I was delighted to see that the US Supreme Court had upheld President Obama’s health care law and had not given in to those who wanted to have it overturned.
While well aware that there are Americans who seem to be perfectly civilised but who nevertheless have no qualms about condemning 47 million of their fellow citizens to a precarious life without health care provision, I was somewhat surprised by the reaction from one of my former students – now returned to the US – and some of his friends whose discussion I followed on Facebook.
My former student – let us call him Marvin – posted: ‘It may be constitutional, but that doesn’t make it smart or change the fact that Obamacare is the biggest TAX ever!! We don’t need it or want it!’ One of his friends agreed: ‘Amen, the idea of health care for all is "nice" but this plan will run the country into financial ruin if it’s not overturned. Socialised medicine will never be the answer’. Marvin was in total agreement with that, adding ‘Big Government can butt out!’ Now, where have I heard that unappetising phrase before?
Another friend, Brad, was of the view that 99% of health care problems would be avoided if individuals behaved ‘responsibly’. I suppose only a healthy young person could think that. One of my friends, who has lived a sober and blameless life, has recently had a large mass removed from her abdomen and faces a long course of chemotherapy. This has nothing to do with a lack of responsibility.
Happily, another of Marvin’s friends (or perhaps, like me, they are ‘friends’ on Facebook but not real friends), Stuart, countered with ‘I want affordable healthcare available to all’.
At a late stage in the discussion, another former student, Hella, from Marvin’s class in Edinburgh, weighed in with ‘I am from Denmark. We have the highest tax pressure in the world and I am fine with it, because health care should be for everyone… You are right, Marvin. What works in Denmark, probably doesn’t apply in the US. That is why you should be happy with Obamacare’. Marvin was not to be moved: ‘Sorry Hella. I would rather keep my wages and pay out of my pocket for the health care I chose, rather than pay higher taxes and have the government choose for me. That is the big difference in our views and why I want Obamacare revoked’.
So there we have two opposing views from abroad – I have truncated the discussion considerably – but their systems are not the only choices available. This is something that we in Britain should ponder, given that we have a health service that is, in the view of at least some of its employees, ‘unsustainable’. In Britain, we insist on funding the NHS from general taxation. Various reports have been commissioned over the years into the funding of the NHS, the most recent of these at Gordon Brown’s behest, but the answer that has always come back is that funding it out of general taxation is the best way.
This is a matter more of ideology than of economics. Of course, as part of former chancellors’ sleight of hand, National Insurance contributions – now considered a tax rather than insurance – have increased, which has brought in more money. The removal of the former cap on NI contributions must have been regarded as a bonanza by the Treasury. But it seems clear now that it was bound to be a fiction that NI could cover the costs of health and social care, even if Beveridge, the architect of the welfare state in the 1940s, believed that it would be actuarially sound.
The only alternative has been to depend on income tax to bail out the NHS. It seems to have escaped politicians and others that, at the very time when health costs have been rising, the rates of income tax have been reduced, including the standard rate which was reduced repeatedly under the Blair governments. I don’t complain about that. But it has meant that the tax take from income tax has been reduced. I don’t think that the argument that lowering taxes leads to a higher tax take washes in the case of the standard rate – and I deeply doubt that it washes in the case of higher rates, either.
The NHS is, of course, sacrosanct. We dare not suggest an alternative. The chief criterion appears to be that it should be ‘fair’. Fairness is all. If everyone has to wait 18 weeks to see a consultant for a particular condition, that is fair. The fairness lies not in the length of the wait but in the fact that everyone has to wait for the same length of time. It used to be reckoned to be fair when people had to wait 68 weeks. My neighbour, who was in considerable pain at the time, was told some years ago that she would have to wait 68 weeks for an orthopaedic procedure. She thought she had heard ‘a six to eight week wait’, and was shocked when she was disabused of that misunderstanding.
I do not know what waiting times are for appointments and procedures in the various European insurance systems – although waiting seems to be virtually unknown in Germany – but I am confident that they are not of the order of waiting times in the UK. Recent revelations about the extent of waiting times in Lothian have been shocking. One poor woman had been waiting for over a year for treatment for a urinary complaint. Is that ‘fair’?
I had a very small recent experience of this. My cancer consultant said that a post-treatment examination had been inconclusive and he wanted me to have a biopsy. He would write to the surgeon – write to him via a typing pool when they work in the same hospital? – and ask him to see me ‘very soon’. When I saw the surgeon, quite soon, it was at my own expense. He told me that he couldn’t have predicted when I would have had an appointment with him in an NHS context, and that his NHS outfit was having to send patients to Glasgow for treatment. So I am a ‘queue-jumper’. Or, I could argue, I have removed myself from the queue and speeded things up (very slightly).
I am very conscious that I am fortunate in being able to take this course of action – but the fact that I have not spent a few thousand pounds on having breast implants has made it possible.
With an ageing population and ever more sophisticated and expensive forms of treatment, medicine is going to require increasing funds – perhaps exponentially increasing funds. In the US, Stuart, Marvin’s critical friend, says that he pays about $60 a week for health insurance, with another $10 for optical and dental care – and pays it before tax, thus lowering his taxable income. Brad, Marvin’s friend, thinks Stuart is ‘a lucky man’. His own experience is that ‘I got health insurance before Obamacare was passed. The premiums never raised until…wait for it…Obamacare passed. In fact, last time they raised from $260 to $370 [per month]. That has nothing to do with shareholders or profits. It has everything to do with Obamacare’.
Health care is not cheap, in the US or here. The insurance schemes in countries such as The Netherlands and Germany are said to be less than half as expensive as those in the US. Yet they operate on the basis of solidarity – from each according to his means, to each according to his needs, as a German revolutionary once said. On that basis, contributions are set and care is dispensed.
Brad thinks that in America ‘Insurance works well for those who can afford it, which is pretty much everyone in the United States. For those few who can’t, charities are the way to go’. His fear is that ‘Obamacare’ will lead to ‘rationing of care, higher taxes, lower overall quality of care, the bankrupting of our government’. He cites articles in British newspapers – in the Independent as well as the Daily Mail – discussing rationing of care here, as an awful warning to the US. This is not mere scaremongering. There has been talk of rationing certain kinds of care in Britain, and rationing for certain kinds (i.e. ages) of people, while we know that the purpose of NICE is in fact to ration expensive remedies. The ubiquitous waiting list is another form of rationing.
In Scotland, everything is free, including non-prescription medicines. At least, everything is as free as a free lunch. Sooner or later, there will have to be a debate about the funding of the health service. If Scotland becomes either independent or fully fiscally autonomous, the alleged ‘social democratic consensus’ will ensure that the debate will be short and the result will be a hike in taxes.
There are some – including contributors to this journal – who salivate at the prospect. For the rest, there may be an illusion that ‘the rich’ will pay. One hopes they will. But the major burden of increased taxation will fall on those with moderate incomes. That is the only way to raise the amounts of money that will be required. I say ‘the only way’, because the ideological stance of the main parties in Scotland will ensure that the main alternative – a European-style insurance system – will remain anathema. And if Germans continue to have better healthcare provision – without waiting lists – than we do, so be it. It isn’t health that’s the priority in this country: it’s a rather distorted sense of what is ‘fair’.
Jill Stephenson is former professor of modern German history at the University of Edinburgh
