Chapter Three. From Lenin to Bevan

UThe Few assume to be the deputies, but they are often only the despoilers of the Many/~ Hegel, Philosophy of History. C HAP T E R T H R E E From Lenin to Bevan: Streamlining the Health Schemes LENINand Bismarck had in common the paternalistic philosophy of government which included the supremacy of a trained and solidly disciplined bureaucracy over what they both considered the anarchy of the unregimented market place. To both, the "little man" was either financially or at any rate morally incapable of caring for his own future. Both were motivated by an insatiable thirst for power and utilized to. their own political advantage the alleged responsibility of the State for controlling the insecuri ties of industrial life. Social Insurance or Social Security was essential to their concept of the Good Society. It involved a regimented society ruled by their own superior wisdom. FROM SOCIAL Actually, Lenin and his followers were INSURANCE TO thorough-going admirers of the Prussian SOCIAL SECURITY bureaucracy. Soviet planning was built, at the outset, on the pattern of German military management in World War I. But there the ideologi cal community of the two authoritarians ended. Bismarck presented his project in the name of the Christian idea of the State, confusing it with the state idea of 18th Century enlight enment. 1 (His much vaunted "Christianity" did not interfere with Bismarck's violent opposition to any sort of factory law, such as to enforce minimum hygienic requirements.) Lenin was a genuine revolutionary, basing his communism on a purely materialistic philosophy. To the one, private ownership of the means of production was sacrosanct but was to be regimented; for the other, it was to be wiped out altogether.

28 29 ] FROM LENIN TO BEVAN: STREAMLINING THE HEALTH SCHEMES Bismarck had to compromise with resisting parliamentary forces led by the industrialist Stumm. Even the trade unions were·opposed tooth and nail; they could not foresee-· nor did Bismarck, ofcourse-· that some day they themselves would have the power to use the scheme for·more power. Lenin, by 1922, having wiped out parliamentary resistance, possessed power absolute as no sovereign has had since Genghis Khan. Two basic types of govermnentalized medicine resulted. The Prussian bureaucrat created the obligatory health insur ance of a comparatively limited scope. What the Russian Bolshevisthas bestowed might be described-following recent Anglo-French terminology-as compulsory health security of an unlimited medical orbit. Perhaps they should be distin guished as governmentalized vs. socialized medicine. In the one, the beneficiaries are "insured"; in the other, they; are "registered."

That Social Insurance alaBismarck, ···and Social Security a la Lenin are different in degree only-that the dynamic poten tials of the·one tend to carry·over into.the other-· may aston ish those who do not realize that Bismarck's famous "personal rule," that was to wreck his nation's democracy, was a con scious if abortive· attempt aiming basically at the same political goal which was to materialize in the Politburo (and in.Hitlerism). LENIN vs Bismarck's system meant to be, in appearance BISMARCK at least, what its name indicated: insurance, even if without a true actuarial foundation, and a sub sidized, involuntary plan. At the outset, the insured were to be classified according to risks and to receive cash benefits in proportion to their contributions; a surplus, the equivalent of profit, was to be accumulated as an emergency reserve to guarantee the insurers' (panels') solvency; each type of risk incurred was to be offset by appropriate premiums; prefer ably, the risks were to be distributed by re-insurance; etc.

These are axioms of sound insurance management, most closely approximated at present by the Swiss panels among European cooperative systems of·medical care. Nothing of the kind is aimed at in the Bolshevist pattern, the all embracing program of Comrade Lenin. The· same holds in principle for the compulsory set-ups based on LeninCOMPULSORY MEDICAL CARE AND THE WELFARE STATE [ 30 ian security ideals now in operation in France and Britain. There, too, the pretense of businesslike management has been almost totally abandoned. Bismarck's humanitarianism was limited originally to the worker dependent on hourly wages. Thus the range of per sons falling under the compulsion was defined. This type of legislation, which still predominates on the Continent, restricts panel membership to employees and their families, or to the "economically weak" groups comprising the income brackets not above skilled factory labor.

THE SOVIET In L~nin's ~ind of wo~l~ there is, supposedly, PANACEA one kmd of Income reCIpIentsonly. All are In the same boat; all need the same support. The idea of medical insurance for the underprivileged is inflated into equal medication for everybody. Everyone according to his needs, is the underlying axiom. From a humanitarian' device of restricted confines, the idea has grown into all embracing, communistic dimensions-on paper. In reality, the industrial population only is "secured." In Soviet Russia, from 1922 to 1938, nationalized industry i.e., the government-carried the cost of socialized medicine in the form of a 6.5 per cent "payroll tax" (25 per cent for all social security) with recourse on the national budget to cover eventual deficits. Industries, not labor, were to pay the bill. Similar systems with minor modifications are now being set up in the satellite countries. In the 1948 Bulgarian scheme, for example, the self-employed are the only ones to pay contribu tions-which is one way to hasten their elimination-with all benefits of medical service freely dispensed to everyone.

Of course, Lenin's promises and Stalin's practices are worlds apart. Since 1938, the trade unions, the workers, had to take over about 8 per cent of the total cost. Hazard-classes were re-introduced, and the contributions graded accordingly. Medical benefits have been greatly deflated, while the number of persons covered has risen fourfold in the decade since 1928. And the Soviet health plan has developed into a forceful method of disciplining labor. Cash benefits to adult workers, for instance, are available only at the rate of 50 per cent of their wages after two years of uninterrupted work in the same industrial unit; 60 per cent, 80 per cent and. 100 per cent accrue 31 ] FROM LENIN TO BEVAN: STREAMLINING THE. HEALTH SCHEMES if they stay three, six and more years, respectively. Mother~ hood benefits are guaranteed by the Soviet constitution but are paid only to women who have worked at least seven months in the same plant.2 But the aristocracy of Soviet officialdom and labor receive all .the sickness care their country is able to give, including richly endowed sanatoria and rest-homes in the Caucasus and the Crimea. And Stalin claims credit for being the Great White Father dispensing health security to all of his subjects.

MINIMUM OR ·After World War II,Weste~E~rope's medi MAXIMUM TO cal sc~emes wer~ ~ot revolutIonIzed by open BE PROVIDED? adoptIon of L~mn s pl~n. B~t th~ latter gave a tremendous Impetus m a dIrectIon that has been under way ever since Bismarck. ·The original German set-up was meant to be, to repeat, health "insurance." The weight of the entire scheme rested on cash benefits per day of lost income. Benefits in kind-medical services proper were supplementary only, largely left to the decision of the .individual.panel which had a broad autonomy in .disposing of the means on hand, even in determining the percentage levy on payrolls. The emphasis on cash benefits and on the auton omy .of the panels was a basic feature of that original plan wrested from Bismarck by the Parliamentary opposition. It did not take two decades to reduce to a fraction of the total the share of cash benefits in the disbursements of the German panels. Once services in kind become the mainstay of the sickness scheme, it turns into a queer instrument of wealth redistribution. (All other· branches of social insurance, with the partial exception of workmen's compensations for accidents, are restricted to cash disbursements.) Contributions cease to bear any relation whatsoever to the risk involved.

Policing by physical controls over a most vital sector of private life takes the place of actuarial calculation. Thus, the difference between the Bismarckian and the Len inian patterns tends to fade out. But still, the contrast between the old and the new approach reaches into every comer of the problem. Paternalistic as the .Bismarckian scheme was, it did not intend to free the individual of all responsibility. He ·or she was to be secured to the extent only of absolute necessities. An irreducible minimum of health care and of income guaranCOMPULSORY MEDICAL CARE AND THE WELFARE STATE [ 32 tee was to be dispensed, no more. Accordingly, cash benefits had to be much smaller than the actual income of the recipient when working. Medical services were to offer as much as was objectively necessary to restore health; but the patient was not to be pampered, and his incentive to care for himself and for his family was not to be impaired.

The postulate of economic self-reliance in spite of compul sory "insurance" permeates all meaical schemes built on the Bismarckian pattern. The beneficiaries are supposed to carry a major share of the costsby their own contributions and partly also by "deductibles." As to disbursements, they should be kept at a minimum by thrifty administration of the panel and by sharp control over its spending. Otherwise, there is to be no interference with medical practice. In short, business-likeman agement is the idea of compulsory insurance proper, presup posing businesslike units to do the job in a decentralized, more or less competitive fashion, if under supervision by the authorities. The latest editions of the Welfare State abandon the mis leaoing claim of offering a system of insurance which would imply some sort of quid pro quo between premiums paid and benefits received. In medicine, instead of providing the barest minimum, it promises the ,desirable maximum. Its objective is to fulfill a social function; the emphasis in lip-service is on what the State allegedly owes its citizens. The security organization is centralized; its administration tends to be fully 'governmentalized. Ultimately, all medical personnel is to be nationalized, as we shall see. .

The Bismarckian type still predominates on the Continent but with profound modifications scarcely expected at the outset. The communistic or state-socialistic principle is not being applied fully except in the East. But the Occidental trend is away from the Insurance schemes toward more streamlined, more totalitarian, Security programs. HEALTH POLITICS M?st. instructive is the development in IN BRITAIN BrItaIn. ~n 1911 .Lloyd George put through his health msurance plan after long and arduous bickering with the interested pressure groups. The resulting panel system was to be strictly "insurance," pro viding cash benefits with some medical service thrown into the 33] FROM LENIN TO BEVAN: STREAMLINING THE HEALT~ SCHEMES bargain as an after-thought. ·It was a compromise .that took care olall vestedinterests except the doctors, who were demor alized by political threats and whose suggestionswere ignored.

That system operated at the highest administrative cost of all contemporary sicknessschemes, an average of as much as 17.4 per cent (in Ireland 20 per cent) of all disbursements, and pro duced. fewer sickness benefits than almost any other scheme. So-called Approved Societies were permitted to offer additional benefits. They were to be run ona non-profit basis and by the insured themselves. They soon became profit-making devices -pOften nothing but disguisedsales pipelines of insurance com panies-run by entrenched bureaucracies, whose salesmenwere about the only ones wholly satisfied with the system. The .general. dissatisfaction with Lloyd George's Health Insurance explains in part the enthusiasm that greeted the Beveridge Plan of cradle-to-grave security. Its piece de resist ance was preventive and curative treatment for all of the popu lation. It came at a time when Britain was enamored of the "heroes of Stalingrad," when Communists were the pets of the Allies,and when Churchill indulged in Utopian demagogueries to keep alive the spirits of the British home front. The plan was embraced by a National (coalition) cabinet, headed by· Con servatives.3 By adopting the Fabian ideas of Labor, the Conservatives thought to win the 1945election. Of course,Utopias proclaimed by gentlemen in tuxedos have not the same heart-warming sound as when coming from the lips of old trade unionists with calloused hands. But having committed themselvesin advance, the Conservatives could scarcelyopposein 1946the Bevan legis lation founded on their own promotional efforts. For Bevan, in tum, and for the entire Labor regime, the health. security project became a vital matter. They could seize the political strongholds which the Approved Societies and other indepen dent organizationsrepresented,includingthe financialreserves of the endowed hospitals. By 1948, Labor needed a victory on the home front. Harassed by dollar-shortage, austerity policy, industrial strife, mismanaged planning and other misfortunes, the Party staked its electoral future on an experiment that no one else except Lenin had dared before: complete care for all ailments, the best the country could give·for everybody, and practically free of charge!