Where is the site of struggle in healthcare?

What the fight for health communism looks like under the current regime, and what strategies may help us move forward

This afternoon, as President Trump prepares to sign the “GOP Murder Bill” into law, Artie and I spoke alongside Vicky Osterweil at this year’s Socialism Conference in a session titled Deny, Defend, Depose: Health Struggle After Luigi.

We’ve received a number of requests for a written version of our remarks, and as Artie and I’s were written as a sequential pairing, we wanted to quickly put them together here to make them available.

Audio of the session will also be available soon in the Death Panel podcast feed, which will include Vicky’s remarks.

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Artie Vierkant:

Good morning.

As the title of this panel refers to the person I’ll call “Allegedly Luigi,” I want to start with a few words about the event that I’m sure is top of mind for those coming here today.

The morning of December 4th, the end of last year, many of us woke up to incredible news: an unidentified individual had shot the CEO of one of the largest private health insurance companies in the US, and one of the most ruthless.

Even more incredible — and I’m using that word literally, in the sense of “extraordinary” — was that the following days were filled with an outpouring of support for the act from across the political spectrum.

People left and right cheered on a new folk hero. Even on Ben Shapiro’s YouTube channel, when he first tried to cry foul about the event, his own right wing viewers left comments in support of the act and telling him to “read the room.”

Seemingly the only people in public life who were willing to be upset about it were opportunists like Shapiro himself, and dependably reactionary cable news talking heads. Who mostly, by the way, directed their ire at the people: how could people possibly be celebrating this? What has come of society?

But what this mass response demonstrated is just how fundamental the experience of state abandonment is to anyone living in this country

Because we all know why he did it.

No one had to ask, “why?”

For all the pearl clutching that has happened in the months since, for all the spectacle of Eric Adams personally perp walking Allegedly Luigi — not one person has to ask “why?”

Everyone in this room knows that having health insurance deny care kills. Just as I’m sure everyone in this room who’s a healthcare worker has seen again and again the choices people have to make when they can’t afford their care or they’re already buried in medical debt, or they’ve had to avoid care altogether for so long they’ve become more sick. So many of us know all too well what it feels like to have to choose between going to the doctor and paying rent. Or going to the doctor and being able to eat. And for too many of us, even that choice would seem a luxury. We can’t afford the rent, we can’t afford to eat, and we certainly can’t afford to be sick.

The state and the ruling class know it too. They just call it something detached-sounding like “financial toxicity” — a real term for the added likelihood of death for people who have a serious illness like cancer who cannot pay the extraordinary ransom our society demands they pay to buy their own survival.

Health insurance companies are financial institutions that act as middlemen, siphoning profit off of our misery, doing social murder and calling it social good. Health insurance companies produce capital from slowly killing us. There is no place for them in society.

They are also just one part — of one part — of a massive system. The healthcare system, from who pays for healthcare, to the sites where healthcare happens, who does the caring, who is cared for, and who is abandoned — is a massively distributed beast.

And intentionally so. The massive distribution of the healthcare system is, truly, the main reason we have yet to be able to tear it down.

When we fight for health and disability justice, so often we have to first choose a field of struggle.

Is our target who pays for healthcare? If so, who are we organizing, and who are we organizing against?

Do we pick a single health insurance company that is a particular bad actor, in a field of exclusively bad actors?

Is our target the state? If so, which part of the state health payment architecture? Medicaid? Medicare? The VA? The regulations on ACA plans? The IHS? If it’s Medicaid, how do you form alliances across state lines when Medicaid is so hyper fragmented state by state? Or even, within states? When I posed this very question recently to our friend and collaborator, and Death Panel co-host, Phil Rocco, he talked to me about how the state of Wisconsin’s Medicaid program is not actually one thing, but, as he put it, an archipelago of 24 separate programs operating within the state.

And note that here I’ve only just addressed insurance and who pays — you can do the same with hospital systems, pharmaceutical companies, electronic records companies, the list goes on.

This is what I mean when I say that this massive distribution is intentional. This is an architecture of counterinsurgency.

It is designed to make us feel powerless. It is designed to seem to be too big to fail. Which is what makes the events on the morning of December 4th all the more extraordinary. All of us are used to being thrown around by the health system and having care denied by seemingly faceless companies. In this one act, we are reminded that this system does have a face; and it has many.

So this brings me to the central question I want to leave us with for the rest of the panel, and the rest of our discussion today. Where is the site of struggle in healthcare? Or rather, where are the sites of struggle? Where can we act?

Because, as we meet here today, we are at war. We are assailed on nearly every front of the health struggle.

The state has been captured by a movement that is enacting a health fascist agenda.

What do I mean by that? I don’t have to explain to anyone here why, or in what ways, MAGA is fascist.

But the reason I say “health fascism” to refer to the eugenic wellness arm of the MAGA movement is because there is a fundamental difference between this second Trump administration and the first one, that we all must understand if we hope to defeat it

Because for the first time in decades, the right has managed to create for itself an ideology around health and healthcare that has allowed it to seize the narrative on health

And there are two aspects of this

One is the Make America Healthy Again agenda.

Beatrice will be speaking more about this and how we defeat it. But suffice it to say that behind promises to move “from a sick care system to a wellness society,” in Robert F. Kennedy Jr.’s words, is an actually existing agenda for cutting programs that provide treatments or fund research, cutting public health, and cutting health, labor, and environmental regulations of all kinds that exist explicitly to slow social murder. And explicit in RFK’s claims about wanting to reduce the population of people with chronic disease, or reduce the amount of people who take medication — is an eliminatory impulse that is more about pushing the sick out of society than it is about raising all of our collective quality of life.

The second aspect converging to form the health fascist agenda is what I would call, simply, old fashioned Republican austerity politics.

We are speaking together on the Fourth of July. Exactly seven months from the events of that December morning

And today Trump and the fascist right are celebrating the passage of what has been appropriately derided as the “GOP Murder Bill.” Last I read, Trump plans to hold a signing ceremony at 5pm today.

It is a bill that will strip an estimated 1 trillion dollars out of Medicaid, instead piling a truly catastrophic sum into ICE and mass detainment and deportation.

As one immigration policy analyst noted, it will make ICE “the single largest federal law enforcement agency in the history of the nation,” “with more funding for detention than the entire Federal Bureau of Prisons”

So one trillion dollars out of Medicaid. The healthcare program for the very poor, the program of last resort. Medicaid, far and away the single most important provider of long term care for disabled people in this country.

Tens of millions kicked off the program. Causing, by one estimate, 50,000 additional deaths a year just from creating new uninsured — the bill has the same burden as the average influenza season. Taking so much money out of one of the biggest sources of health coverage in the US that entire hospitals and health clinics will close, and many that don’t will contract, deepening existing crises of under-resourcing and understaffing. (One example that already happened, Vicky will be talking about). All this coming just years after the Medicaid unwinding under Biden, where millions more were kicked off of Medicaid — before the unwinding, as recently as March 2023, 95 million people were on Medicaid — fully one quarter of the US population. And adding work requirements to Medicaid, a draconian, onerous, and unnecessary additional means test that would have been politically unthinkable just years ago. All to fund the expansion of the American gestapo, to fund a wealth transfer from the poor to the rich, and to keep sending bombs to the genocidal settler colony.

The damage done by the One Big Beautiful Bill alone may in itself be so cataclysmic that it, perversely, removes so much of the legacy of great society era welfare programs that it opens space for our demands to fully remake the healthcare system as a communal good.

But again, this is just one front.

We have also seen:

Ongoing, brutal cuts to health agencies, and to basic research;

central figures who did consent manufacture for endless covid spread joining the federal government in top administrative roles — while at the same time state, local, and federal officials push for mask bans and criminalize mutual aid — something that represents the state equally targeting ongoing covid and long covid organizing as it also targets movements in solidarity with Palestinian liberation;

major attacks on trans life and trans healthcare — from the Supreme Court’s recent decision in Skrmetti, to Trump’s HHS manufacturing anti-trans research, to the fact that the budget they just passed had a totalizing, Hyde amendment style ban on Medicaid covering trans care in it up until the very last moment — and we can’t assume they won’t circle back for it;

the castigation of the disabled and sick, with people like CMS administrator and former TV crank Dr. Oz admonishing us of our “patriotic duty” to be healthy specimens of the body politic because, in his words, “healthy people do not consume healthcare resources;”

ongoing threats to massively expand psychiatric incarceration, from Trump’s campaign promises to “reopen the asylums” to New York Democratic Kathy Hochul, a Democrat, holding up her state’s budget bill for weeks this spring, in an effort to secure an expansion of involuntary commitment and a mask ban;

the attempted pitting of migrant organizing against healthcare organizing, in the Trump administration telling states to withdraw coverage from undocumented people, at the very same time as the administration sends ICE into hospitals — which the healthcare workers here and listening to this must be on the front lines of resisting;

and I could go on.

There’s a word for this historically, and that word is eugenics — a fantasy of health that has always drawn its boundaries along lines of class, race, madness, disability, or whatever the state decides is “deviant” in a particular moment, including political beliefs — thus why we see all of these explicit attacks on poor people, disabled people, trans people — and further anyone who doesn’t support their fundamentally white supremacist vision of the American State

And it’s worth saying, of course, that this doesn’t come out of nowhere. This is an escalation. And it’s an escalation that’s been enabled by years of Democrats embracing the idea that “waste, fraud and abuse” is a bigger problem to solve in healthcare than our inability to obtain it. And enabled by years of the Biden administration trying to hide a mass disabling event, the covid pandemic, in plain sight. And by years of liberals and major media organizations like the New York Times laundering anti-trans propaganda under the guise of “just asking questions.”

And it’s an escalation in the sense that this type of abandonment is a fundamental component of capitalism, a feature, not a bug. Bea and I’s book Health Communism is in large part an attempt to trace this historical arc as a bedrock of capitalism, something that existed by other names long before the 19th century brought us the term “eugenics.” That a fundamental part of capitalism’s architecture is social murder, and that capitalist states always operate somewhere on the spectrum of eugenic policy, before it even had that name.

I say all this because because it is important that we are clear about what we are up against

We are not just up against the current administration ripping and tearing through the federal government. We can’t just fight to reset the baseline to a pre-Trump health regime.

To beat health fascism we will need a new, liberatory politics of health that gives no quarter to the health politics of the past, which has remained obsessed with “deservingness” and keeping costs down. You cannot defeat fascism with a tax subsidy on Obamacare plans. You cannot defeat fascism by simply converting police into mental health police.

And the complexity of the system can make it seem almost impossible to act.

Again, that is the point of the system. To make healthcare workers worry about risking their license and class position if they stand in solidarity with patients; to reinforce that if a Young Lords style hospital seizure happened today, somewhere, in an office in Wisconsin, EPIC would remotely shut down access to key records and functions of any new ‘people’s hospital.’ To reinforce that they will always find another Brian Thompson, just maybe the new one will have dye their hair to obscure their appearance — as one UnitedHealth executive did at the end of last year.

But it is not impossible to act.

What it will require however is that we take tremendous risk together.

Even as we fight to defend Medicaid

Even as we fight for Medicare for all

We can fight to topple the system and at the same time work to articulate what our actually liberatory vision of health would be.

And at the same time, build survival programs that are almost certainly going to be what is required in the immediate future of our struggle under health fascism, a bedrock for what we want the future of collective care to be, and a way that we can start practicing that new vision today.

And so as I prepare to pass it on to Beatrice and Vicky, I want to reiterate my questions from earlier. These are questions equally for our discussion together today, as they are for each of you. By which I mean, these are questions I want us all to be asking ourselves today and as we try to think bigger about what we can do together:

Where is the site of struggle in healthcare? Where are the sites of struggle? Where can we act? What can I do, from whatever position I’m in? What is a skill I have that I can offer outside of the system as it exists, even if it means taking on risk? What do I need to survive? What does my comrade need to survive? Can I give it to them? Can I mix estrogen? Can I distribute N95s, or just start wearing one in public again if I stopped? Can I learn to do home care to keep just one comrade alive? Can I teach my friends to do the same? What can I do to keep my comrades from being put in a psych hold? I could go on. These are all sites of struggle just as important as our fights against big systemic federal policy changes. And many of them are things we can take action on today.

We must provide care to each other by any means necessary.

Thank you.

Beatrice Adler-Bolton:

When we talk about the site of struggle in healthcare, we’re trained to look inside the machine: hospitals, statehouses, congress, policy memos, think tanks, spreadsheets. We’re taught to believe that change comes from adjusting the inputs, streamlining and balancing formularies, refining incentives, expanding coverage gradually, one bill at a time. We’re told that the struggle for health justice is a matter of expertise, of lobbying, of backroom negotiations, of merely tweaking the funding mechanisms.

But I want to offer us a provocation that points us in a different direction: What if the site of struggle is not inside the system at all? What if it is in the refusal to accept the system’s supposed limits? In refusing the legitimacy of those limits?

To answer that, we need to start by asking a question that is deceptively basic, and is in fact incredibly hard to answer: What is care? Not care as it appears in the dogma of reimbursement codes, in metrics, statistics, or clinical workflows. Not care as in eligibility or compliance, but care as people want to experience it and as they imagine it. As they need it to be. As we long for it to be. Care as an act of mutual responsibility. Care as a relation. Care as a commitment. Care as a set of material conditions that are met, and in so doing life is made possible.

Because the truth is, most people hold an expansive vision of what care ought to be. And they are right to. We imagine care means being tended to when sick, receiving support in moments of crisis, living with dignity. We imagine care means being seen, believed, held, treated. We imagine that care is widely available. That it can heal. Offer answers, transparency. That it is ours.

But the reality? Our healthcare system is an engine of abandonment. It is a bureaucracy of denial wrapped in the language of compassion. It is extraction masquerading as benevolence. We get rationing disguised as triage, exclusions justified by rigged cost benefit analysis. It does not protect us. It withholds and punishes us. It profits from our suffering. And turns our longing for care into a transaction that few can afford. And even fewer can rely on. The more in need you are, the more disposable you become.

The reality of care is the ambulance you don’t call because you’re worried about what it will cost. The diagnosis you don’t get. The meds you ration or go without. The surgeon who was out of network. The waitlist you’ll never live to see the end of. The nurse who doesn’t have time to listen. The care worker, working two jobs, burned out and blamed. Means-testing. Work requirements. Step therapy. Denials. Appeals. Ghost networks.

And yet we still cling to our dream of care. We must. Because people know what care should be like. What it should feel like. Not because we are naive, but because we are right. Because even in the wreckage, we remember what care should feel like. We know it deep in our bones. That memory is powerful. That fantasy is revolutionary. And it tells us something important and often overlooked: our demands are not too big—they aren’t big enough.

Now is the time to revive the call for Medicare for All—not as a nostalgic slogan, but as a reasonable demand grounded in urgency, clarity, and collective power. The pandemic tore off whatever was left of the myth that our health system works. Millions have been abandoned. Labor conditions for the healthcare workforce have deteriorated. Disabled people, elders, young people, migrant and low wage workers, teachers were sacrificed for the economy. All the while the for-profit insurance companies raked in record profits, while the healthcare system—caught in the chokehold of private equity—continues to consolidate and cannibalize itself in the name of efficiency.

Medicare for All offers us not a final solution but a foundation. One that if done with precision and resolve could immediately end the tyranny of employer-based insurance, eliminate medical debt, and deliver universal coverage while creating new possibilities for organizing beyond the limits of the current system. It is often talked about like it is just too much to ask. But Medicare for All is the most winnable, most transformative, most basic policy demand on the table.

That is why I end every episode of Death Panel with “Medicare for All Now.” Because we need it, urgently, materially. And yet, we cannot mistake it for the finish line. Medicare for All is the floor, not the ceiling. It is the beginning of something not our distant and shared horizon. It's a tool—not the goal. We need to reinvigorate the fight for it, not because it will fix everything, but because it cracks open the terrain.

Yes, it gives access to more people. But it gives access to a system that still doesn’t work for most people. It softens the blow, but it doesn’t transform the logic. It still routes care through the same institutions, systems, and values that made care so cruel in the first place. Redesign the funding, but leave the gears unchanged, and the machine will grind on without mercy or redemption. We can grease the wheels with gold, but the rusted engine of power will still spew oppression—

The problems we face are deeper than access. We are living under a regime that extracts value from illness, that disciplines need, that disposes of the surplus. It does not need to be “fixed.” It needs to be confronted, dismantled, and replaced with something rooted in solidarity, not scarcity. If we want to win real health justice, we have to say clearly: We can’t let the system define the terms of our demands. And we cannot accept a vision of health reform that leaves the most vulnerable behind in order to win the “middle.”

Eldercare is crumbling. Long-term care is treated like a fiscal liability instead of a basic social good. People are dying in nursing homes that operate as decentralized, austerity-driven warehouses. In-home care remains unfunded, undervalued, and excluded from every “serious” conversation about healthcare. Drugs developed with public funding are locked behind patents and priced like luxury commodities maximized for shareholder profit, not survival. We’re told innovation requires this cruelty—but we know better.

…In the end, our elders slip into oblivion beneath flickering fluorescent lights, while care workers—crushed by impossible demands and invisible chains—stand as quiet witnesses to this cruelty, their exhaustion a testament to a system that profits from their sacrifice. And all the while, the architects of this atrocity toast their dividends with blood-stained hands.

And we cannot afford to wait—just as we’ve long said in the fight for Medicare for All, we needed it yesterday.

Because what we face today isn’t just neglect or the rot of profit-driven incentives; it’s the rise of health fascism, tightening its grip as we speak. The rise of Robert F. Kennedy Jr. 's “Make America Healthy Again” campaign has stirred up a lot of energy and concern. On the surface, MAHA sounds like it’s about healing, about fixing a broken system. But the reality is far more complicated, and far more dangerous. Its appeal is rooted in a widespread, deeply felt experience of abandonment by our healthcare system, a system that feels extractive, cruel, expensive, and overall indifferent to everyday suffering.

People are angry, and that anger is real. But MAHA redirects it away from the structural forces that create this crisis toward conspiracy and scapegoating. MAHA is seductive because it speaks to real pain. The pain of being abandoned. But it offers no solidarity, only self-management. Not justice, only blame. Not transformation, only cruelty disguised as wellness. MAHA says: don’t change the system—change yourself. Purify your body. Deny your kid vaccines. Blame the sick for their sickness. It’s magical thinking for a carceral state.

The problem isn’t that simple, we are talking about a massive decentralized system that is organized by competing logics and contradictory incentives, that ultimately is most efficient at extracting profit from sickness while abandoning those who need care most. The collective reality of health under capitalism is complex: We are not all sick, but none of us is well. Wellness isn’t an individual achievement, it’s a social condition shaped by work, housing, food, environment, and care (or the lack of it).

But what would it actually take to make people in this country healthy—not temporarily, not personally, but systemically?

It would take everything. It would take housing, clean air, clean water, food, rest, reproductive autonomy, trans care, elder care, child care, long-term care. It would take freedom from policing, incarceration, borders, medical debt. It would take climate justice, labor justice, racial justice, and the abolition of for-profit care. In other words: it would take transformation, not optimization.

In the world we live in, health is a commodity. Our system of care tears apart the connections between patients, healthcare workers, public health, scientists, researchers, and communities. It pits worker against patient, patient against patient, divides care into market transactions, and erases the collective labor that makes life possible. This extractive abandonment is structural violence, both material and epistemic.

It is social murder: as Engels wrote,

...when society places hundreds of proletarians in such a position that they inevitably meet a too early and an unnatural death, one which is quite as much a death by violence as that by the sword or bullet; when it deprives thousands of the necessaries of life, places them under conditions in which they cannot live – forces them, through the strong arm of the law, to remain in such conditions until that death ensues which is the inevitable consequence – knows that these thousands of victims must perish, and yet permits these conditions to remain,its deed is murder just as surely as the deed of the single individual; disguised, malicious murder, murder against which none can defend himself, which does not seem what it is, because no man sees the murderer, because the death of the victim seems a natural one, since the offence is more one of omission than of commission. But murder it remains.

So what is the antidote? It has to be bigger than a program. It has to be bigger than reform.

The antidote is health communism. What I mean by health communism is this: a refusal to let the system define who is worth caring for. It’s an insistence that all care for all people is not a dream—it’s our demand. Our demand right now, not 15 years down the line. Today.

And the good news is we don’t need to invent this world from scratch. It’s already being built. Let me tell you where care lives. Right now, today. And where our struggle continues.

A trans person gets HRT from a friend-of-a-friend. Someone helps a teen get Plan B across state lines. Someone else ships abortion pills to a locked-down state. A mutual aid crew delivers some leftover meds to someone post-surgery. A community clinic runs out of a church basement and doesn’t ask for ID.

A long-hauler crowdsources treatment protocols because their doctor won’t listen. A disabled person builds a spreadsheet network to redistribute mobility aids, medications and groceries. An insulin sharing group chat. An overdose reversal is coordinated over text. A harm reduction team walking the encampment at dawn, handing out clean syringes and checking wounds.

A healthcare worker refusing to let ICE kidnap their patients. A sex worker organizes a peer health clinic. A rural town with no clinic, but with an entire informal network of aunties and retired nurses keeping each other alive. It’s community fridges, land and water defenders, mobile clinics, street medics, home visit networks, meal trains, gray-market meds, DIY air filtration.

It’s not the kind of care that makes it into policy briefs—but it's what keeps people alive. This is not theoretical, this is real. Most of it is not legal, none of it is covered. And yet, it's functioning. It’s lifesaving. Nothing is recognized as care by our system. But it is care. And, this is the site of struggle. Not only inside institutions, but in the shadows they cast. It’s in every act of defiance that says: we will care for each other anyway. The site of struggle is in that gap just as much as it is on the floor of congress, the back and forth of prior authorization, or the streets of New York in the early hours of the morning.

So what do we do with that? If the site of struggle must go beyond merely making the system better, but also build what we need despite the system, how do we fight?

First: we fight by demanding more than what is politically acceptable. We cannot let the boundaries of what is feasible or electable define our demands. We don’t need means-tested scraps or access to broken programs. We need universal care, no strings attached.

Because if we let the system set the terms, we’ll always be asking for permission to survive. We’ll be told to settle for coverage, not care, inclusion instead of transformation. Care is not a reward for good behavior, it is not merely a line item in a budget. It is a non-negotiable condition of life. And the truth is that people already believe in this. Most people want everyone to have what they need. What’s missing is not public will, it’s political imagination. And that is our job: to make the horizon visible. To remind each other day in and day out that we deserve more than what we’ve been told to expect. To fight like we actually believe everyone deserves to live.

Second: we fight by recruiting defectors from inside the house. This is a call to healthcare workers: betray your training when your training demands cruelty. If it means someone gets what they need to live—betray your bosses, your licensing board, your EMR, your scope of practice. Care is not your credential, it’s your calling, your skills, your knowledge, your access, your obligation to your community. And sometimes that obligation will mean disobedience.

If we are to build the world we need, we need you on our side, not on the side of your administrator. We need you willing to take risks, not just for your reputation, but for the material survival of those around you. The struggle is already here and you can either enforce the harm or interrupt it. We need class traitors in scrubs. We need insurgent care. And we needed it yesterday. If you have access pass it on. If you have knowledge, share it, weaponize it. If you have creativity, run with it.

This is where the real transformation begins. Not just in asking the system to care, but also in building the world we wished we lived in. A world where care is not determined by billing or zip code, or citizenship, or employment status, or formulary, or diagnosis codes. A world where no one is surplus. Where illness is not a source of shame or debt or punishment—but simply a part of life, and a part of being and feeling cared for.

They want us to think care is something we have to qualify for. That it belongs to the insured. The compliant. The deserving. But we win everyday when we reject all of that. When we remember care is a promise. Older than any institution. More powerful than any system. We win when we remember care is a practice, passed hand to hand. When we claim it as ours together, without apology.

All care for all people. That’s what health communism is. Not a slogan. Not a party line. But a strategy. A way of understanding that health is the terrain—not just the issue. That it’s the lever and the battleground. That it is where capital extracts value and where we can begin to sever its hold.

Thank you.