I write this as someone who is interested in American healthcare. Not from the perspective of health systems or processes, but from an ideological perspective; one which considers how healthcare is delivered and managed in the context of an expressly capitalist system. I have pondered this problem before, when we worked through some of the 2017 arguments against the Affordable Care Act (ACA, or so-called Obamacare). On the face of it, the ACA was a good thing. It was intended to require healthcare insurers to accept all applicants at rates based on population averages regardless of health status, with the net result that 9 million previously uninsured people would receive healthcare insurance.
Much of political rhetoric against the ACA related to claims that the government was slipping into socialism. The conversation relied on the idea that at the level of the national imaginary, a fear of socialism would outdo fears about a lack of insurance, were the ACA to be rebuffed. It is these sorts of processes and arguments that I am particularly, interested in, in how different ideological forces are mobilised to bolster or limit specific approaches. This is because these sorts of moves demonstrate a set of reforms, which on one level, could be argued to operate against the collective interest of the majority of the population, so I am interested in the rhetorical moves that facilitate these claims.
A key component to covering over this contradiction appeared to be about contextualising the crisis of legitimacy with the ACA around fears about the triumph of socialism over American nativism. As long as American nativism, with the distaste for big government and universal health care, could out-flank questions of equality and social justice, then ostensibly the contradiction could hold. It was in these sorts of contexts that the spectre of socialist death panels was also raised, whereby opposition politicians made fictitious allegations of a ‘death panel’ of ACA bureaucrats who would decide who was (and was not) worthy of medical care. It is originally attributed to Sarah Palin in 2009. The ’Death Panel’ is also the name of an American podcast concerned with political economy and “health’. They take a direct lead from the death panel opposition to the ACA, rearticulating the rhetoric and advocating Medicare for All now and solidarity forever.
Two of the contributors (Beatrice Adler-Bolton and Artie Vierkant) published a 2022 book entitled Health Communism. This book sets out to demonstrate the fundamental contradiction between health and capitalism, pointing out, with coherence and finesse, the many ways in which capitalism sets out to extract profit from those identified as ‘surplus’. They offer a historical overview of how the idea of ‘surplus’ populations developed in tandem with capitalism, through philosophers like Smith and Malthus, who both talked about the need to differentiate between the population numbers any society could employ (workers) versus how many it might maintain (workers + surplus). More contemporarily, Adler-Bolton and Vierkant demonstrate how the worker/surplus binary has developed around a fundamental conception around issues of workers’ health or disability.
The surplus, or surplus populations, can therefore be defined as a collective of those who fall outside of the normative principles for which state policies are designed, as well as those who are excluded from the attendant entitlements of capital:
The idea that the worker is not a part of the surplus populations, yet faces constant threat of becoming certified as surplus, is one of the central social constructions wielded in support of capitalist hegemony…An understanding that illness, disability and debility are driven by the social determinants of health, with capital as the central social determinant, itself constitutes a threat to capital (p.5).
I think it is in this context that we can more readily make sense of the death panel opposition to more progressive forms of healthcare. It is not socialism that is seen to be the problem, but rather it is the potential threat to capitalism. It is in this context that politicians invoke socialism as a threat to American nativism and it is this threat which underpins and mobilises the opposition.
But in a UK context, we have recently seen attempts by governments to rearticulate who counts as surplus, with moves to push people the other way, out of surplus populations and into working populations, through the rearticulation of what counts (and does not count) as disability. We can see this effect in all manner of social policy contexts, conditional welfare payments, and the most recent pronouncements from Wes Streeting regarding mental health over-diagnosis. In this most recent move, are we seeing evidence that the UK government thinks that those identified as ‘surplus’ are too many (to go back to Malthus, current UK govt policy is that the population numbers the UK can maintain has exceeded the number that workers might support). Those identified as surplus are now being reclassified, not due to improvements in their situation, but because the criteria for their status have been tightened.
For the Secretary of State for Health to be making claims that too many young people are being diagnosed with mental health conditions, in the context of conditional welfare sanctions, insecure employment, and unaffordable housing. This statement comes less than five years after a global pandemic and seems to overlook a significant social crisis of inequality. It shifts the blame onto young people instead of addressing the broader social and political determinants of health. By reverse engineering the principles of surplus creation (the self same principles intended to compel people into work), claims of overdiagnosis function to police the worker/surplus boundary, arguing too many people that could work have been certified as surplus – in effect seeking to move people off Employment Support Allowance and get them ‘back to work’. In doing this, it seeks to make young people themselves responsible for a whole set of social and structural conditions over which they have little responsibility or control. This is a gross mis-representation of the problem, and it is one that does nothing to address the fundamental underlying inequalities that must be tackled if progress is to be made.
Creating a surplus
by Ewen Speed Apr 23, 2025I write this as someone who is interested in American healthcare. Not from the perspective of health systems or processes, but from an ideological perspective; one which considers how healthcare is delivered and managed in the context of an expressly capitalist system. I have pondered this problem before, when we worked through some of the 2017 arguments against the Affordable Care Act (ACA, or so-called Obamacare). On the face of it, the ACA was a good thing. It was intended to require healthcare insurers to accept all applicants at rates based on population averages regardless of health status, with the net result that 9 million previously uninsured people would receive healthcare insurance.
Much of political rhetoric against the ACA related to claims that the government was slipping into socialism. The conversation relied on the idea that at the level of the national imaginary, a fear of socialism would outdo fears about a lack of insurance, were the ACA to be rebuffed. It is these sorts of processes and arguments that I am particularly, interested in, in how different ideological forces are mobilised to bolster or limit specific approaches. This is because these sorts of moves demonstrate a set of reforms, which on one level, could be argued to operate against the collective interest of the majority of the population, so I am interested in the rhetorical moves that facilitate these claims.
A key component to covering over this contradiction appeared to be about contextualising the crisis of legitimacy with the ACA around fears about the triumph of socialism over American nativism. As long as American nativism, with the distaste for big government and universal health care, could out-flank questions of equality and social justice, then ostensibly the contradiction could hold. It was in these sorts of contexts that the spectre of socialist death panels was also raised, whereby opposition politicians made fictitious allegations of a ‘death panel’ of ACA bureaucrats who would decide who was (and was not) worthy of medical care. It is originally attributed to Sarah Palin in 2009. The ’Death Panel’ is also the name of an American podcast concerned with political economy and “health’. They take a direct lead from the death panel opposition to the ACA, rearticulating the rhetoric and advocating Medicare for All now and solidarity forever.
The surplus, or surplus populations, can therefore be defined as a collective of those who fall outside of the normative principles for which state policies are designed, as well as those who are excluded from the attendant entitlements of capital:
I think it is in this context that we can more readily make sense of the death panel opposition to more progressive forms of healthcare. It is not socialism that is seen to be the problem, but rather it is the potential threat to capitalism. It is in this context that politicians invoke socialism as a threat to American nativism and it is this threat which underpins and mobilises the opposition.
But in a UK context, we have recently seen attempts by governments to rearticulate who counts as surplus, with moves to push people the other way, out of surplus populations and into working populations, through the rearticulation of what counts (and does not count) as disability. We can see this effect in all manner of social policy contexts, conditional welfare payments, and the most recent pronouncements from Wes Streeting regarding mental health over-diagnosis. In this most recent move, are we seeing evidence that the UK government thinks that those identified as ‘surplus’ are too many (to go back to Malthus, current UK govt policy is that the population numbers the UK can maintain has exceeded the number that workers might support). Those identified as surplus are now being reclassified, not due to improvements in their situation, but because the criteria for their status have been tightened.
For the Secretary of State for Health to be making claims that too many young people are being diagnosed with mental health conditions, in the context of conditional welfare sanctions, insecure employment, and unaffordable housing. This statement comes less than five years after a global pandemic and seems to overlook a significant social crisis of inequality. It shifts the blame onto young people instead of addressing the broader social and political determinants of health. By reverse engineering the principles of surplus creation (the self same principles intended to compel people into work), claims of overdiagnosis function to police the worker/surplus boundary, arguing too many people that could work have been certified as surplus – in effect seeking to move people off Employment Support Allowance and get them ‘back to work’. In doing this, it seeks to make young people themselves responsible for a whole set of social and structural conditions over which they have little responsibility or control. This is a gross mis-representation of the problem, and it is one that does nothing to address the fundamental underlying inequalities that must be tackled if progress is to be made.