How Healthcare Kills

AntiNote: this article appeared this month as part of an ongoing collaboration between LeftEast and the Balkan web portal, where it can be read in Serbo-Croatian. Reprinted with permission.

“Over the last year and a half, ten Bulgarians committed violent suicide via self-immolation because of the increase of electricity prices; with these ‘well-intended’ healthcare reforms we can now anticipate the next, wider, and more bloody wave of ‘unintended’ mass murder—a murder which Bulgarian protesters and civil society could prevent if they shifted focus from ‘moral indignation against corrupt and dysfunctional capitalism’ to a moral indignation against capitalism as such.”

by Mariya Ivancheva

In the last days of March 2014, a Bulgarian woman, Dobrinka Krumova, age 26, died because neither private nor public hospitals in Dupnitsa in southern Bulgaria admitted her for treatment.

A few years ago the woman was stabbed by her partner and father of her two young children. After she separated from him and moved in with her retired mother, Krumova underwent an operation to repair the life-threatening intestinal injuries she had sustained in the attack. Ever since, she had relied on colostomy bags, as the wound from the surgery would never fully close. In the last six months before her death the young woman lost half her body weight. She also had to give up custody of her two children, putting them in orphanages, because she had no money to take care of them; half of her monthly income of 150 Euros—from her unemployment benefit and her mother’s pension—went for the colostomy bags alone.

The rest barely sufficed for the two women to get by, and so Krumova and her mother could not cover their medical insurance. This resulted in a sum of 250 Euros accumulated debt that made public and private hospitals in town refuse to give her a bed and medical care.[1]

The news of Dobrinka Krumova’s death was only reported in a number of marginal regional media outlets and started no public debate: her story is only an extreme case of a sad and silenced statistic of lethal healthcare reform in neoliberal Bulgaria. While some countries never had free public healthcare, socialist Bulgaria had free service provided for all citizens. The partial privatization of free public healthcare in 1999 brought to Bulgaria the global trend of the commercialization of healthcare, which turns human life and dignity into business.

The new medical system began functioning as a state-controlled Health Fund to which each working Bulgarian has to contribute 6% of their salary in the form of tax. Due to high unemployment rates, high birthrates among the under- and unemployed, and an aging population, healthcare benefits for almost four million Bulgarians are paid out of the revenue generated from just under one and a half million taxpayers. Half a million have private insurance, and two million remain without medical insurance.[2] On average, Bulgarians pay for over 56% of their treatment out of pocket.[3]

Since the reform, and given the souring situation, subsequent governments have annually redistributed further funds to fill the funding gap. Yet they have never committed to a solid sum for sustainable healthcare subsidies, let alone an overall improvement of the healthcare system. Their chaotic quick-fix subsidies also never cover what Bulgarians automatically have to pay out of pocket: expensive diagnostics, medication, transplants and prostheses.

The sector of public healthcare is collapsing. Since 1999 the system has been partially privatized. Visits to General Practitioners are patient-paid (if still 1.5 Euros a visit). Former polyclinics and a number of hospitals have been privatized. Doctors in these places use the same cabinets and state-sponsored facilities to fund both their public and private practice. Places where high-skilled medical service and sciences are developed have remained in the underfunded public facilities. In 2008 the ban on privatization of healthcare facilities was lifted, and only specialized hospitals remained protected as public. Staff members at private hospitals, where only a small number of services are covered by state subsidies, reject complex operations to avoid accumulating debt, unlike public hospitals where enormous debt has been accumulated.[4] Costly World Bank reports, which denounce Bulgaria as having too many hospitals and ‘inefficient’ hospital service, further suggest that the number of beds has also decreased.[5]

The cutting of numerous services in the public sector has happened in both top-down and bottom-up manner. The top-down cutting of budgets was paralleled and reinforced by lowering the incentives for doctors and nurses to work in the underpaid public facilities or serve in depopulated and aging countryside communities. Old specialists and new graduates alike have been pushed into jobs in the private sector. Nurses have also been leaving altogether; by now more than half of the professionals in this field either work abroad or have found alternative employment. Doctors and nurses either sustain a double employment in public and private practices or combine their income with ‘non-regulated’ payment on their public jobs. The latter has become so routine it is no longer viewed as corruption and bribery; it is accepted as a common-sense way to avoid the nonsensical division of labor and the Catch 22 of unregulated but necessary procedures.[6]

As aggravating as all this might sound, it is news only to the impoverished Bulgarian population, which has had, until recently, what was seen as a universal right to free health treatment. This right is still written in the constitution, but is de facto cancelled as a ‘normal’ part of a wider process of ‘development’ characteristic of advanced capitalist societies.

On the road to free market society, which Bulgarians have been asked to embrace as a condition sine qua non of ‘catching up’ with the West, every form of human relation is turned into a transaction. In the case of healthcare, patients are turned into clients. Healthcare budgets are transformed into private funds and then into insurance companies, engaged not in medical aid but in ‘risk management.’ Doctors and nurses are turned into entrepreneurs competing to sell their services at the highest price. Insurance funds are encouraged to be ‘efficient’ by reducing costs and minimizing the coverage of services to those they insure.

In the discourse of neoliberal intellectuals and policy makers who encouraged and carried out this reform in Bulgaria, hospitals are businesses which need to compete on two markets: for funds from insurance companies, and for clients’ preference. If clients cannot pay, too bad: they are not competitive and thus don’t deserve to live.

Policy makers and political spin doctors support “the entry of the Public Health fund in the market as yet another private fund” (Georgi Anguelov, Open Society),[7] “the administration of hospitals as a managerial faculty with little reference to medical care” and the incentive that “money should follow the consumer” (Georgi Ganev, Center for Liberal Strategies).[8] They are in fact an announcement of a final solution for a “free,” “self-regulated” market of human life and welfare. While they are not happy with the only partial privatization of the healthcare system, they try to ‘make the best’ out of the current situation. They opt for minimal state aid to the poor, while everyone else can pick up private insurance according to their capacity to pay, and cherry-pick more and better services.

This statement is cynical as it stratifies the access not just to services, but to life in dignity and to life in general. The few liberal journalists who work on the question of healthcare—widely unpopular in the Bulgarian media and usually featured only in the ‘crime’ or ‘personal drama’ section of tabloids, as with the story of Dobrinka Krumova—also call for the full entry of the market into the healthcare sector. Decrying the ‘monopoly’ of the state-owned Health Fund and the subsidies that government still pays for healthcare, such voices insist on the total marketization of healthcare.[9]

Against this background, the unbearable lightness with which the majority of Bulgarian administrators, doctors, and nurses—but also the majority of Bulgarians—have given up on the idea of free public healthcare is both concerning and symptomatic. It demonstrates how neoliberal incentives of individual self-interest and ‘healthy’ competition—which play on the social-Darwinist trope survival of the fittest—have resonated with societies where discourse and practice have been emptied of any mention or gesture of solidarity, community, and social justice.

Further evidence of this transformation is the fact that some of the harshest reforms in the public health sector have been made over the last 300 days while Bulgarians have been out in the streets. Decrying the government’s involvement with shady business networks, the protesters never express grievances about these inhuman healthcare reforms, which happened in broad daylight.

After allowing that all healthcare funds be turned into insurance companies, the government of the Bulgarian Socialist Party—a hard-core neoliberal party representing the interests of big capital—proposed an ‘unavoidable’ 20% budget cut in the field of public healthcare.[10] Given the current situation in public hospitals and the dependence of most Bulgarians on the crumbs of redistributed money and healthcare subsidies, such a cut entails an effective genocide.

Yet the few liberal media outlets writing seriously about this subject have retorted with accusations against the state on the ‘failed privatization’ of healthcare, the state ‘monopoly’ and the ‘high state subsidies’ in this field.

Over the last year and a half, ten Bulgarians committed violent suicide via self-immolation because of the increase of electricity prices; with these ‘well-intended’ healthcare reforms we can now anticipate the next, wider, and more bloody wave of ‘unintended’ mass murder—a murder which Bulgarian protesters and civil society could prevent if they shifted focus from ‘moral indignation against corrupt and dysfunctional capitalism’ to a moral indignation against capitalism as such.

But as this seems too much to hope for in neoliberal Bulgaria, we are left waiting for the moment the last straw breaks the camel’s back—and a healthcare system that kills is just one of the possible candidates to be this straw.

Featured Image: A half-public/half-private, half-hospital/half-construction site in central Sofia.  Construction of a new public wing for the building has been abandoned, leaving a stark visual totem to the dysfunction of “public-private partnership.” Source: Ed Sutton (cc) 


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