Delinking Innovation and Access: Decommodification of Lifesaving Medicines

by Karry M and Chris Noble 

It’s 2019. We’re living in the age of peak medical innovation yet people are dying of curable diseases because of profit mongering and the unquenchable greed of capitalists and the resulting medical industrial complex.

Graduate students committed to the quest for medical innovation, often inspired by family members and loved ones living with conditions they know in their heart can be cured, underpaid and overworked and often found scavenging the department’s free lunch seminars, are suddenly pulled into a talk with the technology transfer office because, Eureka! They’ve made a discovery! The National Institutes of Health (NIH) funded laboratory they’ve committed years of their lives to have finally struck gold: balanced bioactivity and low toxicity of the possible drug they have been investigating. What else could a biomedical researcher ask for? But suddenly there are new faces in the lab using foreign jargon like “non-exclusive licenses” and “intellectual property”; all of the forms that seemed like standard boilerplate from Human Resources office are flashed on the table. It turns out that the innovation, and, in fact, all of the innovations developed in the university’s labs, have always been predestined to be private property of the university. In an instant, the life-saving cure that was destined to change the world for the better and save countless loved ones, and which inspired many to conduct biomedical research in the first place, and has had dedicated to its discovery innumerable dedicated young adult years, becomes another commodity to be sold to the highest bidder. Rather than being made as accessible as clean air or the water we need to live, this medical innovation will undergo an economic analysis to determine “what the market will bear” aka what consumers are capable of paying that hits the economic sweet spot of just enough catastrophic health expenditures to stay profitable.

But pharmaceutical companies need to keep their prices high in order to finance the highly costly research and development of new life-saving therapies, right?? Wrong!

A recent study from the non-profit biomedical research organization, Drugs for Neglected Disease Initiative (DNDi), has shown that a drug can be developed from lab bench to manufacturing floor for a little as $200 million. This is orders of magnitude cheaper than the industry fueled propaganda conducted by the Tufts Center for the Study of Drug Development (CSDD), that most recently presented a figure of $2.8 billion. The difference between these two rational, evidence based calculations is the intention of the report. The CSDD study intended to show at the very maximum what the research and development of a new blockbuster medicine would cost by not including the amount of research financing that is subsidized by publicly funded NIH grants or other alternative finance mechanisms such government subsidies, tax credits, and the financial benefits of publishing and using open access journals. The CSDD study also included the costs associated with redundant trials from trial failure and the high per-patient clinical trial cost assumptions which were never economically justified in the study’s methodology. The intention of this study was to inflate the cost of research and development to its highest, most economically inefficient value so any rebuttal to the subsequent high priced medical innovation will be mute. This begs the question of the intentions of modern medical innovation: is it to cure diseases and save lives or is the research industry simply for the purpose of more research? Why would a company ever be incentivised to actually find a cure in this economic system? One Goldman Sachs analyst recently even mused, “is curing patients a sustainable business model?”.

In addition to the expensive research and development process, drug companies have been spending more and more on marketing for the past 20 years, increasing to over $20 billion in 2016, according to a recent study in the Journal of the American Medical Association. As of 2013, all but one of the top 10 drug companies actually spent more on marketing than they did on research and development. They also make more in profit than they do on research and development, according to Marcia Angell, former editor-in-chief of the New England Journal of Medicine and author of The Truth About the Drug Companies: How They Deceive Us and What to Do About It (2004). Much of the marketing done by these companies is to providers who assist with clinical trials of their drugs, and then prescribe them once they are approved. Influential doctors are often given expensive special treatment by these companies in the form of speaking deals, board appointments or patent or royalty arrangements. Companies spend huge amounts on “educational” events that meet doctors’ continuing education requirements and also promote specific drugs.

Additionally, much of the research and development that is done by these companies is used to develop “me-too” drugs, or drugs that have nearly identical counterparts already on the market, because they are projected to bring a high return on investment. Consequently, research and development of necessary drugs such as antibiotics and vaccines for neglected diseases is too often ignored. Effective regulation of research and financial relationships with healthcare providers could save billions by preventing wasteful spending on marketing, and focusing on necessary drugs instead of redundant me-too products. The goal of pharmaceutical research and development regulations should be to foster a system that prioritises high quality research for needed innovations rather than high quantity investments with little actual impact on patients’ lives.  

In a time when people are dying because their financial limitations don’t allow them to have access to necessary medicines, we need to start finding ways to ensure that drug development doesn’t come with an enormous price tag for patients. How can we begin changing the system so that pharmaceuticals are treated as a public good? Is it best to start with regulations at the state or federal government level, or to create alternative institutions to take down the pharmaceutical industry from the grassroots? Is it even possible to make such a drastic transformation?

Government regulation

Before 1980, research that was performed by universities, nonprofits and small businesses that were funded by the federal government resulted in the inventions being owned by the government, which would only grant non-exclusive licenses. This caused a delay in bringing products initially discovered through federally funded research to market, because there was no incentive to be the first company to take the financial risk of performing the necessary clinical trials without the guaranteed reward in the form of exclusive rights to the profits. In 1980, the Bayh-Dole Act allowed drugs and other inventions that are funded by federal research to be patented by the universities, nonprofits, and small businesses that perform the initial research, who then license exclusively to companies in order to avoid the previous stalling. For a while, the profit motive this introduced resulted in a dramatic increase in the number of new drug applications to the FDA. March-in rights were added as a safeguard in the Bayh-Dole Act stating that if there is a barrier in bringing a product to market, the federal government can step in and assert its rights to remove the barrier. The government literally has the right to “march in” and license the product to a third party if it has not been brought to market in a reasonable time period or on reasonable terms, if the owner has not made efforts to ensure “practical application” of the product or when needs of the public relating to safety and health are not being met. It’s important to note that these rights have never been used, but have been threatened once before during the anthrax scare of the early 2000’s when the government was seeking to stockpile ciprofloxacin from Bayer Pharmaceuticals, but was unwilling to pay their high prices. In response, Bayer reduced its price by 50% immediately. Despite the fact that unreasonable prices are an obvious barrier to public access, these rights have never been utilized. The stance of the NIH seems to be that if the product is publicly available, they cannot exercise march-in rights. Health justice advocates know that march-in rights are a potential way to put pressure on big pharma, and they are asking the NIH to reconsider its stance.

State governments have introduced their own initiatives to lower drug prices. For example, Maryland has recently introduced the use of a prescription drug affordability board. In April, they were the first state to pass legislation to appoint a committee to study prescription drug pricing and after a year of such study they will make recommendations to the state’s Legislative Policy Committee on how to go about reducing the payment required to purchase them. The bill was originally written to apply to all Maryland residents’ health insurance plans, but it was scaled down to apply only to state and county government employees. They are expected to face pushback from pharmaceutical companies and pharmacy benefit managers, but the legislations’ backers hope to return with a more universal bill in 2024. Massachusetts and Maine are learning from the forward progress made by Maryland and elsewhere with the support of National Academy for State Health Policy (NASHP), and are adapting their initiatives to pursue even stronger legislative strategies. All interested parties can join the MA Prescription Drug Affordability Coalition to join in on these initiatives here in Massachusetts.  

Generic drugs are generally 80% cheaper than their brand name versions, but even generic manufacturing is not immune to price gouging. Drug company executives from 20 companies are currently facing charges from 44 states that they colluded to increase prices of over 100 generic drugs through anti-competitive agreements. According to court documents, the prices of some of the drugs listed in the case were increased over 1000% in a timespan of less than two years. Legislation has been proposed to prevent such price hikes for generics. Senator Elizabeth Warren wrote a bill to nationalize the manufacturing of generic drugs or contract them to be manufactured by a third party, ensuring that they are offered at a fair price. This addresses the problem of generic monopolies, which have driven up the price of generic drugs and restricted their supply. Senators Bernie Sanders and Ro Khanna also wrote legislation addressing the same problem, titled the Prescription Drug Price Relief Act, and it is actually pretty simple in its mechanics: if the US price for a medication is higher than in other developed countries, the drugmaker’s monopoly would be ended and generic competitors could enter the market to sell alternative versions of the drug at a lower price.

True universal single-payer healthcare would effectively solve the problem of high drug prices. The federal government would be the only purchaser of medications for all of its citizens, allowing it to have massive bargaining power with pharmaceutical companies. Even when prescription drug purchases are not themselves nationalized, as is the case in Canada, the federal government generally has oversight of pricing plans. Currently Scotland, Wales and Northern Ireland provide universal drug coverage with no copays, coinsurance or deductibles, while keeping costs significantly lower than the U.S. and Canada. Representative Doggett in Texas has proposed a bill titled, Medicare Negotiation and Competitive Licensing Act, that would give Medicare the authority to issue compulsory licenses to generic manufacturers when fair prices are negotiated with pharmaceutical companies. This initiative has over 125 cosponsors in the house and is an initiative to stay aware of. If Medicare For All becomes a reality, this initiative will set the stage for an effective, efficient, and most importantly, affordable single payer health care system.

Physicians for a National Health Program (PNHP) has drafted a plan for pharmaceutical regulation in a national healthcare program in order to ensure an efficient process of drug research and development. They suggest creating a formulary of necessary drugs, and eliminating funding for unnecessary “me-too” drugs that serve an identical purpose to drugs already on the market. The government may then negotiate prices with drug companies, and in cases in which negotiations over prices of patented drugs fail, PNHP recommends that the government offer up rights to develop generic versions, or create new versions themselves. Publicly funded drugs created by public entities should remain patent-free, suggests PNHP. The FDA should be completely free of financial conflicts of interest. These initiatives would eliminate the billions of dollars that pharmaceutical companies spend on marketing their products to providers (free samples, anyone?) who serve double duty as regulators of the drug industry. Consumer advertising could also be scaled down significantly, in order to save companies money that they could pass along to their customers.

Open source medicine and nongovernmental regulation

In the past few decades, various other innovative methods to create necessary drugs at a lower cost without involving the government have begun to spring up. International nonprofit institutions and so-called “biohackers” are using creative tools to solve the problem of inadequate access to necessary pharmaceuticals in the U.S. and abroad.

One of these is DNDi, a patient-centered non-profit research and development collective working to meet the needs of those with diseases not addressed by the for-profit pharmaceutical companies, especially potentially deadly diseases common in the Global South, such as malaria, trypanosoma, and pediatric HIV infections. Because these are diseases endemic to economically disadvantaged areas, companies do not have a financial incentive to move potential treatment candidates through the costly development pipeline. Companies often discover drug candidates for these diseases, as their importance is well understood but development is usually stuck at the publication phase. DNDi works to develop treatments and vaccines for these illnesses, using open source drug discovery and partnering with pharmaceutical companies (which often lend out their molecular and compound libraries), research institutions, national disease control programs, and universities. They create or enhance clinical trial centers, train clinical trial personnel, and support the use of appropriate technology in areas where the diseases are endemic. They aim to delink the cost of research and development from the cost of the product, and promote financial transparency. They actively work to ensure that the drugs they develop have the widest possible access with the goal of pharmaceuticals as a public good/commons, mostly publicly funded. Intellectual property laws are seen as secondary to equitable access to treatment by vulnerable populations in this model. Intellectual property rights to the drugs that are developed are often waived, and they can then be given out for free or at a deep discount.

Doctors Without Borders/Medicins Sans Frontieres (MSF) works with DNDi, and has its own Access Campaign which aims to lower the price of drugs, stimulate development of generics, and act as a corporate watchdog for pharmaceutical companies. The Access Campaign speaks out for the needs of neglected populations to advocate for research into neglected diseases and bring back into production necessary drugs that are no longer produced due to lack of profit.

The price of insulin has skyrocketed in the past 20 years due to the limited number of patents available. The Open Insulin Project is creating recipes for “homebrewers” to create their own insulin and sidestep patent laws. The FDA currently doesn’t regulate such instructions if they do not make explicit health claims. The project was started at Counter Culture Labs in Oakland in 2015 by a group of self-proclaimed biohackers, some of who use insulin personally, and has been taken up by DIY bio labs around the world. Similarly, OpenAPS has made DIY Artificial Pancreas System technology available to the public at no cost, so that anyone with a compatible glucose monitor and insulin pump can make their own closed-loop system.

The Medicines Patent Pool initiative (MPP), has allowed pooling of patents in order to increase access to high-quality generic HIV medication for over 10 years. In 2008, most low income countries in areas such as sub-saharan Africa, only had access to first-generation HIV medications, which had dangerous long-term side effects, and to which patients could develop resistance. Because of these patent pools, newer and safer treatments have become more affordable in these areas. Now MPP has begun to expand into other necessary medicines for diseases like tuberculosis and hepatitis.

Methods such as open sourcing, flexible intellectual property laws, shared access to compound libraries, development of non-financial incentives, and international cooperation are all recommended by the World Health Organization to promote drug discovery to benefit developing countries. A collection of these alternative financing mechanisms can be found on the website developed by the student lead advocacy organization, Universities Allied for Essential Medicines (UAEM). These methods, if used correctly, could also be used to decommodify the U.S. pharmaceutical industry and create a human centered incentive system that truly puts people before profits.

Karry M is a member of Boston DSA Healthcare Working Group. Chris Noble is a member of Right Care Alliance, a grassroots coalition of clinicians, patients and community members working to hold the healthcare institutions accountable and put patients over profits. 

A Socialist Approach to Mental Health and Well-being: Medicare for All and Beyond

by Andy Hyatt

While the state of the healthcare system in the United States is poor all around, our mental health system is its own particular brand of horrible. Even in a city like Boston, a supposed healthcare mecca where we have more therapists and psychiatrists per capita than almost anywhere in the country, it can be almost impossible to find a clinician you can afford, who takes your insurance, or with whom you feel comfortable (let alone all three at once); people are often paying hundreds of dollars out of pocket to see a psychiatrist to refill their depression or anxiety meds four times a year or waiting months to see a therapist who takes Medicaid. The situation is even more grim in smaller cities and rural areas, where there is even less access than in cities. This all comes at a time of veritable mental health emergency, as the toll from opioid overdose, suicide, and other “deaths of despair” continue to rise, and overall life expectancy is falling for the first time in nearly one hundred years. In short, mental health services are poorly planned, underfunded, inaccessible, and unaffordable for many people in our communities at a time where need has never been higher.

How did we get here?

In order to understand how to fix the shambles we’re in, it’s important to understand how this mess came to be in the first place. With the advent of industrialization and urbanization, persons with mental illness often lost support they would traditionally get from extended kin or village networks, and could be locked up in poorhouses or sent to live on the street. Even today, rates of mental health distress and disability are higher in industrialized areas compared to more rural or agrarian societies.

Modern efforts to improve the treatment of people with mental illnesses began in the 19th century, sparked by horrific conditions at hails, poorhouses, alhouses, and other institutions of social control that incarcerated people with mental illness and disabilities1. Middle class reformers focused on treating people struggling with mental illness with dignity by founding asylums and publicly funded state hospitals to treat individuals away from unsanitary 19th century cities, and advocated for treatment of people with mental illness by medical staff in hospitals as opposed to untrained police, prison guards, and other non-clinical personnel. Unfortunately, these efforts largely ended in failure due to underfunding, overcrowding, and usage of mental health infrastructure by elites to marginalize and control deviant populations without a focus on rehabilitation or support. Psychiatric hospitals became custodial holding environments where individuals were afforded shelter, food, and other basic necessities, but not dignity or support in efforts to live meaningful lives.

The 1950s and 1960s saw the rise of the community mental health movement, which despite its shortcomings, showed glimmers of what a just mental health system could look like.  It emphasized treatment in the community in a person’s existing social context rather than removal from society, and its greatest victory was the 1963 Community Mental Health Center Act, which envisioned a publicly funded, universally accessible community mental health center in every community in the country.  A local example of this was the Cambridge/Somerville Community Mental Health Center (CMHC), which met individuals for treatment wherever they were most comfortable, offered opportunities for socializing and forming meaningful relationships, and helped with job placements. The CMHC even owned its own cooperative apartments for people receiving its services. All of this coincided with a steady decrease in state hospital populations, and it was hoped that instead of locking people up for their entire lives, comprehensive social support would allow individuals to live meaningful, fulfilled lives in the community.

All this is not to idealize the community mental health movement, which had several flaws. Most importantly, clinicians and health systems could be overly paternalistic, often substituting what they thought of as “best” for individuals without truly consulting with the communities affected. These biases were challenged by the recovery and consumer movements, which emphasized individuals’ understandings of their own experiences and their own desires for purpose and meaning over biomedical concepts like “symptoms” and “illnesses.” By giving individuals agency over their own recovery, the consumer movement sought to place the concerns and values of mental health service users first, and let them direct the course of their own lives and their own recovery.  Unfortunately, given that the consumer movement arose in the 1980s and 90s, in significant ways it reflected the neoliberal turn of that era, and its vital emphasis on individual dignity and autonomy also prefigured a greater capitalist turn in mental health care.

The ascension of Ronald Reagan and the brutal regime of austerity that we are still living with today gutted continued funding for mental health services and halted federal spending on new community mental health centers. Laying the groundwork used for welfare reform in the 90s, Reagan cut and block granted funds meant for mental health and turned them over to the states to use as they saw fit. States (including Massachusetts) privatized vast swaths of the mental health treatment system, turning it over to a hodgepodge of private organizations and cut the community mental health centers off from their communities. Individuals now had more “choice” in which providers they could see (if they could afford to see anyone) while centers that served the community were starved of funding and became slowly more like other players in our corporate healthcare system

There have been some recent positive developments, although the scale of the crisis remains vast. The Affordable Care Act (ACA), especially through its Medicaid expansion, helped many people with mental health needs get access to health insurance for the first time. Unfortunately, large deductibles and copayments limit the utility of many insurance plans and people on Medicaid have an extremely difficult time getting access to adequate psychiatric treatment due to extremely low reimbursement of providers. The other positive development was the passage of federal mental health parity legislation in the late 2000s. This prohibited formal discrimination against people using mental health services, but unsurprisingly corporations still found ways around regulations to discriminate against mental health and increase their own profits.  Recent reporting has shown how insurance and managed care companies are flouting mental health parity laws and preventing their beneficiaries from accessing treatment.

Where to go from here?

For any reader that has made it this far through a detailed history of community mental health in America, I am grateful for your fortitude! While we cannot simplistically pine for an overly idealized past (as we on the US Left are tempted to do when remembering the New Deal or Great Society), I do believe that in studying past movements we can discover the seeds of a better future. In my opinion, recovering the best elements of both the community mental health and recovery movements can shed light on what a socialist mental health and wellness system should strive for. In learning from the community mental health movement, we can aspire to easily accessible medical and psychological services, embedded in the communities where people live, with a vision of care incorporating social needs like housing and employment. From the recovery movement, we learn the vital importance of giving mental health service users both agency in their individual recovery and a central role in leading the development of comprehensive freely accessible services for all.

Concretely, the fight for mental health justice is broad, and intersects with many of our other struggles in the Left. Ahead of the 2020 election, grassroots groups like the National Alliance on Mental Illness and other advocacy groups are forming coalitions to press candidates on forthrightly addressing suicide, substance use, and other aspects of the mental health crisis. Thus far they have not suggested any concrete policy goals, but the following could be a good start. Most obviously, mental health services should be de-commodified and made free for everyone at the point of use.  A good first step would be a true single payer, Medicare for All system, which would eliminate onerous deductibles, co-pays, and other unjust forms of cost sharing that discourage use of needed medical care. As a part of this, it is essential that as many providers as possible be brought into the government health insurance system, as the current glut of exorbitant cash-only practices places services out of reach of all but the wealthy. Equalizing wages for clinicians who work with low and high income patients will alleviate some of this, as will a dramatic reduction in the infuriating regulatory and paperwork burdens many clinicians face today. Moving forward, given the complex service needs of some mental health service users as well as the vital importance of coordinating healthcare with other social services, there is a strong argument to be made that the Left should be arguing for a true national community mental health service along the lines of the UK or Sweden. This must include true leadership by both front line service workers and by mental health service users, with the end goal of a truly democratically run health services. As the rallying cry from the disability rights and recovery communities goes, “nothing about us without us.”

While improving, decommodifying, and democratizing healthcare systems is a necessary first step to improving mental health, I don’t want my clinician biases to blind me to the vastly greater importance that structural factors have on the health of communities. Fundamentally, societal improvements in mental well-being have to stem from the lived conditions of communities and the restructuring of our societies to place human needs above market ones. While improving the mental health of communities intersects with nearly every area of our activism, I want to point out a few particularly important areas we should be mindful of. Firstly, we must fight against displacement and for truly affordable homes for all people, through rent control, community land trusts, and social housing. Not living in constant fear of displacement is of course good for one’s mental well-being on its own, but it also helps build the supportive fabric of communities and starts to reverse the incredible fragmentation of our society. We must also fight against all forms of oppression and the violence society inflicts to impose its forms of domination on the basis of race, gender identity/expression, sexuality, country of origin, religion, and more. These forms of domination cannot exist without the widespread traumatization of oppressed communities, and no amount of counseling will fully heal a depressed young girl who spent a year in a border concentration camp waiting for asylum or a person of color traumatized by police brutality and murder.  Finally, the fight for a livable climate and a just transition to a decarbonized economy must be central to our organizing, as there can be no mental health without hope for survival and a livable future.
Locally, Boston DSA’s healthcare working group is base building for healthcare justice by working with low-income communities saddled by medical debt with City Life/Vida Urbana. This Saturday (June 15), we’ll be canvassing in the North End to get conservative Democrat Steven Lynch to sign on to the federal Medicare for All bill (which would fully cover mental health care without any cost sharing). If you’ve been looking for a way to get involved, we’d love to have you join us!

Andy Hyatt is a member of the Boston DSA Healthcare Working Group and a psychiatry resident at a local hospital. 

For Workers and Patients, not Greed and Profits: Vote Yes on Question 1

by Socialist Nurse

For 4 months now, we’ve been waiting for management to fill an open nursing position in our department. The word from the nursing manager is that there are “very few applicants” none of whom appear to be a “good fit.” Insert your bromides about the nursing shortage here, if you’d like, but be prepared to put your foot in your mouth: It is no big secret that the biggest chunk of any hospital’s budget is labor and, therefore, payrolls which are the first to see cuts when CFOs go looking for ways to trim costs. (For some reason, building a new half billion dollar campus is not a cost, but an investment. Pity they don’t value their workers in the same way as buildings or profit margins.) Just over two years ago, our hospital management decided that the best way to cut costs would be to get rid of the most experienced and, therefore, most well compensated workers via a buyout offer. The offer was extended to 9% of the total workforce. Two nurses on our unit decided to take the package: both were nearing retirement and, in part, were made to fear for their benefits if they did not accept. I had been hired to replace one of them: a nurse with almost a decade of experience replacing a nurse with nearly four decades under her belt. It took several months for the department to fill the other position. That person has since left the position as has another recently hired nurse. Both referenced the heavy workload and stressful conditions caused by chronic short-staffing as reasons for leaving. That’s four nurses–all well-qualified–any of whom could have filled the current position.

There is no lack of studies pointing to how more adequate staffing leads to both better patient outcomes and worker satisfaction (for example, see this study looking at effects of the nursing ratios implemented in California; for more, see here). What does short-staffing look like? Well, for me, it is mostly stress-filled days punctuated by an unending chorus of ringing phones with anxious patients on the line and a full waiting room of patients waiting to be seen. However, the stress and burnout that result from short-staffing also  negatively affects the quality of care my colleagues and I can provide our patients. If you speak to any nurse, they could recount numerous situations where either their safety or that of their patients have been put in jeopardy because of short-staffing. The mandate put in place by Question 1 would allow nurses to provide the safe, timely and compassionate care that we want and have been trained to provide our patients. As it is now, we are often forced to choose between our well-being and that of our patients–skipping lunch, working past our shifts or rushing through safety protocols to make sure that we can meet their needs. This, as you can imagine, negatively affects our ability to continue providing the kind of care we want resulting in a vicious circle of overwork and diminishing outcomes across the board.

In short, what hospital executives mean when they say there is a nursing shortage and that it is too costly for them to hire more nurses is that they value profits over both workers and patients. Full stop. They’ve even put a number on it: $19 million–that’s how much hospital executives have been willing to spend to defeat Question 1 through misleading and deceptive ads designed with the singular purpose of stoking doubts and uncertainties among voters about “rigid government mandates” or “closure of small community hospitals.” Neither of these are based in facts. For example, at present, nurses have no say in the type of care they provide nor do they get assignments based on their knowledge and experience. Rather than a rigid government mandate, Question 1 would require healthcare facilities to develop, in partnership with their nurses, tools for measuring acuity to help determine appropriate staffing per unit based on the needs and condition of patients. I think many people would be surprised to find out that such things didn’t already exist. At present, nurses have little to no say in what appropriate staffing levels should be or how much time and care our patients need. These decisions are decided by executives and administrators; in other words, by something even more rigid than any government regulation (hint: it’s profits).

Safe patient limits are both a public health and a labor issue. If Question 1 passes, it would result in dramatically improved patient outcomes and working conditions for nurses in Massachusetts. It won’t solve all the problems facing healthcare today but it will improve healthcare access and health equity in a largely problematic system driven by profit margins and corporate greed.

MA Nurses Say “Yes on 1” and You Should Too. Here’s Why.

by Nafis H.

On Wednesday, August 15th, the Boston DSA Healthcare working group organized a panel on an ongoing crisis in the healthcare industry – chronic understaffing and overworking of nurses leading to poorer patient care. The discussion centered around Safe Patient Limits, a proposal that is appearing as Question 1 on the ballot of the Massachusetts primaries on Nov. 6 and would push for a new patient safety act. The proposed law would limit how many patients can be assigned to each registered nurse (RN) in MA hospitals and certain other healthcare facilities; the max number of patients per RN would vary by type of unit and level of care. More details of the proposed law can be found on the Safe Patient Limits website.

The panelists consisted of a few Boston DSA members, including co-chair Beth Huang, and Jared Hicks, a campaign organizer with the Massachusetts Nurses Association (MNA); MNA is leading the charge on the “Yes on 1” campaign that is pushing for the patient safety law reforms through the ballot question. MNA also put the issue on the ballot after collecting the 150,000 signatures needed to do so over the past year. The goal of the panel was to host a discussion on how the safe patient limits ballot initiative related to Marx’s labor theory of value, the opposition to the campaign by the bourgeois class and how helping the campaign can fit in with Boston DSA’s goal of establishing socialism and liberation of all people.

Marx’s Labor Theory of Value

As a Boston DSA member described, the origin of Marx’s labor theory of value can be traced to Adam Smith’s description of how a free market is supposed to work:

“The real price of every thing, what every thing really costs to the man who wants to acquire it, is the toil and trouble of acquiring it. What every thing is really worth to the man who has acquired it, and who wants to dispose of it or exchange it for something else, is the toil and trouble which it can save to himself, and which it can impose upon other people.”

In simpler terms, this basically says that the price (exchange value) of something is derived from the amount of labor (human effort) put into it; the labor includes both the immediate labor of manufacturing, transporting, marketing and selling the thing, and also the indirect labor associated with the equipment required for such activities. This idea is also applicable for non-physical goods, and thus can be extended to services as well, such as caring for patients.

Marx took this idea all the way to the end, assuming a perfectly functioning capitalist free market, and showed that at the core of this idea is exploitation. He asked that if labor creates all the value, then where does profit come from? Profit, in a nutshell, is the surplus value, i.e. the difference between the value of what a worker produces in a given time and what the worker is paid in wages for the same time period. From the capitalist perspective, it wouldn’t make sense to hire someone if no surplus value can be obtained from that action, and therefore, exploitation is inherently built into the capitalist system. Historically, the surplus value that workers have produced, generations after generations, across societies, has all gone into the pockets of a certain class of people, the rulers and the bourgeoisie, who have maintained this vicious cycle through a combination of law, tradition, and force.

Capitalism further exacerbates the exploitation of workers in the modern era by 1) alienating the workers from immediate means of subsistence (we buy everything we need from the market, a concept Marx termed “generalized commodity production”), and 2) fostering competition between companies in the global market that forces them to reinvest that surplus value constantly. The latter also contributes to a cyclical capitalist economic crisis and environmental destruction. The exploitation of the workers can take many forms in the modern era, but the most profitable ones seem to involve speedup of work (shorter deadlines), increased workload, extensions to the workday (longer working hours), and the blurring of the work-life balance (checking work emails at home or over weekends). Therefore, to paraphrase Marx, what determines a working day is essentially the result of the struggle between the capitalist and the working classes. The class struggle is the fight over control of the surplus value created by workers – we can fight back by demanding higher wages, shorter working hours, better working conditions and less intense working pace. And these tenets are all in accordance with the logic behind the Safe Patient Limits ballot initiative.

Safe Patients Limit Ballot Initiative

The next segment of the discussion was led by Jared Hicks, a fellow Boston DSA member and a campaign organizer with MNA. Jared described the chronic understaffing at hospitals across MA, a problem that has been continuing at least for a decade now. The MNA has been leading the charge in fighting for both nurses’ and patients’ rights, not only in Boston (eg. the Tufts strike last year) but also across the state in western Mass. Nurses are the caregivers that spend most time with patients and therefore, are also liable for their patients. The profiteering nature of the hospitals lead the administration to force more workload on the nurses, thus subjecting nurses to cut interaction time with individual patients and reduce the quality of care that they can provide for such patients. This, in turn, leads to poorer patient care quality, increased number of preventable readmissions, and overall higher cost of healthcare. A fellow DSA member present at the event, Gemma, described how a nurse had caught certain irregularities in her father’s health condition which the doctor hadn’t picked up on, and how that helped her father get earlier treatment and prevent future medical expenses for her family.

The Safe Patients Limit initiative proposes a revision of the Patient Safety Act, and has been written by nurses for patients. Under the new law, which will go into effect Jan 1, 2019, if passed, different limits on nurse-to-patient ratio will be set according to the needs of the units. For example, in units with anesthesia, a 1:1 ratio will be mandated for patients under anesthesia and a 1:2 ratio will be mandated for patients recovering from anesthesia. Also, if this initiative passes, MA will be the second state in the US to have implemented a limit on nurse-to-patient ratio; CA passed a similar law in 1999, which went into effect in 2004.

Of course, the healthcare industry’s “ruling class” is not sitting idly by as MNA gears up their campaign. The MA Health & Hospital Association PAC, under the name “Coalition to Protect Patient Safety”, have funneled money into their opposition campaign against MNA’s “Yes on 1” campaign. The top contributors to this PAC are mostly made up of CEOs and top executives of healthcare companies such as Gene Green (President and CEO, South Shore Health System, Inc.), Mark A Keroack (President and CEO, Baystate Health, Inc.), Bruce Auerbach (President and CEO, Sturdy Memorial Hospital) and Joseph White (President and CEO and Trustee, Lowell General Hospital) (info obtained through MA Office of Campaign and Political Finance). While the publicly available donation amount may seem meager, it is an open secret that ballot initiatives cost millions of dollars and there is a lot of dark money in play, as exemplified by the charter school ballot question from 2016. The PAC is also supported by the American Nurses Association (ANA), the Emergency Nurses Association (ENA), and a long list of Chamber of Commerce boards with a few other industry organizations.

The main arguments against the ballot initiative include increased cost of healthcare that might lead to closure of hospitals, a shortage of nurses, federally mandated nurse-to-patient ratios and not enough money to hire nurses. Some of these arguments have been already proved false by the situation in CA. A 2010 study looking at patient outcomes across different medical units showed that since enactment of the staffing law in 2004, unfavorable outcomes in CA hospitals have decreased compared to hospitals in states without such policies. Additionally, nurses in CA hospitals were less likely to receive verbal abuse and complaints from patients families, experience job dissatisfaction and burnout, and in fact, suffered 30% less occupational injuries. The CA hospitals also showed increased retention of the nurse staff, and the staffing increased at a rate higher than compared to other states. Contrary to fears that overall skill level of nurses would fall because of the law, CA hospitals actually saw an overall increase in skill level of nurses.

The argument that hospitals don’t have enough money to employ more nurses is an age-old boogeyman pulled out by hospital administration everytime the workers have demanded higher wages and better working conditions. Given that hospitals have been found to stow away money in offshore accounts in the Cayman Islands, and that hospital CEOs have been making more and more money every year, this is a laughable argument. The most egregious display of such lies is probably the allegations that Tufts Hospital administration ended up paying a similar amount of money to the temporary nurses they hired during the nurses’ strike which they would have paid to the retirement fund of a certain portion of nurses on strike. An attendee at the panel discussion, Sheridan, herself a RN, attested that temporary nurses can get paid up to $3200 per week plus accommodations, which can pay the salaries of two or even three full time nurses.

“Yes on 1” — A Socialist Campaign?

Following Jared’s talk on the ballot initiative, a discussion led by Steve Stone explored the connection between MNA’s “Yes on 1” campaign and larger socialist ideals. Attendees argued that nurses, belonging to the working class, are easily exploited by the profit-driven healthcare industry where nurses’ wages are the low-hanging fruit when it comes to cutting costs. The workers below the RNs in the hospital hierarchy, such as nursing assistants, are similarly affected, while nurse managers and hospital administrations are not affected as much, thus creating an inequality among the waged laborers within the same industry. On the question of where the surplus value goes besides the pockets of the CEOs, Beth described the intricate relationship between the healthcare industry and finance/banking sector where hospitals will often take out mortgages to construct state-of-the-art buildings to attract consumers and end up with huge amounts of debt. This is directly in line with how a free market operates – capitalism forces constant reinvestment of the surplus value into the market to retain a competitive edge.

Often times, the workplace hierarchy in a hospital runs along racial lines. For example, Gemma described that in Philadelphia, nurses were mostly white working class women, whereas the nurse assistants were mostly women of color. Historically, the ruling class has often incited hatred among the different races in the working class, and therefore a socialist campaign to uphold the interest of working class must also take into account such racial, and in cases, gendered issues.

On the question of whether this campaign is a non-reformist reform or a reformist one, Beth articulated that a non-reformist reform is one where one campaign lays the foundation for a future,more progressive campaign. She described while the issue itself is not the most transformative reform for everyone, it certainly is for healthcare workers, which would set us up for a bigger campaign such as Medicare For All (M4A). Additionally, given that MNA is a critical ally of Boston DSA (the local had supported the nurses strike in Tufts in 2017), the presence of DSA members at the picket line, as well as canvassing with MNA, will strengthen the partnership. Other attendees agreed that this would help set up for the M4A campaign that DSA National has been leading across the country and will also better the conditions of one segment of the working class.

Next Steps

The MNA will bring this campaign to the General Meeting on August 25 and will ask for a chapter endorsement. In the meantime, they are holding weekly phonebanking events at Jobs with Justice (375 Center St.) on Wednesdays, 5-8 pm. There are also canvassing events coming up in the next few weeks, so if anyone is interested to help canvass for this campaign as an individual, please contact the Boston DSA Healthcare working group at


A Case for Safe Staffing Limits

Baystate Franklin nurses mount second strike at Greenfield hospital in 2017

Katie J. & Brad B.

The fight for health justice in the United States is gaining momentum, including rapid take-up of single-payer healthcare as a basic premise of left political platforms and as a rallying point for resistance to the gratuitous inequality of our economic system. Alongside wealth redistribution, health redistribution has become increasingly central to leftist visions for a just world.

However, the fight will not be easy, nor will it be won be overnight. While a majority of Americans support such demands and a Medicare For All Caucus is emerging in Congress, our corporate- and Republican-controlled government has stymied the most egalitarian proposals.

For these reasons, the Healthcare Working Group of the Boston Democratic Socialists of America agreed unanimously in June to endorse the Patient Safety Act, which establishes nurse-to-patient limits across different fields of care. In emergency rooms, for instance, one nurse could be assigned no more than five patients. It will be Question 1 on the Massachusetts ballot in 2018. We understood our endorsement as one component of a broader strategy for achieving health justice, bookended on one side by our mutual aid project to relieve the ravages of medical debt in local communities, and on the other by our continued support for a national single-payer healthcare program.

The Patient Safety Act could be brushed aside as a reformist reform. Its success would not directly call into question the entire system of for-profit medicine in the United States. But to disregard the fight for staffing limitations on these grounds would do a disservice to the workers, particularly organized nurses, struggling to make better care a reality. It would also understate the implications of a possible triumph.

Nurses in the United States face some of the most difficult, often brutal, working conditions in the country. A spate of recent articles have laid out the basic dilemma: salaries have risen marginally, but nurses in the United States are more and more overworked, which has resulted in immense burnout and lower quality of care. Cost-cutting at hospitals and an emphasis on maximizing the extraction of surplus value wherever possible have led to reductions in staffing, which has in turn shifted the psychic burden of care onto fewer and fewer individuals. This occurs alongside the violence and disrespect that nurses experience daily. Public health scholar Jason Silverstein put it bluntly: “We’re working nurses to death.”

This situation must change. America’s nurses have, for many decades, represented one of the most powerful voices of the working class. They have been at the forefront of left politics, particularly the fight for an egalitarian healthcare system. Recently, nurses in Vermont went on strike to demand a model of care that emphasizes patients rather than executive compensation. [] One of their demands was reasonable patient limitations. The Patient Safety Act would represent an important victory for organized labor against the corporate care industry, particularly at a time when labor more broadly is threatened by right-wing politics and union-busting.

Tellingly, opposition to the Patient Safety Act has been led by wealthy hospitals, executives, and a powerful medical lobby. A campaign of disinformation — both in Massachusetts and in other states where staffing limits have come up for debate — has spread apocalyptic claims about the dangers to patient safety and about exorbitant costs. These groups emphasize fear over phrases like “government mandates” and “top-down control,” claims that have long served as bogeymen against left interventions. In some situations, they have resorted to rhetorical blackmail, threatening that hospitals will leave rather than hire additional staff.

It is not simply that these sorts of arguments have been repeatedly disputed, nor that nurses have made their perspective clear (77% of MA nurses believe they are assigned too many patients, with as many as 36% reporting deaths directly attributable to the problem). It is also the case, as Suzanne Gordon recently argued, that the “cost control” model, with its underlying assumption that profits should determine care, has entrenched our unwieldy and exorbitantly expensive healthcare system. The commodification of health has grown steadily alongside its devaluation. However, a consciously planned system with a more egalitarian distribution of health is possible.

Better care from nurses means better hospital experiences for patients, particularly poor and minority residents who cannot afford expensive hospitals and clinics. Throughout history, it has been a common tactic of the dominant to keep workers just healthy enough to work, but not enough to resist or live comfortably. Nurse staffing limitations would increase personalized care where and when it is needed most, shortening stays, lowering readmissions, and decreasing medical errors. Staffing limitations would ensure rested and supported nurses who respond within minutes, rather than hours, to the blinking of patient call lights. In the most difficult times for many families, this kind of care is critical for healing and well-being.

The campaign by Massachusetts nurses has received support and endorsements from groups across the country (only California currently has a staffing law). One important reason is that victories in the Commonwealth have historically spilled over to successes elsewhere. Success for organized nurses here could galvanize the national movement for safe patient limits.

At the same time, it is important to recognize that health provision in Massachusetts will remain unequal. We live in the shadows of Romneycare, the ultimately conservative reforms that led to the Affordable Care Act. The dream of just healthcare in Massachusetts remains unrealized, medical debt continues to afflict residents, and hospitals place the needs of managers over nurses and patients. That dream will require energy and determination beyond present the battles.

Victory against the forces of corporate care would bolster efforts by working class organizations to transform the structure of American healthcare. It would allow nursing unions, occasionally bogged down in staffing battles, to direct their energy fully toward other struggles. Success in support of the Patient Safety Act would send a strong signal that justice and dignity should determine our health, not the needs of for-profit hospitals and the health insurance industry. And it would strengthen the coalition of left political organizations and unions that is fighting for the most significant transformation of them all: free health care, for all, no matter what.


Bios: Katie is a registered nurse and member of Boston DSA. Brad is co-chair of Boston DSA’s Healthcare Working Group and a PhD candidate in History of Science at Harvard.

The Healthcare Working Group usually meets on the third Monday of the month at 7pm, and any changes will be indicated on our Facebook page