The Locomotive of History

Before World War II, Britain’s health system resembled our own: a fragmented mess. Inadequate during peacetime, it was hardly ready for the test of war. Decades of incremental reforms had produced an uneven patchwork that left many underserved. Hospitals were divided into autonomous private and municipal systems, each with different kinds of specialists and facilities. Insurance was confined to the employed — leaving out dependents as well — and could only be used for general practitioners. Poorer neighborhoods struggled with shortages, limited services, and avoidable disease and illness.

The unprecedented threat of aerial bombardment forced the British government to reexamine this system. For starters, they estimated the air raids would injure or kill a staggering three hundred thousand people. But that wasn’t the only problem. It was impossible to predict where casualties would occur, and with each hospital acting on its own, shortages of beds and staff occurred alongside pockets of specialists and medical equipment.

In a bid to patch up the system, the government established the Emergency Hospital Service (EHS) in 1938. The new agency commandeered hospitals of all kinds and organized them into twelve regions centrally planned and funded by the ministry of health. Nurses and doctors were employed directly and were allowed to move freely between the different systems while sharing best practices. Instead of a diffuse mishmash, the system began to pool resources on an enormous scale.

Eligibility for emergency medical services steadily expanded throughout the war years from armed forces to civilians. A thousand new operating rooms were installed, hundreds of thousands of beds were made, and millions of bandages were centrally purchased. Hospitals started stockpiling reserves, regardless of cost.

The historian Charles Webster was led to remark: “The Luftwaffe achieved in months what had defeated politicians and planners for at least two decades.” And those achievements were ready evidence for what a national health service could accomplish in the aftermath of the war.

In 1942, these aspirations would find their urgent expression. Pushing from within a coalition government, Labour commissioned Liberal economist William Beveridge to conduct a survey of Britain’s social services. The resulting document, nicknamed the Beveridge Report, was a radical welfare blueprint aimed at the “abolition of want,” partly through guaranteed medical treatment for every citizen. For the militant ex-miner and future Labour health minister Aneurin Bevan, Beveridge’s prescriptions didn’t go far enough. But it was evidence of profound change, prompting him to quote Leon Trotsky: “War is the locomotive of history.”

When the 1945 general election came around, the Labour Party won a 146-seat majority — a landslide. Thanks to rank-and-file pressure at the party conference a year earlier, Labour had campaigned on a program of public ownership. And Bevan, a standard-bearer for the party during wartime, now held a crucial cabinet post (minister of health) and the enormous responsibility for creating the NHS.

The revolutionary new health service transferred all hospitals, private and public, to state ownership in a regional system. The system was centralized, with fourteen regional boards appointed by the minister of health. Nationalization and regionalization were used to establish a uniform standard of service across the country and to transcend the fundraising limitations of local governments. With the birth of the NHS, health care would be delivered free at the point of use — as a right, not a luxury. For the first time, Beveridge declared, Britain had “a national authority with the duty and the power of attacking disease as the national enemy.”

The United States implemented its own emergency expansion of public health services during World War II. But unlike in Britain, the government kept military and civilian programs separate and determined eligibility based on military service or means-testing. These expansions, while significant, ultimately proved temporary.

The United States Goes to War With a Virus

Seventy-five years later, the United States is the only country in the industrialized world that fails to offer some form of universal health care to its citizens, despite being the wealthiest country on Earth. Even if we had an adequate supply of COVID-19 testing kits, we’d have no institution to administer them freely to tens of millions of people.

Private insurers are an immediate obstacle. Our for-profit insurance system is forcing people to choose between seeking care and drowning in medical bills. Insurers are slowing the mobilization of beds by refusing to discharge completely stable patients.

Private hospitals aren’t helping either. Because they act independently, some are bursting at the seams with patients, while others have empty beds. We are strapped for ventilators as well as personal protective equipment (PPE) because manufacturing has been offshored and hospitals’ profitable “just-in-time” strategy for managing resources makes reserves sparse by design. With ventilators on a monthslong back order, one might expect hospitals to be flooding manufacturers with orders for the lifesaving machines — but hospitals don’t want to gamble on costly devices that could end up unused. And everywhere, there is a lack of nurses, doctors, and infectious disease specialists due to chronic understaffing. The shortage will likely only worsen as unprotected health care workers contract the virus.

In addition to being overrun, hospitals face the risk of going under. Profitable elective surgeries are taking a back seat to costly COVID-19 patients, many of whom will be homeless, unable to self-isolate, or uninsured. Treatment for COVID-19 costs serious money, more than our increasingly means-tested Medicaid program can smooth over. The owner of Hahnemann University Hospital in Philadelphia is keeping the hospital closed unless the city coughs up $1 million a month to lease it. While the beds in these hospitals could play a crucial role in relieving the crisis, the new coronavirus could soon add to the staggering 120 rural hospitals that have closed in the past decade due to collapsing profitability.

If this is war, our front line is in utter shambles.

The Policy Response

Some of the same problems of planning from mid-century Britain can be seen in the COVID-19-wracked US health system today. How do we best coordinate unpredictable demand and disparate capacities? How do we efficiently mobilize patients, health care workers, fiscal resources, and supplies at a national scale, for everyone’s needs? All of these problems are begging for collective action.

So how has the political system responded?

President Trump has declared a national emergency, suspending certain regulations. Health care workers can now cross state lines regardless of license, and providers can serve out-of-state Medicaid enrollees. Vice President Mike Pence has requested that all states order daily reports to the Center for Disease Control on bed capacity from all hospitals receiving tests. Congress has increased Medicaid and Medicare reimbursement rates, and has made the watershed commitment to cover the cost of testing for patients — regardless of whether they are insured. To keep hospitals running, the latest bailout package includes a $100 billion bailout for providers.

In California, governor Gavin Newsom has issued executive orders that allow the state to take over hospitals and other medical facilities, with a goal of adding fifty thousand beds to their capacity. So far, the state has commandeered three hospitals on the verge of closing, and is negotiating for more. Newsom has also issued orders that enable state agencies to share digital medical records (something a single-payer system would already have collected in one place).

In New York, currently one of the most infected states in the country, where some hospitals are already overwhelmed, governor Andrew Cuomo has outlined in detail the state’s emergency planning and the potential need for state intervention to move patients and staff between hospitals all across the state. To help contain the virus, some hospitals will exclusively serve COVID-19 patients.

These are dramatic steps, but they fall short of addressing our current or future needs. Bernie Sanders’s emergency plan is closer to the target. Comparing the pandemic to a “major war,” his proposal calls for expanding Medicare to make sure all COVID-19 patients are covered, regardless of income or immigration status. The Sanders plan would bring together federal agencies including Medicare, Medicaid, and the Centers for Disease Control and Prevention, as well as the private sector, to attack the crisis and marshal every medical professional while reopening shuttered hospitals.

The guiding principle of Sanders’s plan: “We cannot live in a nation where if you have the money you get the treatment you need to survive, but if you’re working class or poor you get to the end of the line.”

Nothing Is Written

Let us be sober. After decades of neoliberal austerity, Britain’s NHS faces new challenges in its war against the coronavirus. The NHS has been battered by Tory cuts and privatization. Under the last decade of Conservative rule, seventeen thousand beds have been cut, and the NHS is short a hundred thousand staff.

And as for the United States, we don’t even have the luxury of trying to rebuild an enfeebled national health system. Insurance companies are already devising a hike in premiums next year to make up for their lost profits. If all we do is hand these companies a bailout and beef up the means-tested Medicaid program, our market-driven system will further entrench itself in the aftermath of COVID-19.

Fortunately, thanks to the Medicare for All movement and the insurgent presidential campaign of Bernie Sanders, we have a ready alternative: universal health care, free at the point of delivery. Democratic primary exit polls unanimously show rock-solid support for the policy, and emergency responses in New York and California could be the nudge that pushes state-level single-payer movements to victory.

As the birth of the NHS shows, how we mobilize today shapes social reconstruction tomorrow. We must push for measures that address the immediate crisis on the basis of universalism, without allowing a return to pre-coronavirus politics. We must harness the burgeoning spirit of solidarity to institutionalize these reforms, paving the way for more permanent solutions like Medicare for All.

If we can do that, then what Nye Bevan called “a piece of real socialism” may become a reality sooner than we think.