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General Healthcare

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Part of the Economic and Financial Law & Policy – Shifting Insights & Values book series (EFLP,volume 7)


The first outline of Chapter 5, entitled “General Healthcare” of the book titled “Covid-19 and Capitalism - Success and Failure of the Legal Methods for Dealing with a Pandemic”, is to examine, on the one hand, what the outlook of the medical care sector was in early 2020, after decades of sustained neoliberal policies, and to what extent this sector was, or could be, still deemed sufficiently resilient to the outbreak of a pandemic. The second purpose of this chapter is to examine how the sector itself withstood the Covid-19 pandemic. Methodologically, it has again been necessary to rely on research evidence and factual research provided by an amalgam of policy institutions, academic researchers, and specialized investigative journalists. The importance of this factual research cannot be overemphasized, as it demonstrates how years of sustained neoliberal, austerity policies had weakened the medical sector’s ability to respond adequately to a pandemic. In this chapter, therefore, the findings of said institutions and authors have each been meticulously synthesized, with explicit acknowledgment that the institutions and authors cited have, in many cases, been the original authors of the relevant, thus-quoted positions and opinions. This chapter paints a rather bleak picture of the impact of neoliberal reorganization and cost-cutting on a sector that is vital to global public health. In recent times, employees of the medical sectors have often been applauded for their heroic efforts in the fight against the Covid-19 pandemic. The question arises, however, whether the sectors would not be better served by scaling back neoliberal policy, so that they once again become sufficiently resilient to fulfil their task of guarding public health and would at least be provided with the necessary means, people and materials to be able to do so. This immediately implies a plea to bring this sector back into public hands, an issue that is itself related to the issue of public funding of countries and their governments. Referring to previous research, the author concludes by raising the question whether the development of new models of public financing, based on an allocation model rather than on the levying of taxes and on public debt, has not become even more pressing as a result of the Covid-19 pandemic.

5.1 Theoretical Debate

5.1.1 General: Towards the Marketization of the Healthcare Sector

In her book “Family Values. Between Neoliberalism and the New Social Conservatism”,Footnote 1 Melinda Cooper has argued that the traditional American welfare state model of the 1960s and 1970s in general, and the sector of healthcare institutions in the broad sense of the word more specifically, from the late 1970s on, was to a large extent dismantled because of a combination of three important events: (1) left-wing liberals stopped to embrace and defend the welfare state—they criticized it relentlessly and advocated far-reaching (albeit often unrealistic) radical alternatives; (2) neoliberal thinking gained more and more ground, especially after the economic crisis of the 1970s set in and Keynesian remedies seemed to fail, and (3) neoliberals entered into an “ideational coalition” with (neo)conservatives and their combined discourse became dominant in public policy over time.Footnote 2

Based upon this approach, the Dutch sociologist Trappenburg has made a similar attempt at describing the evolution of the Dutch healthcare policy of the past decades.Footnote 3 Trappenburg concludes that in the Netherlands, similar ideological movements (both left-wing ideologies, as well as conservative and neoliberal ideologies) became hostile to the (European) welfare state model—criticizing professionals, care institutions and the healthcare system in its totality. This, as of the 1980s, resulted in a partial “marketization” of the healthcare sector.Footnote 4

The evolution in the Netherlands is not so different from the one in other European countries. As of the 1980s, many European countries have been walking a similar neoliberal path, to a large extent steered by EU (austerity-)policy. As a result, the findings of Trappenburg (and those of Cooper herself) are useful to introduce the problem of the “marketization of the healthcare sector” in Western countries.

From this basis, it will appear how the implementation of neoliberal ideas in practice undermined both the social security systems, as well as the working methods of healthcare institutions, in particular hospitals, leaving healthcare systems critically vulnerable just as Covid-19 reached the Western world. This will be the theme of the present Chap. 5.

In the next Chap. 6, we shall investigate how the sector of the long-term nursing and retirement homes suffered from the fact that both in the United States (as of the 1980s) and in Europe (as of the 1990s), public nursing homes were to a growing extent privatized and/or, through other methods, replaced by profit-driven, private companies or corporations. The hospital sector has, in contrast, kept its non-profit character to a bigger extent. However, this does not imply that hospitals have not become subjected to neoliberal logic, albeit by different means, such as severe austerity policy in both the Member States of the EU (including the United Kingdom) and the United States.

This increasing marketization of the health sector in the Western world from the 1980s onward is one of the main reasons why, when Covid-19 hit, it had been so weakened that it took months before a (more or less) proper response was set up to the Covid-19 pandemic, far too late for the many people who had died by then.

5.1.2 Left-Wing Criticism and (Neo)conservative Ethics Feeding Neoliberal Reforms General

In the 1980s (in the United States) and 1990s (in Europe), the neoliberal discourse picked up on former criticism on the working of the healthcare sector from left-wing and conservative ideologies dating from the 1960s already, thus introducing left-wing and communitarian ideas to neoliberal reform actions. The result has been that throughout the Western world, the prevailing healthcare systems started to form a mixture of these neoliberal, conservative-communitarian and radical left ideas.Footnote 5 The Marriage of Left-Wing, Neoliberal, and Conservative Ideas on Healthcare in the United States

At the end of the 1960s, the United States did not look that different from the West-European welfare states. Income differences were kept modest with high taxes and strong unions, higher education was affordable for students from all income classes and the welfare state took care of vulnerable elements in society.Footnote 6

In her book “Family Values. Between neoliberalism and the New Social Conservatism”, the US sociologist Cooper described how the societal equilibrium that was formed in the period after World War II and that had culminated in the Western welfare state model which had its peak moment in the 1960s and early 1970s, was deliberately abandoned in the course of the late 1970s and 1980s. Cooper holds three ideological developments responsible for this decline of the welfare state model, which, according to her, took place almost simultaneously:Footnote 7

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    First, the American “left”—in as much there has ever been an “American left”—in present-time usually referred to as the “liberals”, showed discontent about the limited character of the welfare state model that applied in the United States. Characteristic for this “liberal thinking” was, on the one hand, their fierce criticism of the then designation of the welfare state, while that same welfare state, on the other hand, had to be expanded drastically.Footnote 8 According to Cooper, a heterogeneous liberal front thus spearheaded a general movement of insurrection against the totalitarian institutions and disciplinary powers of the twentieth-century social sciences—the mental hospitals, prisons, and homes for the disabled, the delinquent and deviant—that were considered responsible for defining and policing notions of sexual and racial variance.Footnote 9

    Regrettably, the professional, institutional healthcare which had been so important for the formation of the classical welfare state model, was also severely criticized. E.g., both healthcare professionals and institutions were considered unnecessarily “disciplining”. The assumption was that professional care takers showed a too paternalistic attitude towards the people they helped, which stood in the way of the free development of individuals.Footnote 10

    As the health activists of the New Left remained committed to the expansion of government-funded care and universal health insurance, they still fought to dismantle the disciplinary forms in which these services were according to them too much delivered.Footnote 11

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    While through their severe criticism, it was, strangely enough, the liberals who provided a lot of the theoretical arguments against the then prevailing welfare state model, economists and neoliberals themselves got the wind in the sails because of the economic crisis of the 1970s and 1980s.Footnote 12

    For years it had been customary to couple wages to prices of consumer goods and to conduct a monetary policy based upon a guided inflation model (following Keynesian ideas). At the end of the 1970s, it turned out that Keynesian policy could no longer prevent people from losing their jobs. The simultaneous occurrence of inflation and unemployment started making the neoliberal ideas of Chicago school economists like Milton Friedman, Richard Posner, James Buchananan and Gary Becker very attractive for a wide variety of policymakers (both in the United States, as in West-Europe). Their teachings started to be known as “(economic) neoliberalism”.Footnote 13 In the emerging austerity context, the neoliberal critique of social insurance (being too expensive) gradually moved beyond the walls of academia to find a receptive audience among policymakers and public health specialists.Footnote 14

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    Thirdly, libertarian and neoliberal economists in the United States developed an increasingly close relationship with a wide variety of conservative ideas of Catholics, conservatives, evangelical Christians and communitarians.Footnote 15

    As a result, neoliberal ideas got increasingly influenced by a conservative, moral dimension.Footnote 16 Economic questions such as inflation became a moral problem: it was argued that that people who were “savers” saw their capital increase through hard work and prudent living, while the “needy” were seen as the scum of society, who did not want to work and save their income but preferred relying on handouts from various types of social assistance.Footnote 17

    As regards healthcare, a typical illustration of this coalition between neoliberal and conservative ideas on socio-economic topics was the neoliberal approach towards the aids epidemy that struck in the early 1980s, especially under drug users and homosexual men. Because of this, AIDS soon became stigmatized as a limited societal problem that was only relevant for some of society’s most immoral degenerates. Drug use and unsafe (homosexual) sex were considered to be “lifestyle choices”, implying that the risks incurred by such immoral choices, should be faced entirely by those who made them. AIDS was in this approach considered to be a totally different illness than other infectious diseases, such as whooping cough, measles, or polio. As a result of this symbiosis between the ideas of neoliberal economists and conservative right, the AIDS-crisis received moral connotations: If people refrained from sex before or outside of marriage and did not use drugs, they would never get sick in the first place. This attitude, e.g., inspired Nancy Reagan’s sloganized appeal to the American youth: “Just say no (to sex and drugs).” The aids problem was turned into an argument against a further expansion of public healthcare in the United States, as it was no longer deemed acceptable for decent US taxpayers to have to pay for other people ‘s “Risky Lifestyle Choices”.Footnote 18

    The result was that, at the end of the 1970s and the beginning of the 1980s, the shortly before muted ethics of moral hazard, fault and responsibility that started informing neoliberalism’s academic critiques of the welfare state, found a more fulsome expression in a new public health rhetoric that focused on the relationship between irresponsible lifestyle choices and rising healthcare costs. Through this, the overriding importance of individual behaviour and lifestyle gradually became established as major factors in the nation’s unsatisfactory health status and ever-rising healthcare bill, and soon became one of the guiding principles of public health policy.Footnote 19

Under the presidency of Ronald Reagan in the 1980s, this diabolical combination of, on the one side, theoretical arguments pleading for a thorough reorganization of the welfare state model provided by liberal intellectuals and, on the other side, the coalition of ideas originating from neoliberal economists and neoconservatives, started to determinate US public policy in a wide variety of socioeconomic domains: Poverty reduction and social security, inheritance tax and property tax, student loans and, above all, healthcare policy, the latter moreover strongly influenced by the AIDS epidemic.Footnote 20

Regarding health policy, this has had a disastrous effect: According to one study, in the first half of the 1980s, New York hospitals were forced to close around 1800 beds at a time when AIDS infections were increasing at an alarming pace.Footnote 21 As a result of austerity measures, combined with institutional inertia, grassroots AIDS service organizations were almost fighting alone during the first half decade of the AIDS epidemic. Because of this, in cities hardest hit by HIV—such as New York, San Francisco, Washington and Los Angeles—gay men, lesbian women, transgender men and women, and their allies, marshalled vast amounts of unpaid labour to confront the urgent healthcare, housing and social service needs of the HIV-infected while at the same time having to start nation-wide prevention campaigns.Footnote 22

Rather than relying on sound economic reasoning, US politics of shaping the new neoliberal society thus was based on a mixture of ideas that hardly made any economic sense at all, but that nevertheless would create a new socioeconomic model in which the welfare state model got gradually diminished and the care that it had provided in the past, got increasingly replaced by free market models of providing services in a wide variety of socioeconomic domains, such as education and health and elderly care. The Marriage Between Left-Wing, Neoliberal and Conservative Ideas on Healthcare in Western Europe

A similar merging of the ideas of left-wing critics, neoliberal economists and neo-conservatives occurred throughout Western-Europe.Footnote 23

As a result, as of the 1980s, a covenant of neoliberal, conservative and communitarian ideas saw fit to reform the Western European welfare state model. Here, classical and left economic schools—and on a practical level, political parties—were taken aboard to the extent that they could provide many of the ideas to reshape the welfare state model in accordance with the doctrine of neoliberalism.Footnote 24

In Western Europe, the Dutch care system for example had already been bombarded by left-wing criticism during the heydays of the welfare state—the 1960s and 1970s.Footnote 25

A first criticism concerned the financing of the healthcare system. In many West-European countries, most of the population since World War II got insured through state organized health insurance, financed through mandatory—state-imposed—financial contributions from both employers and employees, next to similar contributions from self-employed people, all such contributions imposed by compulsory legislation. Moreover, citizens with an above average income could insure themselves privately (in addition to the public health insurance systems). However, as these systems had grown organically, the resulting inequalities, by the end of the 1960s, had become a thorn in the eye of left-wing politicians who sought to rationalize these systems.Footnote 26

Secondly, there was criticism on the working methods of healthcare institutions themselves. By the end of the 1960s, these especially focused on medieval excesses characterizing publicly financed institutions for the mentally ill and physically disabled.Footnote 27 While this kind of criticism was obviously well-intentioned, it would at the same time give these institutions a bad name, creating a further common cause for reshaping the healthcare sector in accordance with the (profit-driven) logic of neoliberal economics.Footnote 28

Thirdly, as had been the case in the United States, there was increasing criticism on healthcare professionals. Throughout Western-Europe, the paternalist attitude of healthcare workers in deciding what was good for the patient, without the patient himself having much say in this, became subject of a broad societal debate. Critics also accused healthcare professionals of being more interested in their wallets than in caring for their patients. Professionals were considered not so different from entrepreneurs or shopkeepers, thus disregarding the basics of their professional ethical code (even going back to oath of Hippocrates). Strangely enough, after the neoliberal reorganization of the healthcare sector as of the 1980s, this characteristic of the healthcare sector would be strengthened even more, to the extent that through these neoliberal changes, the whole healthcare sector became subject to neoliberal logic and, through this, either subjected to the working methods of the corporate organization model (especially in the case of nursing homes), or to a far-reaching extent “marketized” by using other methods (e.g., the hospital sector).Footnote 29

Finally, a last radical criticism pointed to the fact that both healthcare professionals and institutions, rather than curing sick people, made them chronically dependent on the healthcare system itself (and, through this, made people even sicker than before). In a broader sense, the idea that society is what makes people sick, gained popularity, and the “paternalistic” healthcare sector was considered to be a huge factor in this.Footnote 30

The fourfold criticism resulted in a search for alternative financing systems for the healthcare sector, based upon: (1) more income solidarity, (2) the patient’s “emancipation principle” (seeing patients more and more as “clients”, intellectually capable of making their own healthcare choices, thus at the same time being considered as “consumers”, rather than as sick to be taken care of), (3) more participation and control, next to (4) the democratization of healthcare and the search for systems of limiting the power of professionals.

As we shall explain hereafter, to the extent that the neoliberal remedy for dealing with these criticisms would turn out to be way worse than the problems of the past ever had been, the critics of the healthcare system of the 1970s and early 1970s, in the end, made things even worse.Footnote 31 Neoliberal Reform of the Healthcare Sector as of the 1980s

Until well into the 1960s, an increase in healthcare expenditure was considered both acceptable and desirable. With the growth of medical options, it was considered logical that expenditure on healthcare would also increase,Footnote 32 moreover given the fact that economies and societies were growing as well.

The economic crisis of the 1970s put an end to this approach. From the early 1970s on, the rising healthcare budget—and, through this, health and elderly care themselves—became, to an increasing extent, a problem.

While many economists rejected neoliberal claims of overfunding in health services, the narrative of “overfunding” was nevertheless, gradually, reinforced by neoliberal economic schools, self-interested private organisations and neoliberal governments.Footnote 33

A first answer to that problem was “planning”, aimed at better organizing the growth of the healthcare sector.Footnote 34

Moreover, the behaviour of private health insurers changed drastically in the late 1970s and early 1980s. During the heyday of the welfare state model, private insurers had always adhered to a kind of gentlemen’s agreement not to compete for the healthy patient. Under the influence of neoliberal ideas, this was one of the first things that started changing. E.g., private insurers gained much more insight in the strong connection between healthcare costs and the age of the insured. In addition, private health insurers were facing stricter regulations on the (financial) reserves that they had to hold to be able to meet their obligations. To keep premiums affordable, private insurers thus started intensely competing for young, healthy policyholders whom they could offer a health insurance for a low premium against a high deductible. Once this dynamic had started, no private insurer could escape from the competitive battle that followed. As a result, young, healthy “customers” started opting more and more for (additional) private insurance policies, while older insured kept relying on systems of public health insurance. Policymakers sought solutions by relying ever more on the private markets (e.g., through tax incentives) and by making access to the public social security systems more and more conditional. This led to a growing revitalization of voluntarism as one of the main ideas driving neoliberal health reforms.Footnote 35

As a result, a growing number of social security systems were (in whole or in part) transferred to private insurers. Under the influence of neoliberal ideas, many policymakers even started to believe that traditional, public healthcare systems, in particular the health insurance systems, did not provide sufficient incentives for effective policy, use and action. This was attributed to the lack of market mechanisms and separation of financing and planning. This would in its own turn incite new regulatory changes, through which the public health insurance systems themselves became subjected to mechanisms originally developed for the private insurance sector. As a result, both private and public health insurance became more and more based on free market logic, rather than on providing care based upon an idea of mutual solidarity.Footnote 36

Ultimately, this would lead to a streamlining of the packages in “compulsory” systems of public health insurance in various Western European countries. This aimed to guarantee every citizen a minimal basic package, to be supplemented with additional private health insurance. As a result, the (private) health insurance package became an important part of the compensation with which (large) companies started rewarding their staff. Obviously, this led to even more inequality, as highly profitable companies with large workforces had the means to offer attractive private insurance packages, leaving the workforces of small(er) companies and the self-employed out in the cold. In doing so, the private health insurance systems themselves became a system that contributed to social inequality. In countries such as the United Kingdom and the United States, this created dire situations in which the lower classes barely had access to, e.g., dental care. As a result, dental care is in said countries in many cases not part of the basic public package, nor is it usually offered to them in the form of an additional private package financed by an employer.Footnote 37

Health insurance in this manner increasingly became a playing field of inequality in healthcare opportunities.

This inequality has—obviously—been a relevant factor during the Covid-19 pandemic. We shall readdress this topic in Chap. 10. Some Further Ideas from After the Year 2000

After the turn of the century, the idea of the “mutually caring society” gained ground in a number of Western Europe countries. The “mutually caring society” approach was based upon a neoliberal right-wing idea of an ideal social model in which people rely on public resources as little as possible.

For conservatives, communitarians and Christian Democrats, this idea leaned on an assumed, self-evident concern for family, partners, and the small community to which one belongs. For the left, the new way of thinking implied a farewell to institutional care: People with disabilities would no longer have to live in care institutions but remain in their neighbourhood and preferably also be employed in a normal workplace. This was seen as a strengthening of the patient’s position. E.g., via systems of “care cheques” (or “vouchers”), the patient himself (or his parents or other relatives) had to take care of the practical organization of the healthcare he needed, which at the same time ensured that he did not spend more than the amounts allowed by such care checks (read: that he did not “profiteer” too much from the social security system).Footnote 38

This approach has also been called “the intrusive model”, implying that people should start taking care of one another in family or other small community assemblies.Footnote 39 As due to neoliberal austerity social service budgets were whittled back, neoliberals and neoconservatives started embracing the virtues of community empowerment through self-care as an essential part of a plan to “give health policy back to the people”.Footnote 40

The result of all this—albeit with great differences between countries—has been that, throughout the Western world, social insurance has become a “multiple-layered” system:Footnote 41

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    Resilient citizens with good jobs continued paying a relatively large amount of taxes and premiums (whether or not through their employers), but got relieved in return: To the extent that they do not have to take care of mentally handicapped or chronically ill family members, they can still call upon professional, often institutional healthcare, the bills of which are for the most part paid by the (public) social security system.

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    Many professionals are employed by the institutionalized health sector where they offer care, help and healing, in exchange for a (good) salary.

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    In such a model, it were mostly the vulnerable citizens who ended up with the “left-wing part” of the new approaches: “the inclusive society” (basically a nice way of saying that they have to rely on themselves).Footnote 42 The resilient citizens got the caring society, and the professionals, to a growing extent, got employed in accordance with the market forces of neoliberal economics.

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    Finally, the rich to extremely rich organize their healthcare on their own, either through financing it directly themselves, or through relying heavily on expanded private health insurance coverage.

Providing informal, “de-institutionalized” care to elderly parents and children with disabilities, however, soon faced a variety of other, often severe problems: E.g., there are indications that informal carers are overloaded and do not always succeed in combining their care duties with a paid job or life of their own. The long-term nursing homes which previously provided care for people who were mildly or moderately dependent on financial contributions from the social security system, started gradually to disappear, while it is not easy for informal carers and well-meaning family members or neighbours to make up for this lack. Here too, policy started to go both ways. On the one hand, there were attempts to facilitate and reward informal care; on the other hand, there were cautious pleas for the reintroduction of a normal amount of institutionalized nursing homes. Moreover, because of decades of marketizing the healthcare sector, it became more and more difficult for institutionalized care organizations and professionals to provide continuity of care. Hospitals and nursing homes got to an increasing extent subjected to market logic, even with an expectancy of similar profits as other private enterprises. Such organizations, in the recent past, even started going bankrupt or had to merge as a result of market forces. Since the healthcare sector increasingly became subjected to market logic, financial risks and the need for private investments increased significantly as well. As a result, in recent years, these started to heavily rely on loans for their financing. Especially in the aftermath of the financial crisis of 2008, banks would, however, become a lot more reluctant to provide extra money. This has made hospitals even more susceptible to financial problems in case of setbacks. It has, hence, become increasingly difficult to get the kind of private investments off the ground that are desirable for the quality, accessibility and affordability of hospital care, with risk-bearing private investors only willing to come up with money if there will be a reasonable compensation in the form of profit distribution, again undercutting affordable care.Footnote 43 The Result: Towards a “Marketized” Health Care System

As a result of the combination of these approaches, healthcare in neoliberally reformed countries has, to an increasing extent, been turned into a particular kind of economic commodity—one that is governed by market principles.Footnote 44 This policy approach has even been promoted by international financial institutions such as the IMF and the World Bank, as well as by the EMU, which especially happened in the aftermath of the financial crises of the past decades, and has in part been justified as a necessary step to increase economic growth (and thus generate revenue to pay off foreign debt). Such a neoliberal policy, obviously, had adverse effects on health care itself.Footnote 45

Viens has pointed to a wide variety of negative consequences of such a neoliberal policy approach in the domain of health care. According to this author, the underlying policy idea for establishing a marketized health care system is that it maximises the instrumental value of health services, thus purportedly attributing to more efficient and innovative health care, certainly when compared to the way health services, in an allegedly inefficient way, are organized under a welfare state system.Footnote 46 However, this shift from public health care to (more) free market-based health care, as well as the “commodification” and/or “marketisation” of health services this has implied, had the side-effect that health care (besides the socioeconomic determinants of health themselves, such as education and housing) is no longer considered as “a right” in itself, but rather a commodity that is provided by the market to be acquired under free market conditions, i.e. against the payment of a market price. Health is thereby no longer considered as “something special”; it is just one more instrumental good to be acquired on the market, which implies that it has also become the mere subject of consumer choices, at the same time making it exchangeable for other (supposedly equivalent) goods or services. Needless to say that such an approach has resulted in huge health inequalities, especially on the preventive side of health care, which in most cases happened to the detriment of the least advantaged.Footnote 47 (Cf., furthermore, Chap. 10.)

The fact that health increasingly became considered as a commodity provided under free market conditions, whereby individuals themselves are moreover free to choose the desired amount and types of health care goods and services they want to have access to, had as a further result that the emphasis on responsibility for the health of people has shifted away from the collective level (i.e., the government, or public institutions) to the individual level. This, by definition, implies that neoliberal states take a much lighter stance on helping people achieve better health,Footnote 48 as they no longer consider it their task to do so.Footnote 49 Instead, neoliberal states resort to other, more indirect techniques to guide and control individuals towards the best health care choices, but without taking on responsibility for the matter themselves. In line with their aspiration to privatise health care, neoliberal states thus started to base their health care on the idea of “individual responsibility”. This approach implies that the state’s only role is to make its citizens aware that they should regard health risks and possible outcomes, such as illness or disease, their own individual responsibility. Such approach to health has, obviously, also caused a huge policy shift, whereby the problem of health governance is no longer a concern for the neoliberal state itself, but rather became framed as a domain based on individual self-insurance and self-care. This trend has, furthermore, been characterized by neoliberal states’ ongoing policy preference for less restrictive health related interventions in the form of awareness and education campaigns. This neoliberal preservation of individual autonomy and the promotion of individual responsibility in all matters relating to health are, hereby, increasingly pursued in an almost dogmatic manner, despite scientific evidence showing the central role of more structural determinants of health beyond the individual’s knowledge or control, implying that under neoliberal health policy, health consumers are largely on their own in making ill-informed health choices.Footnote 50

At a more institutional level, the result of this policy shift has been an actual reduction in public funding for health services. According to Barnett and Bagshaw, during the past decades, the health care sector has thus become gradually underfunded, which obviously implies that in many countries the sector started facing a huge understaffing problem. The result of neoliberal public policy has thus been that the health sector has become increasingly characterized by a demoralised workforce of poorly paid health workers employed in understaffed institutions, and with hospital doctors and nurses in many countries reporting stress, burnout and “intense, unrelenting workloads”.Footnote 51

This approach provided a clear synthesis of the three schools of thought that had incited it since the 1960s, namely (1) the criticism of liberals (in the United States) and left-wing intellectuals (in Europe) regarding the overly paternalistic character of the welfare state model, in combination with modern arguments for more intrusive care models; (2) the purportedly ethical considerations from a more conservative angle that had argued against society having to bear the costs of treating diseases that are contracted because of immoral behaviour, and (3) the neoliberal vision that states should be subjected to austerity policy measures, in particular by cutting funding in the sectors of public services in general and public health (or other) care in particular. Needless to say, in such a neoliberal or marketized healthcare system, the rich gained better access to certain healthcare services than the poor.Footnote 52 The Impact of Neoliberal Politics on the Quality of Healthcare

According to Barnett and Bagshaw, research shows how, on a global scale, poor health outcomes are related to a deterioration in the socioeconomic determinants of health. These socioeconomic determinants of health include income, housing, food security, employment, stress and educational opportunities. According to the same authors, these poor socioeconomic conditions are by no means accidental, but rather the result of neoliberal policy choices that in this manner not only affect mortality, but also lethal diseases, such as obesity, mental health disturbances, and a wide variety of other health risk behaviours.Footnote 53 We shall readdress this topic in more detail in Chap. 10.

Besides the poor economic performance associated with austerity, there is also a negative relationship between “austerity” and health. First, there is a “social risk effect”, or more precisely a “risk-shifting” effect, where those already disadvantaged on a socioeconomic level (i.e., by having a bad job, poor housing, deprivation of educational opportunities…), also have to endure the health related consequences of the deterioration of said socioeconomic determinants of health. The second is through the direct impact on health services itself. E.g., after the financial crisis of 2008, health outcomes for countries where health budgets had to be reduced because of neoliberal policy imperatives, obviously compared unfavourably with countries that managed to maintain their spending on public services.Footnote 54 The latter effect can even be identified within the EU itself. Especially in the in the aftermath of the financial crisis of 2008, a lot of EU member states, notably Portugal, Ireland, Italy, Greece and Spain—also referred to as the “PIIGS” of the EU—all were forced to implement tough austerity packages. Blyth has in this regard identified “Greece’s bloated public-sector debt”, “Spain’s overleveraged private sector”, “Portugal’s and Italy’s illiquidity” and “Ireland’s insolvent credit institutions”, as the main reason why, during and in the aftermath of the financial crisis of 2008, the banking sector of these countries ended up being bailed out by their respective states, which caused huge public debts and deficits. The answer neoliberal EU came up with for addressing these countries’ problems, could be summarized in one word: “austerity”: Cut the government budget, reduce public debt, and all socioeconomic problems will automatically melt away.Footnote 55 This implied that PIIGS cut their public budgets, but without achieving the aspired effect: as these countries’ economies shrank due to a decrease in government spending, their tax income decreased as well while their debt loads got bigger, and unsurprisingly, their credit rating declined, making their interest payments increase and thus their debt position even more problematic. So, what neoliberal austerity accomplished was not the aspired aspect of reducing public debt and deficit and promoting economic growth, but instead making government bonds riskier and, to the extent that European commercial banks hold a lot of those, also big commercial banks riskier themselves.Footnote 56 This in its own turn helps explaining why monetary authorities resorted to the technique of quantitative easing (cf. Chap. 3.), basically implying that monetary authorities themselves have become the ones financing some of the(ir) ailing states (within the EU, in this manner coming close to resorting to monetary financing).

Within the EU itself, one of the sectors that has been severely affected by this EU austerity in the aftermath of the financial crisis of 2008, has notably been the healthcare sector, which was in this manner, in many countries, forced into a transition from being “mostly public” into becoming “mostly private”. This was done through a wave of privatization and marketization movements (which we shall explore in more detail throughout this chapter and Chap. 6.). Some (Scarce) Further Data on the Impact of Neoliberal Policy Choices

In what follows, the reader is asked to bear in mind that it is not easy to get a clear view on the effects of marketization and privatization of healthcare in Europe. Assa and Calderon have indicated the following reason for this:Footnote 57

Much of the literature on the privatization of healthcare involves case studies, and there is thus a lack of comparative studies across countries in this area.

This also explains why regarding the matters dealt with in this chapter (and the following Chap. 6 as well), the empirical and further research material is rather scarce. This also explains why in said two chapters, there had to be relied on the results of but a few such (empirical and other) studies. Moreover, there has hereafter been strongly quoted from this (scarce) research from other authors and institutions, in full acknowledgment that the authors and institutions quoted are the ones having conducted and authored said research, to which reference is here made in support of our own thesis on the detrimental effects of basing health care policy on neoliberal ideology (and without making any claim that the research results and ideas on the state of the health sector in the territories concerned, as quoted from said studies hereafter, are our own).

Assa and Calderon have in this regard pointed to the fact that some of these other studies have linked neoliberal policies to a decrease in life expectancy, especially in poorer countries, although acknowledging that there is still a lack of research on the effects of the privatisation on health outcomes in all countries—developed, as well as developing.Footnote 58 According to these authors, private and public health care systems have different strengths and weaknesses. Among the reported strengths of private health care institutions are: (1) shorter waiting times, as well as (2) better interaction with staff in comparison with public institutions. According to the same authors, disadvantages of private institutions may include: (1) less accurate diagnosis, (2) less strict adherence to medical management standards, (3) a shortage of lower-level staff (especially regarding assistant-physicians, nurses, pharmacists and midwives, rather than specialists and doctors themselves), and (4) sometimes a tendency of over-prescribing antibiotics.Footnote 59 By contrast, an increased spending on public health and on developing universal health care has been leading to higher general well-being.Footnote 60

Again according to Assa and Calderon, privatisation also led to so-called “distributional effects”. An example thereof is that private health care institutions often charge a price for their services that the poor cannot afford, which may discourage people from seeking medical support and treatment.Footnote 61

Still according to Assa and Calderon, while these negative effects of health privatisation have especially been observed in developing countries, they could also been witnessed in many countries in transition from communism to a free market system, where there has during the past decades equally been a massive privatisation of many socioeconomic sectors, including the health care sector. In these countries, the privatization of the health care sector has led to treatments becoming unaffordable, people with pre-existing conditions being denied services or health insurance, and people’s willingness to see a doctor when ill being strongly reduced.Footnote 62 According to the quoted authors, this positive correlation between the privatization of health care and health inequality is confirmed by a variety of further data to which these authors refer, such as data from 147 countries on the effect of inequality on life expectancy (provided by UNDP 2019), and regarding the ratio of private to public health expenditure (provided by WHO 2020).Footnote 63

What is obviously even more important in the context of this book, is the fact that this positive relationship between inequality and relying more on private (or privatized) healthcare, has been of vital importance in the case of Covid-19 itself, with a variety of research having demonstrated that Covid-19 is a disease that has an unequal impact on more vulnerable populations. Although this matter shall be readdressed in some more detail in Chap. 10, it can already be pointed out that this correlation has been pointed out on several levels. First, poorer people have been reported to be more likely to suffer from underlying chronic conditions, and thus of being at higher health related risk of Covid-19 mortality. Secondly, poorer people without public health insurance, or without the means to pay for expensive private health insurance, or for medical expenses themselves, have been reported to also be more likely ignoring social distancing in order to be able to stay at work, both reducing the effectiveness of control measures and making these people more vulnerable of exposure to the Covid-19 virus.Footnote 64

Em. Prof. Dr. Walter Foulon—who was in the past the head of the Department of Obstetrics UZ Brussels (Belgium) and is at present a board member of the “Masereel Fund Vilvoorde”—has pointed to another, important effect of applying neoliberal logic to the health sector.Footnote 65 In addition to market deregulation and the dismantling of public health institutions, a key objective of neoliberal policies has been the reduction of social security expenditure. In order to make “rational” savings in healthcare and not give the impression that cost cuts would come at the expense of quality, the “American Registration System” was introduced to “map the sector”. To this end, the DRG (diagnosis related groups) classification system was installed, not surprisingly on the initiative of the Reagan administration.Footnote 66 A code was hereby assigned to each disease treated in a hospital, which initially was intended to make it easier to find out which pathologies ended up for treatment in hospitals. However, soon this system allowed to deduce how long a hospital stay was needed for a particular treatment of a well-defined pathology. One could, e.g., also start calculating how many staff members were to be involved for treating a particular pathology, how much the medication was to cost, how long the average surgery time would be for an operation etc. Foulon notes that although such information can on itself be useful and not necessarily needs to be intrinsically harmful or dangerous, the system soon became harmful when it started to get used to propagate further savings in healthcare. As a result, hospital physicians were soon confronted with the concepts of a “responsible duration of stay (in a hospital)” and of “responsible hospital expenditure”. Hospitals were even financially rewarded for shorter hospitalizations and penalized for an excessively long hospitalization for a particular pathology. In this manner, the hospitalization duration gradually got shortened for all conditions. Shortening the average length of hospitalization, in its own turn, justified the reduction of the number of “redundant” hospital beds. E.g., In Belgium, there were in 1990 56,327 hospital beds, a number which was progressively reduced to 52,565 by 2019. This amounted to a reduction of 8% (taken into account the population growth). And precisely the shortage of hospital beds (all through the Western world) has been one of the most important reasons for the huge mortality rates of Covid-19 in the Western world (cf. Sects. 5.3.1 and 67

Based upon this calculation method for every aspect of treating any disease, savings were also accomplished in the staffing of hospitals. At the beginning of 2021, the nursing supervision in Belgium was 1 per 9.4 patients, while it is generally assumed that a safe level of supervision requires minimum one nurse per eight patients. Raising the number of nurses has since then become increasingly difficult, moreover given the relatively low salaries and heavy workload.Footnote 68

Because of such approaches (such as “austerity” on a macro-level) and “DRG”-reporting systems (or similar systems) on a micro-level, neoliberal health policy has mainly been about reducing costs. As a result, staffing must be kept as small as possible in all hospital services. According to Foulon, in many hospital departments throughout the EU, there is already a problem when a staff member is unexpectedly absent. According to the same author, one does, of course, not necessarily build out a healthcare system with the assumption that a pandemic is permanently at hand, but neoliberal policy of extreme downsizing the entire healthcare sector, has made the European healthcare systems extremely vulnerable to the slightest overload. For Foulon, it is clear that the inadequacy of the healthcare systems of the Western world to deal with a pandemic such Covid-19, has as one of its most important causes the neoliberal health policy of recent years.Footnote 69 Further Research Methodology

In the next Sect. 5.2, we shall try to elaborate upon the question what the foregoing has meant, in practice, for the organization of healthcare in general and that of the hospital sector in particular, in both (Western) Europe and the United States. Thereafter, in Sect. 5.3, it will be investigated to what extent the European and US “marketized” healthcare sectors have been able to cope—or not—with the impact of the Covid-19 pandemic.

5.2 Practical Outlook of the Healthcare Sector Before Covid-19

5.2.1 The EU General Characteristics of the European Healthcare Sector in 2018 Introduction

Notwithstanding the previously cited remark by Assa and Calderon (cf. Sect., thanks to a relatively recent report by the OECD and the EU Commission working together, a fairly good picture of the state of affairs in European healthcare in 2018 is available.Footnote 70

This 2018 special report entitled “Health at a Glance: Europe 2018”, provides an in-depth, comparative analysis of the health status of EU citizens and the performance of the health systems of the 28 EU Member States, 5 candidate countries and 3 EFTA countries. The authors themselves considered the report a first, important step in the “State of Health in the EU cycle of knowledge brokering”.Footnote 71

The report is in two parts: Part I consists of two thematic chapters, the first of which is devoted to the need for joint efforts to promote better mental health, and the second—which can hardly be surprising, given the EU neoliberal health policy’s emphasis on “austerity”—on “outlining possible strategies for reducing wasteful health expenditure”. Part II of the report covers what the EU Commission considers to be the “most recent trends in key indicators of health status, risk factors and health spending”, together with a discussion of progress in “improving the effectiveness, accessibility and resilience of European health systems”.Footnote 72

The EU’s emphasis on austerity measures is already evident from the first pages of the 2018 report.

In the following overview, we shall refer to and discuss a number of elements of this 2018 report that are relevant in light of the aims of this book. This does not preclude the whole of the report from being commendable literature, not only because of the richness and detail of the data provided, but also because it exposes how proud the supra-national, neoliberal institutions behind this report (in particular, the OECD and the EU Commission) are of their many neoliberal austerity achievements of the past decades. Indeed, the common thread that appears throughout the 2018 report concerns the extent to which the healthcare sector has, in the recent past, been the object of increasingly stringent austerity measures.

Even the modern-day models of “inclusive healthcare”—basically aimed at keeping (poor) people out of healthcare facilities as much as possible, to the extent that medical treatment in such facilities is simply too expensive, and neoliberal authorities prefer especially poor people to be sick at home and be cared for (or not) by relatives or by the local neighbourhood, so no expensive treatments are wasted on them—are dealt with in a detailed manner in the 2018 report (on the theoretical arguments for this so-called intrusive healthcare model; cf. Sect.

It is also remarkable that, notwithstanding the very high degree of thoroughness of the 2018 report which aimed to provide a detailed overview of the overall state of affairs of health policy in Europe, not a single word is said about the subject “prevention or preparation for an epidemic or pandemic”. Indeed, despite prominent, international businessmen (such as Bill Gates) had been calling for years on the governments of (Western) countries to start preparing for the possibility of outbreaks of epidemics or pandemics,Footnote 73 it does not appear from the 2018 OECD/EU report that this was a theme that had already captivated the interest of the EU leadership. In view of neoliberalism’s aversion to any form of planning (the so-called “laissez-faire, laissez-passer” principle; cf. Sect. 2.2.4.), this is hardly surprising at all.

The list of special “risks factors” to which special attention was paid in the 2018 report speaks volumes:Footnote 74

  1. (1)

    Smoking among children.

  2. (2)

    Smoking among adults.

  3. (3)

    Alcohol consumption among children.

  4. (4)

    Alcohol consumption among adults.

  5. (5)

    Illicit drug consumption among children.

  6. (6)

    Illicit drug consumption among adults.

  7. (7)

    Obesity among children.

  8. (8)

    Obesity among adults.

  9. (9)

    Mortality due to air pollution and extreme weather conditions.

For wealthy Europe, which prides itself on being one of the strongest economies on the planet, characterized by a perceived deep—albeit untruthful—concern for the interests of its citizens, it is significant that the specific “risk factors” of public health which were deemed of importance in 2018, all encompass luxury problems—such as drugs, alcohol, obesity and pollution—caused by what Galbraith,Footnote 75 in the past, has described as “the affluent societies”, i.e. societies that are completely subject to the capitalist working methods and in which the generic population but serves to support the capitalistic “production-for-production’s sake-machinery” (and, therefore, the “consumption-for-the-sake-of-consumption” model),Footnote 76 where the view on man is that of what Herbert Marcuse has, in the past, described as the “one-dimensional man”, a “being” which only serves the interests of an economic model, without any aptitude and ability for critical thought and oppositional behaviour whatsoever.Footnote 77

Such a “one-dimensional human being” still only exists in a socioeconomic dimension, thereby primarily fulfilling the following societal functions:Footnote 78

  1. (1)

    The function of “working” from morning till evening, with little time for anything other than working, until as old an age as possible.

  2. (2)

    The function of working for one central external purpose, namely for making the shareholders of the entrepreneurial sector as rich as possible.

  3. (3)

    The function of “consuming” as much as possible, as all one’s income should be spent on paying for the goods and services provided by the capitalist “production for production’s sake” economic model, notwithstanding the fact that many such goods and services are intrinsically useless and, often, harmful to both humanity and the environment.

  4. (4)

    The function of “credit taker”, which helps to ensure that: (1) people consume more than their income allows for; (2) the prison of one’s “duty to perform labour” is ever-more fortified (as credit taken has to be paid back); and (3) that one’s income is certainly not spent on anything else than expenses that make the rich of the planet ever richer.

  5. (5)

    The function of eternal “taxpayer”, as states obtain their income mainly by taxing the working classes.

  6. (6)

    The function of being employed by a repressive (capitalist) state, i.e., of being part of a bureaucracy that helps perpetuate such a (capitalist) socioeconomic order.

The function of being (medically or otherwise) cared (and generally looked out) for, obviously, does not appear on this list, as under the logic of neoliberalism every individuals are themselves responsible for their healthcare and that, at best, society could start organizing intrusive care systems.Footnote 79 (Compare Sect. 2.1, where it has been described in some more detail how this ideological approach has gradually conquered Western health policy as of the 1960s.)

Suffice here further by referring to the following quote of the work “One-Dimensional Man: Studies in the Ideology of Advanced Industrial Society” of Herbert Marcuse, bearing in mind that this was written already in 1964:Footnote 80

The productive apparatus and the goods and services which it produces “sell” or impose the social system as a whole. The means of mass transportation and communication, the commodities of lodging, food, and clothing, the irresistible output of the entertainment and information industry carry with them prescribed attitudes and habits, certain intellectual and emotional reactions which bind the consumers more or less pleasantly to the producers and, through the latter, to the whole. The products indoctrinate and manipulate; they promote a false consciousness which is immune against its falsehood. And as these beneficial products become available to more individuals in more social classes, the indoctrination they carry ceases to be publicity; it becomes a way of life. It is a good way of life – much better than before – and as a good way of life, it militates against qualitative change. Thus emerges a pattern of one-dimensional thought and behavior in which ideas, aspirations, and objectives that, by their content, transcend the established universe of discourse and action are either repelled or reduced to terms of this universe. They are redefined by the rationality of the given system and of its quantitative extension.

The above-mentioned “elements” or “health risks” of concern that drew the attention from the 2018 OECD/EC report’s authors are almost all generated by capitalism itself, and in particular by excessive consumption of things that, in a more normal world, would most likely not even be produced or traded to begin with (e.g., cigarettes, alcohol and industrially prepared food). Many of these products are, moreover, so-called “created wants”, consumed simply as a form of escapism, to cope with unhappiness. Not only does ruthless capitalism ensure that these products are massively produced and traded, but the system is also very aware that these products lie at the root of numerous diseases and broader societal ills.

In light of the content of the 2018 OECD/EC report and the consequences of neoliberal health policy it reveals (in particular, decades of sustained austerity, in addition to an emphasis on the development of “inclusive models of healthcare”, basically a polite way to say that those who are poor and sick, have to take care of their own), it is hardly surprising that when, at the end of January 2020, Covid-19 reached the European continent, no policy level or healthcare institutions were actually prepared for this: Not the EU (through the EU Commission, or one of the many European institutions, albeit all manned with an army of well-paid civil servants), not the national governments of the EU member states (nor those of the United Kingdom that had recently departed from the EU itself; cf. the so-called “Brexit”), not the numerous regional, local or community administrations to which neoliberal central authorities had “detached” many specific tasks of healthcare over the years, and not even the hospitals and nursing institutions themselves, to the extent that these had, in many countries, suffered way too much for many years under a sustained austerity policy.

In fact, if all these many governing authorities and healthcare institutions have one thing in common, it is that none of them had given much attention to crisis prevention and preparation at all.

We shall take a closer look at the neoliberal public policy, with its emphasis on austerity measures, which has caused all of this, in Sect. below. But first, let us take a closer look at some of the findings of the health policy assessment regarding the EU and its member states as made in 2018 by the OECD (and the EU Commission itself) and as based upon the findings of their above-quoted report. Health Insurance Coverage

By and large, the financing of a universal health coverage can happen through two main models that prevail in Europe:Footnote 81

  1. (1)

    The social democratic or “Nordic” model, in which health insurance—as most other public services—is funded predominantly from taxation. This model prevails in countries such as Norway, Finland, Sweden, Denmark and Iceland. Not by coincidence, these countries also count among the happiest on Earth. (Cf. Sect. 2.1.3.)

  2. (2)

    The social insurance or “Bismarckian” model, in which health insurance—besides a wide variety of other social security systems, such as income support—is largely funded through employer and personal (mandatory) contributions.

According to the 2018 OECD-EC report, in 2018, most European countries had universal (or semi-universal) health care that at least covered basic health care services, such as consultations with doctors, tests and examinations and hospital admittance.Footnote 82 However, in practice, coverage of these “core services” might not have been as “universal” in some countries.Footnote 83

Still, in three European countries (notably Cyprus, Bulgaria and Romania), at least 10% of the population was still not universally covered for health services by 2018.Footnote 84

The basic coverage of primary health care in most EU Member States included a well-defined set of services, but in many cases based upon a model of “shared costs”. In some countries, supplementary health insurance could be taken out via private insurance in order to (1) cover costs remaining after the basic coverage (= so-called “complementary insurance”), (2) add additional services (= so-called “supplementary insurance”), or (3) provide faster access or a wider choice of health care providers (= so-called “duplicate insurance”). In most EU countries, only a small proportion of the population had opted for one or more forms of such additional private health insurance. But in five countries (France, The Netherlands, Slovenia, Belgium and Croatia), half or more of the population had reportedly opted for such additional private coverage.Footnote 85

The development of private health insurance was linked to several factors in the 2018 OECD-EC report, including gaps in access to publicly funded services, government interventions targeting private health insurance markets, as well as historical development.Footnote 86 Extent of Healthcare Coverage

One of the first matters that have been investigated in the above-mentioned 2018 report from the OECD and the European Commission and that have been quoted in this book, deals with the extent of healthcare coverage that was achieved throughout the EU by 2018.

From said study, it appeared that across the EU, inpatient services provided in hospitals were among those most comprehensively covered than any other form of medical care in 2018. It, more precisely, appeared from this study that, across the EU, 93% of all the costs related to such inpatient care were borne by public authorities or by mandatory insurance schemes. In many countries, patients even had access to completely-for-free acute inpatient care. This appeared to be the case, e.g., in Denmark, Hungary, Poland, Spain and the United Kingdom, where the government and/or mandatory health insurance systems covered more than 90% of these inpatient costs at the time. In The Netherlands, these inpatient services were also free once an annual general excess was reached. However, in Cyprus, Greece and Ireland, the financial coverage of the costs related to hospital inpatient care was by contrast lower than 70%.Footnote 87

Regarding outpatient care expenditure, it appeared from the same study that, in 2018, more than 75% of the costs were borne by public authorities and/or mandatory healthcare financing Schemes (77%). When excluding Bulgaria and Cyprus, it appeared that at least half of all the costs for outpatient medical care in EU countries were paid for by mandatory third-party payers. There were even a number of EU countries where all outpatient primary and specialist medical care was generally free “at the point of service”, implying that a physician affiliated with the mandatory program had to be consulted at a fixed co-payment. In this group of countries, user fees borne by the patient himself, moreover, still applied for specific services and/or when consulting unqualified providers. Such a system, e.g., applied in Denmark, where 92% of the total outpatient medical cost was covered by the mandatory health programmes, but charges were still made for visits to health providers functioning outside these mandatory schemes, such as psychologists and physiotherapists. A similar system applied in the United Kingdom (84%), where outpatient care outside the services ordered under the NHS system was not covered.Footnote 88

Government or mandatory health insurance coverage for medicines was in the EU generally less extensive than coverage for costs for inpatient and outpatient medical care. According to the study from the OECD and the CE, across the EU, about 64% of all medicine costs were born by government and/or mandatory health insurance schemes in 2018. So-called “over-the-counter medicines”—which are obtainable without a prescription from a physician, and which are usually not covered by a government or otherwise mandatory health insurance scheme—were of major importance in some EU countries. E.g., in Cyprus and Bulgaria, less than 20% of all medication costs fell under public or mandatory health insurance schemes. By contrast, in Germany, this percentage amounted to 84%, with only moderate cost-sharing requirements in accordance with which patients generally had only to pay a co-insurance rate of 10% for each prescribed medicine, up to a maximum of EUR 10 per item within an annual co-insurance cap.Footnote 89 Availability of Doctors

According to the study from the OECD and the European Commission, in (or in the time period preceding) 2018, the number of doctors per capita showed huge differences between EU countries.Footnote 90

According to the study, in 2016, Greece was among the EU countries with the highest number of doctors per 1000 population, namely 6.6. However, the study also mentioned that this number might have been an overestimation, as it included all doctors licensed to practice (including retired physicians and those emigrated to other countries). Other countries that still had high numbers of general practitioners were Austria and Portugal, however in Portugal these numbers were assumed to be an overestimation for the same reason as Greece (even implying that when disregarding this overestimation, the number of practicing physicians in Portugal would probably have been just under the EU average). According to the OECD and CE study, the number of physicians per capita was the smallest in Poland, the United Kingdom and Romania.Footnote 91

From the study, it also appeared that, since 2000, the number of physicians per capita had risen in all EU countries, except in France, Poland and Slovakia, where the numbers had stayed stable. On average across EU countries, the number of physicians per capita was reported to have risen from an average of 2.9 doctors per 1000 inhabitants in 2000, to 3.6 in 2016. In most EU countries, the financial crisis of 2008 had not been of much impact on the growth figure regarding physicians.Footnote 92

In many EU countries, there was already for more than a decade a shortage of general practitioners, with concerns that this problem would not be solved in the near future. This was particularly more the case in rural and remote areas than in urban areas. While the total number of physicians per capita had during the years preceding 2018 increased in almost all EU countries, the proportion of general practitioners had in many countries stagnated or even declined.Footnote 93 Physician density was, moreover, consistently higher in urban regions, reflecting a higher availability of specialized medical services, such as access to surgery, and physicians’ own preference for settling in an urban environment. The differences in the number of available physicians between urban and rural regions were reported to be the highest in the Slovak Republic, the Czech Republic and Greece. Many countries also reported having resorted to several forms of financial and other stimuli to attract and retain doctors in such “underserved areas”. Examples of such stimuli were one-time subsidies to help general practitioners start their practice, as well as recurrent payment schemes, amongst which income guarantees and bonuses. Some EU Member States also had resorted to a policy of stimulating students from underserved regions to start medical school.Footnote 94 Availability of Nurses

By 2018, the number of nurses per capita far outnumbered the number of doctors in most EU Member States, with a ratio of on average two to four nurses per physician in most EU Member States. According to the OECD and CE-study, nurses play a crucial role in the delivery of healthcare, not only in hospitals and long-term nursing facilities (such as retirement homes for the elderly), but to an increasing extent also in primary care and home care schemesFootnote 95 (cf. already Sect., re the “inclusive care model”, which has during the past decades to an increasing extent been promoted and embraced by neoliberal governments in light of their austerity policies).

Notwithstanding the foregoing, many EU countries were increasingly dealing with likely future shortages of nurses, as the need for (more) nurses was expected to increase in a context of an ageing and retiring “baby boom” population in general, and a generation of “baby boom” nurses in particular. This concern had already by 2018 made many EU countries to resort to measures for improving the schooling of new nurses. Other EU countries even started addressing the nurse shortages by attracting nurses from third countries.Footnote 96

On average, there were 8.4 nurses per 1000 inhabitants in all EU countries in 2016, up from 6.7 in 2000. The number of nurses per number of inhabitants was reported to be the highest in Denmark and Finland. However, about a third of the nurses employed in the two latter countries were at the same time reported to be trained at a less advanced level than general nurses and to be performing lower tasks. Switzerland and Iceland were facing a similar situation. In some other countries, such as Italy and Spain, many so-called “health care assistants” (or “nursing auxiliaries” or “nursing aids”) were hired to assist qualified nurses. Greece was reported having the lowest number of nurses per capita among EU countries, but the data available for Greece only included nurses serving in hospitals. Bulgaria, Latvia, Poland and Cyprus also reported relatively low numbers of qualified nurses.Footnote 97

Since 2000, the number of qualified nurses per capita had risen in most EU Member States. Exceptions on this general trend concerned the Baltic countries (Estonia, Latvia and Lithuania), where the number of nurses per capita was reported to have remained stable, and Slovakia, where the number of nurses was reported to have decreased both in absolute numbers and per capita. Most of this decline regarding Slovakia was reported to have taken place between 2000 and 2010.Footnote 98

In other EU countries, there had by contrast been an increase in the number of qualified nurses. This increase in the number of qualified nurses per capita was highest in Denmark, Finland, Germany, Luxembourg, France and Malta. Malta was thereby reported to have resorted to a series of unusual measures for both educating more nurses locally and attracting more nurses from abroad to deal with shortages of the past. E.g., the university training to become a qualified nurse in Malta had become free for students; and after students graduated, they were stimulated to take an educational leave while receiving at least part of their salary.Footnote 99

According to the OECD and CE-study, most nurses in EU Member States serve in hospitals. Relative to the total size of the general population, the number of qualified nurses serving in hospitals, both in absolute numbers and regarding full-time equivalents, had in the decade leading up to 2018 increased in most EU countries (e.g., in Austria, Belgium, Denmark, Germany and Malta). In France, the total number of qualified nurses serving in hospitals per capita had also risen slightly, although the number of full-time equivalents had more or less stayed the same, implying that the average number of laboring hours performed by qualified nurses had decreased slightly. In many EU Member States, the ratio of full-time equivalents to the absolute number of nurses was reported to range from 0.80 to 0.95, with this ratio having remained relatively stable over time. However, this average ratio was reported of being much lower in Belgium and Germany (0.70–0.75), implying that qualified nurses in these countries worked fewer hours.Footnote 100

Many countries also reported a growing number of qualified nurses working in so-called primary care. In response to shortages of GPs, some EU Member States had resorted to introducing or expanding advanced nurse practitioner roles to ameliorate access to primary care. Assessments of experiences with such (advanced) nurse practitioners in Finland and the United Kingdom thereby demonstrated that such schemes could improve access to care and reduce waiting times for medical treatment, while at the same time providing a comparable quality of care as physicians for a range of patients (e.g., patients with minor illnesses or patients requiring only routine follow-up).Footnote 101 Hospital Beds

One of the most vital sets of data in light of the Covid-19 pandemic is most likely the number of hospital beds.

This number gives an indication of the means that are generally available for providing health care services to hospital patients. The impact of the availability of hospital beds on the number of hospital admissions has thereby been extensively documented. From this research, it appears that a greater supply of hospital beds, in general, leads to a lower threshold for hospital admission (the so-called “Rohmer’s law” that a “built bed is a filled bed”).Footnote 102

It must in this regard be underlined that under neoliberal austerity measures of the past decades, EU authorities and EU member state governments aimed at keeping the number of hospital beds as low as still deemed acceptable, which has been one of the most main reasons for the disastrous impact Covid-19 has had in both the countries of the EU and the United Kingdom.

According to the already above-mentioned OECD and CE-study, by 2018, Germany, Austria and Bulgaria still reported the highest amounts of hospital beds per capita, having more than seven beds per 1000 inhabitants in 2016, which was considerably above the EU average of just over five beds per 1000 inhabitants, and more than twice the number of available beds in Sweden, the United Kingdom and Denmark.Footnote 103

Since 2000, in the light of the neoliberal austerity policies that had been strongly geared towards this criterion, the number of hospital beds per capita had drastically fallen in all EU countries. On average, the number was reported to have fallen by no less than 20%Footnote 104 (= which implied that every five beds had been reduced to four). This reduction in the supply of hospital beds had in particular marked in Finland, Estonia, Latvia and Lithuania. The reduction had, moreover, been accompanied by a fall in the number of actual hospital admissions in various EU Member States and by a fall in the average duration of stay in almost all EU countries,Footnote 105 which forms but one illustration of how much the EU prefers austerity above the interests of patients (and thus, ultimately, its general population).

Hospital admissions were by 2018 still the highest in the three countries with the largest amount of available hospital beds: Bulgaria, Germany and Austria. While differences in patients’ clinical needs may present an explanation for some small part of the differences in admission rates, these variations likely mostly reflected other factors, such as differences in hospital bed supply, clinical practices and payment systems.Footnote 106

In all EU Member States, the main diseases resulting into hospital admittance in 2016 were: circulatory diseases, pregnancy and childbirth, injuries and other external causes, diseases of the digestive system, respiratory diseases and cancers.Footnote 107

Hospital admittance rates not only varied between EU Member States but even within countries. In various EU countries (e.g., Finland, Germany, Italy, Portugal, Spain and the United Kingdom), hospital admissions (except those for surgical interventions) varied more than twofold between different regions within the same country. This was believed to be due not only to differences in the availability of hospital beds, but also in the supply and quality of primary care services.Footnote 108

Hospital bed occupancy rates were, moreover, reported to have risen over time in some EU countries with a relatively low amount of hospital beds. This was particularly the case for Ireland, having a curative (acute) care bed occupancy approaching 100% in 2016, well above the number of all other countries. In countries such as Belgium and Germany, bed occupancy had remained relatively the same since 2000, at around 80%. The EU average had also remained stable at around 77%.Footnote 109

Figure 5.1 gives an indication of the number of hospital beds per 1000 population, in 2000 and 2016 (or nearest year) in some European countries. Figure 5.2 gives a similar overview of the occupancy rate of curative (acute) care beds, in 2000 and 2016 (or nearest year).

Fig. 5.1
figure 1

Hospital beds per 1000 population, in 2000 and 2016 (or nearest year) [Source: OECD and European Commission (2018), p. 187]

Fig. 5.2
figure 2

Occupancy rate of curative (acute) care beds, 2000 and 2016 (or nearest year) [Source: OECD and European Commission (2018), p. 187] Impact of EU Neoliberal Austerity EU Monetary and Fiscal Policy as a Method of Inciting EU Member States to Take Austerity Measures Regarding Their Healthcare Sector(s)

In March 2020, Gerrit Zeilemaker made his own, more critical assessment of the past decades of neoliberal policy applied to the EU healthcare sector.Footnote 110

This author started his assessment by pointing out how, for more than a decade already, the EU Commission in its “country-specific recommendations”, insisted that EU member states should continue reducing healthcare costs and expenditures.Footnote 111 According to Zeilemaker, through this policy of austerity “recommendations”, healthcare in EU countries, over the past years, has become completely subordinated to the so-called “Maastricht (budgetary) convergence criteria”. The budget constraints imposed on EU countries as part of the Growth and Stability Pact (cf. Sect. have in this manner been increasingly used as a leverage to cut down on healthcare. According to Streeck, such a policy is a manifestation of an increasing willingness shown by the EU, to decouple its fiscal and monetary policy form national democracy, as demanded by the financial markets.Footnote 112

In 1992, said convergence criteria had been put in place to measure progress in countries’ preparedness to adopt the euro, and defined as a set of macroeconomic indicators, which focus on:

  • Price stability.

  • Sound public finances (with a policy emphasis on keeping these “sustainable”).

  • Exchange-rate stability aimed at demonstrating that an EU and euro area member state can manage its economy without recourse to excessive currency fluctuations.

  • Long-term interest rates, which are an indication for assessing the durability of the convergence.

Table 5.1 gives a schematic overview of the main characteristics of the four Maastricht convergence criteria.

Table 5.1 The four Maastricht convergence criteria [Source:]

The Treaty on the Functioning of the European Union (TFEU, Article 140Footnote 113) stipulates that, at least once every 2 years, or at the request of a Member State with a derogation (not participating in the euro area), the European Commission and the ECB must report to the EU Council on the progress made towards convergence.

Article 140(1) TFEU requires these reports to include an examination of the compatibility of national legislation, including the statutes of the national central bank, with Articles 130 and 131 TFEU and the Statute of the European System of Central Banks and of the European Central Bank (also referred to as “ESCB/ECB Statute”). The reports must also examine whether a high degree of sustainable convergence has been achieved in the Member State concerned, by reference to the fulfilment of the convergence criteria (i.e., price stability, public finances, exchange rate stability, long-term interest rates), and by taking account of the other factors mentioned in the final subparagraph of Article 140(1) TFEU. The four convergence criteria are developed further in a Protocol annexed to the Treaties (cf.; Protocol No 13 on the convergence criteria).

The most relevant convergence criterion, (purportedly) justifying the EU’s severe neoliberal austerity policy, is the one dealing with public finances and is defined in the second indent of Article 140(1) TFEU as:

the sustainability of the government financial position; this will be apparent from having achieved a government budgetary position without a deficit that is excessive as determined in accordance with Article 126(6).

Furthermore, Article 2 of the Protocol on the convergence criteria states that this criterion implies that:

at the time of the examination the member state is not the subject of a Council decision under Article 126(6) of the said Treaty that an excessive deficit exists.

The assessment of convergence in the fiscal area is hereby directly linked to the excessive deficit procedure as specified in Article 126 of the Treaty and further clarified in the Stability and Growth Pact (cf. in particular the excessive deficit procedure, as reinforced by the 2011 reform of the Stability and Growth Pact).Footnote 114 The details of the excessive deficit procedure are set out in Regulation 1467/97, as amended in 2005 and 2011, which establishes how government deficit and debt are to be assessed in order to determine whether an excessive deficit exists, in accordance with Article 126 TFEU. The assessment on fiscal convergence is thus made on the basis of whether the Member State is the subject of a Council decision under Article 126(6) on the existence of an excessive deficit.Footnote 115 Methods of Deploying EU (Monetary and Fiscal) Austerity Policy in Practice General

According to the Corporate Europe Observatory, there are many (both formal and informal) routes “from Brussels to EU capitals” based on the above-quoted EU principles and regulations. Consequently, the enforcement of economic and fiscal policy rules is carried out through a plethora of procedures, with the health sector having been forced to deal with all of them in recent years.Footnote 116

Even the European Commission itself reported that the pressure to cut healthcare costs can be most clearly seen in loan agreements, such as those between the EU and Greece and Portugal in the aftermath of the financial crisis of 2008.Footnote 117 E.g., in Portugal’s 2011 loan agreement (i.e., a “Memorandum of understanding”), the reduction of costs in the health sector was high on the list of demands of EU creditors. As a result, staff expenditure in the Portuguese health sector was reduced by as much as 27% between 2010 and 2012.Footnote 118 In the same vein, in Greece, three consecutive loan-linked adjustment programmes between 2010 and 2016 led to a similar sharp drop—by about 40%—in per capita health expenditure (according to World Bank data).Footnote 119 A Letter from the ECB to Italy on 5 August 2011

Italy, though severely impacted by the financial and economic crisis of 2008, had not immediately been subject to an EU fiscal adjustment program by e.g., the European Commission or the EU Council. Instead, it was the European Central Bank (ECB) itself that would start putting pressure on the Italian government to reform health care spending. This happened under the form of a letter from the ECB addressed to the Italian government, of 5 August 2011 that urged for swift reforms, including austerity measures in healthcare.Footnote 120

Said letter has been described as “a government program”, and a “diktat”, yet there have also been those who questioned its existence at the time. The “secret” letter sent to the Italian government on 5 August 2011 by the (at the time) president of the ECB, Jean-Claude Trichet, and by his successor “in pectore”, Mario Draghi (the later governor of the “Banca d’Italia”—the Italian central bankFootnote 121), was reported to have soon afterwards inflamed the political debate of the summer of 2011, as it implied a public finance manoeuvre never seen before in the history of the Italian Republic. The letter concerned a “strictly confidential” document, which was also intended to remain confidential. Still, the newspaper “Corriere della sera” managed to obtain a copy of the letter and published in its original English text, as well as in an Italian translation, so that everyone could get a clear idea of the (dictatorial) working methods applied by some of the highest EU officials. The letter is uncharacteristically precise and punctual compared to the classical scheme of the liturgy of central banks.Footnote 122

To clearly demonstrate how, through its monetary and fiscal policy, the EU (in this case through the ECB) may call for “marketization” and “privatization” reforms, even in policy domains completely outside the scope of its competences, the letter has been quoted hereafter (in full) in its English version:Footnote 123

Frankfurt/Rome, 5 August 2011.

Dear Prime Minister,

The Governing Council of the European Central Bank discussed on 4 August the situation in Italy’s government bond markets. The Governing Council considers that pressing action by the Italian authorities is essential to restore the confidence of investors.

The euro area Heads of State or Government summit of 21 July 2011 concluded that “all euro countries solemnly reaffirm their inflexible determination to honour fully their own individual sovereign signature and all their commitments to sustainable fiscal conditions and structural reforms”. The Governing Council considers that Italy needs to urgently underpin the standing of its sovereign signature and its commitment to fiscal sustainability and structural reforms.

The Italian Government has decided to pursue a balanced budget in 2014 and, to this purpose, has recently introduced a fiscal package. These are important steps, but not sufficient.

At the current juncture, we consider the following measures as essential:

1. We cf. a need for significant measures to enhance potential growth. A few recent decisions taken by the Government move in this direction; other measures are under discussion with social partners. However, more needs to be done and it is crucial to go forward decisively. Key challenges are to increase competition, particularly in services to improve the quality of public services and to design regulatory and fiscal systems better suited to support firms’ competitiveness and efficiency of the labour market.

a) A comprehensive, far-reaching and credible reform strategy, including the full liberalisation of local public services and of professional services is needed. This should apply particularly to the provision of local services through large scale privatizations.

b) There is also a need to further reform the collective wage bargaining system allowing firm-level agreements to tailor wages and working conditions to firms’ specific needs and increasing their relevance with respect to other layers of negotiations. The June 28 agreement between the main trade unions and the industrial businesses associations moves in this direction.

c) A thorough review of the rules regulating the hiring and dismissal of employees should be adopted in conjunction with the establishment of an unemployment insurance system and a set of active labour market policies capable of easing the reallocation of resources towards the more competitive firms and sectors.

2. The government needs to take immediate and bold measures to ensuring the sustainability of public finances.

a) Additional-corrective fiscal measures is needed. We consider essential for the Italian authorities to frontload the measures adopted in the July 2011 package by at least one year. The aim should be to achieve a better-than-planned fiscal deficit in 2011, a net borrowing of 1.0% in 2012 and a balanced budget in 2013, mainly via expenditure cuts. It is possible to intervene further in the pension system, making more stringent the eligibility criteria for seniority pensions and rapidly aligning the retirement age of women in the private sector to that established for public employees. Thereby achieving savings already in 2012. In addition, the government should consider significantly reducing the cost of public employees, by strengthening turnover rules and, if necessary, by reducing wages.

b) An automatic deficit reducing clause should be introduced stating that any slippages from deficit targets will be automatically compensated through horizontal cuts on discretionary expenditures.

c) Borrowing, including commercial debt and expenditures of regional and local governments should be placed under tight control, in line with the principles of the ongoing reform of intergovernmental fiscal relations.

In view of the severity of the current financial market situation, we regard as crucial that all actions listed in sections 1 and 2 above be taken as soon as possible with decree-laws, followed by Parliamentary ratification by end September 2011. A constitutional reform tightening fiscal rules would also be appropriate.

3. We also encourage the government to immediately take measures to ensure a major overhaul of the public administration in order to improve administrative efficiency and business friendliness. In public entities the use of performance indicators should be systematic (especially in the health, education and judiciary systems). There is a need for a strong commitment to abolish or consolidate some intermediary administrative layers (such as the provinces). Actions aimed at exploiting economies of scale in local public services should be strengthened.

We trust that the Government will take all the appropriate actions.

Mario Draghi, Jean-Claude Trichet.

29 September 2011 08:27.

The message from the ECB top officials to the State of Italy left little to the imagination, not to say that, by their letter, they practically summoned the Italian government to immediately comply with the dictates of EU bureaucracy, and already imposed a blueprint for far-reaching, socioeconomic reforms that Italy was instructed to undertake, amongst other things regarding its healthcare sector.Footnote 124

E.g., the secret letter of 5 August 2011 underlined the need to tighten the criteria for obtaining retirement pensions and to extend the retirement age of women in the private sector, in light of budgetary savings already to be accomplished in 2012. The letter also ‘imposed’ to “significantly” reduce the costs of the public service sector, by strengthening the rules on turnover and, “if necessary, by reducing wages”. In order to accelerate the growth of the Italian economy, Trichet and Draghi also explicitly recalled the need to review the rules on the hiring and dismissal of employees in private enterprises.Footnote 125 These policy dictates clearly resonate with the classical “Iron Law of Wages”—the idea that the wages of the members of the working class should be kept as low as reasonably possible—one of the corner stones of both eighteenth century liberal and present-day neoliberal economic thinking.Footnote 126

But even that was not considered enough. According to Trichet and Draghi, economic growth requires a “full liberalization” of professional associations and local public services, providing for their “large-scale privatization”. Next to a “serious commitment” to abolish or consolidate some intermediate administrative levels, “such as the Provinces”.Footnote 127 In view of the severity of the at the time prevailing financial market situation, the imposed upon measures were, moreover, to be included in a decree law to be passed as soon as possible and approved in Italy’s Parliament by the end of September 2011.Footnote 128

Trichet and Draghi did not go as far as calling for the assembly of the Italian Parliament themselves, albeit coming very close in doing so.

All these “interventions” were considered of an “essential” nature in order to strengthen the reliability of the sovereign signature, the value and the creditworthiness of Italian government bonds.Footnote 129

In the following years, the Italian government did precisely what it had been instructed. At first with some reservation, the Italian government then quickly summoned the Italian social partners, making known the existence of the letter of 5 August 2011 however without revealing it. And on Saturday, 13 August 2011, only a week after, the Italian government went ahead with drafting a balanced budget in accordance with the dictates of the EU central bank leadership. Three days later, when the markets reopened, the ECB and the European system of central banks, whose governors had been immediately informed of the letter and its contents, intervened on the Italian markets.Footnote 130

The type of letter Trichet and Draghi send to the Italian government on 5 August 2011 demonstrates that, once a member state needs monetary or fiscal support, it is no longer its democratically elected parliament—or the government that such a parliament has appointed—but the ECB (as itself driven by the financial markets) that starts determining the socioeconomic policy of such a member state.Footnote 131

One legacy from this era of austerity has been the lowering of the number of hospital beds and ICU beds in Italy: Indeed, in light of the austerity policy dictated by the EU, the number of hospital beds for acute medical care per 100,000 inhabitants had dropped by 13% in the period from 2010 until 2015, a trend that was still ongoing when Covid-19 started hitting Italy.Footnote 132 This fact is, obviously, of severe importance for the Covid-19 pandemic, as higher hospital bed capacity has been considered one of the main conditions for lower Covid-19 mortality rates.Footnote 133 One simply has to compare the numbers of Covid-19 deaths in countries with a high number of hospital beds (e.g., Germany) with countries with a lower number of hospital beds: While Italy and Germany still had been reported of having a similar number of hospital beds per 1000 inhabitants in 1990 (Italy 7, Germany slightly higher), after 10 years of post-2008 crisis EU austerity, in which Italy’s health budget had been slashed to comply with EU fiscal rules, the number of hospital beds in Italy had dropped to 2.6 per 1000 inhabitants, while the number of hospital beds in Germany had remained well above 6. During that same period, from 2008 until 2018, Germany had moreover nearly doubled its total public healthcare expenditure (in nominal terms, i.e. including inflation effects), while Italy’s total healthcare expenditure had only increased by 5.3%.Footnote 134 European Semester

The economic governance procedure that affects all EU countries in the most direct manner concerns the so-called “European Semester”. This system for deploying EU fiscal policy had already been set up during the early stages of the financial crisis of 2007–2008. The European Semester was thereby intended as a policy tool for guiding the economic and fiscal policies of the EU Member States. The system of the European Semester, more precisely, implies that the EU Commission draws up recommendations for each Member State on an annual basis (except for those Member States that already have an adjustment programme, e.g., linked to a loan agreement, cf. Sect. The drafting of this document is then followed by a discussion in the EU Council, which is tasked with adopting the final recommendations. This usually happens in June or July. In practical all cases, these final recommendations are identical or similar to those of the EU Commission (and thus also to those of the EU bureaucracies on which it relies).Footnote 135 For the governments of fiscally compliant Member States, these recommendations are usually of little importance, but for others—countries that are facing economic or fiscal problems—they can contain very serious messages.Footnote 136

The European Semester is considered as an important policy tool enforcing the EU’s “economic governance”. It is primarily designed to prevent EU Member States from breaching fiscal rules on topics as: public deficits, public debt and the public-debt to GDP ratio, besides a variety of so-called “macroeconomic imbalances”, for some of which the EU Commission can even impose a fine. Usually it is EU Member States whose economies are for some reason in a bad state that receive recommendations, specifically addressing the problem areas these countries are facing. This usually involves bringing public spending under control through austerity, but it can also involve implementing labour market reforms in order to make collective bargaining less feasible. This was e.g., the case for France in 2016.Footnote 137

Especially the restructuring of the healthcare sector has reportedly been an important and recurring topic since the first European Semesters were issued in 2011. It has in this regard, e.g., been observed that, by mid-2020, the EU Commission had already issued 107 recommendations concerning the health (care) sector in a broad sense of the word (including “long-term care (or nursing)”). Taking into consideration that each EU member country usually receives four to five recommendations per year, the foregoing demonstrates that health care (and especially the marketisation and privatisation of health care service providing) is an issue high on the agenda of the EU authorities. In practically all EU recommendations, health is said to have been a standard theme, and when ranking the EU proposals, health sector reforms, together with those of the pension system (which are treated as one cluster), they have ranked third or fourth every year since the start of the European Semester system in 2011 (preceded by “tax reforms” and “business environment/regulation”).Footnote 138 Again according to the Corporate Europe Observatory, 76 out of 107 European Semester recommendations adopted between 2011 and 2019 proposed to improve the “cost-effectiveness” of the healthcare system or simply to make cuts in public spending of health care. As in many other areas of socio-economic life, the most frequent recommendation is one relating to the so-called “cost-effectiveness” of the healthcare system, a recommendation that the EU Commission is reported to have proposed and adopted 39 times as of 2011. By contrast, in the list of areas considered for more investment, health care has appeared in a very limited number of cases. In the opinion of the Corporate Europe Observatory, this suggests that the term “cost-effectiveness” is in most cases little more than a “call for cuts” in public spending—as has appeared on many occasions and from many events.Footnote 139

Also regarding the example of Italy, whose as of 2011 ever shrinking hospital system would shortly afterwards be completely overwhelmed during the first wave of the Covid-19 pandemic (cf. Sect., the EU Commission in its “2019 Joint Report on Healthcare and Long-Term Care Systems and Fiscal Sustainability” made the following strict austerity recommendations:Footnote 140

The analysis above shows that a range of reforms have been implemented in recent years, for example, to strengthen primary care provision and its use, to improve efficiency, to improve data collection, information and monitoring systems and the use of ICT solutions, to control overall expenditure and pharmaceutical expenditure while delivering quality healthcare. They were to a very large extent successful and, therefore, Italy should continue to pursue them. The main challenges for the Italian healthcare system are as follows:

  • To continue increasing the efficiency of healthcare spending, promoting quality and integrated care as well as a focusing on costs, to tackle the impact on spending due to population ageing and non-demographic factors.

  • To extend the possibilities of hospitals to provide ambulatory and day care as well as to transfer more healthcare services into the ambulatory sector in order to reduce the number of inpatient care treatments, as well as to strategically direct more resources towards providers of lower levels of care, to increase efficiency.

  • To tackle unwarranted regional variation in waiting times and resource distribution. In particular, monitor and correct potential uneven distribution of hospital beds (follow-up and long-term care), to free-up capacity in acute settings as a driver of lower waiting times. To the same end, further develop ICT solutions to increase service efficiency of operations.

  • To re-think the current mix between doctors and nurses, to favor solutions that relying less heavily on doctors, in the cases where nurses can represent a substitute, consistently with a more primary-care oriented system.

  • To further the efforts in the field of pharmaceuticals by considering additional measures, both on the side of patients and of healthcare professionals, to improve the rational prescribing and usage of medicines. The policies could help reducing the high level of out-of-pocket payments and improving access to cost-effective new medicines by generating savings to the public payer.

  • To ensure a greater and nationally coordinated use of health technology assessment to determine new high-cost equipment capacity, the benefit basket and the cost-sharing design across medical interventions.

  • To implement the National Health Information System across all regions and sub-regional levels which has a strong potential to monitor and relate expenditure with activity and with outcomes and in identifying good practices and areas for improvement.

  • To encourage debate, information exchange, and peer reviews between regions once the system is fully implemented. In this context, the patient e-card (Tessera Sanitaria) should be fully exploited.

  • To continue to monitor regional expenditure policies making regions showing deficit in the health sector budget restore the balance and ensure efficiency and appropriateness in the provision of LEAs. To continue to improve accountability and governance of the system and identify possible cost-savings in the health sector administration, as it currently involves national and regional institutions.

  • To further the efforts to support public health priorities and enhance health promotion and disease prevention activities, i.e. promoting healthy life styles and disease screening.

A similar conclusion (including a set of recommendations) was reached regarding Italy’s (at the time prevailing) systems of long-term care/nursing (including the sector of the nursing homes for the elderly).Footnote 141 We shall readdress the latter in Chap. 6. Further Implementation of the Neoliberal Austerity Agenda on Healthcare

The EU’s direct intervention in domains of socioeconomic life for which it has, as such, no defined authority, e.g., the healthcare sector, is hardly surprising. It is but one of the many illustrations of how the EU bureaucracy is fixated on implementing a neoliberal agenda throughout all of its member states.

As some academics, quoted in the above-mentioned report of the Corporate Europe Observatory, already had remarked in a paper of 2015:Footnote 142

The hierarchy and subordination of policies within the European institutions is not something new and has been reported elsewhere confirming the observed tendency of linking health goals more closely to the EU’s economic growth narrative rather than valuing the health policy objectives in their own right. Despite the existence of official documents supporting the need to invest in health, investments in health infrastructure and human resources as a prerequisite for economic growth do not feature as a priority.

According to the Corporate Europe Observatory, the EU fiscal policy deployed in the past decades has had enormous consequences for the socioeconomic impact of Covid-19. The European Corporate Observatory even claims that if European health systems had been better equipped to deal with a pandemic, the health and socio-economic consequences of Covid-19 would most likely not have been so severe. E.g., better-equipped health facilities, with sufficiently trained nurses, hospital beds, PPE, etc., would obviously have been at less risk of being overwhelmed. This would in turn have reduced the need for strict lockdowns, reducing their disastrous economic consequences. However, in the opinion of the Corporate Europe Observatory, precisely the establishment of such well-equipped public health facilities had actively been discouraged under the neoliberal, short-sighted policy approach as laid down in the European semester reports of the past decade, which have all been characterized by a policy approach that insists on solutions that keep expenditure from rising, and on cutting back on expenses even if this goes to the detriment of public health services.Footnote 143 The significance of the European Semester hereby largely depends on how a EU member country is generally doing with the rules on public debt and deficits, besides a variety of other macroeconomic indicators that have been determining the content of the European Semester in the past.Footnote 144

This policy objective of reducing (public) health care expenditure is often explicitly mentioned in the semester-reports: again according to the information provided by the Corporate Europe Observatory, in the recent past, six EU member countries had been explicitly asked to restrict access to early retirement, while an explicit recommendation to reduce hospital costs (e.g., by reducing hospital treatment and by replacing it with outpatient care, or by introducing activity-based financing) had been issued to four countries (Lithuania, Bulgaria, Romania, and Ireland).Footnote 145

On a practical level this implied that when Covid-19 first hit the European continent, many EU Member States had shortly before been reducing the amount of their hospital beds: according to Eurostat, between 2012 and 2017, the number of hospital beds in the EU-28 had fallen by 3.3%, in some cases at a very fast pace.Footnote 146

Spain is one of the most telling examples of how far-reaching the impact of the European Semester can be: A 2012 loan agreement, entered into to support the country’s financial sector, required the Spanish government to “fully implement the recommendations to address macroeconomic imbalances under the European Semester”. This short and innocent sounding sentence in reality opened the door for years of very direct interference from the part of the European Commission with decision-making in Spain, including on the health budget. Recommendations in 2013 and 2014 urgently called for more “cost-effectiveness” in the Spanish health sector, a policy approach that would have nasty consequences: E.g., in 2012, the Spanish government submitted a law to reduce public spending in the health sector (cf. Royal Decree Law 16/2012). The preamble of this law, more precisely, stated that the immediate application of the law was “necessary, in the prevailing socio-economic context”, and that the measures resorted to by the law were necessary to respond to a variety of factors, including the “viability required by the European Union”. Between 2012 and 2014 alone, this policy approach subsequently resulted into a reduction of no less than 28,500 staff members in the Spanish public health sector (whereas the total number before that time had amounted to around 477,000 such staff members). This also has been of fundamental significance during the Covid-19 crisis, where a lack of staff members has been indicated as one of the main problems the overwhelmed Spanish hospitals have been dealing with throughout the Covid-19 pandemic, ultimately attributing to Spain’s high mortality rates.Footnote 147 (Cf. Sect.

Moreover, the Corporate Europe Observatory explicitly shared its belief that the days of the European Semester’s interference with the health policies of EU Member States are far from over. An indication for this was derived from a recommendation issued by the EU Council of June 2020, hence of the midst of the Covid-19 pandemic. In this recommendation, the EU Council stressed that the suspension of the most binding rules on public budgets, debts and deficits, had been of a temporary nature only. This implied that, once the Covid-19 crisis would be over, the “moratorium” on neoliberal austerity would be lifted again, with EU Member States again having to go back to “normal” and to start working on keeping public debt and deficits within the EU targeted ranges, a policy that will most likely imply cutting on public services. What the EU Council seems to have implied is that when European countries would again emerge from the Covid-19 pandemic, albeit in a poor economic shape, the EU’s economic governance rules would again be reactivated in full, which will likely require more cuts in public spending, including in the health sector. However, in the opinion of the Corporate European Observatory, if the Covid-19 pandemic has taught one lesson, it is that exactly the opposite needs to be done, especially considering that scientists globally started warning that further pandemics may be very likely due to a variety of factors, such as variants of the Covid-19 virus itself, as well as the rate of destruction of biodiversity which may lead to new virus outbreaks (cf. Sect. 2.2.2.).Footnote 148 The Resulting Outlook of the Healthcare Sector (by the Time Covid-19 Hit the European Continent)

Although health(care) is as such not a formal competence of the EU, the EU has, through the fiscal policy tools mentioned above, at least indirectly, considered it to be an economic activity, thus at the same time justifying its subjection to EU internal market rules (in particular the principles of free movement of goods, persons, capital and services, besides public procurement and state aid rules).Footnote 149

Moreover, as has been made clear in the previous Sects. and, the healthcare sector has been subject to severe scrutiny in the context of EU austerity measures for at least the past decade.

This has, furthermore, attributed to an increasing degree of “marketisation” and privatisation of health care, which in turn started to further erode the public character of health care. The public health sector was opened up to a variety of further (neoliberal) practices, such as outsourcing, encouraging competition among different providers, public-private partnerships, besides a wide variety of other marketisation and privatisation policies, ultimately even going as far as selling public hospitals and nursing or care homes to private investors.Footnote 150 Private market-oriented reforms such as the People’s Health Movement (PHM) were hereby “undertaken under the guise of increasing efficiency and quality through competition and choice”, but, again in the words of the Corporate Europe Observatory, in reality “contributed to a significant rise in inequalities in health and access to health care” and “weakened the public healthcare systems”.Footnote 151

The Corporate Europe Observatory even made the remark that, as part of this EU-initiated marketization and privatization gulf, private for-profit providers started to lobby for what they referred to as a “level playing field” for both private and public health care providers. This implied that the new generation of private health care providers started making claims for their “fair” share of public funds. This was partly due to a wrong assessment from the start, as policymakers assumed that private health care has to be sufficiently profitable, apart from a select minority of rich clients that are sufficiently wealthy to pay for the full costs and private sector profit margins. This does not comply well with the fact that those who need health care the most, are often the ones least able to pay the “market price” for it.Footnote 152

Several of the neoliberal governments of EU member states, for their part, made use of the frenzy provided to them by the neoliberal, EU austerity policy in order to push unpopular savings policies in their country even further. The result for the healthcare sector has been: (1) continuous cutbacks (including on staff members), (2) increased workload compared to lower wages for the remaining medical staff (esp. nurses), (3) fewer and fewer available hospital beds (cf. Sect., (4) bankruptcies of hospitals (and care and nursing homes), and (5) ever-more privatizations in the EU healthcare system.Footnote 153

In recognition of the need to “improve access” to care outside of hospitals, many EU countries also started taking desperate steps to increase the availability of so-called “primary” and “community” care, as well as to introduce new models of so-called “intermediate care”, as alternatives for (often more decent) medical care provided in hospitals or care and nursing homes.Footnote 154 (Cf., furthermore, Sect., on the theoretical background for this so-called “inclusive model” of health care.) One of the perceived problems of the past years had been that many people started reporting to hospitals because their primary care providers were unavailable (or were over-demanded).Footnote 155 A growing number of EU countries thereby started to adhere to the opinion that, in order to remain able to effectively respond to the needs of their ageing population, characterized by an increasing burden of chronic diseases, further efforts would be needed both to improve access to primary care and to provide more continuous and coordinated care outside hospitals and nursing homes.Footnote 156

EU austerity policy, furthermore, started to focus on “measuring and addressing overuse in hospitals”. This was based on a growing belief that many medical services provided for in hospitals only result in modest benefits for patients, or for only a limited number of patients.Footnote 157 Another comparable trend for both justifying and implementing EU austerity measures was based on the notion of “unlocking the potential of outpatient surgery”. It was assumed that outpatient surgery may help reduce the (ab)use of hospital resources, with the added belief that most patients prefer outpatient surgery anyhow, as it allows them to go home on the same day of their medical procedure. Advances in surgical and anaesthetic techniques also played a role here, but we cannot ignore the significant institutional factors supporting a marked increase in the use of day surgery in all EU countries during the past decade. Still, the spread of this preference for day surgery varies, with some countries leading the way in advocating day surgery as an easier and faster alternative to ever more complex medical interventions.Footnote 158 This practice, in its own turn, became a further argument for reducing the number of hospital beds even more (with all the adverse consequences this entails).

The effects of economic recessions on health inequalities also differ according to the policy response of national governments. E.g., countries such as the United Kingdom, Greece, Italy and Spain, that implemented severe austerity measures in the aftermath of the financial crisis of 2008 (amongst others, through significant cuts in health and social protection budgets), experienced far worse health outcomes than countries, such as Germany, Iceland and Sweden, that had chosen to keep relying on public health care spending and social safety nets. Older research has, in a similar manner shown that countries with a high level of social protection (such as Sweden) did not experience an increase in health inequalities during the economic recession of the 1990s. Similarly, in the United Kingdom, old age pensions were protected from austerity in the aftermath of the financial crisis of 2008, and this has prevented health inequalities among the elderly population. Such findings are consistent with other research on the effects of public sector and welfare state retrenchment and expanding trends in health inequalities, as seen in countries such as the United Kingdom, the United States and New Zealand. It has, e.g., been pointed out that inequalities in premature mortality and infant mortality by income and ethnicity in the United States had declined during the period of wealth expansion (i.e., the so-called “war on poverty” era between 1966 and 1980), but had again risen during the Reagan-Bush period (from 1980 until 2002) when under the impulse of the neoliberal wave, welfare provisions and health coverage had been scaled back. Similarly, in England, inequalities in child mortality rates had decreased as child poverty had declined during a period of public sector and welfare state expansion (i.e., mostly between 2000 and 2010), to drastically increase again as soon as austerity measures were implemented, with child poverty rates increasing again from 2010 until at least 2017.Footnote 159

According to Sumonja, economic neoliberalism has gradually entered an “authoritarian” phase after 2008. As a result, it has broken with elements of formal democracy and even started to violate fundamental rights (or at the very least stopped caring about these).Footnote 160 The evolution of the healthcare sector is a clear example of this evolution. This is undoubtedly at the same time one of the main socio-economic factors that contributed to the disastrous way in which the EU and its Member States responded to the Covid-19 crisis. We shall look at this in more detail in the next sections. Further Data on the Impact of EU Austerity Policy in the Healthcare Sector in Some EU Member States Italy

In 2011, the EU applied its austerity-driven approach to Italy, only providing ECB-support against normal interest rates if severe cuts were made in the healthcare sector.Footnote 161 (Cf. Sect.

The Italian government implemented these EU imposed reductions, resulting in the closing of 15% of Italian hospitals in a mere decade. After this savings operation, Italy was left with 3.2 beds per 1000 inhabitants, while Germany still had 8 and France still 6. Since then, Italy spent less than USD 3500 per year per person on healthcare, to which the government contributed only about USD 2500, the lowest amount in Western Europe.Footnote 162

Zeilemaker has pointed out that, when, at the end of February 2020, Italy was as one of the first European countries faced with the outbreak of Covid-19 on its territory (cf. Sect., the country immediately asked the EU for support for its healthcare under the argument that this had been “over-rationalized” during the preceding years at EU insistence. No aid whatsoever followed. No European country responded by sending urgently needed medical equipment or medical staff. An explicit emergency call from the Italian ambassador to the EU remained completely ignored. Christine Lagarde, President of the European Central Bank, furthermore, refused to cut interest rates to help Italy; it was a statement that many Italians perceived as a sign of utter contempt. Neither the EU, nor other EU member states, showed any willingness to help Italy, although part of the problems the country was facing had been the direct result of EU policy. The Czech Republic and Poland even kept for themselves medical urgency equipment provided by Russia and destined for Italy. Germany, for its part, held back 800,000 face masks ordered by Italy in China for two weeks because of “customs control”.Footnote 163 Spain

In the recent past, also Spain had to commit to a severe EU imposed austerity program. (Cf. Sect. As a result, healthcare costs had to be decreased by 5.7% in 2012 alone. Spain thus became one of the four EU member countries that had to cut and privatize healthcare the most in the aftermath of the financial crisis of 2008. While at the beginning of 2020, the country spent on average, 3300 EUR per inhabitant on healthcare, that figure amounted to 6000 EUR in Germany. In Spain, 30.1 per 1000 inhabitants worked in medical facilities and hospitals; in Germany this number amounted to 71. And while Spain had 9.5 intensive care places per 100,000 inhabitants, in Germany there were about 34. Moreover, many of Spain’s retirement homes for the elderly had been privatized in the aftermath of the financial crisis of 2008, often falling into the hands of investment funds. Zeilemaker has illustrated the severity of this situation by pointing to the fact that when Covid-19 hit Spain in March 2020, most nursing home operators simply remained silent for weeks about the circumstances in these homes. When shortly after the military started disinfecting retirement homes, soldiers were reported to have found not only seriously ill people, but also dead people lying unattended in their beds.Footnote 164

We shall come back to this disaster in the Spanish nursing homes for the elderly in the next Chap. 6. (Cf. Sect. Greece

Obviously, Greece is known to have been among the countries hit the hardest by the financial crisis of 2008. According to Zeilemaker, Greece became because of this subject to a severe austerity program implemented by both the EU and the IMF, resulting in government contributions to the health sector being cut in half, from 16.2 billion EUR, to 8.6 billion EUR between 2009 and 2016. In this period, more than 13,000 physicians and more than 26,000 other healthcare workers were simply fired. 54 of the country’s 137 hospitals were closed, and the budget for the other hospitals was reduced by 40%. Between 2011 and 2016, on a population of 11 million Greeks, more than 3 million found themselves completely outside the scope of any health insurance protection. According to Zeilemaker, the message “Austerity kills,” was painted on a wall in the Athenian city centre. At a time when entrepreneurs still received substantial government support in Greece, workers and civil servants were asked to give up half of their wages.Footnote 165

Notwithstanding outstanding official figures on both the Covid-19 contamination and death cases, the real impact of Covid-19 in Greece remains unclear. Upon the arrival of Covid-19 in Greece, the country completely locked down, but testing in remained minimal because of a lack of testing material. Results were often delayed or simply not provided. It is therefore assumed that the official (and very low; cf. Sect. Covid-19 contamination numbers may be of a merely symbolic nature. In private clinics, on the other hand, there were enough Covid-19 tests available for those who could afford them. The Greek neoliberal government even made 30 million EUR available for testing in private hospitals alone. The same government also increased the reimbursement for the use of intensive care beds in private clinics from 800 to 1600 euros per day. In the meantime, state hospitals did not receive any testing material at all.Footnote 166 Germany

According to Zeilemaker, not only southern European countries suffer from a broken healthcare system. In Germany as well, trade unions, professionals and patient associations have been reporting nursing staff shortages going back to 2008. Against the background of a general decline in healthcare, nursing staff was believed to have been reduced by approximately 50,000 staff members. This also implied that the number of patients per care provider increased and working conditions deteriorated, all due to an increasing shortage of nurses. After the outbreak of Covid-19, Germany also faced a shortage of protective gear and testing equipment.Footnote 167 (Cf. Sect. Ireland

Zeilemaker, furthermore, pointed out that, under pressure from the same EU, also Ireland became the victim of severe cuts in healthcare during the past decade. In reaction to the Covid-19 outbreak, the Irish state simply decided to nationalize private clinics, following a similar example of Spain, in order to make sure that a minimum of healthcare would still be provided.Footnote 168 Belgium

Foulon has pointed to the fact that Belgium’s healthcare system has long been well regarded. However, based on several health indicators from 2015, this does not appear to be the case (anymore). According to Foulon, the statistics speak for themselves. E.g., mortality within 30 days of hospital admission after a heart attack or stroke is in Belgium above the European average. Belgium also has less than average nurses per hospitalized patient. Belgium is, moreover, characterized by a high rate of suicides and an alarming use of antidepressants, both factors indicating that the situation in Belgium is not as rosy as people are made to believe. Note a telling statistic: the average life expectancy at birth in Belgium is also below the European average.Footnote 169

Foulon has, furthermore, pointed to the fact that the proportion of care that patients have to pay themselves (= the so-called “patient contribution”) is in Belgium quite high compared to other European countries, while the intended health effect of this co-payment system, namely to reduce overconsumption, is small. According to Foulon, the latter is due to the overlooked fact that overconsumption often originates with the healthcare provider, and not with the patient. The Belgian healthcare system also lacks all openness about the quality of healthcare providers and hospitals to guide healthcare choices.Footnote 170

A recent element that has been detrimental in the development of European healthcare in general and the one of Belgium in particular, has been the rising costs. Both countries that based their healthcare system on private insurance, such as Switzerland, as countries which have resorted to collective health insurance and health insurance funds, such as Belgium, have been subjected to this increase. While this phenomenon is often attributed to the ageing population in European countries, this is only true to a limited extent. The real causes for the rising costs of healthcare all over Europe, are new treatments and the use of new medicines.Footnote 171 According to Foulon, also regarding drug pricing, there is a clear lack of transparency. E.g., pharmaceutical companies that bring a new drug to market can freely determine its price as long as the patent is running. The cost price of some innovative drugs is hereby in most cases not proportional to the development cost.Footnote 172

A further element of the Belgian situation that, still in the opinion of Foulon, needs to be reconsidered is how the government determines the budget reserved for healthcare. Often budgetary works start from the existing expenditure of preceding years to which 1% is simply added or subtracted. For Foulon, this system does not work properly. There should be an open societal debate about the size of this government budget, where the priorities should lie and where exactly savings can be made if necessary.Footnote 173 Some Specific Facts and Opinions on the Impact of the Austerity Policy in the Healthcare Sector of the United Kingdom, as Assessed by Viens

As reminded by Viens, neoliberal economic policy is based on the idea of perpetual economic growth,Footnote 174 implying that austerity measures resorted to in times of economic difficulty (mainly by cutting on social expenditure), are explained as a natural response that has to be put in place for the economy to recover. According to this author, this neoliberal viewpoint has been clearly showing in much of the policies of the Conservative government(s) in the United Kingdom during the past decade(s).Footnote 175

Still according to Viens, while the pervasiveness of the ideology of economic neoliberalism, as adhered to by the governments of many Western countries, makes a resort to austerity seem completely inevitable, it is nevertheless but a political choice guided by a given political morality, or, to phrase it in another manner, by a given ideology.Footnote 176 For Viens, the conclusion from this insight is clear: neoliberal austerity is a huge policy failure, and its consequences are totally morally reprehensible, especially because of its direct and indirect detrimental effects on a wide variety of social issues, amongst which health and health equity. This is, moreover, not only true in the United Kingdom itself, but for the whole capitalist world.Footnote 177

The pains caused by neoliberal austerity are, simply put, not distributed in a fair manner throughout society, and not even in such a manner that the burden of such austerity would fall mostly on those best able to bear it, namely the rich. Instead, in countries, such as the United Kingdom, that have suffered the most from the doctrines of economic neoliberalism during the past decades, it is precisely the economically and socially most deprived who have suffered the most. This happened after the financial crisis of 2008, but, as Viens shows, this kind of policymaking can be traced back much earlier in UK history, all the way back to the neoliberal governments of ThatcherFootnote 178 that had stifled economic growth, cut tax revenues (to the benefit of the rich), increased public deficits and, on health care, cut funding for the National Health Service.Footnote 179

Needless to say that, even before the outbreak of Covid-19, the impact of austerity in the United Kingdom on health and health equity has been devastating. According to Viens, the following effects, amongst others, of neoliberal healthcare policy have occurred: (1) mortality rates have risen (including so-called “preventable deaths”), (2) life expectancy has stagnated, (3) social and health care in general became grossly underfunded, (4) child and pensioner poverty has been dramatically on the rise, (5) the number of homeless people has increased dramatically, and (6) dependence on food banks has increased drastically.Footnote 180 Moreover, the effects of both past cuts in social expenditure and current public deficits continue to have a negative impact on health and well-being.Footnote 181

While the cuts in social expenditure are a clear illustration of the characteristics of the neoliberal determinants for health and health (in)equity, the neoliberal political approach in the United Kingdom, even beyond these cuts, has taken a significant and extremely worrying toll on the country’s health systems. Neoliberal agendas for cutting taxes (to the benefit of the rich) drive up public debt and deficits even further which, under the logic of economic neoliberalism, then justifies the need for more austerity, as well as the need for charging user fees (for public services that in the past were for free) or for the acceleration of privatization programmes, with the poor at the same time continuously being told that the United Kingdom can no longer afford health and social programmes. According to Viens these are all factors designed to strengthen the insidious political morality hidden under the ideology of economic neoliberalism.Footnote 182 Provisional Conclusions

It is clear from the foregoing that the catastrophic EU neoliberal austerity measures of the past decade have dangerously weakened healthcare in Europe. Even after the financial crisis of 2008, much to the surprise of a wide variety of academics and left-wing politicians who believed that the events of 2008 would make people think and look for other solutions than those presented by crisis-prone neoliberalism,Footnote 183 neoliberal policy has, regretfully, been further propagated.Footnote 184 Because of Covid-19, the populations of entire countries have now been able to experience how they are all paying the price for this politically and economically elitist and morally wrong socio-economic model;Footnote 185 perhaps this time, it will make people think if they still want to adhere to it.Footnote 186

Nevertheless, no matter how bad the crises caused by economic neoliberalism may become, there seems to remain great disinterest for socio-economic themes that among the populations of Western countries. Just as the 2008 financial crisis failed to bring about such a sufficient drive for change, it cannot be assumed that post Covid-19, the neoliberal socio-economic model will be sufficiently questioned.

We shall come back to this under Chap. 11.

5.2.2 Looking for an Equilibrium Between Marketization and Governance Aid in the United States Healthcare in the United States Before 2008

In the 1980s, one of the biggest, earliest exercises in implementing the ideology of economic neoliberalism concerned so-called “Reaganomics,” especially President Reagan’s 1981 “Program for Economic Recovery” and “the Economic Recovery Tax Act”. Under these socioeconomic policies, the Reagan administration reduced both government spending and regulation, while at the same time cutting taxes to the benefit of (big) corporations and the rich.Footnote 187

Since this early-day implementation of neoliberal policies as of the 1980s, one of the sectors affected most by neoliberal ideology has undoubtedly been the healthcare sector. More specifically, under Reagan-era policies, the US healthcare industry was largely marketized and partly privatized, and this is how it has remained ever since.Footnote 188

This marketization of healthcare in the United States was aimed at giving people the freedom for choosing their own physicians, while at the same time accomplishing shorter waiting times, as well as (purportedly) better health care facilities. In reality, marketized healthcare soon left 15% of the Americans without healthcare. It also resulted in higher costs for individuals and households and created huge inequalities between rich and poor regarding access and quality of health care.Footnote 189

According to some, since the Reagan era, the United States, has become of the few industrialized countries in the world that almost completely relies on private, largely investor-owned corporations for providing a wide variety of healthcare services. The United States, in this manner, became one of the first industrialized countries that started treating healthcare like any other free market commodity, instead of as a public or social service.Footnote 190 Through this, healthcare in the United States largely started functioning in accordance with free market principles.Footnote 191

As a first consequence of subjecting healthcare to Reaganomics, healthcare no longer got distributed in accordance with medical need, but rather in accordance with financial capability of the patient who moreover got gradually referred to as “the consumer of health care services”. This, obviously, created a fundamental mismatch between medical need on one side and actual access to and availability of medical treatment on the other side. This policy approach, moreover, implied that, in many cases, those with the greatest need of medical care were at the same time those least able to pay for it.Footnote 192

In the opinion of Sahoo, although free markets may be good for some things, they are not a good method for distributing healthcare. The simple truth is that businesses’ first aim is to increase revenues and maximize profits (to the benefit of their shareholders).Footnote 193 A symptom of this fact is that corporate hospitals in the United States, e.g., often advertise their services. This is not a coincidence, but rather because, like all businesses, corporatized hospitals want more, not fewer customers—but only if the latter can pay their increasing bills. According to this author, submitting healthcare to these principles has, obviously, resulted in a completely unfair—and even unethical—healthcare distribution: As an example the author points to the fact that, especially before the enactment of the ACA (cf. Sect., people who are wealthy, or well insured, are in the United States likely to get an MRI (i.e., a “Magnetic resonance imaging”) upon request, even if they do not need it, whereas those without money and insurance, are as likely not to get an MRI that they actually do need.Footnote 194

Since the United States first started to subject health care to free market methods, in practice, most Americans under 65 who have a (good) job (still) receive (tax-free) health insurance from their employers. Employers usually choose the insurance companies, as well as the health insurance programmes that will be provided to their employees. Employers usually have to pay a part of the insurance premiums. The employees (i.e., the insured) in most cases do not have much say in this, but are still expected to pay their own share of the premiums, based on a “take-it-or-leave-it” approach. Furthermore, offering such insurance benefits happens on a strictly voluntary basis as there is no legal duty to do so, as a further consequence of which not all employers want to commit to this “best practice”. When they do, benefits may in some cases be incomplete as employers want to keep the costs for insuring their personnel within (in their eyes) reasonable boundaries. One evolution in this regard has been that, in order to cut expenses, employers started capping the contributions that they are willing to pay themselves, implying that the burden of rising insurance costs in most cases falls on the employees themselves. The latter, in turn, may be inclined to turn down such health benefits in cases that they cannot afford to pay their own (increasing) part of the insurance premiums.Footnote 195

At the other side of the contractual spectrum, the private insurers with whom employers conclude insurance contracts are usually for-profit companies owned by private investors who are after a return on their investment. As private insurers try to keep premiums low and profits high by limiting risks, this business model may have serious detrimental effect on the access to medical services. In reality, the best way for private insurers to remain competitive on the private market, is to not insure high-risk patients. This practice of avoiding high-risk people as clients has been referred to as “cherry picking” or “cream skimming”, and is often rationalized by claiming that this is the only method for limiting the costs of insuring other illnesses. As a consequence, a lot of the insurance programs offered by employers to their employees exclude (rare) illnesses (both for the insured employee himself as for his dependents) for which the treatment requires expensive medical services, such as a bone marrow transplantation. Moreover, the whole insurance system, including the choice for the insurance programme actually offered, is in general based on marketing, bookkeeping and taxation practices, under which a substantial part of the actual costs for medical treatment is still passed on to patients under the form of deductibles, co-payments and denied claims.Footnote 196 This brought Angell to the observation that one even could have the impression that—certainly before the introduction of the ACA—the United States actually had/has a healthcare system based on avoiding that (too) sick people get access to it.Footnote 197

The American private insurance-based health care system also greatly increases administrative overhead costs, because a system based on private insurers requires a lot of paperwork between all contracting parties concerned. Private insurers also need creative marketing in order to select and attract the wealthy and healthy as their clients, and to avoid the poor and ill.Footnote 198 Medicare General Characteristics of Medicare

Before the presidency of Barack Obama, the best-known and probably most popular part of the American healthcare system has been the government-managed system for Americans over the age of 65 years, called “Medicare”.

On its own website,Footnote 199 Medicare is described as the federal health insurance programme for:

  1. (1)

    People who are 65 years of age or older.

  2. (2)

    Certain young people with disabilities.

  3. (3)

    People with End-Stage Renal Disease (i.e., permanent kidney failure requiring dialysis or organ transplantation, also known as “ESRD”).

When it was first installed, Medicare clearly answered a practical need: as explained in the previous Sect., for people under 65 who are still working, it is assumed that their employer will provide for an adequate private insurance. In this sense, Medicare was intended as an alternative system for people who are no longer working and in most cases are not sufficiently well-off to be able to finance private insurance themselves, while on the other hand, the age of 65 is the age from which medical care becomes increasingly necessary.

Although managed by the federal government, Medicare is still, in essence, a single-payer health coverage programme that is subjected to free market logic. It is at the same time considered to be one of the most efficient parts of the American healthcare system, with estimated government overhead of only about 2%. The system includes as good as everyone over the age of 65. It also grants everyone who subscribes to Medicare the full range of benefits offered, as the system cannot be manipulated to avoid the high-risk or chronically ill.Footnote 200 A Brief History of Medicare

In the United States, the discussion about installing a national health insurance programme open for all Americans already dates back to the presidency of Theodore (Teddy) Roosevelt. When Roosevelt, who had been president from 1901 until 1909, had again run for president in 1912, his election manifesto had included general health insurance. As Roosevelt did not get re-elected, the idea of a general, national health care program for all Americans would again be buried, until it would be picked up by President Harry S. Truman (president from 1945 until 1953).Footnote 201 More precisely, on 19 November 1945, just seven months into his presidency, President Truman sent a message to the American Congress in which he called for the creation of a national health insurance fund that would be open for all Americans. The plan that President Truman proposed was to provide health insurance for individuals and would cover all typical medical expenses, such as visits to or from physicians, hospital visits, laboratory services, dental care and nursing care.Footnote 202 Although Truman worked hard to pass a bill for implementing his plan during his time in office, he regretfully did not succeed.Footnote 203

President John F. Kennedy was the next president (from 1961 until 1963) to make his own failed attempt to establish a national health care programme, although his plan was less ambitious and remained limited to senior Americans. Kennedy launched this proposal after it had appeared from a national study that 56% of the American people over 65 had no health insurance at all.Footnote 204

But it was not before 1966 that Medicare finally took effect. This occurred after President Lyndon B. Johnson (1963–1969) on 30 July 1965 signed the “Medicare law” or “H.R. 6675”, in Independence, Missouri. During the signing ceremony, former President Truman was presented with the very first Medicare card, and his wife Bess with the second. In 1965, the first budget for Medicare amounted to approximately USD 10 billion.Footnote 205

Since then, of course, numerous changes have been made to Medicare.Footnote 206

The introduction in 1965 of Medicare (for elderly American residents) and Medicaid (for some low-income American residents) managed to reduce the percentage of uninsured people by about half. Despite initial expectations that a sequence of additional reforms to the Medicare law would gradually result in a real “universal health system” (UHC), the election of President Reagan in 1980 and the neoliberal agenda that his presidency pushed through, would completely destroy these hopes. Instead, Reagan’s health policy has even been qualified as foreshadowing the attempts of President Trump to completely privatise Medicare and Medicaid, cut services in low-income communities, and generally deregulate health and medical care provision. Under Reagan himself, a mix of government spending cuts and pro-free market policies was touted as the miracle cure for what was referred to as medical inflation. In reality, healthcare spending would increase during the Reagan presidency, with a variety of treatments becoming inaccessible for the poor, while the American health care system in general started at the same time to drastically diverge from that of other high-income countries that managed to uphold the principles of the welfare state model to a much larger extent.Footnote 207

President Clinton’s (1993–2001) attempt to expand health insurance coverage in 1994 again failed. This would stifle any further progress regarding the creation of a universal health care system, until the election of President Obama in 2008. Under Obama’s presidency, the Democrats finally succeeded, albeit only after fierce discussions in Congress and under harsh resistance from Republican legislators, in passing the so-called “ACA” (cf. Sect. 208

Over time, Medicare has proved successful and became one of the cornerstones of American health policy, while the main problem remained that it was only accessible to people aged 65 and older (in addition to certain other people with specific diseases or disabilities). Pleas for a universally accessible federal healthcare system have been made ever since, but this was met with stubborn resistance from conservative politicians (especially Republicans).

Nevertheless, at the beginning of 2019, it was reported that there were 60.6 million people receiving health coverage through Medicare. Medicare spending was reported to have amounted to USD 705.9 billion in 2017, which equalled about 20% of total healthcare spending in the United States in that year.Footnote 209 Although Medicare spending projections are said to fluctuate over time, in 2018, Medicare spending was projected to account for 18% of total federal spending in the year 2018, up from 15% in 2017.Footnote 210 Per capita Medicare spending was also reported to have grown, albeit at a much slower pace in recent years, averaging 1.5% between 2010 and 2017, as opposed to 7.3% between 2000 and 2007. This per capita spending was however expected to grow faster in the next decade, but not as fast as during the first decade of the twenty-first century.Footnote 211 In February 2019, there were approximately 60.6 million people enrolled under Medicare. This implied a huge increase compared to the year 2014, when fewer than 50 million people had been enrolled. One of the main reasons for this huge increase has been that people belonging to the baby boom-generation started to turn 65.Footnote 212

However, Medicare is by no means perfect and has, moreover, suffered from changes brought about by the Bush and Trump administrations. E.g., by 2008, out-of-pocket costs for Medicare beneficiaries were significant and still rising. In addition, because Medicare payments are made in a market-based private insurance system, it experiences many of the inflationary forces that affect private insurance in general. Regarding health insurances, these e.g. concern profit-maximising physicians working in (large, for-profit) hospitals or in physician groups. Moreover, physicians’ fees remain structured in such a manner that highly paid specialists are rewarded for performing as many expensive procedures as possible. Because of this, inflation endured by the Medicare system is said to be as high as other private insurance forms, and equally unsustainable.Footnote 213 Medicaid

Medicaid (“Title XIX of the Social Security Act”) was created in 1965, along with the Medicare programme (“Title XVIII”) itself, but with a different purpose.Footnote 214

On the one hand, the Medicare program was set up as a federally funded and managed health insurance program for retirees (i.e., people over the age of 65), disabled workers and their spouses and dependents. On the other hand, Medicaid was set up as a joint federal-state program through which states, the District of Columbia and the territories, have access to federal financial means intended for sharing the costs for providing health and long-term care services to low-income families and individuals that are federally eligible for this kind of support.Footnote 215 Medicaid was, phrased differently, intended to expand access to regular health care for low-income individuals and families. The underlying idea was that the federal government would grant money to states to cover half or more of the costs of providing medical and health care services to these eligible beneficiaries. The programme was at the same time designed to grant states considerable leeway in designing their more specific medical assistance programmes.Footnote 216 The Medicaid programme accomplishes these goals by combining federal mandates with options chosen by the states themselves as to who is eligible for receiving services and for defining what services can be offered.Footnote 217

Over the past decades, there have, obviously, been many changes to the Medicaid law as well. These include changes regarding eligibility, benefits, payment arrangements and a wide variety of other administrative details. The effect of these alterations—in combination with states’ own decisions about the scope of their programmes—has been that Medicaid got expanded beyond its original focus on providing primarily acute care services to those eligible for public assistance. As a result, Medicaid has also become the primary public funder of long-term care for people suffering from disabilities. Despite many such changes in the federal law, the fundamental organisational nature of the programme, namely its relationship between the federal government providing financial assistance and the states defining eligibility, has not changed substantially.Footnote 218

By September 2018, nearly 73 million people had been enrolled in Medicaid. By 2017, the programme was reported to account for 17% of national healthcare spending.Footnote 219 Medicaid hereby covers the most common forms of medical and health care. Medicaid is said to cover at least the same health care services as Medicare, besides some other services targeted at people suffering from disabilities that Medicare does not cover. Medicaid can also pay Medicare premiums, deductibles and co-payments for people who are enrolled under both programmes. A separate section of Medicaid covers long-term nursing home care. The income and asset rules for these long-term home care programs are usually more relaxed than those applying to regular Medicare programs.Footnote 220 Obamacare Enactment of the ACA/Obamacare

To address some of the major shortcomings of the American healthcare system, the Obama administration developed the so-called “Obamacare” legislation in 2010.Footnote 221 This led to the “Patient Protection and Affordable Care Act” (generally abbreviated as “ACA”) of 2010, commonly known as “Obamacare”, a federal law that aimed to (1) extend health coverage to most Americans, (2) reduce costs, and (3) improve the quality of already existing health care systems. As of 1 January 2014, most US citizens are required to have a basic level of health coverage under the said ACA.Footnote 222

The main goal of President Barack Obama’s reform initiative was to make healthcare more affordable for every American citizen, especially by reducing costs for those who could not afford them. A second goal of the ACA was to ensure universal access to medical care. Before the ACA, insurance companies could, e.g., exclude people with pre-existing medical conditions; the ACA aimed to end these exclusionary practices.Footnote 223 Also before the ACA, poor people—often those most in need of health care—sometimes had to abstain from getting insured, or settle for an insurance policy that did not cover a pre-existing medical condition. Because these people could in many cases not afford regular doctor’s visits as well, they often showed up in hospital emergency rooms and, in many cases, could not pay for the cost of the treatments they needed. In order to deal with this huge societal problem, the ACA required everyone to have health insurance, or pay a tax penalty. At the same time, the ACA aimed to make health insurance costs more affordable for people with low incomes, based upon programmes for subsidising these costs.Footnote 224 These subsidies were mainly made available through “premium tax credits” that reduced costs for households whose income ranged between 100% and 400% of the official federal poverty level.Footnote 225 One of the further objectives of the ACA was to curb the rising costs of health care in general.Footnote 226

Under the ACA, Medicaid was expanded to people earning up to 138% of the official federal poverty level.Footnote 227 However, by 2020, 14 states had chosen not to expand Medicaid, in this manner limiting access for their residents. These states were mostly Southern states.Footnote 228

In order to ensure that insurance companies could afford to grant insurance to people with pre-existing medical conditions, the ACA also aimed to ensure that healthy people would participate as well, by initially requiring everyone to take health insurance for at least nine of every 12 months, or, by means of a penalty for non-compliance, to face a tax (the so-called “mandate”). In this manner, it was ensured that the risk pools of the private insurers would be sufficiently diversified to amount to sound business models. However, in December 2017, the US Congress repealed this penalty, effective 2019, through the so-called “Tax Cuts and Jobs Act”. Although, since that time, the ACA mandate no longer applies, some other taxes related to Obamacare still remained in effect.Footnote 229 Although by repealing the mandate, the US Congress has cut one of the legs under the ACA, people can still benefit from the parts of the ACA that are still in force.Footnote 230 E.g., the so-called “health insurance exchanges”—considered of being the most important part of the ACA—have remained open for enrolment between 1 November and 15 December of each year.Footnote 231

Under the presidency of Donald Trump, the American Congress made some further major changes to Obamacare (or tried to do so). Still, the ACA is believed to stand strong.Footnote 232 Perhaps this is the reason why, in June 2020, the Trump administration requested the Supreme Court to simply overturn Obamacare. The Supreme Court’s decision on the matter was on 15 May 2021 not yet announced.Footnote 233 Main Impact of Obamacare on the US Healthcare System

The ACA is widely believed to have drastically changed the American healthcare system, especially by extending health insurance to 20 million Americans and in this manner having saved numerous lives.Footnote 234

Starting in 2010, the ACA led to one of the largest increases of health care coverage in American history. In 2010, 16% of all Americans were reported to be uninsured; in 2016, this number was already down to 9%. An estimated 20 million additional Americans are reported to have gained health insurance since the ACA went into effect. This, moreover, happened across all income levels and to the benefit of both children and adults. The ACA also reduced coverage disparities among racial and ethnic groups.Footnote 235

Two of the ACA’s largest coverage expansion provisions came into effect in 2014: the expansion of “Medicaid” on one side, and the launch of the “health insurance marketplaces for private coverage” on the other side. By 2020, these two programmes together were reported to cover tens of millions of Americans. In 2019, considered on a national level, 11.4 million people had enrolled in coverage plans through the ACA health insurance marketplaces. By 2020, the Medicaid expansion covered an additional 12.7 million people who had become eligible through the ACA for the first time.Footnote 236

The ACA also aimed at ending the practice of “medical underwriting”. This practice, that was common before the enactment of the ACA, implied that private insurers routinely set prices and insurance conditions regarding the exclusion of benefits, and denied coverage to people based on their health status. On a practical level, this had as a result that, to the extent that nearly one in two non-elderly adults in the United States suffers from a pre-existing medical condition, half of the adult population was discriminated against on the basis of their medical history if they sought insurance on their own.Footnote 237

Evidence has shown that better affordability has effectively translated into more and better access to medical care services. In short, according to Rapfogel et al., the ACA has ensured that millions of Americans obtained access to insurance coverage. This programme was not only lifesaving, but lifechanging for millions of people who were previously uninsured, had lower incomes, or had pre-existing medical conditions.Footnote 238

Yet major gaps in insurance coverage and access remained: at the time of Donald Trump’s election, 28 million people were still uninsured, a fact that has been held responsible for an estimated 37,000 premature deaths in 2017. Moreover, the ACA also failed to stop a growing trend of “underinsurance” (i.e., insurance coverage with such high cost-sharing conditions that enrolees are still unable to pay off medical care). As a result, in 2016, still more than one-third of adults under the age of 65 (including 25% of those insured) suffered problems with medical bills or medical debt, and a similar proportion of the American people reported waiving necessary medical care because of the costs involved. Meanwhile, bankruptcies due in whole, or in part, to illness remained commonplace even after the ACA had been implemented.Footnote 239 The General Outlook of the US Hospital Sector

In the 1980s, hospitals in the United States were still largely not-for-profit institutions that generally operate in accordance with a set of professional and ethical standards that restrict their behaviour for the benefit of patients.Footnote 240 The hospital sector in the United States had not yet been subject to an as far-reaching degree of “corporatisation” as the nursing home sector.

By 2021, most hospitals in the United States were still of a non-profit nature. Their (in most cases) tax-exempt status generally requires them to offer community-based health programmes, and to assist all patients, regardless of their financial status.Footnote 241 Of the approximately 5200 non-federal hospitals, about 3000 belong to this group of not-for-profit hospitals.Footnote 242 These non-profit hospitals mainly serve people who need ambulatory surgical care, inpatient surgery, or other usual hospital services.Footnote 243 The concentration of not-for-profit hospitals varies by geographic location. In general, there are more not-for-profit hospitals in the West, Northeast, Southwest and Midwest compared to the South. While for-profit hospitals have to put the interest of their shareholders and investors first, a not-for-profit institution can, by contrast, put the interests of its patients first.Footnote 244

The large number of not-for-profit hospitals, which are considered charitable by the IRS (under the condition that they meet the guidelines for non-profit organisations, such as providing certain benefits to the community), do not pay federal income tax or state and local property tax. Moreover, in keeping with their charitable purpose and community focus, non-profit hospitals are often affiliated with a particular religious denomination.Footnote 245 As one would expect, non-profit hospitals, on average, provide more unrelated care than for-profit hospitals. Contrary to what one might expect, however, for-profit hospitals also tend to serve lower-income populations, while not-for-profit hospitals tend to be located in communities with less poverty, higher incomes and fewer uninsured patients.Footnote 246

On the other hand, for-profit hospitals are more specialised in the latest medical technologies and are thus often better suited for advanced care. E.g., in Florida, Nevada and Texas, for-profit hospitals make up more than 50% of the facilities.Footnote 247 For-profit hospitals are usually owned by private investors or by a publicly traded company.Footnote 248 In many of these for-profit hospitals, private equity investors resort to economies of scale for increasing efficiency. This has led to corporate chains buying up multiple hospitals in order to consolidate back-office functions, such as sending out bills and accounting. On the downside, such investor-owned hospitals show a tendency of offering a narrower range of medical services and of sending patients with particular or complex medical needs to non-profit facilities that still provide such non-profitable care. E.g., many for-profit hospitals no longer offer neo-natal intensive care or perform organ transplants, as such services are too expensive and do not generate profits. Another problem reported regarding to for-profit hospitals is that they do not always succeed in attaining the level of required efficiency; in such cases, they will often simply dispose of facilities when these have become too leveraged without generating the aspired for profits. Fraudulent billing has been indicated as another major problem, as for-profit hospitals may try to make a profit by overbilling third payers such as Medicare or private insurers.Footnote 249 (Illegal) practices that have been reported in the past, include the systematic referral of patients with diseases that are not profitable enough, besides exploiting Medicare loopholes for making claims for unearned payments in the hundreds of millions.Footnote 250

Like all capitalist businesses, investor-owned hospitals, moreover, aim to maximise profits and minimise costs. However, such strategies that increase profitability often degrade efficiency and quality. In addition, managers of for-profit institutions in many cases are mostly concerned with reaping princely rewards, diverting money from healthcare services themselves. These huge CEO incomes explain part, but not all, of the high administrative costs which in investor-owned healthcare companies are usually much higher than in not-for-private institutions. This implies that investor-owned hospitals may spend much less on nursing than not-for-profit hospitals, while their administrative costs are generally higher (presumably due to their closer attention to financial details).Footnote 251

According to Woolhandler and Himmelstein, even for honest for-profit institutions, the careful selection of lucrative patients and medical services is the key to success, while meeting the general needs of the community may often pose a threat to profitability.Footnote 252 In recent years, encouraged by the ACA imposed shift to value-based purchasing, large health institutions have increasingly bought up independent hospitals and physician practices, in order to use their thus acquired monopoly power to negotiate higher service rates. However, as a result of such large mergers and acquisitions, hospital profits have risen, while the availability of primary care and other services has declined, promised quality improvements have not materialized, and overall patient experience has deteriorated.Footnote 253

In February 2021, investor-owned for-profit healthcare companies were reported to employ tens of thousands of doctors. The market share of for-profit hospitals, moreover, increased by 8 percentage points over the past 15 years. By February 2021, most outpatient haemodialysis centres, nursing homes, psychiatric inpatient facilities, health maintenance organisations, and even hospices in the United States were reported to be for-profit organisations.Footnote 254

Meanwhile, data on the clinical and cost implications of private investor ownership are worrying. E.g., mortality rates in for-profit dialysis facilities are reported to be higher than in not-for-profit facilities, with the differences implying that for-profit ownership is associated with up to 3800 additional deaths per year in the United States. Research also suggests that quality of care is, in general, inferior in for-profit nursing homes and home health agencies, and that for-profit hospitals still have a tendency of shunning unprofitable patients. Venture capital and private equity firms have been reported of forcing the dermatologists they employ to increase their income by promoting (unnecessary) cosmetic procedures, introducing billing practices that saddle emergency patients with huge and unexpected bills, and closing urban hospitals sitting on valuable real estate.Footnote 255 Further Decline of the Healthcare Sector Under President Donald Trump General Assessment of Trump’s Healthcare Policy

At the time of President Donald Trump’s inauguration, in January 2017, the health of the American population was reported to be in a downward spiral for the first time in almost a century. Average life expectancy in the United States had, more precisely, fallen from 78.9 years to 78.7 years between 2014 and 2018, a time period that included the first 3-year drop in life expectancy since World War I and the flu pandemic of 1918.Footnote 256 Health progress in the United States had thus stalled during the longest period of sustained economic expansion (i.e., between June 2009 and March 2020) in American history, which implied an unprecedented disconnect between the health of the general population and GDP growth.Footnote 257

For much of its history, the United States has been characterized by a far more even distribution of income and wealth than most of Europe. Since the 1980s, however, inequality between socioeconomic classes has widened, as high-paying manufacturing jobs disappeared in the wake of trade liberalization and the resulting delocalization of industries, trade unions had been stifled, and tax and social policies increasingly started favouring the rich to the detriment of the rest of society. Despite a booming stock market and low unemployment rates, many people in the United States were forced into meagre jobs with low pay and no or insufficient (health) benefits. The resulting income inequality, obviously, also increased inequality of access to health care.Footnote 258

Although in the opinion of Woolhandler et al., Donald Trump’s rise to power was driven by a mix of irrational tendencies appealing to man’s dark side, such as racism, nativism and fear of deprivation, his policies themselves were a well thought out, deliberate and intensified attack on both the health and general well-being of people in the United States and elsewhere. (Cf. Sect. 2.1.4.) In the best of neoliberal traditions, one of Trump’s most important legislative achievements, namely a trillion-dollar tax cut for the rich, caused a hole in the American public budget, that then served as a further argument for justifying the cutting in food and housing subsidies that had before in recent history been installed to prevent malnutrition and homelessness for millions of people throughout the United States; as a result, the number of homeless schoolchildren alone increased by 150,000 during the first year of Trump’s presidency.Footnote 259

Between 2002 and 2019, the share of spending on public health in the United States fell from 3.21% to 2.45% (which amounted to about half the share of public health spending in Canada or the United Kingdom). Meanwhile, funding for the “Public Health Emergency Preparedness Programme” (which has been indicated as the main source of federal support for public health emergency capacity at the state and local level) fell by a third. As a result of these funding shortfalls, state and local public health authorities lost 50,000 jobs, which represented a 20% reduction in the front-line workforce for combating epidemics.Footnote 260

Since 2003, the resources, but also the independence and the scientific authority of the Centers for Diseases Control and Prevention (CDC) have been gradually eroded, initially by the instalment of a business model and the resulting departure of experienced scientists from the agency, as well as by a 10% (inflation-adjusted) budget cut. A further recruitment freeze in 2017 simply left hundreds of CDC positions for researchers and officials vacant. In 2018, cutting measures deployed by Trump’s administration went as far as simply transferring the already partially depleted “Strategic National Stockpile” of drugs and medical supplies from the CDC, to the Office of an Assistant Secretary of the Department of Health and Human Services.Footnote 261

In the early years of Trump’s presidency, the public health emergency response capabilities of several other federal agencies were also drastically eroded. In 2018, e.g., the White House scrapped the National Security Council Directorate for Global Health Security and Biodefence, an agency that had been established as recently as 2014 in order to coordinate reactions to the Ebola virus and similar global disasters. Moreover, in 2019, almost half of all scientific leadership positions in federal agencies remained vacant. (Cf. Sect. 262

Access to medical care, which—as has been explained in the previous sections—has never been fully adequate in the United States in the first place, continued to shrink even more during the Trump administration. As a result, one million healthcare workers and a large (but undetermined) number of migrant workers at high risk of Covid-19 exposure, were un- or underinsured at the start of the Covid-19 pandemic in February 2020.Footnote 263

In 2017, the Trump administration also halted the Occupational Safety and Health Administration’s nearly completed effort to develop airborne infection control standards for workplaces, which were to be released in October 2017.Footnote 264

All of these problems caused by the policy of the Trump administration during the first years of Trump’s presidency, would be exacerbated even more by the Covid-19 pandemic. Woolhandler et al. have attributed this to the following factors:Footnote 265

  1. (1)

    An insufficiently coordinated federal leadership led to delayed or inconsistent guidelines for both national and local response.

  2. (2)

    Due to the dependence on free market forces for the supply of all essential equipment to both prevent (e.g., face masks and protective gear) and treat (e.g., respiration devices) Covid-19, states and hospitals had to compete with each other, and sometimes even with the federal government itself, for acquiring such material.

  3. (3)

    The Trump administration rejected test kits from the WHO in anticipation of the production of American tests. This obviously hampered both testing itself and testing capability. Other bottlenecks (e.g., insufficient capacity to carry out and analyse diagnostic tests) further delayed the policy response to Covid-19.

  4. (4)

    Public health authorities were continuously discredited by senior government officials, amongst which the president himself, leading to: (i.) an increasing disregard for scientific expertise, (ii.) misleading public communications, (iii.) official (i.e., originating from President Trump himself, and/or from the US Food and Drug Administration) approval of therapies without any proof of efficacy, (iv.) the promotion of unproven theories about Covid-19, and (v.) President Trump’s refusal to wear a face mask, engage in physical distancing or avoid mass meetings (cf. Sect. 2.5.).

  5. (5)

    In an unprecedented show of distrust for scientific advice, many states did not follow recommendations provided by the CDC and instead joined multi-state coalitions from April–May 2020 to actively proclaim policies to reopen the economy and schools.

  6. (6)

    Many people lost their health insurance due to the loss of jobs as a result of the Covid-19 pandemic.

  7. (7)

According to Woolhandler et al., the combination of these policy problems caused by the Trump administration and the structural inequalities of the American health care system, have caused that the death and the misery of Covid-19 has fallen most heavily on the following categories: people of colour, workers in low-paid jobs where physical distance was challenging, people in prison, and nursing home residents and others of poor health.Footnote 266

We shall come back to this in Sect. 5.3.2. ACA Under Trump Neoliberal Healthcare Policy of the Trump Administration in General

In 2014, a year before Donald Trump announced his presidential candidacy, one of the most important achievements of his predecessor Barack Obama, the ACA, had been successfully implemented.Footnote 267 (Cf. Sect. By the time Donald Trump became president in January 2017, as a result of the ACA, 20 million additional American residents had enlisted for new health coverage, although 28 million were still uninsured.Footnote 268

According to Woolhandler et al., it was against this backdrop that President Trump’s health care policy—in essence aimed at limiting health coverage—may at first glance seem like an aberration, more precisely as a diversion from the path to greater health protection. However, still in the opinion of Woolhandler et al., the truth is more complicated: Although Trump’s policies vary from those of several previous administrations, they have in essence picked up with the neoliberal traditions of deregulation, privatisation and austerity (for low-income communities) that had already been established as of the 1980s.Footnote 269 President Donald Trump’s efforts to reform the health sector are, therefore, much closer to the ideological underpinnings of President Ronald Reagan’s neoliberal policies of the 1980s, than to the continuation of the efforts of predecessors, such as Presidents Bill Clinton and Barack Obama, to establish universal health coverage. Attempts to Repeal the ACA

The debate over abandoning the ACA had already been ongoing before President Trump’s inauguration.Footnote 270 The ACA had, more precisely, never been taken for granted by right-wing elements of the American society. Going back to the architects of American neoliberal thinking, the idea of a universal, public healthcare system was by some even considered an aberration: Under their ideology—and even general life philosophy—everyone must take care of himself, also regarding matters of healthcare (e.g., by resorting to private health insurance, instead of depending on publicly installed health insurance systems). This had, for instance, been the popular line of thought of Ayn Rand, whose influence on the public policy of the Reagan administration had been huge. (Cf. Sect. 2.5.2.) Rand was, in general, completely opposed to the idea of a public insurance system, even though, when she suffered from cancer at a late age because of years of heavy chain smoking, she still approached the public health services herself in order to have her medical treatment financed.Footnote 271

In the assessment of Jones on this apparent contradiction between Rand’s teachings and her actions:Footnote 272

In the simplest terms, Rand discovered at the end of her life that she was only human and in need of help. Rather than starve or drop dead — as she would have let so many others do — she took the help on offer. Rand died in 1982, as her admirer Alan Greenspan had begun putting her ideas into practice in Reagan’s administration, making sure (…) that the system was “more favorable to the creators and entrepreneurs who were more valuable to society,” in his Randian estimation, “than people lower down the ladder of success.” After well over three decades of such policies, we can draw our own conclusions about the results.

But for right-wing America, these were just details that hardly stood in the way of their ongoing aversion to public service systems in general, and public health systems specifically. This aversion to public health insurance focused particularly on the ACA, which to many Republicans had become the nexus of everything that went wrong in the United States. Hence, it is no surprise that, already before the presidency of Donald Trump, US Republicans had repeatedly introduced bills to repeal the ACA, even dating back to President Obama’s own time in office, although the assurance of a veto from the part of President Obama had rendered these past initiatives purely symbolic. It was against this background that (the proposal for) the “American Healthcare Act” (abbreviated as “AHCA”) which the Republicans initiated in March 2017, for the first time posed a real threat to the efforts previously made towards a universal healthcare coverage. E.g., if the AHCA would have become law, it would especially have reduced federal Medicaid expenditure by USD 839 billion over the period of one decade, slashed subsidies to low-income households and individuals for acquiring private insurance, and decreased protections for people with pre-existing medical conditions.Footnote 273 The “Congressional Budget Office” (abbreviated as “CBO”) at the time made an estimation that the enactment of the AHCA would nearly have doubled the number of people without health insurance.Footnote 274

In May 2017, the AHCA successfully passed the American House of Representatives. However, its counterpart bill was defeated by narrow margins in the US Senate after a last-minute defection by some Republican senators. This defection was inspired by the bill’s unpopularity among the American people (as it, e.g., had appeared from a poll that only 17% of the American population was in support of the AHCA), in addition to a wave of “grassroot” opposition: in one dramatic moment, disabled activists had to be dragged out of the offices of Republican members of Congress while still in their wheelchairs.Footnote 275

After the AHCA had failed, the Republicans abandoned their attempts to reform the American healthcare system through one sweeping piece of legislation. Instead, they started resorting to executive action and to small legislative steps with the overall intent of gradually weakening the ACA and bringing forward a more free market-oriented view on healthcare issues.Footnote 276

In 2016, then-presidential candidate Donald Trump had conducted his electoral campaign on a promise that, if elected, he would already start repealing the ACA on his first day in office.Footnote 277 Therefore, on 20 January 2017, the day President Donald Trump effectively took office, he signed his first of several presidential, executive ordersFootnote 278 on health care financing (cf. Table 5.2). This concerned “Executive Order 13,765”, entitled “Minimizing the Economic Burden of the Patient Protection and Affordable Care Act Pending Repeal” a title that clearly made reference to the president’s campaign promises. It was, moreover, the first executive order signed by Trump in his capacity of American president, a fact that further underlined the symbolic importance of the measure. The presidential order not only confirmed the Trump administration’s persistent intention to repeal the ACA,Footnote 279 but, in addition, gave the head of the US Department of Health and Human Services (abbreviated as “HHS”), besides the heads of several other federal agencies, broad powers to grant waivers, deferrals and/or exemptions, all with the overall attempt to delay parts of the ACA that could result in what the Trump administration referred to as “fiscal or regulatory burdens on individuals, providers or government entities”.Footnote 280 The presidential order confirmed Trump’s intent to simply disregard parts of the ACA until it would no longer be law, while at the same time looking ahead to a “free and open market in (…) health care services and health insurance”.Footnote 281

Table 5.2 Examples of executive orders and actions on health-care financing during the Trump era [Source: Woolhandler et al. (2021), p. 726]

Already in the same year 2017, the Trump administration abruptly put an end to the funding of governmental advertising that encouraged the general public to enrol in ACA programmes.Footnote 282 Starting in 2017, Trump also began subjecting the ACA to relentless—and often factually incorrect—rhetorical downsizing. Woolhandler et al., even made the observation that, during the period from January 2017 until April 2019, President Trump made 662 misleading or outright false statements about the American healthcare system, nearly half of which concerned downsizing the stability of the ACA and/or the need for repealing it as soon as possible.Footnote 283 President Trump additionally shortened the length of enrolment periods for ACA insurance during the years 2017–2018. The president also cut funding for so-called “navigators” (i.e., agencies that assist individuals in navigating the ACA’s complicated enrolment process).Footnote 284

Another central executive order by which President Trump aimed to further “marketize” health insurance coverage concerned the Presidential Executive Order 13,813, which was signed on October 12, 2017.Footnote 285 With this directive to federal agencies that only counted approximately 1100 words, President Trump laid the groundwork for a growing collection of health insurance products, primarily (1) comprehensive plans to be offered through small employer associations, besides (2) a greater reliance on the use of short-term medical coverage. This presidential order was the first attempt since efforts to repeal the ACA had failed in the American Congress, that Trump undertook for implementing his vision on how to rebuild the American health care system by resorting to executive presidential powers. Said Presidential Executive Order 13,813 immediately sparked a debate over whether the measure would fatally undermine the ACA’s marketplaces or imply welcome alternative choices for consumers who had complained about too high insurance premiums and too little choice.Footnote 286

Section 1(b) of Executive Order 13,813, furthermore, provided that of the myriad areas where the prevailing ACA regulations limited both choice and competition, the Trump administration would prioritize three areas for improvement in the near future: (1) association health plans (AHPs), (2) short-term limited-duration insurance (STLDI), and (3) health reimbursement plans (HRAs). Similarly, Executive Order 13,813 stated in its section 1(c) that the Trump administration would continue to focus on promoting competition in healthcare markets and on limiting excessive consolidation in the healthcare system.Footnote 287

One of the basic premises of Executive Order 13,813 was that individuals and small businesses would be allowed (and encouraged) to group together to insure themselves, or to buy a large group health insurance policy. Presumably, this would help small enterprises in overcoming a competitive disadvantage that the ACA had imposed on them, by allowing them to enhance the terms and conditions of their health insurance policies. The Executive Order was also aimed at helping small enterprises in circumventing certain burdensome ACA requirements. Most importantly, the Trump administration saw AHPs as a means of providing more affordable health insurance options for poor Americans, whereby these groups would be able to negotiate better health insurance terms because of a greater ability to spread risk and share administrative costs.Footnote 288

In practice, the Presidential Executive Order 13,813 implied that the Department could grant employers operating in the same industries more flexibility to offer group insurance to their collective employees across state lines, giving them access to a far wider range of insurance policies at lower rates.Footnote 289 Another practical implication of the Presidential Executive Order 13,813 was that, although short-term limited duration insurance (STLDI) was intended to function as transitional coverage—e.g., to the benefit of workers finding themselves between jobs—an increasing number of Americans simply began using this possibility as an alternative to traditional, long-term insurance products.Footnote 290 A final priority area outlined in the Presidential Executive Order 13,813 dealt with so-called Health Reimbursement Arrangements (HRAs). These HRAs were to be distinguished from Health Savings Accounts (HSAs), the latter indicating the most widely promoted products in conservative health policy circles. Basically a payment mechanism for health care, HRAs were in fact tax-advantaged accounts that offered employers an enormous degree of flexibility. In these HRAs, employers had the greatest possibilities for recovering healthcare costs, through a wide range of options, such as choosing eligible expenses, deciding whether or not funds could be carried over, and considering whether or not to fund the accounts in the first place. It was the Trump administration’s further intention to propose even more lenient regulations and/or to revise the manual on how to make it easier for employers to offer such HRAs to their employees.Footnote 291 One of the ultimate ideas behind this all was to expand on the ability for employers to simply give employees an amount of money through such HRAs in order to allow them to buy their own coverage on the market.Footnote 292

But while Presidential Executive Order 13,813 was in fact the Trump administration’s preliminary thinking document on expanding choice on the insurance market, a purportedly much more impactful action on the insurance marketplace was launched through a press release issued by the Department of Health and Human Services (HHS). The referred decision to immediately stop paying cost-sharing reductions (CSRs)Footnote 293 would not only have significant implications for the open enrolment period, but also for the wallets of some of the most vulnerable Americans.Footnote 294

In response to these measures, six renowned physician groups, including the American Academy of Family Physicians expressed their concerns that:Footnote 295

allowing insurers to sell narrow, low-cost health plans likely would cause significant economic harm to women and older, sicker Americans who stand to face higher-cost and fewer insurance options.

By contrast, many health insurers simply remained silent on the measures contained in the Executive Order 13,813. Only a small minority of health insures expressed their concern that the approach laid down in the Executive Order 13,813 could destabilise the whole market.Footnote 296

However, most of the changes brought along by the Presidential Executive Order 13,813 could only be made through further regulations decided upon by federal agencies for its implementation. This implementation process, which includes a period of consulting the public for comments, was expected to take months. This at the time implied that the Presidential Executive Order was unlikely to still affect insurance coverage for 2018, albeit it could lead to major changes as of 2019.Footnote 297

To undermine some of the ACA’s basic requirements that private insurers must cover essential benefits and enrol applicants regardless of health status, the Trump administration also widened certain loopholes that exempted some insurance plans from those rules. These “exempt plans” (cf. Table 5.2) allowed for the charging of lower premiums and for offering meagre coverage (e.g., excluding maternity care). These exempt plans tended to attract more healthy enrolees who expected to need little medical care, soon raising concerns that the exempt plans would ultimately pull such healthy enrolees away from the ACA marketplace, thus destabilising its risk pool. The Trump administration additionally tried to end payment schemes for compensating ACA marketplace insurers for the cost-sharing subsidies they had to offer to eligible low-income enrolees (a move that was however blocked by the courts). Meanwhile, the then Republican-controlled Congress eliminated the ACA penalty for remaining uninsured, i.e. the so-called “mandate”, the part of the legislation that also provided new tax breaks to high-income individuals and enterprises, including pharmaceutical companies.Footnote 298

Fortunately, the Trump administration’s various attacks on the ACA had less effect than had been feared when Trump had initiated his attempts of bringing the ACA down. E.g., the elimination of the individual mandate and the expanded availability of substandard, exempt insurance forms and plans did not end up luring a large amount of people away from the regular ACA marketplaces. This is probably because subsidies continued to make marketplace premiums sufficiently attractive. Nevertheless, all of these deregulatory actions revealed Trump’s underlying, neoliberal agenda of wanting to establish a transformation of healthcare into a free market commodity available to those who can afford the price for it, rather than at establishing a universal health care system, supported and funded by the entire American community, as some of Trump’s predecessors had pursued.Footnote 299

Table 5.2 gives an overview of some examples of executive orders and actions on health-care financing during the Trump era. Attacks of the Trump Administration on Medicaid

Unfortunately, Trump’s attempts to undermine Medicaid would prove to be far more consequential than his largely failed attempts to repeal the ACA.Footnote 300

In March 2017, government officials reportedly sent a letter to the country’s governors urging them to make alterations to Medicaid that previous governments had banned. These alterations included imposing new out-of-pocket costs for low-income enrolees, besides a requirement that adult enrolees, notwithstanding their disability, should perform work amounting to at least 80 h a month, or else actively seek employment.Footnote 301 In response to this letter by the Trump government, many states applied for and effectively obtained waivers under the Medicaid law, allowing them to implement these alterations. At the same time, however, the work-related requirements were blocked by the courts.Footnote 302

In the period before the Covid-19 pandemic, the Trump administration had already proposed to cut USD 920 billion from Medicaid over the decade to come. The Trump administration was also on the verge of imposing a series of onerous eligibility checks and tightened standards under which older working people with disabilities could still apply for Medicaid support. The Trump administration also hoped to replace indefinite federal funding commitments by far stricter block grants in some states.Footnote 303

During the first 3 years of Donald Trump’s presidency, the number of American residents without coverage increased by 2.3 million, mainly due to a reduction in the Medicaid coverage itself. The trend for coverage of children (<19 years) especially raised concern, to the extent that an additional number of 726,000 children had become uninsured. Even before the outbreak of the Covid-19 pandemic, the CBO had projected a steady increase in the number of uninsured Americans to 35 million by 2027. However, this projection did not consider the millions of Americans who lost their jobs and/or work-related coverage due to the Covid-19 pandemic itself. This implies that, since then, the exact extent of coverage loss has remained unknown.Footnote 304

It was, moreover, feared that even more people would lose their coverage if the US Supreme Court would decide to invalidate the ACA. In a former 2012 decision, the Supreme Court had upheld most of the ACA, reasoning that the US Congress’ constitutional power to tax also allowed it to impose tax-based fines for not purchasing insurance. However, after the US Congress had reduced this fine to USD 0, a federal court in Texas had ruled that the entire ACA was unconstitutional. The case was still on appeal to the US Supreme Court by 15 May 2021, with Trump’s Justice Department having jumped in to support the position of Texas.Footnote 305 Trump’s Healthcare Financing Vision and Some Further Implications of Trump’s Healthcare Marketization Efforts

The further healthcare reform plans of President Trump, as based upon a mixture of conservative and neoliberal ideas, were set out in a little-noticed October 2017 white paper that advocated “choice and competition in health-care markets”, rhetorical cover for a policy aimed at deregulation, privatization, marketization and commercialization of health services.Footnote 306

This White paper was intended to complement Trump’s healthcare budget proposal of 2017.Footnote 307

The White Paper focused on (1) Medicare reforms; (2) Medicaid reforms, and (3) FDA activities. The bulk of the reforms that were proposed in the white paper related to the Medicare and Medicaid programmes.Footnote 308

Regarding Medicare, the Trump administration’s proposals largely focused on (1) aiding beneficiaries who face high out-of-pocket costs, and (2) redirecting incentives to change prescription practices and reimbursement policies.Footnote 309

Trump’s White Paper also called on the government to expand the supply of physicians, hospitals and other healthcare providers, by deregulating the sector (e.g., by relaxing professional licensing standards). The White Paper similarly called for a far-reaching deregulation of the private insurance sector, under the assumption that the exorbitant cost of healthcare in the United Sates was mainly caused by state and federal government requirements (notably the ACA itself) that were criticized for forcing private insurers to provide excessively generous benefits (a neoliberal claim that was hard to comprehend by America’s more than 41 million uninsured residents). To combat this wasteful use of health care, the White Paper suggested to limit benefit packages, increase coverage rates, and encourage patients to seek cheaper providers.Footnote 310 President Trump also wanted to remove subsidies to health insurance companies for helping to pay the out-of-pocket costs of people on low incomes.Footnote 311 Without these subsidies, insurance markets would have quickly unravelled. Insurers responded by saying that these proposals would result in higher premiums and that they might pull out of the insurance exchange markets set up under the ACA if the subsidies were to be ended.Footnote 312

During the following years of Trump’s presidency, the Trump administration gradually advanced its free-market-based agenda, e.g., leading to attempts to use funds from the Veterans Health Administration (abbreviated as “VA”) for purchasing private care programmes for veterans and, even more strikingly, by continuing what has been referred to as “the creeping privatization” of Medicare that had already decades before been initiated by the Reagan administration (in an attempt to mirror British strategies of undermining Britain’s National Health Service, as these strategies had been deployed by Margaret Thatcher in the 1980s). In the end, many American government officials simply hoped to replace Medicare’s uniform benefit guarantee with a (far cheaper) system of vouchers that would allow older enrolees to shop around for private health insurance, with affluent seniors being able to top up their vouchers through their savings in order to buy broader coverage and preferential access to care.Footnote 313 (Cf. Sect., on the underlying ideological ideas that form the basis for such a voucher system.)

As damaging as Trump’s healthcare policies have been, Woolhandler et al., have, in light of the foregoing, assessed them as a merely more aggressive continuation of decades-old neoliberal tendencies towards deregulation and towards deploying free market-based alternatives for public services. Obviously, such a policy approach favours large private organisations and drives up costs for the consumers making use of these marketized services which, ultimately, benefits the shareholders of the private service providers.Footnote 314

To conclude this section, we refer to the following quote from the study from Woolhandler et al., of 2021, titled “Public policy and health in the Trump era”, who have summarized the legacy of the health care policy of the Trump administration in the following catching manner:Footnote 315

The Trump administration’s regulatory rollbacks have increased disease, injury, and death among workers in the USA.


Ironically, the negative effects of the Trump administration’s environmental and occupational rollbacks have taken their largest toll in states whose voters heavily supported President Trump in the 2016 election. By contrast, comparatively progressive states that have maintained robust state-level protections have lessened the effect the rollbacks have had on health (…).

The adverse health effects of the Trump administration’s deregulatory actions are concentrated in the states and demographic groups most affected by rollbacks in health insurance coverage. Therefore, these harms are compounding one another and are widening disparities in health by race, social class, and geography.

5.3 Impact of Covid-19

5.3.1 The EU: When the Free Market Becomes a Killing Machine—Part 1 The Devastating Impact of EU Neoliberal Austerity on Private Hospitals’ Lesser Use in Fighting Covid-19 ICU Beds Shortages and Their Causes

In light of the above, it is not surprising that when Covid-19 hit the European continent, one of the biggest problems the EU hospital sector immediately faced was a shortage of hospital beds in general, and of ICU beds more in particular.Footnote 316

This bed shortage had as one of its main causes the EU’s neoliberal austerity policy of recent years, which had, on average, forced the EU Member States to gradually reduce their number of hospital beds by one fifth, although there have been EU member countries in which the decrease of hospital beds has even been bigger.Footnote 317

Already in 2012, Rhodes et al., had warned that a shortage of critical care capacity in European hospitals was likely to occur in the near future in many countries.Footnote 318 These authors had also pointed out that more research on the topic was needed, as most countries were not even able to quantify the shortage problem accurately. The future increase in demand for care capacity predicted at the time was, according to said authors, to be attributed to a number of factors, including (1) significant alterations in the size and age of the European population, (2) an increasing prevalence of relevant comorbidities, and (3) changing perceptions of what critical care can provide.Footnote 319 The same authors had also pointed to the large differences between countries, from which they had drawn the conclusion—largely confirmed by the Covid-19 crisis itself—that the different levels of capacity between European countries were bound to have a major impact in practice, and thus presumably on health outcomes themselves. Based upon a more detailed comparison between Portugal and Germany, Rhodes et al., had considered it impossible that a same number of patients could be admitted to intensive care in Portugal, as in Germany. The implication was, therefore, that either patients in Portugal needing critical medical care would not be able to receive it, or that Germany was providing too much intensive care capacity to its population.Footnote 320

Secondly, under neoliberal impulses, especially private hospitals had started to prioritise the most “suitable” patients—by which is meant: the patients most likely to bring profits. This had led to a policy of prioritising chronic diseases and day surgery, rather than focusing on emergency care or intensive care units (ICUs). As a result, when the Covid-19 crisis hit in early 2020, the private hospital sector in particular faced a general shortage of hospital beds—especially ICUs—in large parts of Europe. And, as research has pointed out, increased hospital capacity (in beds, especially ICU beds, per 1000 people) was a crucial requisite for reducing the Covid-19 mortality rate.Footnote 321 This even went so far that private hospitals, which generally had fewer (ICU) beds than their public/non-profit counterparts, were in some countries practically useless for dealing with Covid-19.

Table 5.3 shows that, on a more global scale, at the time Covid-19 hit, the countries characterized by more inequity had, ceteris paribus, fewer beds per 1000 people. But, in the opinion of Assa, the correlation is neither perfect nor deterministic. E.g., while the United States and China showed similar average levels of inequality in the period from 2011 until 2018 (showing Gini coefficients of 41.2 and 40.1, respectively), China still had 4 beds per 1000 inhabitants, while the United States only had 2.9. Serbia and Russia qualified as being only slightly more equal (with Gini coefficients of around 39 for both), but still had 5.7 and 8.4 beds per 1000 inhabitants respectively. Japan and Korea, which had been the early epicentres of the Covid-19 pandemic, had since then coped very well with the Covid-19 crisis, most likely, at least in part, because they had 13.4 and 10.9 beds per 1000 inhabitants respectively. In other words, the latter two countries had three to four times more hospital capacity than the United States, despite the fact that their per capita income was about one third lower (even using PPPs).Footnote 322

Table 5.3 Some countries’ number of hospital beds compared to other data on 27 March 2020 [Source: Assa (2021)] Some Further Findings of the Corporate Europe Observatory

From a cross-country analysis that has been undertaken by the “United Nations Development Programme” (abbreviated as “UNDP”) in order to examine the impact of health care privatisation on Covid-19 and that has been quoted by the Corporate Europe Observatory, it appeared that a 10% increase in private health expenditure was associated with a 4.3% increase in Covid-19 incidence, and a 4.9% increase in Covid-19-related mortality. Phrased differently: greater privatisation of health care significantly increased the rates of Covid-19 prevalence and Covid-19 related mortality across countries. In the opinion of the Corporate Europe Observatory, this may be attributed to the fact that privatisation policies are more costly and deadly because of the long-term damage they can do to countries’ ability to cope with a rapidly spreading infectious disease, such as Covid-19.Footnote 323

The Corporate Europe Observatory has also described how, after the first wave of the Covid-19 territories had hit their territories in a disastrous manner, commentators from Italy and Spain started describing how badly privatization had affected their healthcare and long-term care systems, in this manner having contributed to the disastrous impact of Covid-19 in both countries.Footnote 324 In its January 2021 report, the Corporate Europe Observatory, e.g., quoted Professor Vittorio Agnoletto, who described private nursing homes being paid (apparently USD 150) by the region of Lombardy to take Covid-19 patients from its overwhelmed hospitals. As we shall see further in Chap. 6, the subsequent spread of the Covid-19 virus among the vulnerable elderly residents of these nursing homes would have a devastating impact.Footnote 325 As we shall also see in Chap. 6, similar practices of refusing admission elderly residents of nursing homes into hospitals because of a shortage of hospital beds, would be applied in Belgium about a month later. And also in Spain, over-crowded hospitals, confronted with a shortage of beds, were in a similar manner forced to turn away patients from nursing homes, and guidance was even issued by the government telling nursing homes not to refer residents with Covid-19 to hospital.Footnote 326

According to sources in the sector quoted by the Corporate Europe Observatory, there is much resistance to making the mortality figures in hospitals public, because there are large differences between hospitals and regions. In some hospitals, things are said to have gone seriously wrong, with many more deaths than one would normally have expected from Covid-19.Footnote 327

The Corporate Europe Observatory noted with some irony, that notwithstanding all neoliberal, ideological rhetoric that privatization and marketization would ease pressure on public budgets and deficits, the UEHP—a European lobby organization for private hospitals—had shortly before the outbreak of the Covid-19 pandemic started making claims that private hospitals should get more access to public money. These demands had been underpinned by the application to healthcare of certain principles on which the EU internal market is based, such as the non-discrimination principle. The effects of the Covid-19 crisis have even been used for adding to this argument.Footnote 328 Some Further Research Results on the Detrimental Impact of Neoliberal Policy

Several other authors have similarly pointed to the devastating impact of neoliberal policy in general, and neoliberal austerity more in particular, on the European health care sector.

In the opinion of Alfredo Saad-Filho, the Covid-19 pandemic struck Europe after four decades of economic neoliberalism had done its job of: (1) exhausting the EU state capacities for providing public services in the name of a presumed “superior efficiency” of the free market, (2) accomplishing a far-reaching degree of “deindustrialization” against the background of a far-reaching “globalisation” of production,Footnote 329 as a result of which everything useful for fighting a pandemic could no longer be produced in Europe itself, and (3) building a fragile financial framework that dominates the entire socio-economic order, while only being secured by “magical thinking” and state guarantees. This had, moreover, all happened in order to enhance the short-term profitability of the corporate sector for its rich shareholders.Footnote 330 On a practical level, this resulted into a disintegration of the world economy, which had reduced the richest and most uncompromising neoliberal economies (the United States and the United Kingdom, besides these of several other Western economies) to being unable to produce any useful material for fighting the Covid-19 pandemic themselves. This truth especially applied to: (1) face masks, (2) personal protective equipment (PPE) for the health personnel of hospitals and nursing homes, and (3) respirators to keep the hospitalised Covid-19 patients alive. Still in the opinion of Saad-Filho, these shortcomings were not so much the result of a lack of production capacity because of changing technologies, or because of China’s bigger trade capacity, but rather of deliberate neoliberal policies deployed by Western governments themselves: from universities, to laboratories, to industries, economic neoliberalism had actively caused and promoted the fragmentation and dismantling of a wide range of production facilities throughout the Western world. This had especially happened by submitting individual companies to the neoliberal doctrine that emphasises the making of short-term profits above both long-term planning and respect for any other societal values than money-earning itself.Footnote 331 As a further result, based upon neoliberal treaties and legislation that actively stimulated the free movement of capital and labour, many companies had simply moved their production capacity to territories where wages were lower and social requirements lesser.Footnote 332

According to Saad-Filho, these shortcomings of neoliberal economic theory were even more exacerbated by a deliberate destruction of the state’s planning capacity and the resulting incapability and unwillingness of Western neoliberal governments, at the outbreak of the Covid-19 pandemic, to use all necessary means to mobilise industry, labour and private capital in the general interest, ergo for fighting the pandemic by all possible means.Footnote 333 Still in the opinion of Saad-Filho, economic neoliberalism has in this manner appeared to have effectively eroded, fragmented and (partially) privatised health care systems throughout the Western world, while also having created a both precarious and impoverished working class that is deprived of all savings capacity. At the outbreak of the Covid-19 pandemic, working classes of neoliberalised countries were therefore extremely vulnerable to both disruptions in their earning capacity, as well as to health threats, because of a combination of: (1) low savings, (2) poor housing, (3) inadequate nutrition, (4) pre-existing diseases, and (5) working patterns and conditions incompatible with being able to conduct a healthy life. (Cf., furthermore, Sect. 7.11.1 and Chap. 10.) Meanwhile, the deliberate destruction of the trade union movement and the deliberate erosion of the once powerful social-democratic left, had at the same time stripped the working classes of political and socioeconomic protection. Still according to Saad-Filho, at the outbreak of the Covid-19 pandemic, these processes culminated in unseemly brawls to acquire the products still produced by (state-run) Chinese factories: under the leadership of Donald Trump, the United States acted like “a drunken gangster” in stealing face masks, protective gear and respiratory devices it could no longer produce or buy itself, and “insulting other countries for being too weak to do anything about it”.Footnote 334

Assa and Calderon’s research has, in addition, shown that the privatization and marketisation of health care (instead of investing in public health care) has significantly increased the prevalence and mortality of Covid-19 in all countries, even after eliminating the effect of other factors, such as income, urbanisation, demographic structure, exposure to globalisation and political system. According to said authors, these findings add to existing research that has pointed to the inadequacy of private health systems for tackling infectious diseases, such as tuberculosis, and—as of 2020—Covid-19 itself.Footnote 335 According to Assa and Calderon’s research, in particular the reduction in the number of hospital beds per 1000 people, which has been caused by neoliberal austerity policies, has proven crucial for the high Covid-19 morbidity rates in several countries, as understaffed hospitals lacking sufficient capacity were overwhelmed with workload, and infected patients urgently needed access to specific medical equipment and treatment that was simply not available.Footnote 336 Situation in Some European Countries Belgium

In January 2021, a study was published on Covid-19 mortality in the intensive care units of Belgian hospitals during the first wave of the Covid-19 pandemic. Said study appeared in a regional edition of the professional journal “The Lancet”. From this study, it became clear that there were huge differences between Belgian hospitals. In some hospitals, the death of a Covid-19 patient admitted to the hospital’s ICU department turned out to be almost three times more likely than average. By contrast, in other hospitals, this probability was almost two times less than average. Although the study did not actually focus on the differences between care institutions, the authors did refer to it explicitly in one paragraph and they themselves considered it an “important finding”. The average mortality rate in Belgian hospitals for Covid-19 nationally was 21.8%. This implies that on average one in five patients did not leave the Belgian hospitals alive.Footnote 337

According to Foulon, when the images of the Italian hospitals started to reach Belgium, it had been decided to do everything possible—even not to treat the elderly part of the population in hospitals—in order to avoid ending up in a similar situation. Hospital capacity was thus rapidly scaled up and emergency departments significantly expanded. But it soon became clear that a shortage of beds and respirators would not be the main problem for Belgian hospitals.Footnote 338 A lack of adequately trained staff due to years of unrelenting, neoliberal policy of cuts in healthcare posed a much greater bottleneck. When Covid-19 hit Belgium, both doctors and nursing staff had to give their best to keep the situation more or less manageable. Residential care centres (e.g., nursing homes for the elderly) were largely left on their own, while their residents were even being refused admittance to the hospitals in a systematic manner in order to keep a sufficient number of beds free for the rest of the Belgian population (cf. Sect., resulting in the needless deaths of thousands of elderly people who got locked up in nursing homes where there was a lack of professional supervision, expertise, resources and trained staff.Footnote 339

Foulon’s estimate is confirmed by figures published by the “Federal Healthcare Knowledge Centre”. According to a special report the latter Centre issued in 2020, the Belgian hospital landscape was then characterized by a large number of hospitals and hospital beds: While the OECD countries had an average of 3.7 acute beds per 1000 inhabitants, Belgium ranked sixth highest with 5 acute beds per 1000 inhabitants. Belgium moreover had 17.4 intensive care beds per 100,000 inhabitants, putting it on the fourth highest place (compared to an average for the OECD countries of 12 intensive care beds per 100,000 inhabitants). This number is important because the number of intensive care units has been one of the main bottlenecks for the treatment of the most severe Covid-19 patients in hospitals throughout the world. However, while beds were deemed to be sufficiently available, Belgium had only 11 practicing nurses per 1000 inhabitants. Albeit higher than the OECD average of 8.8 nurses per 1000 inhabitants, the Belgian number of Covid-19 patients per nurse in the ICU units of hospitals nevertheless appeared to be among the highest in Europe: In 2019, a Belgian nurse had to care for an average of 9.4 patients. From this, it appears that Belgium was facing a shortage of high-trained nurses in ICU units. Belgium also had relatively few doctors. The number of practicing physicians was 3.1 per 1000 population, compared to the OECD average of 3.5 physicians per 1000 population.Footnote 340

Consequently, the problem of Belgium was not so much a shortage of beds/rooms, but rather a shortage of medical staff capable of functioning within ICU-departments. This also explains why, at a given point, even personnel infected with Covid-19 were called to work anyway.

By July 2020, the NGO “Doctors Without Borders” (“Artsen zonder Grenzen”/“Médecins sans frontières”) released a staggering report entitled “Left to their Fates”Footnote 341 (quoted in more detail in Sect., dealing with the subject of the situation in the Belgian nursing homes during the first wave of the Covid-19 pandemic. For Foulon, this report shows “nail-bitingly” how the nursing home sector had been completely neglected during (the first wave of) the Covid-19 pandemic, with staff inadequately trained and prevention absent. In order to keep enough beds free for other categories of the Belgian population, the referral of elderly people to hospitals was curbed. Chaos reigned in many nursing homes. The lack of policy was reported as a complete lack of basic respect from policymakers for Belgium’s elderly population.Footnote 342

In the opinion of Foulon, the disaster that Belgium has been experiencing during the Covid-19 pandemic has mainly been the result of years of cuts in healthcare. As a result, hospitals got overburdened, and nurses and doctors physically exhausted. The Covid-19 pandemic has shown how weak Belgian society has become to protect its own people. The reason is clear: everything is driven by profit maximisation, shareholder value and austerity. According to Foulon, it is time to remember that running a society and its health sector is mainly about other values.Footnote 343 Italy

Italy’s capacity of acute care beds was already below the European average for years. Moreover, the number of acute beds per 1000 people had decreased even further, from 7 in 1990, to 2.6 in 2015, mainly due to EU austerity measures. Figures further show that, just before the outbreak of the Covid-19 pandemic, 68% of all acute hospital beds in Italy were “public”, 4% “private not-for-profit”, and 28% “private for profit”. For ICU beds in particular, the situation was even more disastrous: Of the 5300 ICU beds available in Italy, only 800 belonged to private hospitals. This implied that while private hospitals owned 30% of the total number of acute beds, they only owned 15% of the ICU beds. Consequently, the ability of private hospitals to contribute in the fight against Covid-19 has been minimal. Through the earlier American example, private hospitals had become accustomed to leaving these forms of non-profitable medical care in the hands of public hospitals.Footnote 344

At the beginning of March 2020, Lombardy—Italy’s richest region—was all over the world news, allowing everyone on the planet to witness the disastrous impact of the Italian first wave of the Covid-19 pandemic, with hospitals overflowing, the army being mobilized to collect dead bodies from hospitals, and medical staff describing the situation in Lombardy as akin to “a world war”. (Cf. Sect. In April 2020, Italian doctors interviewed mainly blamed the Italian healthcare system “in which private and public clinics compete(d) for taxpayers’ money”.Footnote 345

According to the Corporate Europe Observatory, the situation of the Italian hospitals at the beginning of the Covid-19 outbreak could be described as follows:Footnote 346

The system in place when COVID-19 hit was “skewed in favour of the private sector” as patients were eligible for care in either private or public facilities, giving private clinics the best of both worlds, receiving both insured and uninsured patients, “foisting the burden of the free treatments on the taxpayer, at a higher cost”. As a result, privatisation had boomed: the share of public funds captured by private facilities jumped from 30 per cent to 50 per cent between 2010 and 2020.

Over the same period public facilities waned, even as they were forced to compete for public funds against private “rivals that offered ‘customer first’ patient experiences – better bedlinen, better food, more in-ward entertainment – over the less market-friendly considerations of community healthcare”. Community healthcare, which plays a crucial role in an epidemic and helps to keep people out of hospital, was depleted by “years of ‘patient-focused’ care” that made trips to hospital the go-to whatever the illness. When COVID-19 hit, this enabled its rapid spread through hospitals which, soon overwhelmed thanks to a reduced number of beds, sent symptomatic people home to spread the virus further, and even discharged COVID-19 patients to elderly care homes, with devastating results (…).

One academic described what happened in Lombardy as “the logical endpoint of a system” which had allowed profit “incentives to distort healthcare priorities over a long period of time”.

Commentators in Italy have condemned Lombardy’s health system for putting “profit over prevention”, and transforming “health into a commodity”. As the New Statesman investigation concluded: “preparing for a pandemic involves spending money in the hope that it is not needed. This is something that only the public sector, freed from the motive of profit, can accomplish”.

Italian health care policy in force when Covid-19 struck Italy, was predominantly in favour of the private sector. As a result, the privatization of the hospital sector was on the rise. Between 2010 and 2020, the share of public funds that went to private institutions had increased from 30% to 50%, although the number of private institutions was much smaller than the number of non-private hospitals.Footnote 347 This was a clear indication that Italy was going through efforts to privatise its health care (as had been mandated by the ECB itself; cf. Sect. During the same period, the share of public health care facilities was gradually decreasing, amongst others, because they had to compete for public funds with private rivals that offered the patient a “customer-oriented” experience, based on purportedly better bedding and food, besides more entertainment in the facility, rather than on the less consumer-friendly accommodations with which community health care was associated. Community health care, which is vital for fighting a pandemic and for keeping people out of hospitals, had thus been completely depleted by years of “patient-centred” care, as a result of which, regardless of the disease, admittance into a hospital had become the general practice in the region. When Covid-19 struck, a mentality of going immediately to a hospital prevailed. It is believed that this has contributed to the extremely rapid spread of Covid-19 originating from hospitals which, overwhelmed by the numbers of Covid-19 cases while at the same time facing a shortage of hospital beds, began to send even symptomatic patients home, where they could further spread the Covid-19 virus, and even (as would happen in Belgium less than a month later) started to discharge Covid-19 patients to elderly rest homes, all adding to a crushing spread of the Covid-19 virus.Footnote 348

The catastrophe that occurred in Lombardy in March 2020 has since been described as the logical end point of a (neoliberal) system that had allowed profit to distort healthcare priorities for too long. Several commentators in Italy, hence, condemned the Lombardy healthcare system for having put “profit before prevention”, and for having turned “health [into] a commodity”, all practices that, for decades, had been prescribed by neoliberal doctrine and imposed through EU austerity measures.Footnote 349

By March 2020, the disastrous consequences of Italy’s adaptation to economic neoliberalism (cf. especially Sect., in which it has been described how Italy was forced to “rationalise” its hospital sector as of 2011) had, hence, become clear for the whole world to witness.

During the second wave of the Covid-19 pandemic, the infectious diseases department of Milan’s Sacco hospital again warned that the situation was once more “largely uncontrollable”. Italy’s National Association of Internal Medicine at the time stated that Italian hospitals in the worst affected northern part of the country were, once again, on the verge of collapse due to the number of Covid-19 patients being admitted. In an open letter published by Italy’s ANSA news agency, the association declared that hospitals were still confronted with medical staff shortages and a lack of beds “in the face of an abnormal influx of patients due to the rapid and staggering spread” of Covid-19.Footnote 350 Spain

From a recent survey regarding Madrid, undertaken just before the Covid-19 outbreak and referred to by the Corporate Europe Observatory, it had appeared that the workload of nurses employed in private health care was substantially higher than that of nurses employed in public facilities, with nurses employed in private hospitals treating an average of five more patients per day. By contrast, salaries in the private sector were 20–25% lower. Moreover, 82% of the nurses employed in private hospitals and other healthcare centres were of the opinion that their complement of medical staff was insufficient to still perform a quality job. Amnesty International was quoted by the same Corporate Europe Observatory describing how a decade of austerity policies (introduced in part to comply with EU fiscal rules; cf. Sect. had led to a decrease of public spending on healthcare by 11.2% between 2009 and 2018, even as Spain’s GDP had grown by 8.6%.Footnote 351

When Covid-19 struck Spain, primary care services were soon overstretched. They appeared to be both understaffed and underfunded, which left health workers with an impossible workload, personal risks, fatigue, and stress. In the assessment of the Spanish anti-privatisation movement “Coordinadora Antiprivatización de la Sanidad”, the lack of investment in public health services had been to the benefit of private pockets: two out of every ten euros spent on health care in Spain was said to go to public-private partnerships.Footnote 352 The United Kingdom

A similar disaster scenario occurred in hospitals throughout the United Kingdom.Footnote 353

According to data provided by the NHS, as quoted and interpreted by Campbell and Barr, in England, more than 40,600 people have in the course of 2020 been likely infected with Covid-19 while being treated in hospital for another reason, raising concerns about the NHS’s inability to protect them. In one in five UK hospitals, at least a fifth of all patients diagnosed with the Covid-19 virus, had caught it while being an inpatient in a hospital. The North Devon district hospital in Barnstaple was reported for having the highest rate of such cases among acute trusts in England, at 31%. The NHS England figures, furthermore, revealed stark regional differences in patients’ risk of catching the Covid-19 virus during their stay in hospital. Just under a fifth (19%) of those in hospital in the north-west of the country had become infected while an inpatient, almost double the 11% rate in London hospitals. “Hull University teaching hospitals trust” and “Lancashire teaching hospitals trust” had the joint second highest rate of patients—28%—who had become infected while inpatients under their care. The former has had 626 such cases, while the latter has had 486. However, the big differences in hospitals’ size and the number of patients they admitted, implied that the rate of hospital-acquired infection was a more accurate reflection of the success of their efforts to stop transmission of the potentially lethal virus. The trusts with the next highest rates were Stockport (28%—386 cases), Brighton (367 cases—27%) and James Paget in Norfolk (27%—319 cases). At least one in four of all inpatients having contracted the Covid-19 virus in hospital became infected at 10 of England’s 127 acute trusts.Footnote 354

Across England as a whole, one in seven (15%) of all patients treated for the Covid-19 virus between August 2020 and March 2021, got it while in hospital. Data showed that hospitals in England estimated that a total of 40,670 people probably caught Covid-19 while in hospital under their care during that time. Both physicians and hospitals suspected that many of the infections were caused by the NHS’s lack of beds and limitations posed by some hospitals simply being old, cramped and poorly ventilated, as well as health service bosses’ decisions that hospitals should keep providing normal care, while the second wave of Covid-19 was unfolding, despite the potential danger to those inpatients receiving non-Covid-19 care. NHS England did not publish figures showing how many of those deemed likely to have caught Covid-19 as a hospital inpatient later died. But experts in hospital-acquired infections pointed out that many of those being admitted for other reasons—such as an operation, or after a fall or flare-up of an existing medical problem—were frail and vulnerable and had underlying poor health, so would have been more likely to die if they did get Covid-19. Dr. Rob Harwood, at the time chair of the British Medical Association’s consultants committee, commented on this as follows:Footnote 355

The NHS went into the current pandemic underfunded, understaffed and overstretched. The knock-on effects – particularly limited bed and workforce capacity – has unfortunately meant that controlling the spread of Covid-19 within hospitals has been more difficult than necessary.

What Dr. Harwood has in fact pointed out is that decades of neoliberal austerity in healthcare has come at the expense of quality in healthcare, rendering the UK health care industry unable to cope with the outbreak of a pandemic. The neoliberal EU and UK policymakers are in this manner responsible for tens of thousands of sick people and who knows how many additional deaths. The question arises whether this is of any real concern to them, as austerity targets (both in the United Kingdom and the EU) continue to prevail over any other socio-economic value.

Again during the second wave of the Covid-19 pandemic, UK hospitals were once more embattled by surging cases. In the Midlands of England, hospitals were near capacity with little wiggle room left. Coventry’s University Hospital, e.g., had to operate at 96–98% capacity as it battled the second wave of Covid-19.Footnote 356

5.3.2 The United States Introduction

Already from the early start of the Covid-19 outbreak on American soil, it appeared that a prolonged underfunding of federal, state and local public health agencies had left the American health sector ill-prepared for the challenges Covid-19 imposed, the first evidence of this being the occurrence of a complete Covid-19 testing fiasco.Footnote 357 (Cf. Sect.

A second problem the United States faced upon the outbreak of Covid-19 on American soil, concerned a lack of (ICU) bed availability. The problem the United States faced did not concern capacity as such. Indeed, while the American overall hospital bed coverage was at the moment of the Covid-19 outbreak relatively low, its ICU bed supply per capita still ranked among the highest in the world.Footnote 358 However, those (ICU) beds were often not where they needed to be: already from a study that had been published in the “Journal of American Medical Association” of 2010, it had appeared that the United States was characterized by large regional disparities regarding the availability and distribution of ICU beds. Already then, there had been warnings that in the face of a major epidemic, some areas might end up with empty beds, while others would have too few ICU beds available. In line with the general characteristics of the American healthcare system (cf. Sect. 2.1.4.), these discrepancies in distribution were, moreover, far too often driven by market logic, rather than by health needs.Footnote 359 From another study of 2012, it had, moreover, appeared that the future provision of critical (ICU) care in the United States was unlikely to be able to meet the estimated demands.Footnote 360

Thirdly, soon after the Covid-19 hit the United States, it appeared to what extent healthcare in the country was both uncoordinated and ungoverned. E.g., from the early beginning of the Covid-19 epidemic, hospitals and city and state governments started waging bidding wars over crucial supplies and ventilators. It was, basically and in best neoliberal tradition, every hospital and/or city for itself: Some started making pleas to the community for donations of masks; while, presumably, others were well-stocked. The already above (cf. Sect. quoted advice that US President Donald Trump gave to state governors at the time speaks volumes:Footnote 361

Respirators, ventilators, all of the equipment – try getting it yourselves.

Further difficulties in responding adequately to Covid-19 have been attributed to two further main characteristics of the American health insurance system.

A first and more general problem the American health care system was facing, concerned the extremely low level of social and health care protection for the working classes. The quality of life of the American working classes in general had deteriorated enormously during the preceding decades as a result of an increase in what has been referred to as “precariousness” characterizing the American labour market. This, in its own turn, had subjected many working class people to a need to have multiple jobs in order to still have a decent income.Footnote 362 This, obviously, had a negative impact on overall health, directly attributable to decades of neoliberal policymaking.

According to a study by the “Brookings Institution” that was published in 2019, 44% of workers in the United States (i.e., a percentage equalling more than 53 million employees) were reported of having (too) low salaries. The average salary amounted to less than USD 18,000 per year. The report, therefore, concluded that almost half of US workers earned a salary that is insufficient to provide socioeconomic security. This percentage of underpaid working people had, moreover, risen significantly under the presidency of Donald Trump. These underpaid employees in most cases also lack decent social security. A key indicator of the scarcity of social protection in the United States is that most workers have no sick leave, implying that if they are unable to work due to illness, they do not receive an alternative income or financial assistance—whether private (i.e., provided by their employer or by a private insurer) or public (out of social security money). This finding is more than a mere academic observation, as it has been one of the main reasons for the huge spread of the Covid-19 virus in the United States. This characteristic of the American labour market, more precisely, explains why, after the Covid-19 virus had struck on American soil, workers who tested positive for the virus and/or started exhibiting Covid-19-related symptoms, were in many cases themselves among those most resistant to stop working, or to take some time off, as this would have halted their income.Footnote 363 This also helps to explain why many individuals belonging to the working classes who became ill with Covid-19, in the United States simply continued to work, in this manner infecting others and contributing to the spread of the Covid-19 virus.Footnote 364

A second, even more dramatic aspect of the scarcity of social protection in the United States at the moment when Covid-19 hit, was that large parts of the American population still did not have access to health care insurance, and through this, to affordable health care itself. Even years after the ACA had entered into force (cf. Sect., almost 30 million adult people in the United States still had no health insurance at all, and another 27 million only had an extremely inadequate health insurance coverage. Navarro attributes this to the fact that the United States has no universal health care coverage system that would have guaranteed such a universal access as a matter of civil rights. By contrast, most health care for working adults in the United States was still based on private insurance, with a view on health care as a free market commodity, an approach that under Trump’s presidency had even expanded more in line with neoliberal ideology (cf. Sect. 365

A third factor that was as good as unique to the United States (in addition to, e.g., Brazil) and that has stood in the way of an adequate response to the Covid-19 outbreak was the strategy deployed by President Donald Trump’s administration of simply denying that there was a health problem going on, and of accusing the Democratic Party of having fabricated a non-existent epidemic (a so-called “hoax”), with Trump himself usually dismissing it as “fake news”.Footnote 366 At the beginning of the outbreak of Covid-19 on American soil, the Trump administration had even seen fit to order the CDC (whose yearly budget had only shortly before been cut by 18%Footnote 367) to prohibit Covid-19 testing by any entity other than the CDC itself. This policy has, obviously, kept the number of Covid-19 tests, and hence the number of registered Covid-19 contamination cases itself, to a bare minimum: between 3 January and 11 March 2020, the period during which the Covid-19 virus rapidly spread all over the United States, only 26 tests per one million population had been conducted in the United States, while, by contrast, South Korea had conducted 4000 tests per one million population during the same period.Footnote 368 Still, notwithstanding this initially deployed strategy of denial, the high level of public unrest in the United States that was brought along by Covid-19, would ultimately force even President Donald Trump to acknowledge that the Covid-19 pandemic did indeed exist, although it is assumed that he recognised this fact more because of the extreme drop in stock market prices, than because of the increased suffering of the American population itself.Footnote 369 Shortages

It has already been pointed out in Chap. 2 how the complete lack of preparedness of the (neoliberal) Western world in general, and of the United States more specifically, to properly respond to the outbreak of a virus-based pandemic, among others, appeared from the American (and Western) health sector’s strict adjustment to contemporary capitalism’s “long-chain” and “just-in-time” delivery systems, developing a preference for reduced storage regarding all possible medical equipment and protective gear.Footnote 370 In a similar sense, a “buy-from-the-cheapest-source” mentality had become globalized,Footnote 371 leading to a diminished manufacturing capacity in the Northern hemisphere during the latter half of the twentieth century. In many cases this implied sole dependence on a few (foreign) suppliers, often located on the other side of the world. This was especially true for the American markets, as many of these supply systems had been conceived in the United States itself, in the context of neoliberal economic doctrines that generally favour extreme short-term strategies (aimed at increasing corporate profits by cutting on all kinds of costs) over any form of long or medium-term planning.

Hence, it should by no means come as a surprise that immediately after the outbreak of Covid-19 on US soil, the hospital sector—having no stock of medical gear and equipment themselves, nor having access to suppliers who would have had such stock—started facing serious challenges,Footnote 372 such as:

  1. (1)

    Shortages of test supplies in combination with extreme long waiting times for test results: Already shortly after the Covid-19 outbreak, American hospitals had reported that they were facing extreme shortages of test supplies, as well as long waiting lists for test results. This was indicated as one of the main reasons why hospitals were as good as unable to monitor the health of both patients and members of medical staff. Several hospitals in particular indicated that they could not comply with the demand for Covid-19 testing due to the fact that there were no complete test kits available. There was, similarly, also a complete lack of individual parts and supplies needed for performing Covid-19 tests. In addition, several hospitals throughout the United States reported waiting times for receiving test results of on average 7 days or more. A side-effect of this has been that, when patients’ hospital stays had to be extended upon waiting for test results, the shortage of hospital beds, PPE supplies and staff members was put under even more pressure.

  2. (2)

    Widespread PPE shortages: Upon the outbreak of Covid-19, hospitals throughout the United States reported widespread PPE shortages. They also immediately noted that these shortages were extremely risky for both members of medical staff and hospital inpatients. Hospitals thereby also pointed to a more intensive use of PPE than usual because of Covid-19, which added even more to the PPE shortages. Hospitals, in addition, observed that the lack of a robust supply chain was crucial for delaying PPE deliverances, which prevented hospitals from replenishing the PPE needed to protect patients and staff members even more. Hospitals finally reported an ongoing uncertainty about the availability of PPE from federal and state sources, while at the same time pointing out that, because of increased demand and shortages of supply, prices for PPE from private suppliers continued to rise sharply.

  3. (3)

    Difficulties in retaining members of staff and for providing staff support: Upon the outbreak of Covid-19, American hospitals reported that they were in many cases no longer able to retain sufficient staff, and/or to provide their remaining staff members with adequate support. A common remark concerned a shortage of specialised medical staff members needed to manage the increasing inflow of Covid-19 patients. Another recurrent concern was that staff exposure to the Covid-19 virus could itself exacerbated staff shortages and overwork for the remaining staff members. Hospital directors also shared their concern that fear and uncertainty were taking a huge emotional toll on staff members, both professionally and personally, and that they lacked the means for adequately dealing with this problem.

  4. (4)

    Difficulties in maintaining and expanding hospital capacity in order to be able to treat patients: Already shortly upon the outbreak of Covid-19, capacity concerns were reported due to the fact that hospitals were overwhelmed, or were expecting to be so, by an influx of Covid-19 patients in need of ICU beds and separate rooms for treating and containing infections. Many hospitals also reported that post-acute care facilities required a negative Covid-19 test before being allowed to discharge them, which implied that some patients who no longer required acute care, were taking up valuable bed space while awaiting discharge.

  5. (5)

    Shortages of essential supplies, materials and logistical support: Upon the outbreak of Covid-19, American hospitals reported that shortages of essential supplies, materials and logistical support, which would have allowed for more beds, were affecting their ability to care for patients. Hospitals hereby reported a need for a wide variety of items for supporting a patient room, such as intravenous therapy (IV) poles, medical gases, bedding, toilet paper and food. Others hospitals reported shortages of infrared thermometers, disinfectants and cleaning supplies. Isolated and smaller hospitals reported that they were facing an especially difficult time in keeping up with needed supplies and replenishing them quickly when they ran out.

Assa has made a direct connection between the extreme shortages in American hospitals in the first period after the outbreak of Covid-19 on American soil, and the extreme neoliberal “laissez-faire, laissez-passer” policy that American authorities on various levels relied on. According to this author, the extreme neoliberal policies of the United States over the past four decades had weakened the public health system, while at the same time having brainwashed millions of voters to view public initiative as evil. In the opinion of Asa, this is the main reason why, when Covid-19 broke out, the United States, although being one of the most prosperous countries on Earth, faced shortages of everything from face masks, testing equipment, respiratory ventilators, hospital (ICU) beds, and even medical personnel. In the words of this author, “Laissez-faire” (“let happen”), in the extreme, had thus come down to “Laissez-mourir” (or “let die”): This comes down to the simple fact that numerous people have died because public services had been destroyed under years of neoliberal austerity.Footnote 373

As shown in Fig. 5.3 developed by Assa (based on World Bank data), in 1960 the United States had still been the world leader with 9.2 beds per 1000 people (compared to 8.7 in the OECD group of industrialised countries). By the second decade of the twenty-first century, this ratio had dropped to 3/1000 in the United States (which came down to a two-thirds drop), while the OECD had an average of around 4/1000. Meanwhile, poor and emerging countries had increased their hospital capacity from 1.4/1000 beds in 1970, to 2.4/1000 in 2011.Footnote 374

Fig. 5.3
figure 3

Hospital beds (per 1000 people) [Source: Assa (2021)] Looking for Solutions

As the Covid-19 pandemic unfolded, the overburdened healthcare system in the United States further suffered numerous practical problems for which the Trump administration did not provide immediate solutions, if any at all.

In April 2020, as the Covid-19 pandemic continued, the term “delayed care” began to catch on in healthcare circles. This term referred to the fact that many people started avoiding visiting a doctor’s office or hospital for any medical procedure that was not urgent. However, the AJMC reported a Gallup poll that pointed to a darker side to this phenomenon: From this pool, it had appeared that one in seven Americans had declared that they would not seek medical care in case of a fever or dry cough—both classic symptoms of Covid-19, in some cases because of concerns about the costs for medical care, and in other cases out of concern for losing one’s job when having to report sick. The people most likely to avoid medical treatment for said symptoms were young people under the age of 30 and who had an income of less than USD 40,000 on a yearly basis.Footnote 375

Around 5 months after the Covid-19 pandemic had been declared a national emergency in the United States, 49% of low-income areas (especially rural areas) reported that their hospitals had no free ICU beds anymore. Hospitals even reported being forced to transfer their sickest Covid-19 patients to care facilities located in wealthier areas. Among the counties most affected, those of the Southwest and West were facing a particularly difficult bed shortage.Footnote 376 By 17 August 2020, Covid-19 had become the third main cause of death in the United States. In a span of just 4 days, there had at the time been a 3.2% increase in Covid-19-related deaths, bringing the total number of deaths to 170,434. This had put the Covid-19 disease in third place for causing death, after cardiovascular disease in the first place and cancer at number 2. The number of deaths on a daily basis then exceeded 1000 per day, while there were more than 5.4 million contamination cases nationwide.Footnote 377

In general, American hospitals responded to these combined challenges by first trying to obtain the necessary PPE, equipment and supplies themselves, as their president had advised them to do. In order to obtain the necessary PPE, equipment and supplies, hospitals also reported turning to new, sometimes unverified and non-traditional sources of supplies. E.g., in an attempt to try to maintain existing supplies of PPE, hospitals reported uncommon practices as: (1) preserving and reusing single-use or disposable PPE, (2) using (or exploring to use) ultraviolet (UV) light for sterilizing used masks, and/or (3) bypassing sanitary guidelines by having medical staff place surgical masks over N95 masks. Hospitals also reported using non-medical PPE, such as construction masks or handmade masks and aprons. Still, hospitals expressed their belief that these approaches were likely to put their medical staff at risk.Footnote 378

Secondly, hospitals tried to ensure adequate staffing to treat patients with Covid-19, by training and/or reallocating other medical staff members, such as anaesthetists, hospital physicians and nurses from other departments, to help care for ICU patients put on ventilators.Footnote 379

Thirdly, hospitals started to support their medical staff members in accessing a variety of (time-consuming) services, such as childcare, laundry, grocery services and even hotel accommodation to facilitate the separation of elderly family members.Footnote 380

In order to control patient inflow and hospital capacity, some hospitals also started to provide outpatient care to patients with less severe symptoms. Hospitals also started offering telehealth services, where possible, and setting up “alternative facilities”, ranging from fairgrounds, empty student houses and closed penitentiaries, as additional spaces for providing patient care.Footnote 381

Fifthly, as the need for respiratory equipment increased, hospitals tried to obtain additional capacity by renting general ventilation equipment, purchasing single-use ventilation equipment to be deployed in emergency transport, and/or obtaining ventilation equipment through an affiliated facility. Some hospitals even started converting other medical equipment, such as anaesthesia equipment, for use as respiratory ventilators.Footnote 382

On 28 March 2020, the Centers for Medicare & Medicaid Services (CMS) announced that it would start making prepayments to hospitals and other health care providers, and on 30 March 2020, CMS announced a series of regulatory measures meant to increase the flexibility of hospitals and other health care providers in responding to the Covid-19 pandemic, including changes to support facility capacity and staffing.Footnote 383

Around 23–27 March 2020, hospitals themselves began to submit requests for assistance to the US Department of Health and Human Service (HHS) in which they expressed their own suggestions. Most of these requests related to:Footnote 384

  1. (1)

    Tests, supplies and PPE: Many hospitals observed that they had to compete with other consumers, in many cases other hospitals or healthcare facilities, for limited supplies. They suggested that government intervention and coordination would be able to deal with this problem at a federal level. Hospitals in addition suggested that the federal government would ensure access to testing material (such as test kits and swabs). They, moreover, requested the federal government to speed up testing procedures, e.g., by allowing more agencies to conduct and produce tests. They also requested that the federal government would help hospitals in obtaining PPE supplies and other equipment, such as respirators.

  2. (2)

    Allocation of staff: Various hospitals asked the federal government to allow for the transfer of qualified professionals and for a reallocation of tasks if necessary. These requests were aimed at obtaining more flexibility from qualified medical professionals practicing in another state, and at obtaining more relief from regulations that may limit the use of contracted staff or doctors in other facilities.

  3. (3)

    Facility capacity: Hospitals asked for more flexible rules on issues such as bed allocation, the possibility of establishing additional facilities in non-traditional settings, and telehealth. These requests, moreover, concerned flexibility in the categorizing of services, service providers and modalities eligible for reimbursement.

  4. (4)

    Financial assistance: Various hospitals, especially small rural hospitals, expressed their need for financial assistance, including faster and higher Medicare payments, in addition to loans and grants.

  5. (5)

    Communication and information: Hospitals made calls for more centralised communication and public information, including evidence-based guidance, reliable data and predictive models. Hospitals similarly called for the establishment of a central repository for all Covid-19-related guidance, data and information.

5.4 Trump’s Disregard for Workers’ Health During the Covid-19 Pandemic

In Chap. 7, we shall explain in more detail how the so-called “reopening of the economy” that, under the impetus of the Trump administration, already was called for in late April 2020, has been one of the main reasons for the Covid-19 pandemic to reach such proportions in the United States (as well as in, e.g., many European countries that would similarly reopen their economies too early). In line with neoliberal tradition, the Trump administration indicated that it essentially did not care about the lives of the members of the working classes. According to Woolhandler et al., the adverse health effects of the Trump administration’s deregulatory actions in reopening the economy too early were, moreover, concentrated in states and focused on demographic groups that had already been most affected by rollbacks in health insurance coverage. As a result, both categories of harms were reinforcing one another, in this manner especially widening disparities in health according to race, social class, and geography.Footnote 385 (Cf., furthermore, Chap. 10.)

However, the Trump administration’s complete disregard for the health and safety of the members of the working classes, has also been particularly evident in dealing with the Covid-19 pandemic itself.Footnote 386 E.g., despite having received nearly 18,000 complaints from employees concerning Covid-19-related hazards in their workplaces (as of 4 July 2020), the Occupational Safety and Health Administration (as of 15 September 2020) reportedly took action against only one of the involved employers.Footnote 387

Another example that we shall readdress in more detail in Chap. 7, is that in April 2020, President Donald Trump made the unprecedented decision of qualifying meat processing factories as “essential infrastructure” for purposes of national security, which compelled the meat processing industry’s workers (many of them immigrants) to return to their physical working places although their safety, and by extension that of the general public, could not be guaranteed. As will be elaborated upon in more detail in Chap. 7, this decision was made despite numerous and clear evidence that employers in the meat processing industry were failing to maintain personal hygiene and physical distancing among their employees. Because of this, as of mid-September 2020, 42,606 meat-packing workers were reportedly infected with Covid-19, and 203 people had died. This at the same time turned the meat processing industry into a nexus of contagion across the country.Footnote 388

The Trump administration’s complete disregard for human life was as evident regarding the medical and nursing staff who had been pre-eminently putting their own lives and health in service of the fight against Covid-19. This sacrifice however, did not impress neoliberal leaders around the world. Their attitude undoubtedly contributed to the American government’s anaemic and incompetent efforts to ramp up the supply of personal protective equipment, as well as to its non-existent oversight of infection control practices. As a result, in the United States alone, there were officially 2921 Covid-19-related deaths of health-care workers as of 26 December 2020.Footnote 389

5.5 Conclusions

5.5.1 Assessment by the Corporate Europe Observatory

The Corporate Europe Observatory has shone a bright light on the disastrous consequences of four decades of neoliberal health policy. The consequences of cutting back on public health systems through austerity, and of privatization and commercialisation of public health services have been shown to be disastrous. In the wake of the biggest pandemic since the Spanish flu came a total inability of the private, for-profit health sector to provide even the most basic medical treatment in times of need. Meanwhile, critically underfunded public hospitals struggled to fill the gap.Footnote 390

To illustrate this point, the Corporate Europe Observatory made special reference to the events that, in March 2020, occurred in Italy, one of the countries hardest hit by the Covid-19 pandemic. As explained before, years before the Covid-19 pandemic, EU enforced cutbacks in the Italian health system resulted in an inconceivable reduction in beds and personnel. Hospital beds were reduced by 50% between 1997 and 2015, and qualified hospital personnel saw their numbers cut by 46,000 between 2009 and 2017. Although Italy was an extreme example of neoliberal EU austerity, it was certainly not the only one. Add to these systematic downsizing practices, the outsourcing of certain medical services in search of cutting down on personnel costs, not to mention the lack of policy measures and incentives ensuring that health companies invest emergency preparedness—e.g., by always keeping enough hospital beds empty, by supplying hospital rooms, or floors, with sufficient face masks and gloves, and/or by permanently investing in the development of vaccines and/or in researching undetected viruses and other disease-causing factors (cf., furthermore, Sect. 9.2.)—and the result has been a global public health crisis that had not occurred in more than a century,Footnote 391 most notably in Western, neoliberally oriented countries.Footnote 392

Covid-19 has exposed the dramatic consequences of economic neoliberalism in general, and of neoliberal austerity in particular, especially concerning the extreme degree to which vital health care services (in the broad sense of the word), have been turned into a free market commodity, especially since the 1980s (in the United States) and the 1990s (in many European countries). According to the Corporate Europe Observatory, while states should not be relieved of their human rights obligations when transferring core public services to the free market, the reality throughout the Western world has been just that. People who used to have public rights, were turned into the clients (or consumers) of private enterprises that are only out to maximise corporate profits and that are not accountable to the general public, but only to their shareholders.Footnote 393

This assessment is not just another attack on neoliberal ideas, but concerns a matter of life and death. Indeed, there is growing evidence that the commercialisation and privatisation of healthcare has contributed to a greater spread of, and more deaths from, Covid-19. People have died during the Covid-19 pandemic because of neoliberal policy, which implies that fighting the neoliberal-inspired techniques of privatising or marketizing health care services is, literally, a fight to save lives.Footnote 394

Still, as has already been explained before (in Chap. 4), in November 2020, the EU Commission presented its first proposal for a “European Health Union”. This European Health Union has as main purpose to give the EU more power over health policy. The proposal includes a series of measures that could be achieved without changing the EU Treaties, ranging from an EU-wide pandemic readiness plan to a proposed new EU agency for health emergencies.Footnote 395 (Cf. already Sect.

Under the logic of the European Treaties which deal primarily—if not exclusively—with economic matters, health policy is primarily a responsibility of the Member States, with the EU institutions themselves only having limited formal powers. There is a strong need for more and better cooperation between EU governments in dealing with pandemics. However, it is as important to consider what the EU would do with more power over health policy. After all, the EU’s combined policy concerns, especially those related to the application and monitoring of the E(M)U monetary convergence standards (cf. Sect. have been one of the main causes of weakening public health systems. At the same time, the EU has left the growing private health sector largely untouched (cf. e.g., the completely lack of European quality or supervision rules regarding the private health care sector).Footnote 396 The various ways by which the EU has dealt with the Covid-19 pandemic raises some serious doubts as well.

To reiterate, the EU has:

  1. (1)

    Stimulated a far-reaching privatization and marketization, to a large extent eroding the health care sector—besides, as we shall examine further in Chap. 6, the nursing home sector as well—as a result of which this sector was totally unprepared for a pandemic;

  2. (2)

    Abstained from any significant action during a month and a half at the outbreak of Covid-19 on European soil in January–February 2020 (cf. Sect. 2.3.);

  3. (3)

    Turned the start and first months of the European vaccination campaign into a complete fiasco, as we shall investigate further in Chap. 9.

One may seriously wonder what to expect of a centralized, European health policy, at least as long as the EU keeps adhering the ideology of economic neoliberalism.

Still, the EU is already proceeding with its plans to make health an EU policy matter. As the Union keeps pushing the neoliberal agenda, consequences for the lives of European citizens could be dire.

As has already been addressed in some more detail in Chap. 4, the EU Commission’s health reform plans include an EU health crisis/pandemic preparedness and response plan, with measures including:Footnote 397

  1. (1)

    Improved reporting by Member States on their preparedness and response plans.

  2. (2)

    Stress tests to be carried out regularly at a national and EU level in the area of public health.

  3. (3)

    Supporting Member States to strengthen the resilience, accessibility and effectiveness of their health systems through cooperation, training, technical assistance and funding from EU programmes.

As elaborated in more detail in Chap. 4, the EU has already launched a multi-billion “EU4Health” funding programme for the period 2021–2027, “to build resilient health systems in the EU to better equip us for the future”. (Cf. Sect. Besides proposed measures to tackle cross-border health threats and making medicines more available and affordable, EU4Health also includes a third pillar of “strengthening health systems”. Under this point, the EU Commission wants to “improve accessibility, efficiency and resilience of health systems “and “reduce inequalities in accessing healthcare”.Footnote 398

However, what is still noticeably lacking in the EU plans is any recognition of the importance of maintaining, or even strengthening, “public” and “non-profit” healthcare systems, or even better, a recognition that health care services should exclusively be kept in the public and non-profit policy domains.Footnote 399

All of this does not come as a surprise, as the EU Commission has traditionally (and wrongly), usually equated “greater efficiency” with greater reliance on the free market (or, put in another way: with less public initiative and less “public good”).

In the opinion of the Corporate Europe Observatory, in order to strengthen Europe’s health systems, the EU should at the very least put an end to its neoliberal policy-agenda, e.g. the monetary and fiscal policy that lead to harmful budget cuts and created pressure to privatise or marketize health care and elderly care systems, thereby weakening Europe’s preparedness for any future epidemic, pandemic or similar public health crisis.Footnote 400 According to some more specific and practical proposals of the Corporate Europe Observatory, the EU should:Footnote 401

  1. (1)

    Put an end to austerity, by at the very least starting with a commitment not to return to the pre-Covid-19 austerity rules, including the SGP.

  2. (2)

    Remove all pressures for (neo)liberalising, marketizing, commercialising and/or privatisation public health care systems.

  3. (3)

    Stop diminishing the domain of the general good and undermining the welfare state model.

  4. (4)

    Ensure that Covid-19 recovery funds are used to strengthen public facilities and the public health care system, rather than private for-profit hospitals.

  5. (5)

    Protect public services from being further opened up by the EU’s trade and investment agenda and make sure that other areas of the European health agenda—ranging from digitalization, to integrated care—are not (entirely) taken over by private for-profit enterprises only seeking to increase private profits and market share.

5.5.2 Taking the Reform Debate One (Big) Step Further

In view of all the foregoing, it should come as no surprise that numerous authors also increasingly advocate the abandonment of the tenets of economic neoliberalism, especially regarding their application to the health care sector in the broad sense.

E.g., in the opinion of Viens, there are very convincing empirical and moral objections against economic neoliberalism in general and austerity in particular, especially when applied to health care.Footnote 402 In the similar opinion of Assa and Calderon, in order to make health care sustainable, there is an urgent need to reconsider neoliberal policy choices, especially those on privatising health care.Footnote 403 Likewise, the American researchers Reinhart, Dawes and Maybank argued that in order to protect public health in the United States, the prevailing inadequate welfare and worker protection systems should start to be seen as ethical and political failures urging to do much better.Footnote 404 Reference can also once more be made to Saad-Filho who has expressed similar ideas.Footnote 405

The opinion of these authors is, moreover, fully in line with what we ourselves have written in some of our earlier work.Footnote 406

What is abundantly clear is that the Covid-19 health crisis in the West, especially when compared to the much more efficient Covid-19 responses deployed in the East (cf. Sect., has demonstrated that radical neoliberal administrations are unable—and probably even unwilling—to perform the most basic functions of governance: protecting human lives and securing livelihoods.Footnote 407

In the further opinion of Viens, the time has come to start radically looking for alternative approaches to organizing societies than those developed under economic neoliberalism.Footnote 408

We have already come up with ideas in this regard in some of our earlier work.Footnote 409

Under the “new international monetary system” that we have proposed in our previous books,Footnote 410 it would become possible to finance a care state model under a much fairer and more just socio-economic order than would ever be possible under the rule of unbridled capitalism. Even the classical welfare state model could be surpassed, to the extent that states are still dependent on capitalist financing methods such as taxation and predatory capital markets. By contrast, under this future monetary system, state financing would no longer occur by taking away profits earned by enterprises, or from income earned by working people. “Taxes” and similar “contributions” or “duties”, such as state-imposed “social security contributions” would be replaced by a newly proposed system of money creation, managed by a Monetary World Institute (MWI)—this could obviously be the IMF, after having altered its working rules, as established in its Articles of Agreement—which would attribute periodical allocations to the countries participating to this new international monetary order.Footnote 411 (Cf., furthermore, Sect. 11.3.)

Although such a system could, to some extent, already start happening within the prevailing international monetary order—which however would imply that the IMF would actually start using its power to attribute Special Drawing Rights (SDR’s) to its member states in a far more systematic manner than is presently the caseFootnote 412—the proposal that was formulated in our previous work would take Keynesian thinking a step further, by installing a system in which all the member-states would obtain the entirety of their financial means out of such (periodical) allocations.Footnote 413 Under such a system of financing states it would become possible to withdraw the public domain from the power of private money creation and, therefore, from the collectively of the private, financial institutions and markets that in the current monetary order dictate the whereabouts of everyone, including states. This would, phrased differently, imply that states should no longer be “tax states” and/or “debt states”.

This newly proposed monetary system has been extensively described in our previous work, to which further reference is made here.Footnote 414

In the treaties establishing this proposed new international monetary order, the contours of this new welfare/care state model could be worked out in more detail, for example by providing lists of the public services and social security systems that should be made universally accessible based upon the financial means each state will obtain out of said allocations.Footnote 415

While in neoliberal states, funding healthcare happens through a range of mechanisms, such as taxes, semi-taxes, health insurance funds and private sources,Footnote 416 under the proposed new monetary order, it would become far easier to provide states all over the world with the necessary funding to establish a universal healthcare system within their respective jurisdictions. These would be healthcare systems in line with the WHO’s commitment to “the fundamental right of every human being to the enjoyment of the highest attainable standard of health, without distinction of any kind”.Footnote 417 Such an approach would, moreover, substantially contribute to reducing, or even completely ending, the health inequalities prevailing under the present neoliberal, socio-economic order.Footnote 418

We shall readdress these proposals in some more detail in Chap. 11 (containing the final conclusions to this book).


  1. 1.

    Cooper (2017).

  2. 2.

    Trappenburg (2019), p. 289.

  3. 3.

    Trappenburg (2019), p. 289.

  4. 4.

    Trappenburg (2019), p. 289.

  5. 5.

    Trappenburg (2019), p. 289.

  6. 6.

    Trappenburg (2019), p. 291.

  7. 7.

    Cooper (2017), pp. 180–188.

  8. 8.

    Cooper (2017), p. 184.

    Liberals, for instance, started pleading for a much further expansion of the welfare state model, a plea that resonated in the “Great Society program” of President Johnson. In this vision, the extension of the welfare state model had to be paid out of systems of property taxes. (Cf. Cooper (2017), p. 184.)

  9. 9.

    Cooper (2017), p. 183.

  10. 10.

    Cooper (2017), p. 185.

    Liberals in the same manner criticized the education regime at universities and campaigned against the American medical organizations. By the end of the 1960s, their calls for a radical change of American society were widely supported. (Cf. Cooper (2017), p. 185.)

  11. 11.

    Cooper (2017), p. 185.

  12. 12.

    Trappenburg (2019), p. 292.

  13. 13.

    Trappenburg (2019), p. 292. Cf., furthermore, Streeck (2013), p. 87.

  14. 14.

    Cooper (2017), p. 184.

  15. 15.

    Trappenburg (2019), p. 292.

    Thinkers such as Lawrence Mead, Patrick Moynihan, Irving Kristol and Daniel Bell in this regard drew the attention of the “Libertarian Circle”. In her book “Family Values”, Cooper explains the close relationship between economic neoliberalism and political conservatism—even in case the latter speaks the language of anticapitalist critique—as equally constitutive expressions of modern-day capitalism (cf. Cooper (2017), pp. 15–16).

  16. 16.

    Trappenburg (2019), p. 292.

  17. 17.

    Trappenburg (2019), p. 292.

  18. 18.

    Trappenburg (2019), pp. 292–293.

  19. 19.

    Cooper (2017), p. 185.

  20. 20.

    Cooper (2017), p. 188; Trappenburg (2019), p. 293; Byttebier (2017), pp. 180–184; Byttebier (2018), pp. 92–96; Byttebier (2019), pp. 69–75.

  21. 21.

    Cooper (2017), p. 191.

  22. 22.

    Cooper (2017), p. 192.

  23. 23.

    Trappenburg (2019), p. 293.

  24. 24.

    Trappenburg (2019), p. 293.

  25. 25.

    Trappenburg (2019), p. 294.

  26. 26.

    Trappenburg (2019), p. 294.

  27. 27.

    Trappenburg (2019), pp. 294–295.

  28. 28.

    Trappenburg (2019), p. 295.

  29. 29.

    Trappenburg (2019), p. 295.

  30. 30.

    Trappenburg (2019), p. 296.

    Also this criticism gradually started resonating in political programs, in present times still resonating in the neoliberal attitude (which, throughout Western Europe, still inspires numerous neoliberal politicians and policymakers) that people cannot possibly be ill for a long time. It is hereby assumed that long-term ill people are just mala fide “shirkers” out to profiteer from the social security system, which is of course deemed unacceptable. As a result, neoliberal healthcare got increasingly reshaped in order to ensure that the sick can go back to work as quickly as possible, since the entire neoliberal societal organizational model is based on the idea that everyone, sick or not, must work as much and as long in life as possible.

  31. 31.

    Trappenburg (2019), p. 296.

  32. 32.

    Trappenburg (2019), p. 298.

  33. 33.

    Barnett and Bagshaw (2020).

  34. 34.

    Cf. Cooper (2017), pp. 188–209.

  35. 35.

    Cooper (2017), p. 190.

  36. 36.

    Cooper (2017), p. 190.

  37. 37.

    Byttebier (2018), p. 77.

  38. 38.

    Cooper (2017), p. 190.

  39. 39.

    In the United States, this idea had before also been appealing to the Reagan administration that envisaged volunteer labour performing a similar transformative role in the healthcare and non-profit sectors. (Cf. Cooper (2017), p. 190.)

  40. 40.

    Cooper (2017), p. 190.

  41. 41.

    Cooper (2017), p. 190.

  42. 42.

    Incidentally, this more-speed approach gained a much broader scope than just healthcare, but has gradually started to cross the whole social security and public services system of the Western world—albeit again with large differences from country to country. E.g., bearing in mind the left-wing ideals, vulnerable people are nowadays allowed to attend ordinary schools; they live in ordinary neighbourhoods and should work for ordinary companies and organizations. However, these promises are not always realized: ordinary schools and ordinary bosses do not stand in line for pupils, students and employees with (serious) disabilities or behavioural problems. Furthermore, the in-part ‘de-institutionalization’ of the inclusive model also often leads to loneliness. Without institutional care, some desperate disabled or psychiatric patients even commit suicide. Outside the institution, people with intellectual disabilities also run an expanded risk of becoming victims of criminals who hasten their carts. Research also showed that many people with intellectual disabilities are constantly overly challenged by normal society, and the frustration that this produces leads to aggression, which may subsequently lead to imprisonment. (Cf. Cooper (2017), p. 190.)

  43. 43.

    Cooper (2017), pp. 190–191.

  44. 44.

    Viens (2019).

  45. 45.

    Assa and Calderon (2020).

  46. 46.

    Viens (2019).

  47. 47.

    Viens (2019).

  48. 48.

    Viens (2019).

  49. 49.

    Viens (2019).

  50. 50.

    Viens (2019).

  51. 51.

    Barnett and Bagshaw (2020).

  52. 52.

    According to Cooper, beyond the charmed circle of the privately insured family, healthcare was no longer readily available, unless one took care of oneself. Personal responsibility was invoked nowhere more forcefully than at the margins. (Cf. Cooper (2017), p. 193.)

  53. 53.

    Barnett and Bagshaw (2020). Cf., furthermore, Byttebier (2018, 2019).

  54. 54.

    Barnett and Bagshaw (2020).

  55. 55.

    Blyth (2015), p. 3.

  56. 56.

    Blyth (2015), p. 4. Cf., furthermore, Streeck (2013), p. 87.

  57. 57.

    Assa and Calderon (2020), p. 1.

  58. 58.

    Assa and Calderon (2020), p. 5.

  59. 59.

    Assa and Calderon (2020), pp. 5–6.

  60. 60.

    Assa and Calderon (2020), p. 6.

  61. 61.

    Assa and Calderon (2020), p. 6.

  62. 62.

    Assa and Calderon (2020), p. 6.

  63. 63.

    Assa and Calderon (2020), p. 6.

  64. 64.

    Assa and Calderon (2020), p. 7.

  65. 65.

    Foulon (2021).

  66. 66.

    Cf. Millenson (2010); Ginsberg (1987), p. 64.

    In 1982–1983, President Ronald Reagan and a US Congress that at the time was reported to be split between Republican and Democratic control, reached an agreement on a radical new payment scheme for Medicare. According to Ginsberg, it concerned the most far-reaching and critical legislative action in healthcare policy undertaken by the Reagan administration, or any other administration, since the days of Lyndon Johnson. (Cf. Ginsberg (1987), p. 64.)

    A first resulting legislation of this reform action concerned the “Tax Equity and Fiscal Responsibility act” (TEFRA) of 1982 (Public Law 97-248, 96 Stat 324). TEFRA may be considered as the forerunner of the DRG’s. As reported upon by Kenton and Berry-Johnson, TEFRA was developed to reduce the growing federal deficit in various domains, by closing loopholes in the tax system, introducing stricter compliance and tax-collection measures, such as increasing excise taxes on cigarettes and telephone services, as well as increasing corporate taxes. TEFRA also “rescinded” some of ERTA’s—by which reference is made to the “Economic Recovery Tax Act” of 1981—reductions in personal income-tax rates that at the time had not yet gone into effect. TEFRA also removed some of the tax breaks businesses received under ERTA, such as accelerated depreciation. Still according to Kenton and Berry-Johnson, TEFRA, furthermore, instituted a 10% withholding tax on dividends and interest paid to individuals who had no certified tax identification numbers. TEFRA at the same time affected a broad range of taxpayers an tax systems, as it modified the rules governing pension plans, life insurances, corporate mergers and acquisitions, the redemption of corporate stock, and safe harbour leases. (Cf. Kenton and Berry-Johnson (2020).)

    Shortly after, in February 1983, President Reagan submitted his long-awaited “Health Incentives Reform Program” (HIRP) to the American Congress, which consisted of a multipronged strategy for reducing health costs. One of the components of HIRP that became law was a “prospective payment system” (PPS) for inpatient hospital services based on 468 diagnosis-relate groups (referred to as so-called “Diagnosis-Related Groups” or “DRGs”). On April 20, 1983, after what has been referred to as “a whirlwind passage through Congress”, the “Social Security Amendments Act” of 1983 (H.R. 1900, PL 98-21), putting the DRG system into effect, became law (cf. Preston et al. (1997), p. 147). Under the DRG system, which was by and large following the approach of TEFRA of 1982, the American federal government would still only pay a flat rate for each DRG. (Cf. Ginsberg (1987), p. 66). Before, from 1966 on, when Medicare had begun, until 1982, US hospitals had been reimbursed retrospectively and on the basis of real costs; that is to say that hospitals were reimbursed in full for necessary and reasonable costs expended in service provision. These costs were, furthermore, calculated on a so-called “per diem” basis. The PPS model was meant for replacing this costing regime. PPS was more precisely based upon a set of 467 product lines called “Diagnosis-Related Groups” (DRGs) which classified and grouped together patients with similar principal diagnoses, the assumption being that these diagnoses required similar treatment protocols and, hence, similar amounts of resources. (Cf. Preston et al. (1997), p. 147.) The purpose of this new system was to guarantee the quality of Medicare services and to save money for the government by eliminating unnecessary hospital admissions and by encouraging greater utilization of outpatient services. (Cf. Ginsberg (1987), p. 68.) The DRG system was thus aimed at trimming billions of dollars from the federal budget and at plummeting medical inflation to plummet, while (purportedly) still guaranteeing quality of care. The DRG system led to a permanent change in how both the public and private sector pay for healthcare in the United States, and has, since then, gone curiously unmentioned during health reform debates to follow, to the extent that some have suggested that the topic simply raises too many squirm-inducing questions, inciting political discretion instead of debate. The 1983 DRG system was reported to be conceptually simple: Medicare was more precisely told to pull the plug on paying hospitals whatever they billed the government as their costs, plus an additional profit margin piled on. Instead, Medicare would still only be committed to paying a fixed price linked to each patient’s clinical condition, or “diagnosis-related group” (DRG). That price might vary somewhat due to adjustments such as regional wage levels, but it was in essence a price set in advance; hence the term “PPS” or “prospective payment system” for describing the underlying methodology. The effect of this system of prospective payment was believed to be felt immediately: Soon after the introduction of the law, the growth in Medicare hospital payments plunged from 16.2% per year from 1980 through 1983, to just 6.5% per year from 1987 through 1990. Between 1982 and 1988, Medicare hospital days plummeted a further 20%. (Cf. Millenson (2010).)

  67. 67.

    Foulon (2021).

  68. 68.

    Foulon (2021).

  69. 69.

    Foulon (2021).

  70. 70.

    Cf. OECD and European Commission (2018).

  71. 71.

    Cf. OECD and European Commission (2018).

  72. 72.

    OECD and European Commission (2018), p. 11.

  73. 73.

    In a 2015 TED talk, Microsoft co-founder, billionaire and self-proclaimed philanthropist Bill Gates cited lessons from the 2014 West Africa Ebola virus crisis, saying that the United States and other (Western) countries had even in the aftermath of this crisis basically remained unprepared for any future pandemic that was bound to hit them. “If there is anything that kills more than ten million people in the next few decades, it is most likely a highly contagious virus rather than a war,” Gates had said. “Not missiles, but microbes.” Bill Gates noted that many countries have worked for years to reduce the risk of nuclear war, and that they should pay the same attention to mass mobilisation against a deadly virus. “We have actually invested very little in a system to stop an epidemic,” he said, echoing warnings in recent years from infectious disease doctors. “We are not ready for the next epidemic.” “A virus “like the Spanish flu of 1918,” Gates had added, “would spread around the world very, very quickly. And you can cf. that over 30 million people died from that epidemic. So this is a serious problem. We have to be concerned.” “Individual countries, the World Health Organisation and others need to set up medical attack teams that train like military soldiers, conduct simulated pandemic exercises and prepare to move quickly into areas where pandemics are starting to test and treat victims,” Gates had added. “Governments also need to invest much more in medical equipment, research on vaccines and other ways to prepare. Now I don’t have an exact budget for what this would cost, but I’m pretty sure it’s very modest compared to the potential damage,” Gates had also said. “The World Bank estimates that if we have a global flu epidemic, global wealth would fall by more than $3 trillion and we would have millions and millions of deaths.” “There is no reason to panic,” Gates had, furthermore, said in conclusion. “We don’t need to hoard cans of spaghetti or dive into the basement. But we do need to get going, because time is not on our side.” (Cf. Rogers (2020).)

  74. 74.

    Cf. OECD and European Commission (2018), esp. Chapter 4 “Risk factors”, pp. 111–130.

  75. 75.

    Galbraith (1974).

  76. 76.

    On this, cf. Byttebier (2017), p. 200.

    Particularly interesting is Galbraith’s remarks on “created wants”, one of the systems through which the capitalist machinery makes sure that it can keep going on: “So it is that if production creates the wants it seeks to satisfy, or if the wants emerge pari passu with the production, then the urgency of the wants can no longer be used to defend the urgency of the production. Production only fills a void that it has itself created. The point is so central that it must be pressed. Consumer wants can have bizarre, frivolous or even immoral origins, and an admirable case can still be made for a society that seeks to satisfy them. But the case cannot stand if it is the process of satisfying wants that creates the wants. For then the individual who urges the importance of production to satisfy these wants is precisely in the position of the onlooker who applauds the efforts of the squirrel to keep abreast of the wheel that is propelled by his own efforts. That wants are, in fact, the fruit of production will now be denied by few serious scholars. And a considerable number of economists, though not always in full knowledge of the implications, have conceded the point. In the observation cited at the end of the preceding chapter, Keynes noted that needs of “the second class,” i.e., those that are the result of efforts to keep abreast or ahead of one’s fellow being, “may indeed be insatiable; for the higher the general level, the higher still are they.” And emulation has always played a considerable role in the views of other economists of want creation. One man’s consumption becomes his neighbour’s wish. This already means that the process by which wants are satisfied is also the process by which wants are created. The more wants that are satisfied, the more new ones are born”. (Cf. Galbraith (1974), pp. 96–97.)

  77. 77.

    Marcuse (1964).

  78. 78.

    Byttebier (2021), pp. 127–128.

  79. 79.

    Cf. especially in the works of Ayn Rand. (Cf. Rand (1982, 1992, 2008).)

  80. 80.

    Marcuse (1964).

  81. 81.

    Banett and Bagshaw (2020).

  82. 82.

    OECD and European Commission (2018), p. 174.

  83. 83.

    OECD and European Commission (2018), p. 174.

    According to the OECD/EC report, in Ireland, e.g., only about 50% of the population was covered (at the time of the report) for the cost of GP visits. In Greece, a new law in 2016 (Law 4368/2016) provided universal health coverage for the entire population, closing the coverage gap for the 10% of the population who had previously been uninsured. These previously uninsured people have since legally recognised access to a wide range of services and goods (including hospital care and prescription drugs). (Cf. OECD and European Commission (2018), p. 174.)

  84. 84.

    OECD and European Commission (2018), p. 174.

    According to the OECD-EC report, in Bulgaria, the percentage of the population that was insured had fallen after 2010, when a tightening of the law implied that people lost their social health insurance if they did not pay their contributions. However, it was common for uninsured people who needed medical care to go to hospital emergency departments, where they were encouraged to get insurance (without paying a financial penalty for not having had insurance before). Still according to the same report, in Romania, although social health insurance was mandatory, only 89% of the population was insured in 2017. The uninsured population mainly included people working in agriculture, the self-employed or unemployed who were not registered for unemployment or social security benefits, as well as Roma who did not have an identity card (which prevented them from registering in the social security system). These uninsured had access only to a minimum package of benefits, which included emergency care, treatment of communicable diseases and care during pregnancy. (Cf. OECD and European Commission (2018), p. 174.)

  85. 85.

    OECD and European Commission (2018), p. 174.

    In France, almost the entire population (96%) was reported to have supplementary private health insurance to cover the costs of the social security system. The Netherlands had the largest supplementary market (87% of the population), with private insurance paying for dental care not reimbursed by the government. Duplicate private health insurance, which provides faster access to medical services in the private sector when there are waiting times in the public systems, was highest in Ireland (45%). The population covered by private health insurance had in some countries substantially increased over the preceding decade, notably in Denmark, Slovenia and Belgium. (Cf. OECD and European Commission (2018), p. 174.)

  86. 86.

    OECD and European Commission (2018), p. 174.

  87. 87.

    OECD and European Commission (2018), p. 176.

  88. 88.

    OECD and European Commission (2018), p. 176.

  89. 89.

    OECD and European Commission (2018), p. 176.

  90. 90.

    OECD and European Commission (2018), p. 178.

  91. 91.

    OECD and European Commission (2018), p. 178.

  92. 92.

    OECD and European Commission (2018), p. 178 (cf., furthermore, the report itself for further figures and prognoses on this matter).

  93. 93.

    OECD and European Commission (2018), p. 178.

  94. 94.

    OECD and European Commission (2018), p. 178.

  95. 95.

    OECD and European Commission (2018), p. 180.

  96. 96.

    OECD and European Commission (2018), p. 180.

  97. 97.

    OECD and European Commission (2018), p. 180.

  98. 98.

    OECD and European Commission (2018), p. 180.

  99. 99.

    OECD and European Commission (2018), p. 180.

  100. 100.

    OECD and European Commission (2018), p. 180.

  101. 101.

    OECD and European Commission (2018), p. 180.

  102. 102.

    OECD and European Commission (2018), p. 186.

  103. 103.

    OECD and European Commission (2018), p. 186.

  104. 104.

    OECD and European Commission (2018), p. 186.

  105. 105.

    OECD and European Commission (2018), p. 186.

  106. 106.

    OECD and European Commission (2018), p. 186.

  107. 107.

    OECD and European Commission (2018), p. 186.

  108. 108.

    OECD and European Commission (2018), p. 186.

  109. 109.

    OECD and European Commission (2018), p. 186.

  110. 110.

    Zeilemaker (2020).

  111. 111.

    Zeilemaker (2020).

  112. 112.

    Streeck (2017), p. 128.

  113. 113.

    Article 140 (ex Articles 121(1), 122(2), second sentence, and 123(5) TEC) states as follows: “1. At least once every two years, or at the request of a member state with a derogation, the Commission and the European Central Bank shall report to the Council on the progress made by the member states with a derogation in fulfilling their obligations regarding the achievement of economic and monetary union. These reports shall include an examination of the compatibility between the national legislation of each of these member states, including the statutes of its national central bank, and Articles 130 and 131 and the Statute of the ESCB and of the ECB. The reports shall also examine the achievement of a high degree of sustainable convergence by reference to the fulfilment by each member state of the following criteria: – the achievement of a high degree of price stability; this will be apparent from a rate of inflation which is close to that of, at most, the three best performing member states in terms of price stability, – the sustainability of the government financial position; this will be apparent from having achieved a government budgetary position without a deficit that is excessive as determined in accordance with Article 126(6), – the observance of the normal fluctuation margins provided for by the exchange-rate mechanism of the European Monetary System, for at least two years, without devaluing against the euro, – the durability of convergence achieved by the member state with a derogation and of its participation in the exchange-rate mechanism being reflected in the long-term interest-rate levels. The four criteria mentioned in this paragraph and the relevant periods over which they are to be respected are developed further in a Protocol annexed to the Treaties. The reports of the Commission and the European Central Bank shall also take account of the results of the integration of markets, the situation and development of the balances of payments on current account and an examination of the development of unit labor costs and other price indices. 2. After consulting the European Parliament and after discussion in the European Council, the Council shall, on a proposal from the Commission, decide which member states with a derogation fulfil the necessary conditions on the basis of the criteria set out in paragraph 1, and abrogate the derogations of the member states concerned. The Council shall act having received a recommendation of a qualified majority of those among its members representing member states whose currency is the euro. These members shall act within six months of the Council receiving the Commission’s proposal. The qualified majority of the said members, as referred to in the second subparagraph, shall be defined in accordance with Article 238(3)(a). 3. If it is decided, in accordance with the procedure set out in paragraph 2, to abrogate a derogation, the Council shall, acting with the unanimity of the member states whose currency is the euro and the member state concerned, on a proposal from the Commission and after consulting the European Central Bank, irrevocably fix the rate at which the euro shall be substituted for the currency of the member state concerned, and take the other measures necessary for the introduction of the euro as the single currency in the member state concerned”.

  114. 114.

    Cf. European Commission (2020), pp. 33–34.

  115. 115.

    European Commission (2020), pp. 33–34.

  116. 116.

    Corporate Europe Observatory and Tansley (2021), p. 18.

  117. 117.

    Corporate Europe Observatory and Tansley (2021), p. 18.

  118. 118.

    European Commission (2020), pp. 33–34.

  119. 119.

    European Commission (2020), pp. 33–34.

  120. 120.

    European Commission (2020), pp. 33–34.

  121. 121.

    For a short biography, cf. (Accessed on 15 May 2021.).

  122. 122.

    Sensini (2011) and Rose (2011).

  123. 123.

    For the English version of this letter, cf. Cf., furthermore, (Both sites accessed on May 15, 2021.)

    For the Italian version, cf. (Accessed on 15 May 2021.)

  124. 124.

    Sensini (2011).

  125. 125.

    Sensini (2011).

  126. 126.

    Cf. Byttebier (2018), p. 158; Byttebier (2019), pp. 102–103.

  127. 127.

    Sensini (2011).

  128. 128.

    Sensini (2011).

  129. 129.

    Sensini (2011).

  130. 130.

    Sensini (2011).

  131. 131.

    This delivers yet another argument that there is a need for a thorough rethinking of the monetary and budgetary logic that drives the world, starting with a rethinking of the systems of money creation, including their submission to transparent and democratic control systems. (Cf., furthermore, Chap. 11.)

    But the latter is clearly not something that will be accomplished in the near future. At present, because of Covid-19, we have on the contrary all been confronted with the disastrous consequences such neoliberal, dictatorial austerity policy may have, which, e.g., in the case of Italy, has taken the form of the disastrous scenario that rolled out in late February-early March 2020 in Lombardy, curtesy of the neoliberal EU austerity policy (as initiated by the ECB).

  132. 132.

    European Commission (2020), pp. 33–34.

  133. 133.

    European Commission (2020), pp. 33–34.

  134. 134.

    Corporate Europe Observatory and Tansley (2021), p. 18.

  135. 135.

    Corporate Europe Observatory and Tansley (2021), p. 18.

  136. 136.

    Corporate Europe Observatory and Tansley (2021), p. 19.

  137. 137.

    Corporate Europe Observatory and Tansley (2021), p. 19.

  138. 138.

    Corporate Europe Observatory and Tansley (2021), p. 19.

    Documents released by the European Commission also show that it regularly consults with private healthcare providers when drafting its country reports as part of the European semester. E.g. as part of a Commission fact-finding mission to Paris in November 2018 (in the context of drafting the 2019 macro-economic imbalances reports and 2019 country report on France), DG ECFIN and DG SANTE invited the French private hospitals lobby FHP, alongside the French public hospitals association FHF, to share its views.

  139. 139.

    Corporate Europe Observatory and Tansley (2021), p. 19.

  140. 140.

    European Commission (2019), pp. 51–52.

  141. 141.

    European Commission (2019), pp. 398–400.

  142. 142.

    Corporate Europe Observatory and Tansley (2021), p. 20, referring to Azzopardi-Muscat et al. (2015).

  143. 143.

    Corporate Europe Observatory and Tansley (2021), p. 20. Likewise Foulon (2021).

  144. 144.

    Corporate Europe Observatory and Tansley (2021), p. 21.

  145. 145.

    Corporate Europe Observatory and Tansley (2021), p. 20.

  146. 146.

    Corporate Europe Observatory and Tansley (2021), p. 21.

  147. 147.

    Corporate Europe Observatory and Tansley (2021), p. 21.

  148. 148.

    Corporate Europe Observatory and Tansley (2021), p. 21.

  149. 149.

    Corporate Europe Observatory and Tansley (2021), p. 6.

  150. 150.

    Corporate Europe Observatory and Tansley (2021), p. 6.

  151. 151.

    Corporate Europe Observatory and Tansley (2021), p. 6.

  152. 152.

    Corporate Europe Observatory and Tansley (2021), p. 6.

    According to UEHP, inequality only occurs in cases that the public sector refuses to pay private hospitals for patients’ care, leaving patients with high co-payments. And that, in the opinion of the UEHP, is the fault of the public sector gatekeepers, not of the private hospitals themselves. UEHP has, therefore, stated that it is essential that the system would start treating private and public hospitals equally. This has even become one of the main demands of the private hospital group lobby: they basically want (more) public money to be used for patients admitted to private hospitals, in this manner taking more taxpayer money away from chronically underfunded public hospitals in favour of profitable private hospitals. The coverage of a UEHP event by a lobby group called “Health First Europe” (whose secretariat is run by lobbying consultancy “Instinctif Partners” of which UEHP itself is also a member) has in this regard noted that although a significant decline in the number of hospital beds can be observed in several EU Member States, the private hospital sector itself has increased from 17.56% to 20.45% of the total number of beds in the EU (from 2007 to 2015). According to the Corporate Europe Observatory, this dynamic has been important due to the fact that, while national and EU austerity measures cut public health budgets, resulting in public hospitals being closed or sold to private companies, private hospitals (as well as PPPs and PFIs) started flourishing. (Cf. Corporate Europe Observatory and Tansley (2021), p. 6.)

  153. 153.

    Zeilemaker (2020).

  154. 154.

    OECD and European Commission (2018), p. 49.

  155. 155.

    OECD and European Commission (2018), p. 49.

  156. 156.

    OECD and European Commission (2018), p. 49.

  157. 157.

    OECD and European Commission (2018), p. 49.

  158. 158.

    OECD and European Commission (2018), p. 54.

  159. 159.

    Bambra et al. (2020), p. 967.

  160. 160.

    Sumonja (2020).

  161. 161.

    Zeilemaker (2020).

  162. 162.

    Zeilemaker (2020).

  163. 163.

    Zeilemaker (2020).

  164. 164.

    Zeilemaker (2020).

  165. 165.

    Zeilemaker (2020).

  166. 166.

    Zeilemaker (2020).

  167. 167.

    Zeilemaker (2020).

  168. 168.

    The Irish Health Minister Simon Davis announced: “During this crisis, the state will take control of all private hospital facilities and manage all resources for the benefit of all our people. There is no room for public versus private when it comes to a pandemic”.

  169. 169.

    Foulon (2021).

  170. 170.

    Foulon (2021).

  171. 171.

    Foulon (2021).

  172. 172.

    Foulon (2021).

  173. 173.

    Foulon (2021).

    The basis for a social and fair financing of healthcare is a solidarity-based collective health insurance, with as main, underlying purpose to ensure healthcare for all. In the opinion of Foulon, all medically necessary services need to be part of a system based on this principle of solidarity. The health of the population must remain a task of public services, and not be turned into one more means of private profit making. It is time to make it clear to the general public that at no time and in no place has the private sector ever proven that it can provide better care to all segments of the population. Moreover, it is an illusion to think that privatization is equivalent to defending free medicine. Nowhere is freedom of diagnosis and treatment more restricted than in private managed care systems. However, a system based on solidarity also implies that the efficiency of healthcare is improved, and that all policy choices should be made in a transparent manner. (Cf. Foulon (2021).)

  174. 174.

    Cf., furthermore, Byttebier (2017), pp. 228–231, and Byttebier (2018), pp. 133–134.

  175. 175.

    Viens (2019).

  176. 176.

    Viens (2019). Cf., furthermore, Byttebier (2018), pp. 37–44; Byttebier (2019), pp. 65–75.

  177. 177.

    Viens (2019). Similarly, as regards the United Kingdom in particular, cf. Byttebier (2017), p. 184; Byttebier (2019), pp. 74–75.

  178. 178.

    Byttebier (2017), p. 184; Byttebier (2019), pp. 74–75.

  179. 179.

    Viens (2019). Cf., furthermore, Byttebier (2018), p. 186; Byttebier (2019), pp. 124–132.

  180. 180.

    Viens (2019).

  181. 181.

    Viens (2019).

  182. 182.

    Viens (2019).

  183. 183.

    Cf. especially Byttebier (2015a, b, 2017, 2018).

    Cf. e.g., at Byttebier (2018), pp. 282–284: “This cocktail of economic factors would already in 2007–2008 culminate in probably the worst financial crisis the Western world has known since the depression of the 1930s, where it can be observed that especially the financial sector has been able to remain on the ground thanks to a massive state support (known as “bail-outs”), causing that the financial deficits which were created by the financial institutions have largely been shifted towards the government budgets. This in its own turn provided a new excuse for those adhering economic neoliberalism to dismantle welfare states even further, an approach that, strangely enough, has hardly met any noteworthy societal turmoil. (…) There is, in other words, above all need for a new way of “socio-economic thinking”. This should mainly come down to resolutely abandoning the value choice made by capitalism which alleviated egoism, selfishness, and greed to be the determining socio-economic principles, in favor of choosing for altruism and mutual affection as the new driving forces of the socio-economic order, and of (finally) activating the dynamics of democracy in order to put these in practice. (…) One can, hence, conclude that the noble ideas to establish a more just society are conceptually perceivable, albeit it remains an open question if there will be ever a sufficient willingness to put them into practice. Without any doubt, this will at the very least require a fundamental reversal of the “sclerosis of the heart” caused for decades already by the doctrines of economic neoliberalism”. (Byttebier (2018), pp. 282–284.)

  184. 184.

    Zeilemaker (2020).

    This is, e.g., expressed in a 2019 opinion piece from Joseph Stiglitz. (Cf. Stiglitz (2019)). Stiglitz started this opinion piece with the question “What kind of economic system is most conducive to human wellbeing?” According to Stiglitz, precisely this question is defining the current era, because, after four decades of implementing economic neoliberalism in the United States, as well as in other advanced economies, we know what does not work: “The neoliberal experiment—lower taxes on the rich, deregulation of labour and product markets, financialization, and globalisation—has been a spectacular failure. Growth is lower than it was in the quarter-century after the second world war, and most of it has accrued to the very top of the income scale. After decades of stagnant or even falling incomes for those below them, neoliberalism must be pronounced dead and buried”. (Stiglitz (2019).)

  185. 185.

    Zeilemaker (2020).

  186. 186.

    Cf. already before Byttebier (2017), p. 491; Byttebier (2018), p. 283; Byttebier (2019), p. 237.

  187. 187.

    Sahoo (2018). On Reaganomics, cf., furthermore, Byttebier (2017), pp. 180–184.

  188. 188.

    Sahoo (2018).

  189. 189.

    Sahoo (2018).

  190. 190.

    Angell (2008).

  191. 191.

    Angell (2008).

  192. 192.

    Angell (2008).

  193. 193.

    As Galbraith has phrased it (cf. Galbraith (1967), p. 109): “The market has only one message for the business firm. That is the promise of more money. (…) It must try to make money and, as a practical matter, it must try to make as much as possible. Others do. To fail to conform is to invite loss, failure and extrusion. Certainly, a decision to subordinate interest in earnings to an interest in a more contented life for workers, cows or customers would, in the absence of exceptional supplementary income, mean financial disaster. Given this need to maximize revenue, the firm is thus fully subject to the authority of the market”. (Cf. Galbraith (1967), p. 109.)

    Cf., furthermore, Galbraith (1992), p. 55; Bakan (2005), p. 256; Simonet (1970), p. 47; Byttebier (2018), pp. 23–24.

  194. 194.

    Angell (2008).

  195. 195.

    Angell (2008).

  196. 196.

    Angell (2008).

  197. 197.

    Angell (2008).

  198. 198.

    Angell (2008).

    Based on information from 2008, Angell estimated what happens to a healthcare dollar on its way from employers to physicians, nurses and hospitals that provide medical services. According to this author, private insurers in most cases skim a significant portion of the income out of premiums (about 15%–25%) for their administrative costs, marketing and profit margins. The rest is often channelled into what said author has described as a veritable array of satellite companies that have sprung up around the healthcare sector. These include brokers to close deals, disease management and utilisation review companies, drug management companies, legal services, marketing consultants, billing agencies, as well as information management companies. They also are responsible for siphoning off a large portion of the premiums, including enough for covering their own administrative costs, marketing and profit margins. According to Angell, it has been conservatively estimated that in 1999, 31.0% of all health care expenditures in the United States went to overhead, almost twice as much as the 16.7% similarly estimated at the time in Canada. (Cf. Angell (2008).)

  199. 199.

    Cf. Cf., furthermore,

  200. 200.

    Angell (2008).

  201. 201.

    Norris (2020).

  202. 202.

    Norris (2020).

  203. 203.

    Norris (2020).

    After the presidency of Truman, it would take yet another 20 years before some slimmed-down new plan for installing national health insurance would finally be turned into reality. Reference is made to “Medicare” itself that however did not address all Americans, but only those aged 65 and over, in addition to certain disabled young people. (Cf. Norris (2020).)

  204. 204.

    Norris (2020).

  205. 205.

    Norris (2020). For a detailed report on the signing ceremony, cf.

  206. 206.

    For an overview, cf. Norris (2020). Cf., furthermore, for a more detailed historical overview

  207. 207.

    Norris (2020).

  208. 208.

    Woolhandler et al. (2021), pp. 723–724.

  209. 209.

    Norris (2020).

  210. 210.

    Norris (2020).

  211. 211.

    Norris (2020).

  212. 212.

    Norris (2020).

  213. 213.

    Angell (2008).

  214. 214.

    U.S. Department of Health & Human Sciences (2005).

  215. 215.

    U.S. Department of Health & Human Sciences (2005). Cf., furthermore,

    Before Medicaid was created, limited federal payments were made to states for health care services they purchased for recipients of public assistance. In 1960, Congress authorized unlimited federal payments to states for health care services for indigent elderly. Yet in the early 1960s, states still varied widely in the extent of the health services they funded for low-income individuals and families. (Cf. U.S. Department of Health & Human Sciences (2005).)

  216. 216.

    U.S. Department of Health & Human Sciences (2005).

    States wishing to participate in the programme had to provide a basic package of health services to recipients of public assistance. They were also allowed to offer additional services at their discretion and could choose to help medically needy individuals who were not receiving assistance. (Cf. U.S. Department of Health & Human Sciences (2005).)

  217. 217.

    U.S. Department of Health & Human Sciences (2005).

  218. 218.

    U.S. Department of Health & Human Sciences (2005).

  219. 219. (2021).

  220. 220. (2021).

  221. 221.

    H.R.3590—Patient Protection and Affordable Care Act—111th Congress (2009–2010) For the full text cf.

  222. 222.

    Amadeo and Brock (2020).

  223. 223.

    Amadeo and Brock (2020).

  224. 224.

    Amadeo and Brock (2020).

  225. 225.

  226. 226.

    Amadeo and Brock (2020).

  227. 227.

    The poverty line usually rises each year to keep pace with inflation. People who earn too much for Medicaid get a tax credit if their income is below 400% of the poverty line. The credit is applied monthly, rather than as an annual tax credit. They also pay lower co-payments and deductibles.

  228. 228.

    Amadeo and Brock (2020).

  229. 229.

    Amadeo and Brock (2020).

  230. 230.

    Amadeo and Brock (2020).

  231. 231.

    Amadeo and Brock (2020). Registration is via the website

  232. 232.

    Amadeo and Brock (2020).

  233. 233.

    Amadeo and Brock (2020).

  234. 234.

    Rapfogel et al. (2020). Cf., furthermore, Robert Wood Johnson Foundation (2016).

  235. 235.

    Rapfogel et al. (2020); cf., furthermore, Robert Wood Johnson Foundation (2016), pp. 3–4.

    According to calculations made by the Robert Wood Johnson Foundation, an estimated 11.2% of the nearly 274 million Americans under the age of 65 were uninsured in 2015. The 2015 uninsured rate was, moreover, already significantly lower than the 18.0% uninsured rate in 2010 (i.e., before the ACA had been enacted). The adjusted uninsured rate for 2010, which took into account shifts in the composition of the population from 2010 to 2015, was 18.2%. Furthermore, nearly 19.2 million Americans gained insurance coverage between 2010 and 2015, representing a change in the uninsured rate of −38.4%. Americans in every age, gender, and race/ethnicity group surveyed by the Robert Wood Johnson Foundation were reported by the latter to have experienced an increase in health insurance coverage between 2010 and 2015. (Cf. Robert Wood Johnson Foundation (2016), pp. 3–4.)

  236. 236.

    Rapfogel et al. (2020).

  237. 237.

    Rapfogel et al. (2020).

    The ACA added a number of important new protections for people with pre-existing conditions. Among the reforms were changes to the rating rules, which no longer allow insurers to vary premiums based on gender or health status and limit their ability to vary premiums based on age. The ACA also introduced guaranteed issue, meaning insurers must issue policies to everyone and can no longer refuse people based on their health status. Another crucial protection for people with pre-existing conditions is the ACA’s requirement that plans must cover categories of essential health benefits, including prescription drugs, maternity care and behavioural health care. This prevents insurance companies from effectively excluding patients with higher costs by excluding basic benefits from coverage. The law also prohibits insurers from setting annual and lifetime limits on benefits, which previously denied some of the sickest people access to necessary care and provided Americans with insufficient financial protection against catastrophic medical episodes. (Cf., furthermore, Rapfogel et al. (2020).)

  238. 238.

    Rapfogel et al. (2020).

  239. 239.

    Woolhandler et al. (2021), p. 724.

  240. 240.

    Hawes and Phillips (1986).

  241. 241.

    Healthcare Management (2021).

  242. 242.

    In 2019, there were about 5141 community hospitals in the US. The majority of these hospitals were non-profit, while only about 1233 were for-profit. (Kahn (2019)).

  243. 243.

    Healthcare management (2021).

  244. 244.

    Healthcare management (2021).

  245. 245.

    School of Business at the George Washington University (2020).

  246. 246.

    School of Business at the George Washington University (2020).

  247. 247.

    Healthcare management (2021).

  248. 248.

    School of Business at the George Washington University (2020).

  249. 249.

    Kahn (2019).

  250. 250.

    Woolhandler and Himmelstein (2004).

  251. 251.

    Woolhandler and Himmelstein (2004).

  252. 252.

    Woolhandler and Himmelstein (2004).

    In the United States, there are, e.g., specialised for-profit hospitals that only offer cardiac or orthopaedic care. Most of these hospitals duplicate services available at nearby not-for-profit general hospitals, but the newcomers avoid money-losing programs such as geriatric care and emergency rooms (a common entry point for uninsured patients). The profits thus generated go to the investors of the private for-profit hospitals, where the losses go to the non-profit hospitals, and the overall cost to society increases due to the unnecessary duplication of expensive facilities. It has in this regard been pointed out that a real market would require multiple, independent buyers and sellers, with free access to the market, while in practice many hospitals exercise virtual monopolies. A city’s only hospital cannot compete with itself but can use its market power to boost its revenues. It is, therefore, not surprising that for-profit hospital companies in the United States have concentrated their purchases in areas where they can acquire a large share of the local market. (Cf. Woolhandler and Himmelstein (2004).)

  253. 253.

    Woolhandler et al. (2021), p. 727.

  254. 254.

    Woolhandler et al. (2021), p. 727.

  255. 255.

    Woolhandler et al. (2021), p. 727.

  256. 256.

    Woolhandler et al. (2021), p. 707.

  257. 257.

    Woolhandler et al. (2021), pp. 706–707.

  258. 258.

    Woolhandler et al. (2021), p. 707.

  259. 259.

    Woolhandler et al. (2021), p. 707.

  260. 260.

    Woolhandler et al. (2021), p. 708.

  261. 261.

    Woolhandler et al. (2021), p. 708.

  262. 262.

    Woolhandler et al. (2021), p. 708.

  263. 263.

    Woolhandler et al. (2021), p. 708.

  264. 264.

    Woolhandler et al. (2021), p. 708.

  265. 265.

    Woolhandler et al. (2021), p. 708.

  266. 266.

    Woolhandler et al. (2021), p. 708.

  267. 267.

    Woolhandler et al. (2021), p. 723.

  268. 268.

    Woolhandler et al. (2021), p. 723.

  269. 269.

    Woolhandler et al. (2021), p. 723.

  270. 270.

    Woolhandler et al. (2021), p. 724.

  271. 271.

    Cf. Jones (2016).

  272. 272.

    Cf. Jones (2016).

  273. 273.

    Woolhandler et al. (2021), p. 724.

  274. 274.

    The funds freed up by these cuts were to be redirected to cover the cost of tax breaks for corporations and the elimination of the ACA’s surtax on high-income individuals, granting them a USD 172 billion windfall. (Cf. Woolhandler et al. (2021), p. 724.)

  275. 275.

    Woolhandler et al. (2021), p. 724.

  276. 276.

    Woolhandler et al. (2021), pp. 724–725.

  277. 277.

    Rasmussen (2017). “Obamacare must be replaced,” Trump had declared in a speech on 1 November 2016. “And we will do it and we will do it very, very quickly. It is a catastrophe.” (Cf. Rasmussen (2017).)

  278. 278.

    In particular, Presidential Executive Order 13765.

  279. 279.

    Section 1 of Presidential Executive Order 13765 held the following: “section 1. It is the policy of my Administration to seek the prompt repeal of the Patient Protection and Affordable Care Act (Public Law 111-148), as amended (the “Act”). In the meantime, pending such repeal, it is imperative for the executive branch to ensure that the law is being efficiently implemented, take all actions consistent with law to minimize the unwarranted economic and regulatory burdens of the Act, and prepare to afford the States more flexibility and control to create a more free and open healthcare market”.

  280. 280.

    Rasmussen (2017).

  281. 281.

    Woolhandler et al. (2021), p. 724.

  282. 282.

    Woolhandler et al. (2021), pp. 724–725.

  283. 283.

    Woolhandler et al. (2021), p. 725.

  284. 284.

    Woolhandler et al. (2021), p. 725.

  285. 285.

    Cf. Executive Order 13813. Cf., furthermore, Pear et al. (2017).

  286. 286.

    Pear et al. (2017).

  287. 287.

    Webb (2017).

  288. 288.

    Webb (2017).

    Critics of the AHPs model pointed to a series of unintended consequences for patients and for the market as a whole. First, it was felt that the use of AHPs could lead to market segmentation that could threaten the viability of other insurance products, making it more difficult for high-cost individuals and groups to obtain coverage. Second, there were concerns that AHPs could circumvent state protection of patients, such as access to certain services (e.g. emergency rooms and specialists) or state solvency requirements. Third, some noted that AHPs would be unlikely to receive lower provider payment rates than larger insurance companies, but rather would have to “rent” provider networks and pay associated access fees—at the expense of the potential savings they could achieve. (Cf. Webb (2017).)

  289. 289.

    Luhby and Liptak (2017).

  290. 290.

    Back in October 2016, the Obama administration had made an attempt to curtail the use of such temporary plans as primary insurance, by limiting their duration to 90 days (instead of 364 days). By contrast, in Executive Order 13,813, the Trump administration highlighted the ACA non-compliant nature of these temporary plans as part of their appeal. As purportedly viable, alternative mechanisms for obtaining insurance, without having to comply with the mandates and regulations of the ACA, the Trump government hoped to extend the total length of time during which policyholders could have STLDI plans, as well as the number of times they could resort to such policies. Ultimately, support for a longer “short term” (364 days versus 90 days) would prove to be centred around the idea that STLDI was an attractive insurance alternative for some Americans, and that eliminating it through regulation—as a means of protecting or improving the ObamaCare health insurance exchanges—would amount to unfair government intervention. (Cf. Webb (2017).)

  291. 291.

    Webb (2017).

  292. 292.

    Luhby and Liptak (2017).

  293. 293.

    The two health insurance marketplace subsidies created by the ACA are the “premium tax credit” and the “cost-sharing subsidies”. The cost-sharing subsidies reduce out-of-pocket expenses (deductibles, co-payments and coinsurance) for marketplace participants with incomes from 100% to 250% of the federal poverty line who are enrolled in a silver plan. These CSR payments cost the federal government USD 7 billion in 2016, and seven million people—or 58% of all Obamacare enrolees—were eligible for these CSR subsidies for 2017. After the ACA was passed, the Obama administration began determining how it would pay for the cost-sharing reduction payments. While the Treasury’s permanent allocation for tax credits could be used for premium tax credits, Treasury advisors determined in 2012 that this allocation could not be used for CSR payments. After initially requesting an annual allocation of USD 4 billion for CSR payments in the FY 2014 budget, the Obama administration later withdrew this appropriation request, arguing that it was legally authorised to fund the CSR programme through the premium tax credit account. The House of Representatives filed a lawsuit against the Obama administration in July 2014, challenging government reimbursements to health insurers for CSRs on the grounds that Congress had not appropriated the money to fund them. In May 2016, the District Court for the District of Columbia ruled in favour of the House of Representatives, saying that the cost-sharing programme spent money not appropriated by Congress. Nevertheless, the court ruled that Congress had in fact authorised the creation of the programme. Although the Court’s ruling would have prohibited the CSR grants until there was a valid appropriation, the judge suspended the ban and allowed the grants to continue pending the appeal. After the election of President Trump, the appeal was stayed while the House and the Trump Administration attempted to negotiate a settlement. In February 2017, the House of Representatives and the Trump administration’s Justice Department asked the court to temporarily postpone a court ruling on the appeal to allow time for other solutions, including possible legislative action. After Congress failed to pass legislation to repeal/replace the ACA, the government decided to go ahead with the district court’s determination that the payments were unlawful, terminate the appeal, and immediately cease CSR payments. (Cf. Webb (2017).)

  294. 294.

    Webb (2017).

  295. 295.

    Pear et al. (2017).

    The Trump approach “would draw younger and healthier people away from the exchanges and drive additional plans out of the market,” warned Ceci Connolly, the chief executive of the Alliance of Community Health Plans. (As quoted by Pear et al. (2017).)

  296. 296.

    Pear et al. (2017).

  297. 297.

    Pear et al. (2017).

  298. 298.

    Woolhandler et al. (2021), p. 725.

  299. 299.

    Woolhandler et al. (2021), p. 725.

  300. 300.

    Woolhandler et al. (2021), p. 725.

  301. 301.

    Woolhandler et al. (2021), p. 725.

  302. 302.

    Woolhandler et al. (2021), p. 725.

    In Arkansas, the only state to implement these rules before the courts intervened, the new rules have created great confusion and bureaucratic obstacles for low-income beneficiaries, almost all of whom should have remained eligible for Medicaid. About 18,000 people were excluded from coverage without an increase in work participation. (Cf. Woolhandler et al. (2021), p. 725.)

  303. 303.

    Woolhandler et al. (2021), p. 725.

  304. 304.

    Woolhandler et al. (2021), p. 725.

  305. 305.

    Cf. Center for Budget and Policy Priorities (2021).

    According to the Center for Budget and Policy Priorities, based upon an estimation by the Urban Institute of October 2020, the striking down of the entire ACA would drastically increase the number of uninsured Americans by 21 million, or 69%. Striking down the ACA would not only end the ACA’s major coverage expansions—such as Medicaid expansion, premium tax credits, and health insurance marketplaces―but other important protections as well. This would harm tens of millions of people. Among the negative effects of striking down the ACA, the Center for Budget and Policy Priorities mentioned the following: “● Insurers could again resort to putting annual and lifetime limits on insured coverage, including for people with employer plans. ● Young adults would no longer be allowed to stay on their parents’ insurance plans up to age 26. ● Insurers would be allowed to reimpose cost sharing with regard to preventive services, including under employer plans and Medicare. ● Reversing the ACA’s alterations to how Medicare pays plans and providers, and to how state Medicaid programs determine eligibility, was expected to cause massive disruption. ● Medicare beneficiaries would face higher prescription drug costs due to the Medicare “donut hole” reopening”.

    By contrast, higher-income households would receive very large tax cuts from repeal of the ACA’s revenue measures, for an estimated average of USD 42,000 per year for those with incomes over USD 1 million. (Cf. Center for Budget and Policy Priorities (2021).)

    If the Supreme Court would throw out only parts of the ACA, the result could still be nearly as devastating. E.g., allowing insurers to again discriminate based on health status (including pre-existing medical conditions) would jeopardize coverage for millions who could be charged more, denied coverage for certain illnesses, or blocked from individual market coverage altogether—a particularly dire consequence during an ongoing pandemic. Eliminating ACA protections could also allow insurers to charge higher premiums to women and people in certain occupations, reimpose pre-existing condition exclusions in employer coverage, and make premium tax credits nearly impossible to administer. (On these concerns, cf. Center for Budget and Policy Priorities (2021).)

  306. 306.

    Woolhandler et al. (2021), pp. 725–726. Cf., furthermore, Pear et al. (2017).

  307. 307.

    US Department of Health and Human Services (2021).

  308. 308.

    Sachs (2018).

  309. 309.

    Sachs (2018).

  310. 310.

    Woolhandler et al. (2021), p. 726.

  311. 311.

    The subsidies, known as “cost-sharing reduction payments”, totaled USD 9 billion in 2018, and a projected amount of nearly USD 100 billion over the 2017–2027 period. (Cf. Pear et al. (2017).)

  312. 312.

    Pear et al. (2017).

  313. 313.

    Woolhandler et al. (2021), pp. 726–727.

  314. 314.

    Woolhandler et al. (2021), p. 727.

  315. 315.

    Woolhandler et al. (2021), pp. 733–734.

  316. 316.

    Assa and Calderon (2020), p. 17.

  317. 317.

    Rhodes et al. (2012) surveyed the situation in Europe from July 2010 to July 2011. The authors came to the conclusion that there were at the time 2,068,892 acute care beds and 73,585 (2.8%) critical care beds across Europe. The authors however noted that, due to a heterogeneous description of these beds in the individual European countries, it was not possible to distinguish between intensive care and intermediate care beds in most cases. On average, there were 11.5 intensive care beds per 100,000 inhabitants, with large differences between countries (Germany 29.2, Portugal 4.2). The authors also found that the number of critical care beds per country, adjusted for population size, was positively correlated with GDP (r2 = 0.16, p = 0.05), the number of acute care beds adjusted for population size (r2 = 0.12, p = 0.05), and the percentage of acute care beds classified as critical care beds (r2 = 0.59, p < 0.0001). These figures were however not correlated with the share of GDP spent on health care. Already at that time, the authors concluded that the number of emergency care beds varied significantly between countries in Europe and that a better understanding of these numbers was needed to enable better planning of emergency care capacity and use in the future. (Cf., furthermore, Rhodes et al. (2012).)

  318. 318.

    Rhodes et al. (2012).

  319. 319.

    Rhodes et al. (2012).

    In their study, Rhodes et al., found that in many countries precise and easily accessible data on the number of ICU beds were simply not available. In some countries, such as the United Kingdom, there was government census data. In others, data were available through national associations (e.g., Germany). In others, no data were available and local clinicians had to count the beds themselves (e.g., Portugal). There were also clear differences in the design of intensive care services between countries: in some countries, intensive care services were separate from intermediate care services, while in others, both services were managed flexibly within one service. Some countries also had a higher level of care in acute general wards, e.g., the Czech Republic. For the period July 2010–July 2011, the authors found a total of 2,068,892 acute care hospital beds in Europe, with clear differences in the total number of beds, as well as in the number of adjusted beds per 100,000 inhabitants between countries. On average, there were 409 acute care beds per 100,000 capita. For the whole of Europe, a total of 73,585 intensive care beds had been identified. This corresponded to an average of 11.5 beds per 100,000 inhabitants for Europe as a whole. The country with the highest number of beds was Germany (23,890), and the country with the lowest number of beds was Andorra (6). When the total number of beds per country was adjusted for population size, the differences became less pronounced, but were still present. Germany remained the country with the highest number of beds (29.2/100,000), while Portugal had the lowest number of beds (4.2/100,000). The total number of intensive care beds per country, adjusted for population size, was, furthermore, positively correlated with population size (r2 = 0.69, p < 0.0001), but only weakly correlated with the country’s gross domestic product (GDP) (in millions of US dollars) (r2 = 0.16, p = 0.05), the proportion of GDP spent on health care (r2 < 0.0001, p = 0.91) or the proportion of elderly patients in the population (r2 = 0.04, p = 0.31). On average, there were 2.8 emergency care beds for every 100 acute care beds in Europe. Again, however, there were large differences, with Germany and Luxembourg having the highest rate at 5.1/100,000 and the Czech Republic the lowest (1.3/100,000). The number of acute care beds was correlated with the number of acute care beds adjusted for population size (r2 = 0.12, p = 0.05) and also with the percentage of acute care beds relative to emergency care (r2 = 0.59, p < 0.0001). (All this quoted information being provided by Rhodes et al. (2012).)

  320. 320.

    Rhodes et al. (2012).

  321. 321.

    Corporate Europe Observatory and Tansley (2021), p. 7.

  322. 322.

    Assa (2021).

  323. 323.

    Corporate Europe Observatory and Tansley (2021), p. 8.

  324. 324.

    Corporate Europe Observatory and Tansley (2021), p. 11.

  325. 325.

    Corporate Europe Observatory and Tansley (2021), p. 11.

  326. 326.

    Corporate Europe Observatory and Tansley (2021), p. 12.

  327. 327.

    Bossaert (2021).

  328. 328.

    Corporate Europe Observatory and Tansley (2021), p. 9.

    In April 2020, UEHP even had dared to write to EU institutions emphasizing that private hospitals’ engagement in the public health Covid-19 crisis had shown that they were an “indispensable element” and “should be acknowledged as partners with equal rights”. The Covid-19 pandemic was thus being used as another argument for why private for-profit hospitals should be on a level playing field with public hospitals in terms of receiving public funds. UEHP had also been lobbying as part of EU Health Coalition (whose members include pharma lobby “EFPIA” and biotech lobby “Europabio”) to ensure that the EU’s multi-billion Covid-19 recovery plan would prove profitable enough to them. The EU Health Coalition particularly welcomed the Recovery Plan for Europe’s second strand, which aims to support “more efficient and inclusive health systems”. It also made reference to the Commission’s “European Semester” Country Specific Recommendations, which has historically been a tool pushing cuts to public healthcare expenditure (cf. Sect. (Cf. Corporate Europe Observatory and Tansley (2021), p. 10.)

  329. 329.

    Cf. Byttebier (2017), pp. 71 and 215–217.

  330. 330.

    Saad-Filho (2020).

  331. 331.

    Cf. Byttebier (2017), pp. 184–206.

  332. 332.

    Cf. Byttebier (2017), pp. 216–217.

  333. 333.

    Under the pressure of the pandemic, services were changed beyond recognition; online working became the norm in countless areas in a matter of days instead of the years this transition would normally have taken, while the neoliberal worship of consumption dissolved into empty supermarket shelves, fights over hand sanitiser, pasta and sardines and fistfights over toilet paper. (Cf. Saad-Filho (2020).)

  334. 334.

    Saad-Filho (2020). This author adds to these observations that this plundering strategy deployed by the United States seriously damaged the legitimacy of the American Empire.

  335. 335.

    Assa and Calderon (2020), p. 17.

  336. 336.

    Assa and Calderon (2020), p. 17.

  337. 337.

    Bossaert (2021).

  338. 338.

    The question is, however, to what extent this estimate itself is entirely accurate and adequately takes into account that the fact that there were no shortages of ICU beds (during the first wave of the Covid-19 pandemic) was also the result of elderly people being systematically denied access to hospitals in order to die at home or in their retirement homes instead. (Cf. Sect.

  339. 339.

    Foulon (2021).

  340. 340.

    Federaal Kenniscentrum voor de Gezondheidszorg (2020).

  341. 341.

    Médecins sans frontières (2020).

  342. 342.

    Foulon (2021).

    Still according to Foulon, the problem with the nursing homes during the first wave of the Covid-19 pandemic, has not been limited to Belgium, but has occurred in most European countries. For years already, there had been a shortage of both resources and qualified personnel in this whole sector. Nursing homes had in many cases become at the mercy of private investors who are mainly out to make profits. The fact that there are more elderly people because of an increased life expectancy, is hereby clearly no longer seen as a positive fact by European, neoliberal policymakers. For them, the elderly have become a too expensive burden on society. The Covid-19 pandemic has made this very clear. (Cf. Foulon (2021).) In Belgium, it has even become easier for an elderly person to get euthanized, than to be cared for, while many of the elderly people themselves have been given the feeling that they are but a burden to society, and that euthanasia is in this regard basically an act of kindness bestowed on them by the best of (neoliberal) societies…

  343. 343.

    Foulon (2021).

  344. 344.

    Corporate Europe Observatory and Tansley (2021), p. 7.

  345. 345.

    Corporate Europe Observatory and Tansley (2021), p. 7.

  346. 346.

    Corporate Europe Observatory and Tansley (2021), p. 7.

  347. 347.

    Corporate Europe Observatory and Tansley (2021), p. 7.

  348. 348.

    Corporate Europe Observatory and Tansley (2021), p. 7.

  349. 349.

    Corporate Europe Observatory and Tansley (2021), p. 7.

  350. 350.

    Dettmer (2020). According to this author, the National Association of Internal Medicine also called for a total national lockdown, urging that the situation, which it described as “dramatic”, was not be trivialized.

  351. 351.

    Corporate Europe Observatory and Tansley (2021), p. 10.

  352. 352.

    Corporate Europe Observatory and Tansley (2021), p. 10.

  353. 353.

    Campbell and Barr (2021). Cf., furthermore, Otte (2021).

  354. 354.

    Campbell and Barr (2021).

  355. 355.

    Campbell and Barr (2021).

  356. 356.

    Dettmer (2020).

  357. 357.

    Gaffney (2020).

  358. 358.

    This had already been the case in the period July 2010–July 2011. The overall number of critical care beds for Europe was in that period 11.5/100,000 head of population. This was in marked contrast to the number for the United States, which was found to be 28/100,000 in 2010. (Cf. Rhodes et al. (2012).)

  359. 359.

    Gaffney (2020).

  360. 360.

    Rhodes et al. (2012).

  361. 361.

    Gaffney (2020).

  362. 362.

    Navarro (2020).

  363. 363.

    Navarro (2020).

  364. 364.

    Navarro (2020).

  365. 365.

    Navarro (2020).

  366. 366.

    Navarro (2020).

  367. 367.

    President Donald Trump had, more generally, at that time suspended 20% of the federal programmes for infectious emergencies and at the same time disbanded the National Security Council’s pandemic response team (cf. already Sect. As a result, the National Security Council had started to focus its activities exclusively on military security and to abandon its security activities related to the general well-being of the American population. President Donald Trump had in a similar manner severely cut back on the research funds and activities of the National Institutes of Health, including research on coronaviruses (of which the Covid-19 virus itself forms a strain). It is hereby assumed that if the National Institutes of Health would have been allowed to continue or complete their research, this would have helped to prevent or at least contain the Covid-10 pandemic. (Cf. Navarro (2020).)

  368. 368.

    Navarro (2020).

  369. 369.

    Navarro (2020).

  370. 370.

    Nelson (2020).

  371. 371.

    As we shall explain further in the text, as of the end of 2020, this “buy-from-the-cheapest-source mentality” has also been one of the factors explaining the complete “fiasco” of the European vaccination strategies. (Cf., furthermore, Sect. 9.4.)

  372. 372.

    U.S. Department of Health & Human Services Office of Inspector General (2020).

  373. 373.

    Assa (2021).

  374. 374.

    Assa (2021).

  375. 375.

    AJMC Staff (2021).

  376. 376.

    AJMC Staff (2021).

  377. 377.

    AJMC Staff (2021).

  378. 378.

    U.S. Department of Health & Human Services Office of Inspector General (2020).

  379. 379.

    U.S. Department of Health & Human Services Office of Inspector General (2020).

  380. 380.

    U.S. Department of Health & Human Services Office of Inspector General (2020).

  381. 381.

    U.S. Department of Health & Human Services Office of Inspector General (2020).

  382. 382.

    U.S. Department of Health & Human Services Office of Inspector General (2020).

  383. 383.

    U.S. Department of Health & Human Services Office of Inspector General (2020).

  384. 384.

    U.S. Department of Health & Human Services Office of Inspector General (2020).

  385. 385.

    Woolhandler et al. (2021), p. 734.

  386. 386.

    Woolhandler et al. (2021), p. 733.

  387. 387.

    Woolhandler et al. (2021), pp. 733–734.

  388. 388.

    Ironically, the negative effects of the Trump administration’s environmental and occupational rollbacks have taken their largest toll in states whose voters heavily supported President Trump in the 2016 election. By contrast, comparatively progressive states that have maintained robust state-level protections lessened the effect the rollbacks have had on health. (Cf. Woolhandler et al. (2021), p. 734.)

  389. 389.

    Woolhandler et al. (2021), p. 734.

  390. 390.

    Corporate Europe Observatory and Tansley (2021), p. 22.

  391. 391.

    Sumonja (2020).

  392. 392.

    Corporate Europe Observatory and Tansley (2021), p. 22.

  393. 393.

    Corporate Europe Observatory and Tansley (2021), p. 22.

  394. 394.

    Corporate Europe Observatory and Tansley (2021), p. 22.

  395. 395.

    Corporate Europe Observatory and Tansley (2021), p. 22.

  396. 396.

    Corporate Europe Observatory and Tansley (2021), p. 22.

  397. 397.

    Corporate Europe Observatory and Tansley (2021), pp. 22–23.

  398. 398.

    Corporate Europe Observatory and Tansley (2021), p. 23.

  399. 399.

    Corporate Europe Observatory and Tansley (2021), p. 23.

  400. 400.

    Corporate Europe Observatory and Tansley (2021), p. 23.

  401. 401.

    Corporate Europe Observatory and Tansley (2021), p. 24.

  402. 402.

    Viens (2019).

  403. 403.

    Assa and Calderon (2020), p. 19.

  404. 404.

    Reinhart et al. (2021).

  405. 405.

    Saad-Filho (2020).

  406. 406.

    Cf. Byttebier (2017, 2018, 2019, 2021).

  407. 407.

    Saad-Filho (2020).

  408. 408.

    Viens (2019).

  409. 409.

    Cf. in particular Byttebier (2017, 2019).

  410. 410.

    Cf. Byttebier (2017), Chapters 4 and 5 (pp. 353–487). Cf., furthermore, Byttebier (2019), Chapter 5 (pp. 137–180).

  411. 411.

    Compare Saad-Filho (2020): “States must secure jobs, incomes and basic services, including the rapid expansion of the health system. This is not merely for reasons of economic policy but as part of efficient health policies: guaranteed jobs and incomes make it possible for more people to stay at home, which will ease the load on the health system, speed up the end of the pandemic and accelerate the recovery. In order to do this, the banking system should be nationalized to secure the flow of credit and prevent speculation and Central Banks should ensure that there is enough liquidity to keep the economy afloat. Key services should be taken over by the state to ensure that basic needs are served and if the central authorities can give tens of billions to the airlines, the railways, health providers and supermarket chains, the public might as well own them”. (Cf. Saad-Filho (2020).)

  412. 412.

    Cf. International Monetary Fund (2021).

  413. 413.

    As explained in Byttebier (2019), pp. 164–169, such a system of financing states could imply that, each (working) year, each of the participating states would obtain a working budget out of the hands of the in Chapter 5 of Byttebier (2019) proposed (N)MWI that should enable it to install and maintain a new type of state model, thus turning the “repressive state model” presently prevailing under the yoke of capitalism, into a “care state model” based upon a view on society that all people should be willing to take care of each other.

  414. 414.

    Cf. especially Byttebier (2015a, 2017).

  415. 415.

    Cf. Byttebier (2019), pp. 186–187.

    Galbraith has defended this approach in his usual (brilliant) way: “But merely to list them is to cf. that all are, in substantial measure, at public cost. Thus the problem: rather than take on that cost, it is far easier for the comfortable to find flaws in the character of those who make up the underclass and increasingly also in the immigration law and their enforcement. And to find social virtue in a seemingly principled resistance to taxation and the invasive state. And, as trouble looms, to call for more police and more stringent jail sentences or to move to the suburbs”. (Galbraith (1995), p. 265.)

  416. 416.

    World Health Organization (2014), p. 23.

  417. 417.

    Global Conference on Primary Healthcare (2018), under point I.

  418. 418.

    Cf. Byttebier (2019), pp. 192–194 (as regards healthcare) and pp. 196–197 (as regards elderly care). Cf., furthermore, World Health Organization (2014), p. 23.

    By granting states the means to focus on prevention, the costs for such a universal healthcare could even be kept within very reasonable boundaries. (Cf. World Health Organization (2014), p. 23.) According to the WHO, the per capita cost for a preventive universal healthcare would be representing only an annual investment of under USD 1 in low-income countries, USD 1.50 in lower middle-income countries and USD 3 in upper middle-income countries. Also according to the WHO, these figures represent just 1–4% of current health spending. (Cf; World Health Organization (2014), p. 23.)


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Byttebier, K. (2022). General Healthcare. In: Covid-19 and Capitalism. Economic and Financial Law & Policy – Shifting Insights & Values, vol 7. Springer, Cham.

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