the Voice of
The Communist League of Revolutionary Workers–Internationalist
“The emancipation of the working class will only be achieved by the working class itself.”
— Karl Marx
the Voice of
The Communist League of Revolutionary Workers–Internationalist
“The emancipation of the working class will only be achieved by the working class itself.”
— Karl Marx
Aug 1, 2025
The U.S. spends almost twice as much on health care as it did 20 years ago, even accounting for inflation, and almost twice as much per person as other large, wealthy countries. For those who can access it, all this spending has created some of the best care in the world, and the U.S. continues to lead in all sorts of medical research.
Moreover, spending allocated for workers’ health care has increased along with spending on care for the wealthy. But despite the increased spending, overall U.S. life expectancy has been stagnant for decades and is today shorter than in much poorer countries like Turkey or Uruguay. Life expectancy is not just a question of health care: Americans’ lives are shortened by overwork, addiction, unhealthy food, and many other factors. But it is an indication of the deterioration of health care available to the working class.
The health care crisis facing the working class is part and parcel of the deterioration of every aspect of workers’ lives, as finance capital drains increasing amounts of wealth out of what is spent on health care, as from every useful human activity. It’s a particularly good example. What started out in the nineteenth century as a multitude of measures by various organizations that devoted some resources to the population’s health, has become today essentially a way to channel wealth to the capitalist class.
The first improvement in health came through public measures which aimed to correct unsanitary conditions, particularly in the big cities. The U.S., despite the rapid development of its economy in the post-Civil War period, lagged behind a few European countries in providing such services, particularly Great Britain. But eventually, the construction of clean water and sewer systems, the organized cleaning of streets, and then finally the administration of vaccines served to eliminate the periodic epidemics that had previously wiped out towns. Measures that had started in the more developed cities of the Northeast eventually spread to big cities across the country.
A medical system as such began to develop during the same period, uncoordinated and spotty. The first public hospitals in the U.S. had been founded as far back as the 1700s in New York and Philadelphia. Other cities slowly followed suit in the 1800s. At the beginning, the aim of those hospitals was simply to separate the sick from the rest of the population, but they formed the initial centers of large-scale medical care.
With the Civil War, development of surgical treatment and anesthesia came from the army itself. And this ultimately led to spreading these measures to hospitals everywhere.
While the first hospitals were publicly funded ones, the rapid increase in immigration led to a new kind of “charity hospital,” that is, hospitals organized by religious organizations. Catholic nuns established hundreds of hospitals with the aim of keeping Catholic immigrants linked to the church. In places where they were concentrated, Lutheran, Jewish or other religious organizations built their own hospitals for similar reasons.
But such developments were restricted to the big cities. In rural areas, medical care, to the extent it existed, depended on doctors whose training might have been in the army or “medical colleges,” where training was not systematic. Many of those rural doctors doubled as veterinarians, or vice versa. The largest provisions of medical care in the countryside, however, rested on midwives who helped women deliver their babies.
In other areas of the country across the mountain West, employers had their own medical services—especially in isolated mining and lumber camps where labor was scarce, and on projects to build railroads and aqueducts that brought large numbers of workers into unpopulated places.
The first moves to research the problems related to medicine came in the first university medical schools. But a big step in standardizing care came through the efforts of some doctors to standardize licensing through the American Medical Association. In fact, under the guise of making the practice of medicine more scientific, licensing was aimed at limiting who could call themselves a doctor, that is, among other things, pushing out midwives and those practitioners who had not gone to approved medical schools. By limiting the number of doctors, the AMA served to make it more of a “profession,” one better remunerated. It also started the practice which creates a shortage of doctors today.
By the early 1900s, the different types of hospitals were providing treatments carried out by licensed doctors and nurses. The basic purpose of those medical facilities, regardless of who organized them, was not to produce a profit in the rapidly developing capitalist economy. But existing in that economy, they bought the things needed from businesses whose purpose was profit. They might not have required a payment to provide treatment, but they did ask for payment. Despite being organized as charities, they could not escape the heavy hand of profit which rested on the whole system.
By the 1920s, a patchwork of hospitals had spread across various parts of the country, universities were beginning to standardize the training, and therefore the treatment carried out in them. But there was no overarching organization, and hospitals did not come close to providing medical care for the whole population.
The first big move to centralize and coordinate medical care came as a way to organize the payments for medical care. Hospitals, hit by the various crises which were endemic in capitalism, faced a long-term problem: how could they be funded? And this was aggravated by the Great Depression, which began to develop in the late 1920s.
The first version of health insurance emerged in response to this problem. Some unions had long pooled workers’ dues to offer a form of insurance that paid for a funeral or for time lost to injury. As medical care got more expensive in the early 20th century, some, like the Dallas teachers, also offered their members prepaid hospital subscriptions. In December 1929, Baylor University began selling these prepaid hospital subscriptions to the public.
The American Hospital Association soon backed this idea of hospital insurance. In the 1930s, it helped establish the Blue Cross network that would organize not-for-profit health insurance organizations, eventually in every state. A few years later, the American Medical Association backed a similar plan to pay doctors, which became the Blue Shield network.
Different forms of medical insurance developed, many tied to employment status. Some companies, like Henry Ford or Kaiser, set up their own medical systems. Others managed their own funds, set aside to pay for care for their workers. But most big companies paid for workers to have the insurance set up by hospitals and doctors in the Blue Cross Blue Shield networks.
The federal government fully entered the field when it expanded the program that became Medicaid, and introduced Medicare (for people over 65).
As a result of the growth of both employer-provided insurance and government programs, from World War II until about 1970, the share of the population with health insurance increased year by year until it reached about 83%.
Well into the 1970s, the big insurance networks and hospitals remained organized not essentially to produce profit. Of course, they still diverted large sums of money to corporations making profit from the growing health care system—for example, drug makers and companies that produced medical equipment.
In the 1970s, as the postwar boom ended, companies trying to reduce labor costs turned to for-profit insurance companies. They offered cheaper plans by excluding or charging much more for older people who were likely to need more medical care. The for-profit companies, which had long offered other types of insurance, had begun offering health insurance in the 1950s. This shift to for-profit companies began slowly, but then accelerated.
As the for-profits insured a higher proportion of the younger people, many Blue Cross Blue Shield organizations began to lose money.
In response, in the late 1970s and 1980s, the Blues, focusing on their own bottom lines, began to operate like the for-profits: charging more for older people or those with “pre-existing conditions,” adding copays and deductibles that would be paid for by the insured worker rather than out of the premiums paid by an employer, and selling plans that limited which doctors or hospitals someone could go to. They also began creating or buying for-profit subsidiaries that sold other types of insurance, or that provided services that the Blues parent company purchased.
By the mid-1980s, most were operating like standard for-profit corporations. Finally, in 1994, the Blue Cross Blue Shield board allowed local Blues to officially convert into for-profit corporations, meaning they could sell stock to investors who could draw out dividends and other returns from the corporations’ income.
Between the late 1990s and the 2008 financial crisis, capital flowed into the health insurance industry. This capital restructured insurers, which had been set up to serve doctors and hospitals, to instead focus on making profit for the investors who bought their stock or the banks that loaned them money.
For instance, Anthem, the Blue Cross Blue Shield insurer of Indiana, was originally a customer-owned cooperative, or mutual company. But in the late 1980s and 1990s, it began expanding with borrowed capital. It bought and sold Indiana’s largest investment bank, set up a brokerage that sold insurance and other employee benefit programs, and began buying other insurers in Ohio, Kentucky, Connecticut, Nevada, New Hampshire, and Maine. In 2001, it “demutualized” and became officially a for-profit company whose stock was publicly traded—after which, its buying spree accelerated.
Blue Cross of California went through a similar evolution. In 1993, even as it remained officially not-for-profit, it spun off its most profitable business—managed care—into a publicly traded, for-profit company named WellPoint. The “not-for-profit” Blue owned 80% of the for-profit company. In 1996, Blue Cross of California gave up the pretense and officially converted into a for-profit company, making WellPoint the parent organization. Like Anthem, it raised capital by selling stock and taking out loans and began buying Blues and other insurance companies across the country.
In 2004, Anthem and WellPoint merged, creating the largest company to come out of the Blue Cross Blue Shield network, renamed “Elevance Health” in 2022. The combined company was immediately one of the largest financial institutions in the country, drawing income from its tens of millions of policy holders, and speculating with that money just like other financial institutions.
While it was consolidating the Blues, capital was also pouring into for-profit insurers like UnitedHealth Group. This company had begun in 1974, managing claims for a doctors’ group in Minnesota. In 1977, it began offering an early version of managed care for seniors. By creating a network that included family doctors, specialists, and hospital treatment, managed-care plans could reduce administrative costs. But they also reduced costs by limiting which doctors and hospitals people could go to, making patients get prior approval to see a specialist.
In the 1990s and early 2000s, capital began flowing into United Health, allowing it to expand rapidly. It bought insurers across the country, including the health insurance wings of MetLife, Travelers, and John Deere. It also bought companies that distribute drugs, pharmacy benefit managers, and even a bank that specializes in financing health care corporations. It eventually became the largest health care corporation in the world. Health insurance was an attractive investment—like mortgage payments, health insurance premiums offered a consistent “revenue stream.”
The capital flowing into health insurers in this period did not expand care. The share of the U.S. population with health insurance was about 83% in 1970—and it remained at about 83% until 2010. This process also reversed the dynamic between the hospitals and doctors who had originally set up the Blue Cross-Blue Shield network, and the insurers. Those hospitals, doctors, and even the government were the ones that originally decided which care was necessary. But especially since the late 1990s, insurers have increasingly made those decisions on the basis of their own bottom line. Doctors’ offices, nursing homes, and every other health care provider can afford to give only what insurance companies will pay for. The decisions are made on a financial basis, not a medical one.
Which hospitals or doctors’ offices stay open depends on whether they can successfully bill insurance for enough reimbursement to pay their costs. Pharmaceutical and equipment companies also need insurance companies to pay for the drugs and equipment they produce.
In other words, even though health insurance was originally set up by hospitals and doctors to pay for the care they provided, the operations of this capitalist economy transformed insurance into a means of distributing profit, not care.
The U.S. government reacted to the 2008 financial crisis by handing over enormous sums to the financial industry to try and reinflate the speculative bubbles that had begun to pop. This money didn’t just go to the banks—the insurance companies were another part of the financial industry that also got increasing amounts of government money, especially with the passage of the Affordable Care Act (ACA).
The ACA was sold as a step toward publicly provided health care. In reality, it did the opposite and increased privately-owned insurance company control over the health care system—and increased insurance industry profits. It should not have been a surprise that the main push for passing the ACA came from the medical insurance industry.
The ACA set up a government-run marketplace for individuals to buy insurance. Most people can’t afford to pay the high premiums set by the marketplace. So to cover the gap, the government included a sliding scale subsidy, that is, government money that goes to the insurance companies.
The ACA also expanded who is eligible for Medicaid—and increased the role of the insurance companies in managing this program and determining the money they can make from it.
Medicare, the largest government program paying for medical care, has been even more transformed into a cash cow for private insurers. In 2009, one study cited by Obama in his push to pass the ACA estimated that private insurers offering managed “Medicare Advantage” plans charged about 15 billion dollars more than traditional Medicare would have cost. By 2022, a study by Physicians for a National Health Program found that the amount that Medicare Advantage plans overcharged the government had grown to between 88 and 140 billion dollars.
According the Kaiser Family Fund, the ACA did reduce the number of uninsured people in this country by about half. But the average person—including the insured and uninsured—pays more out of pocket today than they did before this law was passed.
Nor did the ACA slow the growth of health care spending overall. By 2023, the federal government estimated that total national health expenditures had reached about five trillion dollars—double what they had been in 2010—of which about half was spent by government at various levels.
Despite all this spending, the population’s overall health has not improved. Just the opposite—life expectancy was lower in 2023 than it had been in 2014, when the ACA fully went into effect.
Over that same period, insurance company profits more than doubled. And it’s not just insurance companies that profit. A report by the McKinsey consulting company estimated that the total profit made at all points in the health care sector added up to 583 billion dollars in 2022. Analysts expect health care profits to continue to grow—the same McKinsey report estimated that by 2027, health care profits will be 819 billion dollars, an increase of more than 40% in just five years.
The capital that has flowed into healthcare has driven so many mergers and acquisitions that just a few companies increasingly dominate each industry and are able to charge monopoly prices. Six companies issue 64% of all health insurance policies. Three distribute more than 95% of the country’s pharmaceuticals and dominate the distribution of other medical supplies. Two companies own almost all the country’s dialysis centers and take in more than 90% of the revenue in that industry.
As recently as 2014, no health care company was among the top ten revenue-producing U.S. corporations. Today, four of the top ten U.S. corporations are health care corporations: UnitedHealth Group, CVS Health (which owns Aetna), and the medical supply and drug distributors McKesson and Cencora (Cardinal Health, the biggest competitor of McKesson and Cencora, is #14). Cigna Group is #16—between Chevron and Ford Motor Company. In all, 43 health care corporations are in the Fortune 500.
These corporations operate like all the others. They spend hundreds of billions buying back their own stock to drive up the price and reward their stockholders. They pay large dividends. Their CEOs and other top executives take home millions.
In the Communist Manifesto, Marx and Engels wrote that the bourgeoisie “has converted the physician, the lawyer, the priest, the poet, the man of science into its paid wage laborers.” That idea may have indicated the trend of development already in 1848. Today, even if doctors are much better paid than most, their work has been demeaned as they are driven to work 12-hour shifts as cogs in hospital machines dictated to by insurance companies. This is not to speak of nurses, CNAs, cafeteria staff, and all the different types of techs who are run into the ground to maximize productivity in the interests of profit.
The result of the reorganization of health care for profit has been a disaster for the population.
Getting access to care has become increasingly difficult. In the last 20 years, more than 100 hospitals have shut, especially in rural areas and inner cities, either because they couldn’t get insurance to pay enough to cover their costs, or because they were purchased and cannibalized by investment groups, in the same way Sears or Toys R Us were destroyed. Hundreds more have reduced the services they offer. The networks of doctors and hospitals are shrinking every year, and insurance dictates where people can go. Patients must get tests and treatments pre-approved by an insurance company that has every interest in “delaying and denying” care. And that’s not to mention the exorbitant out of pocket costs in copays, deductibles, and premiums, such that medical debt causes about two-thirds of all U.S. bankruptcies.
All of these obstacles mean that huge numbers of people don’t get the health care they need. On top of the uncountable number of deaths that result from cancer or heart disease caught too late, almost 25% of the U.S. population lives with chronic pain. Much of this would be treatable if people could get regular physical therapy, or treatment for conditions like TMJ that affects the jaw—but these are expensive.
Then there are the 1.6 million people parked in nursing homes, three-quarters of them in a for-profit facility. Almost 200,000 residents and staff died during the COVID pandemic. These “homes” are notorious for being so understaffed that patients are left in their own filth for hours.
Even those public health measures that played the largest part in reducing disease are under threat by the predations of capital. Water systems have failed in Flint, Michigan and Jackson, Mississippi and are underfunded across the country. And as increasing numbers of people lose faith in a medical system that is not set up to help them, charlatans like Robert Kennedy Jr. are undermining support for vaccines, contributing to new outbreaks of all-but-eradicated diseases like the measles.
In 1939, Leon Trotsky wrote that “Human progress is stuck in a blind alley.” He used the example of agriculture: “despite grandiose productive possibilities, secured by experience and science, agrarian economy does not emerge from a putrescent crisis, while the number of the hungry, the preponderant majority of mankind, continues to increase faster than the population of our planet.” Today, we might use the example of health care in the U.S. Despite grandiose expenditures, amazing medical knowledge, and the dedication of millions of healthcare workers, the length and quality of life are going backwards for the working class majority.
The cause of this contradiction is obvious: enormous sums supposedly devoted to health care for the population are increasingly drained off for profit by finance capital.
The development of healthcare shows that no part of this society, no matter what it was set up to do or how much capacity it has, can be safe from the predations of capital. Every human need is increasingly subordinated to profit. Until the whole system of capitalism is overthrown, these parasitic vampires will keep draining an ever-increasing share of the resources needed to provide for the population’s well-being.