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The Ideas Q&A

Medicare for All Is Not Enough

Beatrice Adler-Bolton and Artie Vierkant make the case for health care revolution.

Courtesy of Verso
Artie Vierkant and Beatrice Adler-Bolton

The number of Americans without health insurance has been on the rise since 2016, and every year tens of thousands of people die because they are uninsured. Twelve percent of Americans have significant disabilities; this group is more than twice as likely to avoid care because they can’t afford it. Nearly seven in 10 Americans support a public option. Over half support Medicare for All. But you’d hardly know it, given conservatives’ fierce opposition to any threat to private insurance and the Democrats’ inability to rally behind significant changes.

Every morning, Beatrice Adler-Bolton—an artist, health care activist, and co-host of the Death Panel podcast—tweets a “daily reminder” that “if you don’t support Medicare for All—you want disabled & poor people to die.” She and her co-author, Artie Vierkant, also an artist and a co-host of the podcast, gave their new book, Health Communism, a self-consciously provocative title. “We take a lot of inspiration from artists who have had political lives and careers pushing for health justice outside of their art practice,” Bolton told me, citing the writer Gregg Bordowitz, who was an organizer with ACT UP. “One of my mentors at Cooper Union, Marlene McCarty, was a member of Gran Fury. They made propaganda posters for ACT UP, and they took the name of their group from police cruiser cars.”

Health Communism: A Surplus Manifesto
by Beatrice Adler-Bolton and Artie Vierkant
Verso, 240 pp., $24.95

Surveying a century of sickness under an increasingly privatized system, in Health Communism Adler-Bolton and Vierkant argue that we have to demand much more than Medicare for All in order to fix health care. I spoke with them recently about health, how the logic of austerity has made us sicker, and the sort of health system they envision. This conversation has been edited for length and clarity.

Spencer Green: We’re used to seeing the language of health commodified. It’s used to sell things; it’s used to promote specific ideas about bodies and minds and how they should be or shouldn’t be. What do you mean by health in the book?

Beatrice Adler-Bolton: Well, I think when we think of “health,” we’re really trained to think of it as a consumer good, or a quality that belongs to an individual person. There’s so many things that we think of as pieces that we’re responsible for, as individual consumers, when we evaluate if we’re healthy or not: what our diet is, what our employment is, where we live. But a lot of that is out of your control and has nothing to do with your personal moral or behavioral choices, right, beyond that. So when we say “health communism,” it’s lowercase-c communism. What we’re really pointing toward is that health is not an intrinsic personal quality; it’s a population-level phenomenon. It’s something that is built by everyone’s individual actions but also built by the state, the institutions around us, our laws.

S.G.: The U.S. has long had one of the most expensive and restrictive health care systems in the world. What kind of system are you pushing for instead?

Artie Vierkant: We try in Health Communism to make the argument as expansive as possible, so that people can understand that something like single payer is a necessary systemic health finance reform. But we need to broaden our demands to something that I think can best be summarized by saying “All care for all people,” and really radically reshaping how we conceive of how expansively care is needed and how expansively care can be given.

If we limit our demands—even though something like single payer is not incremental reform, it is a major step—it’s important to understand the degree to which the actual implementation of something like that could too easily be compromised into something very incremental if we don’t have a very straightforward, broad goal in mind when we demand things for health justice or health communism.

S.G.: Do you see any health care systems that currently exist in the world as possible models for the U.S.? You mention the U.K.’s NHS—but you don’t see it as a model. Why is that?

A.V.: I would caution that we’re not necessarily saying like, “Oh, we don’t want an NHS, we don’t want a national health system.”

BAB: It’d be great.

A.V.: We do want that, actually. But we don’t want to just carbon copy what exists in the U.K. because the NHS actually is a perfect example of why doing universal health care but making it operate still under principles of austerity only accomplishes so much.

BAB: Though it has greatly improved a lot of health metrics for all sorts of people, it also leaves out so many of the most vulnerable, and is sort of artificially designed to reproduce some of the worst extractive dynamics that result in things like delayed care or not having enough physicians or not having enough nurses, right, because part of what the NHS’s problem is, is ultimately, always that it has been run under principles of austerity and trying to save money.

A.V.: We’re so used in the United States to saying, “Oh, every other country has socialized medicine.” And one of the really important parts of what we’re saying is that we can’t stop our demands at this imagined idea of systems that do not fundamentally exist in the way that they’re referred to in popular discourse, without then immediately facing the reality that these systems are designed for austerity.

BAB: Moving forward, we can’t simply say that we want to reproduce systems wholesale, we can’t hold things up to be heroic, when there are critiques that are teaching moments for how to not repeat the mistakes that we’ve already made. We’ve already made those mistakes. It’s up to us to make new mistakes, and learn from those.

S.G.: I was really struck in your book by your discussion of how our health system treats sick people, the disabled, the elderly, the unemployed. That they are talked about like they’re expensive, they’re a drain—but at the same time private equity companies are buying nursing homes, and you write about how Wall Street portfolios literally list the bodies of people who are housed in some of these facilities as an asset. What do you make of that?

BAB: There’s a fundamental economic valuation of life where we take someone and we say, “OK, you as a human being, you’re not intrinsically valuable; you’re valuable based on what your tax bracket is, how many dependents you support, you know; how big your assets are, what your output is, as a worker, what kind of surplus profit you make for whoever you work for.” That’s sort of how we think of valuing people. And for people like me, who are sick, who can’t work, we’re sort of seen as having negative assets, on the other side of that. It’s this idea of, well, if there are too many disabled people, we’ll sort of be overwhelmed by all of these burdens.

But in actuality, a sick person like me—I create jobs, technically. There are a lot of people whose jobs it is to take care of people like me. I have nine doctors! I have an infusion nurse who comes once a month, there’s an infusion company who coordinates my infusion, there’s someone who has to do the insurance billing, [who] gets paid to fight the insurance company, someone in the insurance company gets paid to fight my doctor, to try and deny me care. And I’m not even someone who lives in a nursing facility. And that’s just one part of the economy that my care creates around me.

S.G.: You’ve talked particularly about how nursing homes extract value from the people they are supposed to take care of.

BAB: This is a kind of situation where removing someone from their home and from their community allows us to maximize extraction, while minimizing the expense that goes into taking care of them through economies of scale, through congregating a lot of people together and seeing how little staffing we can get away with. These are the kinds of dynamics that are oriented not toward supporting those people in a bed, but toward knowing that each person in one of those nursing home beds gets X amount of federal dollars and maybe X amount of state dollars. And then it’s up to the company that’s running the facility to squeeze a profit out of it. This is a business model. What that results in is that a person becomes more valuable as a body that occupies a bed than as a human being. And it’s a kind of fundamental stripping of personhood and autonomy.

That is why, as much as we might like to think that we could simply fix health care by fixing the payer, we have to address these fundamental logics and dynamics that are much bigger than who’s paying for it. Because simply saying, “OK, venture capital has to get out of nursing homes, and they can’t do nursing homes anymore” doesn’t change the logic. It does nothing to disrupt that fundamental dynamic of, “Well, you’re gonna get X amount per person.”

S.G.: The book’s title is Health Communism—which seems like an attempt to get ahead of arguments that the right likes to make about socialized medicine, that it will lead to full-blown communism. You are both also co-hosts of a podcast about health care, and its title, Death Panel, also winks at a right-wing talking point. How do you engage with the right-wing arguments against universal health care?

BAB: We’ve seen how powerful these myths can be in terms of defining what we think of certain types of health care. We’re appropriating these ideas and frameworks to minimize them and play with them. You know, really, what are conservatives afraid of? They’re not afraid of communism. They’re afraid of health capitalism, because it’s a fundamentally extractive and destructive force. If you were to really investigate what’s at the heart of the anxiety under the “death panel” myth, it’s that, you know, we are disposable to capitalism. You can work really hard your whole life, and it can be out of your hands whether you’re going to survive or not. You don’t have a lot of power in that relationship. It’s a trope to say, like, oh, “Such and such is the real death panel.”

A.V.: “Capitalism is the real death panel.”

BAB: “The Supreme Court is the real death panel.” But at the end of the day, what a “death panel” is is a type of logic. It’s an acknowledgment of how you can work and be the perfect worker, and that will never save you from being part of the meat grinder at the end of the day.

A.V.: I constantly am thinking back to arguments that happened during the “Medicare for All” debates in 2016 and 2020. So much of what we’ve tried to tackle in Health Communism and in Death Panel, what we’ve been reacting against, is how readily people will take up the frameworks that capital made and privileges. Things like the economic valuation of life, or the idea of, “If we did Medicare for All, if we did universal single payer, it would be this huge fiscal drain.” And then people on the left will take that logic, and they will say, “Oh, well, we made this spreadsheet, and here’s this thing that says, actually, it’s gonna be cheaper.”

BAB: For decades now, we’ve been circling the drain of this question, “We need better health care, how do we make it cheaper?” Part of what we’re trying to do, in the book and in all of the work that we do is to really do our best to break a crack in that facade and leave an opening for the conversation to go elsewhere.