What will health care become once Capital is buried 60 feet under in North America and across the planet? Its demise will spell the end of:
the private pharmaceutical industry and stranglehold of corporate Big Pharma interests and structures
private medical insurers, the whole shebang
the privately-owned industries for high-cost medical equipment
fee-gouging practices by countless physicians in the name of profit over people
the network of costly, profit-oriented private clinics and hospitals
Their disappearance will open up radically new vistas on health care provision and preventive medicine as an inherent public good.
My article today, grounded on many years of direct experience in provincial post-communist Bulgaria, asks if past paradigmatic experiments that strove over decades to create socialized medicine are useful historical experiments worth looking at and possibly learning from?
I wish to argue that we need to revisit the various experiments in universal health care in the socialist states of Eastern Europe. Those experiments now lie largely dismantled, demonized by the neoliberal corporate and political (dis)order that has descended on much of the former Eastern Bloc. My guiding thesis: in moving toward ‘socialism 2.0,’ the international left needs to look unblinkered at redeemable past real-socialist achievements in medicine, housing, guaranteed full employment, people’s education, salvaging and retrofitting what seems viable. This essay explores one such ‘experiment in people’s medicine’ that lost the Cold War, namely in the socialist People’s Republic of Bulgaria.
Bulgaria’s socialist experiment and grounded experience of universal socialist health care may have been the most positive of any of the various (and quite different) states inside what was called the Warsaw Pact. I have become ever more convinced, mainly by living long-term among Bulgarians of a generation born circa 1974 and earlier, that what Bulgaria achieved before the catastrophe of 1989-90 and the demise of its socialist system—it did not self-destruct—was indeed exemplary and is worth looking at and learning from. My own long-standing ties to social-anarchist imaginaries have been reshaped by repeated discussion with Bulgarians who are certain their own lives in the People’s Republic (1944-1990) were far more happy and ordered, materially and socially, then than now, and radical equality was a central value.
We need to ask what that system of medical social welfare actually was, how it was experienced, what it accomplished, as revealed by people’s oral history: building an oral history of socialist medicine as it was experienced and remains reflected in the memory of real people, its living subjects. What can we learn from its past for the project of a new more libertarian ‘socialism 2.0’ in our own century? What were its shortcomings and failings, as a system within a one-party authoritarian communist state operating under the myriad constraints of the Cold War? But exploring that requires an open mind among socialists, ready to rethink long-held shibboleths—beyond all the distortions of Cold War perceptions in North America, and on the North American left, unfortunately still operative down to the present day.
In real-socialist Bulgaria, medical care was universal and cost-free, including hospitalization and surgical procedures. Waiting periods for admission to hospital were kept to a minimum. Citizens did not pay for state ‘insurance’ coverage; rather, it was offered to all adults and children as a state benefit.
This fact was closely intertwined with a core aspect of the socialist economy: guaranteed full employment. Bulgarians in interview speak about “three people doing the job of one,” in effect a form of real-socialist job-sharing, all with a guaranteed livable egalitarian wage. Citizens with a primary school education (or less) were also all employed—as factory hands, toilet attendants, in agriculture, street cleaners and other simple jobs, all at a livable egalitarian wage. This was in effect a socialist UBI or ‘unconditional basic income’ for one and all, but tied to actually having an assigned job of some kind. Not to accept a job was viewed as a misdemeanor, in effect a crime not to work. The state enforced full labor, it was policed. Since there was ‘full employment,’ with the state as universal employer, it had no need to levy a special added monthly or annual fee for medical coverage (as exists today).
Virtually everyone over the age of 19 or 20, including many married women, had some assigned job. All doctors also worked for the state, there was no private practice, it was basically prohibited. The egalitarian system of incomes ensured that wage differentials among most workers—from professors, factory heads, doctors, lawyers, writers, artists, actors, railroad workers, to office personnel, sales personnel, street cleaners, you name it—were relatively minor. In their narratives, people recount that wages were quite adequate for most needs since costs of many essentials were kept at a minimum, and some aspects of virtual ‘demonetization’ (for example, of utilities like water, steam heat and electricity, or public transport) were clearly in effect. Prices were also uniform everywhere, and generally quite stable over long periods. Low-cost restaurants, nearly cost-free workplace canteens and vacation resorts were also once the familiar and welcome norm.
Doctors and dentists were assigned to all schools, factories, and agricultural collectives, as well as to set hours at clinics and in hospital. What this meant at a school, for example, is that children were regularly checked for general health and dental health, by an in-school medical practitioner. This system of preventive medical care was, in common memory, deemed quite exemplary: it led to an excellent standard in oral hygiene, promoted in and by the school. Doctors’ physical exams on the spot at school made sure kids were healthy, and not overweight. Physicians assigned to factories were available for any accident on the spot, and also ensured regular check-ups for workers. Doctors and nurses were also available at cost-free summer camps, which were very widespread as a means to educate children and youth and provide out-of-school recreation and training.
Patients could in addition go to any doctor of their choice, including a specialist. People narrate that care in hospital was in their memory excellent, as was food for patients. Patients were charged nothing for hospital stays and various procedures, or for medications. The ratio of hospital beds to population was high. Technology for accurate diagnosis and treatment was of a relatively high standard, given the constraints of the Cold War and the country’s relatively small size (peaking at approximately 9 million in 1988).
Importantly, pharmacies were all state-owned. The pharmaceuticals, from state-owned Bulgarian manufacturers and imported largely from other socialist economies, were, in people’s memory, of high quality and quite inexpensive. Only a non-profit pharmaceutical manufacturing industry could ensure the functioning of such a system. Nor was there advertising of such products. There was no perceived need.
In socialist Bulgaria, from the 1950s, there was a widespread network of rural primary care clinics, staffed by doctors and nurses and paramedics assigned to such posts. This helped significantly to overcome the inevitable differences in the geography of access to medical care, urban vs. rural.
After the collapse of socialism, the ‘class war from above’ under the naked rule of Capitalism resurrected in the former socialist states of East-Central and Eastern Europe, a ‘new periphery’ of global Capital, in some ways a ‘neocolonial’ topography of contradictions is particularly virulent and barbaric in Bulgaria. Today its population, economy, and levels of morale are in massive contraction under unfettered Capital’s ‘shock therapy.’ It is now the lowest-income post-socialist state, with the highest levels of economic emigration in Europe.
The once paradigmatic Bulgarian system of people’s health care lies largely in ruins, its restructured remnant seriously underfunded. The changes are striking. Many Bulgarians remain reluctant or simply unable to pay the current monthly fee for obligatory state health insurance (about the equivalent of $11), and so nearly 20 percent now are not legally insured. Nonetheless, hospitals now account for a third of all public debt in capitalist Bulgaria.
The contrast between ‘then’ and ‘now’ is stark and for many Bulgarians truly overwhelming, even devastating for the most impoverished, a large segment of the pensioned senior citizenry, and nearly all of the Roma ethnic underclass, the most severely afflicted victims in the reborn free-market economy. Once nearly all Roma were gainfully employed, despite the endemic racism against them; today Roma joblessness, in part due to the same now more virulent racism, is in the range of 85-90 percent; many Roma have emigrated westward in order to survive.
What then can we learn from the experiments in a now gutted people’s Bulgaria? Can some of real-socialist health care be retrofitted for tomorrow? Is a less centralized, more locally-controlled socialist commonwealth possible? How a far more ‘self-determining’ yet sustainable communist society could be vibrantly constructed from the ‘bottom up,’ based more on autonomous production units, remains an open question. Perhaps one key paradigm, both in the Balkans and North America, turns on creating worker self-directed enterprises (WSDEs) as a mass anti-capitalist movement, as Richard Wolff envisions. Would an economy grounded on WSDEs be able to forge a bold new system of socialist cost-free health care? As a material basis for that, could it engineer a decentralized mode of full employment anchored in radical hands-on democracy at work? Or is guaranteed full employment achievable only in a highly centralized command economy, with all the hierarchical architecture of top-down planning and control that can entail?
In all such visions of a post-capitalist future, egalitarian, cost-free, sustainable health care as a public good is a central challenge. So a working sub-thesis here might suggest: social-anarchist and real-socialist vision and practice can learn much from each other in a mutually fruitful if dialectical bond. That is a rare proposition, but we live in singular critical times.