Emergent Universality vs Top-Down Healthcare
Reclaiming Collective Care Without the State
Our prevailing notion of “universal healthcare” rests on a seemingly unshakeable assumption: coverage for all requires one large, centralized program, typically run by the state. While schemes like the NHS or Medicare often improve upon for-profit models, they remain deeply bureaucratic, frequently top-heavy, and ultimately incomplete.
Anarchist approaches challenge the idea that comprehensive healthcare can only be delivered from above, arguing for a decentralized web of community-driven clinics that achieve genuine universality through voluntary cooperation and mutual aid, rather than top-down control.
Rethinking Universality Beyond the State
Over time, entire societies have become accustomed to seeing government as the only mechanism capable of managing universal programs. Historical examples reinforce this perspective: modern welfare states offer flagship services—healthcare, education, and social security—to millions. When we consider the sheer logistics of delivering care across diverse populations, it’s natural to imagine that only powerful central agencies have the reach and authority to coordinate everything. On top of that, many people worry that if taxes or mandates disappeared, nobody would willingly pay for universal coverage.
Such concerns help cement the idea that “universal care” must involve a massive, unified system—a view so commonplace that alternatives rarely get a hearing.
And yet, throughout history, grassroots models have quietly shown that decentralized cooperation can address even large-scale needs. Volunteer firefighting in remote areas and global open-source software collaborations illustrate how communities, bound by mutual interest, handle sophisticated tasks successfully without government orchestration.
The failure to imagine grassroots healthcare on a similar scale reflects a cultural conditioning—decades of political messaging have simply taught us to equate “universal coverage” with “one big national agency.”
Anarchist Healthcare in Practice
From an anarchist standpoint, community health doesn’t hinge on waiting for official decrees or ballooning bureaucracies. Instead, it emerges from local clinics that people manage themselves, connecting horizontally through mutual aid. These clinics pool knowledge and resources freely, rather than relying on a single chain of command; each group decides how care is delivered, trusting neighbors and fellow workers instead of deferring to external authorities.
Because these clinics are voluntary, funding doesn’t flow from forced taxation but from strategies that treat healthcare as a communal responsibility. The profit motive is removed, replaced by a sense that everyone’s health belongs to everyone else. Medical knowledge, moreover, is widely shared, so no elite group of specialists can monopolize decisions. Often, these clinics partner with other grassroots projects—housing co-ops, disability justice circles, childcare networks—on the understanding that stable housing and social support are integral to well-being. In Inherent Care, I explore how caregiving, by its nature, flourishes best as a mutual endeavor rather than a service priced and regulated from above.
Critically, people remain free to reshape or abandon a clinic if it becomes exploitative or mismanaged. That’s the essence of non-coercion: accountability rises from the bottom up, preventing the sort of rigid hierarchies that plague centralized systems. Drawing from Coercion as Fragility, the aim is to ensure power stays fluid and correctable by the community itself.
The Incomplete Universality of State Systems
For all their rhetoric about “coverage for everyone,” official programs often stifle or even outlaw smaller, autonomous caregiving efforts. Alternative clinics—whether run by street medics or uncredentialed healers—fall outside state approval, making them vulnerable to sanctions, no matter how well they serve local needs. In places like Canada or the UK, governments tend to regard themselves as the only legitimate healthcare provider. Parallel efforts, though sometimes more immediate and accessible, get sidelined, policed, or co-opted.
At the structural level, bureaucracy can overwhelm organizers with endless forms, zoning laws, and liability regulations, leaving little time or energy to build truly communal care. Larger nonprofits often absorb scrappy grassroots projects, morphing them into top-down social services that prize compliance metrics over radical solidarity.
Meanwhile, austerity can exhaust communities, robbing them of the bandwidth to launch new health initiatives. In many countries, “minimum viable” public services prevent crises just enough to quell the push for genuine, bottom-up change. Yet as Actuarial Medicine and Hidden Exclusion explains, even seemingly neutral approaches—like risk scoring—routinely exclude those who need help the most, undermining the promise of universality.
The Abundant Intangible
In Abundance Is Not a Future, It Is a Forbidden Present, I argue that our society habitually masks the resources needed for full universality. The refrain “we can’t afford it” frames austerity as inevitable, while local networks and volunteer medics demonstrate that practical care, offered to all, is already possible—when these grassroots initiatives aren’t suppressed.
The belief that we lack the means is less about physical scarcity and more about cultural narratives that reinforce hierarchy and privatization.
Where Emergent Universality Already Thrives
Far from an idealistic fantasy, anarchist universal healthcare takes shape today through countless local efforts, from neighborhood clinics to housing co-ops providing basic medical support, all under the radar of hostile laws or indifference. This patchwork underscores that broad coverage can mature from the ground up—without the supposed necessity of a monolithic agency. The real bottleneck is not technical or economic; it’s the lack of permission for these networks to operate openly and expand.
By centering trust and voluntary cooperation, anarchist models refute the notion that universal care has to hinge on distant authorities or corporate profit. Instead, they harness the everyday willingness of neighbors to look after one another.
If no one is excluded, coverage is universal by definition—not because the government mandates it, but because the community refuses to abandon anyone.
