aged and disabled should logically be cut to the bone.

Those welfare programs that exist have been achieved as a result of mass social struggles. In 1934, the year before the passage of the Social Security Act, there were three victorious citywide organizing strikes: one led by Communists in San Francisco, the Trotskyist-led Minneapolis Teamsters strikes and a general strike led by left-wing socialists in Toledo. In fact, Social Security and other New Deal programs were part of an effort by the bourgeoisie to head off growing leftist political radicalization and the burgeoning labor struggles in the 1930s. Medicare as well as Medicaid and other “war on poverty” programs were enacted to buy social peace during the turbulent 1960s, a period marked by the civil rights upsurge and the Vietnam antiwar movement.

In the U.S., every president since Ronald Reagan has trimmed spending on Medicare, the federal health insurance program for those aged 65 and older as well as younger people with disabilities. The slashing of the social safety net—given added impetus by the capitalist counterrevolution that destroyed the Soviet Union in 1991-92—has been accompanied by a vicious anti-union offensive. The dearth of strikes in recent decades has helped pave the way for the exploiters to butcher health care, pensions and other union gains with impunity. Free, quality medical care is today a burning need for the mass of the population. The labor movement would galvanize broad support if it were to take up this fight as part of a struggle for jobs and decent pensions for all.

To wage such battles poses the need to oust the pro-capitalist trade-union leaders, who peddle the lie that the workers have interests in common with their exploiters. They must be replaced with new leaders based on a program of class struggle in opposition to the capitalist class enemy and its political parties, the Democrats and Republicans. The two parties play a time-honored game of “hard cop, soft cop” in which the Republicans demand draconian cuts in social programs and the Democrats posture as friends of working people while implementing much the same austerity agenda as the Republicans. The working class needs its own party: a workers party that fights for a workers government, which would expropriate the productive wealth of the capitalist class and build and develop a planned economy.

Discarding Those They Cannot Exploit

The responsibility of caring for the older generation in this country has always fallen primarily on younger family members. In the overwhelmingly rural America of the 18th and early 19th centuries, when extended families tended to live in close proximity and women did not work outside the home, kinship networks were in some ways better equipped than today’s families to handle such care. In addition, elder care then was typically less onerous. Before the development of antibiotics in the mid 20th century, the aged often died precipitately of infectious diseases rather than suffering for extended periods with debilitating or chronic illness as is now common.

Urban and industrial growth increasingly undermined the ability of families to care for the elderly, not least because urban families were smaller than rural ones. Yet even as families were finding it more difficult to cope with elder care, the ruling class had not the slightest intention of taking on that role. Throughout the 19th century, state and local governments maintained some bare-bones assistance (termed “outdoor relief”) for the impoverished in the interest of social stability. As one historian explained, “The poor were seen as a threat to civil order, and those in a position of authority sought an effective way of relieving (and calming) them” (Thomas Streissguth, Welfare and Welfare Reform [2009]).

Except for the favored few who received some financial assistance, the policy for those elderly who had no family to provide support was so-called “indoor relief”: They were simply locked up in poorhouses. These dreadful institutions were direct descendants of the English workhouses that had existed since the 16th century essentially to punish the poor for their lamentable state. Far from seeking to ameliorate the condition of the infirm and disabled, the purpose of institutionalizing them was to isolate them and remove them from view. The American bourgeoisie of the 19th and early 20th centuries subjected the most needy of the elderly population to inhuman, prison-like conditions: overcrowded cells swarming with vermin, noxious air that was often barely breathable, rampant disease.

By the mid 19th century, scores of Protestant evangelical and other reform societies had set up charities to enable those who could become productive members of society (and lead virtuous Christian lives) to escape the corrupt influence of the poorhouse. Often, the aged—who, it was assumed, could no longer be productive—were specifically excluded from these uplifting endeavors. The New York Association for Improving the Condition of the Poor piously resolved “to give no aid to persons who, from infirmity, imbecility, old age, or any other cause, are likely to continue unable to earn their own support” (quoted in Carole Haber, Beyond Sixty-Five: The Dilemma of Old Age in America’s Past [1983]).

By the late 19th century, sectors of the poorhouse population were increasingly transferred to newly created, specialized institutions—orphans to orphanages, the insane to insane asylums and the homeless to flophouses. The poorhouses were essentially transformed into “homes for the aged and infirm,” as many began calling themselves. By the early 1920s, more than 70 percent of the country’s poorhouse inmates were over the age of 55, and most were seriously disabled.

With the passage of the Social Security Act, the bourgeoisie seized the opportunity to do away with the poorhouses, the Dickensian horrors of which had become a national embarrassment. No less important to the Franklin Roosevelt administration was the argument that a system of small pensions would be a cheaper way of providing minimal elder care than maintaining the poorhouses, which were swarming with victims of the Great Depression. Thus, the law prohibited Social Security payments to the elderly inmates of public institutions. Almost overnight, a new industry was born as the direct legacy of the poorhouses: privately owned, for-profit nursing homes.

The Nursing Home Pestilence

Providing professional care for elderly people in this country is big business, and it will become even bigger with the baby-boomer generation entering retirement age. At the center of that business are for-profit nursing homes, often run by giant corporations. As is true of all capitalist enterprises, nursing homes must drive down expenses in the pursuit of profits. Many nursing homes avoid admitting elderly patients who are afflicted with dementia or other chronic diseases—precisely those who need care the most—due to the high cost of looking after them.

Likewise, nursing homes minimize the number of registered nurses employed, almost never hire on-staff doctors and pay the direct-care staff (almost always non-unionized) a wage they could earn at McDonald’s. Often, even in the better nursing homes, there is not enough staff to ensure that residents are properly fed. What they do not stint on are tranquilizers and other drugs that allow them to cut corners in attending to residents. As one academic researcher told the New York Times (23 September 2007), nursing home chains “have made a lot of money by cutting nurses, but it’s at the cost of human lives.”

This also exacts a toll on the remaining nurses and other staff. Nursing homes are stress-filled, physically demanding workplaces where non-fatal injury rates are greater than in the construction, meatpacking and mining industries. Inadequate training and equipment, higher patient loads and mandatory overtime feed the problem. Nursing home workers, who are predominantly women, need to be organized into the trade unions that represent nurses and other health care workers. Backed by the industrial unions, whose role in production gives them far greater potential social power, this fight must be part of a broader campaign to organize all the unorganized, a struggle that is crucial to reversing the decades of attacks on labor.

With employers taking aim at wages, benefits and working conditions, unionized nursing home workers have engaged in several strikes in recent years. One involving 600 workers at five Connecticut nursing homes operated by HealthBridge began last summer after the bosses froze pensions and imposed other takebacks. The company responded to the strike with naked union-busting: Scabs were brought in as permanent replacements and a RICO lawsuit was filed claiming that the activities of the union, which is affiliated with the SEIU 1199 service workers, amounted to “a shake-down by a lawless enterprise.” On March 3, union members returned to the job, three months after a federal judge ordered management to take them back under the terms of their existing contract. Following in the footsteps of many other businesses attempting to void labor contracts, the five HealthBridge nursing homes have filed for bankruptcy.

The struggle for decent wages and working conditions is directly linked to the quality of care. For decades, Congressional committees, journalists and academic researchers have documented the indifference, abuse and outright cruelty of the nursing-home owners toward residents. As a result, the industry is one of the most regulated in the country. Yet nursing homes that provide low-quality care or mistreat their residents face no real consequences because Congress is not about to appropriate the funds for the necessary inspections or to pursue sanctions against those that are non-compliant. Families that try to bring wrongful death lawsuits in egregious cases of neglect are often stymied by a complex web of corporate ownership put in place to shield nursing-home operators from legal responsibility.

Even a generation ago, when defined-benefit pension plans were included in many union contracts, the exorbitant cost of quality nursing homes put them largely out of reach of the working class. Nationally, the average cost of a semi-private (shared) room in a nursing home is today almost $75,000 per year—in New York, it is over $120,000. The elderly will typically soon exhaust their life savings paying for care and, once they are indigent, apply for meager government assistance under Medicaid.

As is true throughout the U.S. health care system, there is a two-class system of nursing homes in which the well-to-do get near-adequate (sometimes even high-quality) care while everyone else receives outrageously dreadful treatment. Many nursing homes will only accept residents who can afford to pay the cost and shun those who are on Medicaid, which typically pays about 30 percent less than what residents would pay out-of-pocket for the same care.

Low-budget nursing homes that cater to impoverished Medicaid recipients, especially those located in poor black and Hispanic communities, are often simply foul-smelling hellholes. According to a 2005 study by the U.S. Government Accountability Office, at least one in six nursing homes provides such poor care that residents are at risk of physical harm. Such conditions often persist despite the best efforts of health care workers, who seek to provide quality care in defiance of the rapacious nursing-home bosses. In the case of Hurricane Sandy, it was the staff, often putting in 36-hour shifts, that carried out the emergency evacuations of dozens of stricken New York City nursing homes. There was no good reason why people could not have been evacuated in an orderly fashion before the storm hit. It was penny-pinching by Mayor Michael Bloomberg that left the elderly in harm’s way.

Under capitalism, nursing homes hardly even begin to address the social need for elder care. Only about one person in eight aged 85 or over is placed in a nursing home. Of course, many prefer staying with their families, especially with what is on offer at most old-age facilities. The whole setup is focused on profiteering. By raking in about $160 billion per year while holding down costs, private nursing homes have been quite successful in maximizing their shareholders’ return on investment. This industry provides an object lesson in how the capitalist system is incompatible with satisfying basic human needs.

For Socialized Elder Care!

In the early 19th century, the utopian socialist Charles Fourier observed that the status of women serves as a hallmark of overall emancipation in any society. A not-unrelated hallmark is how society treats its elderly and disabled. The prize-winning 1983 film The Ballad of Narayama depicts a primitive 19th-century Japanese village so impoverished that the elderly were expected to die voluntarily so that a new generation could survive. Amid brutal images of near-starvation, the film contrasts the dignity of the protagonist’s ascent of Mt. Narayama to die there of exposure.

In capitalist America, that contrast is cruelly inverted. Modern industrial society is fully capable of providing quality health care for all, including for the aged, disabled and chronically ill. Yet the bourgeoisie’s treatment of the elderly population denies many—especially working people, minorities and the poor—even basic human dignity. In a study published last October, Home Alone: Family Caregivers Providing Complex Chronic Care, the AARP and the non-profit United Hospital Fund offered “recommendations for action” that are premised on younger family members’ responsibility for long-term care of the elderly. The study simply lists various ways that “family caregivers” could be provided with additional “training and support.” And no politicians in Washington are offering anything remotely resembling an improvement in the conditions of the elderly.

We have written extensively about the Marxist program of replacing the institution of the family—the main source of women’s oppression under capitalism—with socialized childcare and housework. In “The Russian Revolution and the Emancipation of Women” (Spartacist [English-language edition] No. 59, Spring 2006), we described how V.I. Lenin’s Bolshevik Party, after leading the working class to power in Russia in 1917, sought to free women from the drudgery of housework by setting up communal childcare facilities, dining halls and laundries, as well as by introducing paid maternity leave and free health care. Such measures represent the concrete expression of our slogan: For women’s liberation through socialist revolution!

Socialized elder care, like socialized childcare, would represent a significant step toward replacing the institution of the family. Yet elder care is fundamentally different from childcare in that it addresses a process of increasing, not decreasing, dependence. That calls for flexible institutional solutions corresponding to the successive stages of decline in old age. Different levels of group care for the aged, requiring increasing levels of medical supervision, would be necessary, from assisted living and nursing facilities to long-term hospitalization.

The aged in today’s society overwhelmingly wish to remain in their homes as long as possible. A workers state would establish communal facilities attractive to the aged who require care. The needs of the aged who remain attached to their homes could, through state support, be largely met in the same way as for the rich today: by bringing nursing services into their homes on a daily basis. A wide-ranging effort would be undertaken to provide housing, transportation, custodial care and the many other needs of older people that working families today attempt to meet.

We Marxists are for socialized medicine—the expropriation of the pharmaceutical, health care and insurance companies, including the parasitic private nursing home industry—as part of the fight for a workers government. To this end, a workers party is needed to lead the proletariat in the fight to overturn the capitalist order through socialist revolution, ushering in a society based on production for need, not for profit. A rational, internationally planned economy would lay the basis for a qualitative development of the productive forces, opening the road to the elimination of poverty and the creation of an egalitarian socialist society. Based on material abundance, the future communist society would adopt the rule, as Karl Marx declared in his 1875 “Critique of the Gotha Program”: “From each according to his abilities, to each according to his needs!”