The Political Economy of Medical Care

This presentation provides an alternative explanation of the present composition, nature, and functions of the health sector in the United States to those frequently given in sociological, economic, and medical care literature. These explanations usually maintain that the American health sector is a result of the value system of the assumedly middle class American society. In this presentation it is postulated that the present economic structure of the United States determines and maintains a social class structure, both outside and within the health sector, and that the different degrees of ownership, control, and influence that these classes have on the means of production, reproduction, and legitimization in the United States explain the composition, nature, and functions of the health sector. It is further postulated that the value system is not the cause, but a symptom, of these class controls and influences. The paper is divided into three sections. The first part provides a description of the class structure, which includes the corporate class, upper middle class, lower middle class, and working class, and it describes the mechanisms whereby this structure is maintained and replicated, both outside and within the health sector. The second section analyzes: (1) the production characteristics and social make-up of the three main sectors of the U. S. economy-the monopolistic, state, and competitive sectors-and it focuses especially on the monopolistic sector, which is assumed to be the dominant sector in the U. S. economy, with its needs determining to a large degree the functions of the social sectors, including those of the health sector; (2) the increasing dominance of the monopolistic sector in the health sector, by means of the financial institutions, which conflicts primarily with the providers' relative control of the financing of health services; and (3) the main conflict in the control of the reproductive (academic) and distributive (delivery) institutions which, it is postulated, is not, as is generally believed, between the providers and the so-called consumers, but rather between the corporate and upper middle classes (including the providers), who control those institutions, and the majority of the U.S. population, the lower middle and working classes, who do not control them. The third section analyzes the increasing importance of state intervention in determining the nature and outcome of the conflicts analyzed in the previous section. It is postulated in this section that, to understand both the nature and effects of state intervention, it is necessary to analyze the different degrees of control and/or influence that the social groups and classes defined in the first section have on the organs of the state, and primarily on the executive and legislative branches of the federal government. These different degrees of control and influence determine the main functions of state intervention, both outside and within the health sector, and these are postulated to be (1) the legitimization of the political system, and (2) the strengthening of mainly the system of private enterprise, in which the monopolistic sector is dominant.