An opportunity at the end of the coronavirus crisis? Fighting for a fundamental change in the healthcare system

Article in the Perspectives series by Matthias Neumann (active in Care Revolution Freiburg and the Solidarity Healthcare Network Freiburg). (Article as PDF) Note from the editors of the Perspectives blog on the Care Revolution website: We are very happy to receive further assessments of the situation, collective reflection and joint sharpening of the analysis. We therefore cordially invite you to take up the suggestion for discussion in this text and to write contributions to the debate for the blog(comments). It has - rightly and fortunately - often been emphasised in recent days and weeks that this country's healthcare system was already operating at the limits of its ability to function before the coronavirus crisis. The commitment of employees is still keeping it going, but they too are falling ill, exhaustion is increasing and material capacities cannot be increased at will after they have reached such a low point. In countries such as Italy or Spain, the limit of functional capacity has obviously already been exceeded and in Germany, too, there is a threat of the healthcare system being overloaded with dramatic consequences. [caption id="attachment_4159" align="alignright" width="320"] People before profits, photo: private[/caption]Fatal healthcare policyI don't want to reiterate the shortcomings in German hospitals here, but a few facts will demonstrate how the politicians now entrusted with crisis management in the face of the coronavirus have created these shortcomings: while the number of non-medical hospital staff fell by 4.1%, the number of cases treated increased by 33.4% during this period(Destatis 2018: Grunddaten der Krankenhäuser 2017. p. 11/12. Own calculation). These patients stayed in hospital for a significantly shorter period of time, meaning that although the number of occupied beds fell, the intensity of care increased due to the high proportion of newly operated patients. (The fact that the German healthcare system is poorly positioned here is also shown by the OECD comparison of nursing staff per day of occupancy, which takes the length of stay into account. Here, Germany is in last place. Bertelsmann Stiftung 2017: Pflegepersonal im Krankenhaus; p. 3.) The number of beds per inhabitant fell by 28% during this period(Destatis 2018: Grunddaten der Krankenhäuser 2017. p. 11. Own calculation). The number of hospitals also fell across the board during this period. Only recently, a study by the IGES Institute on behalf of the Bertelsmann Foundation argued in favour of a further significant reduction in the number of hospitals by more than half, as well as the number of beds, and also justified this with the aim of reducing costs. The conditions for being able to react appropriately to an epidemic have therefore deteriorated from year to year. This is mainly due to cost pressure and privatisation. Firstly, cost pressure: The system of flat rates per case, i.e. the reimbursement of fixed amounts according to the allocation of treatment cases to Diagnosis Related Groups (DRG), is rightly emphasised time and again. On this basis, some diseases and injuries are more lucrative for hospitals, while others are less lucrative, resulting in systematic overuse or underuse. (This partial overuse in areas that are lucrative for hospitals also means that healthcare expenditure in Germany is relatively high by international standards ). In particular, however, it is vital for every hospital to base its calculations on these flat rates per case and to minimise costs that do not lead directly to income: The doctor carries out the treatment that leads to income, while the work of the nurse is also necessary, but merely causes costs. This explains the development described above. Although the Nursing Staff Strengthening Act (Pflegepersonal-Stärkungsgesetz ) loosened the connection in this sharpness at the beginning of 2019, this is not to be understood as a reorientation, but as a reaction to the overworking of carers and public protests. In addition to the personnel issue, however, running costs are also being reduced as much as possible in other areas, and this is now taking its toll. Hardly any hospital can afford to keep beds, equipment and specialist staff that are not constantly utilised. It is no coincidence that paediatric clinics, which are particularly full during the flu season and are otherwise under-utilised, are being prioritised for closure. According to this logic, it is also economic nonsense to be prepared in terms of equipment for an emergency situation that does not occur all the time. Hospitals are also exposed to constant underfunding in the area of investment because the federal states are responsible for financing the necessary investments, but do not fulfil this obligation adequately: While 9.2% of hospital expenditure was still paid for by state subsidies in 1992, the proportion was only 3.1% in 2017(own calculation). As a result, funds earmarked by the health insurance funds for ongoing operations must also be used for this purpose. In addition to the effects of cost pressure, the situation is exacerbated by the transfer of hospitals to private, profit-oriented groups. This increase in the proportion of private hospitals is also reflected in the figures from the Federal Statistical Office: while 8.9% of hospital beds were in privately owned facilities in 2002, this proportion had increased to 18.7% by 2017(Destatis 2018: Grunddaten der Krankenhäuser 2017. p. 16). A hospital run for the purpose of making a profit should always generate corresponding profits. For this reason, privately operated hospitals were pioneers in the economisation of hospital operations: between 2005 and 2013, they were able to more than double their revenues(Krankenhaus statt Fabrik 2019: Fakten und Argumente zum DRG-System und gegen die Kommerzialisierung der Krankenhäuser; p. 26). One of the reasons they achieved this was that staff costs per employee in all non-medical areas were significantly lower than those of other hospital types (Krankenhaus statt Fabrik 2019; p. 96). In addition, part of the profit is withdrawn from hospital operations as dividends, for example, and is no longer available for more staff or better equipment. [caption id="attachment_4161" align="alignright" width="260"] Abolish flat rates per case, photo: private[/caption]This healthcare policy is systematicThe development in the healthcare sector cannot be explained by the sector itself, but in the context of neoliberal policy as a whole: firstly, in order to keep economic growth high and support the utilisation of the capital employed by companies, it is aimed at international competitiveness and only secondarily at domestic demand. In this context, social security contributions, which are used to finance current healthcare expenditure, represent costs for companies that should be reduced wherever possible. Healthcare expenditure also reduces the profit of companies via tax levies, which are used by the federal states to finance hospital investment costs, for example, unless they are active in the sector itself. On the other hand, there is a lack of profitable investment opportunities. The response to this shortage is the expansion of private companies into previously state-run or other providers (charitable organisations, churches). In this respect, both cost pressure and privatisation are determined by macroeconomic dynamics. In view of the coronavirus crisis, the social importance of healthcare and the work of those employed in it are being recognised more than ever before - and the discrepancy between the resources and staffing levels required by hospitals is becoming more of an issue than ever before. However, this is not a completely new development: experience from the ver.di collective bargaining campaigns to relieve the burden on nursing staff and from the support alliances in various cities, as well as the referendums in four federal states for more nursing staff in hospitals, showed that the public's sensitivity to this issue was very high even before the coronavirus crisis. In particular, it is much higher than that of the government. This willingness to support corresponding healthcare policy demands is therefore nothing new; it is just particularly evident at the moment. However, if the government has its way, this desire for a change in healthcare policy will most likely not result in anything more than verbally expressed appreciation. This is because the fundamental political decision outlined above to keep the costs of capital as low as the lobby of healthcare companies and the medical profession would allow is not in question. The resulting lack of resources arose in a situation in which the state would have had room for manoeuvre. However, at the end of the coronavirus pandemic, the country will find itself in a deep economic crisis that will be at least as drastic as that of 2008/9. At the same time, the state is currently taking on massive amounts of debt in order to prevent company bankruptcies due to a lack of liquidity and the subsequent breaking of payment chains. In this situation, there will therefore be little political will on the part of those in power to invest resources in the healthcare system, which would put additional pressure on the state budget or the profitability of companies. This is already apparent if you look at the budget package adopted by the government, which earmarks €3.5 billion of the €156 billion allocated for the healthcare system. Even if this package is less about structural economic decisions and more about maintaining solvency, these figures show that fundamentally better funding for hospitals cannot be expected without a political battle. The current government cannot therefore be expected to pursue a fundamentally different policy than the attempt to restore a form of neoliberalism at the end of the crisis: Possibly more authoritarian, possibly with a little more social elements, but certainly not significantly different. However, this would make a fundamental reorganisation of the healthcare system a foreign element in this policy, which would disrupt the neoliberally organised exploitation of capital. At the same time, the German government is currently receiving broad approval for its crisis management. As long as the strained health care network does not tear, this will certainly remain the case. There is therefore no real starting point for questioning this government in this scenario. Anything else would be wishful thinking as long as its crisis management is reasonably effective - even if only by global standards. I do not want to question the fact that voices are also being raised within the social left that are calling for a fundamental reorientation based on the experiences with the coronavirus crisis. If the medical and social crisis escalates dramatically, we will have completely different problems anyway, including politically. [caption id="attachment_4164" align="alignright" width="260"] More staff, photo: private[/caption]Opportunities for a different policyHowever, we have the opportunity to argue for a fundamental reorientation of the healthcare system. It is assumed that a social majority is currently achievable for this. In this case, "realignment" means that we as employees and patients need this sector to be socialised. Instead of group-owned hospitals being geared towards generating returns, they should be managed by state or jointly organised institutions. Such social control also requires a political form, such as health councils in which the various interest and stakeholder groups are represented. (A similar discussion has already taken place within the trade unions during the financial crisis, when the issue was how companies rescued from insolvency with state funds could be used for convergence and regional development. Cf. for example "Active out of the crisis - Together for a good life. IG Metall's action plan.") In addition, instead of cost pressure organised by means of flat rates per case, we need needs-based funding of healthcare that also provides funds for crisis situations. This funding must be considered both from the point of view of needs-based care and the situation of employees: generally binding collective agreements can ensure a sufficient wage level for all hospital employees; the German Collective Bargaining Act states, among other things, that such a step is justified if "the declaration of general applicability appears necessary in the public interest". (§5 TVG) When, if not now, should this apply? The same applies to a minimum wage for nursing staff on the wards. This demand has been achieved by ver.di in recent years in some hospitals through industrial action; the outcome of the coronavirus crisis would also provide an opportunity to secure minimum staffing levels for private or church-run hospitals. Because, according to ver.di: "If enough skilled staff are to be recruited and retained today and in the future, attractive working conditions are needed. In addition to good pay, adequate staffing levels are a basic prerequisite for this."It is therefore worth engaging in an intensive debate about a fundamentally improved healthcare system: Here, the failure of state policy and private companies became clear even before the crisis, provoking protest as well as sympathy for employees and also patients who are suffering as a result. There will be agreement with the statement that after the crisis, those responsible cannot be allowed to "carry on as before". This is because many hospital employees and their organisations will also emphasise that they have mastered this huge task despite the state of the healthcare system and not because of it. The debate may initially end in partial successes such as the abolition of flat rates per case, an increase in investment funding by the federal states, statutory minimum staffing levels in nursing or the renunciation of further privatisation and site closures. But even that would be a lot and the conflict could also strengthen local and regional alliances. In view of climate change and global misery, far greater steps away from the capitalist mode of production would be necessary. Various parties are voicing thoughts in this direction. However, the fight for a different healthcare system is already a major challenge. Moreover, this is not simply a struggle for reform, but contains elements of revolutionary realpolitik: 1) The situation for healthcare workers and patients will be directly improved. 2) The introduction of health councils increases the political capacity to act in this area. Similarly, the abolition of flat rates per case, which makes cost pressure on individual hospitals compulsory and non-negotiable, gives them more room for manoeuvre. 3) The experience gained from the attempt to push back the logic of utilisation from a central area of society is instructive in itself. 4) A utopian surplus is created, an idea of how self-administration and needs-orientated control of a social sector can function instead of cost pressure and the pursuit of profit. However, statutory regulation of the healthcare sector takes place at federal level and funding at federal and state level. Furthermore, in view of the expected deep crisis, we will probably only have a short window of time in which to decide on possible reorganisations. This is because in the expected constellation of a deep recession and a sharp increase in national debt, the current financing of the healthcare system will quickly be presented as having no alternative. It is therefore necessary to prepare, plan and launch a large-scale campaign now, which also involves major players such as the trade unions and the politically open sections of the welfare organisations and churches. Organisations such as the Care Revolution network or local health alliances, trade union and party branches can now push this forward. "Pushing" means making proposals for a few, concise demands and planning a campaign that can begin online at an early stage and reach beyond that once the restrictions on freedom of movement and freedom of assembly have ended. Making such a proposal in this politically paralysing situation seems almost a little crazy to me, because the discrepancy with the current restrictions on our own ability to act is so great. However, it seems to me that there is a really great opportunity here that we must not squander. It would be important for me to hear from people who are active in this area whether they think the opportunity described also exists, how we can come together and what approach we could agree on in order to actually get something big rolling together.