A visit to the ‘land of freedom’ with its catastrophic health care costs is a warning not to be complacent about the NHS …
Where it’s brushed against poison ivy, Kelly’s skin is badly blistered, a rash slowly spreading down her back. But with no job, and no health insurance, there is no money for a doctor’s appointment or a prescription, so we try to find something over the counter that will work. A year into a job, her friend SallyAnn is luckier to have just qualified for health insurance when a gynae problem means several investigations are needed. The $2500 dollar excess is going to be tough to meet, though. At the clinic, ahead of her in the queue for pharmacy, Mrs O’Hare is trying to navigate the Medicare ‘donut hole’ that hits many by this time of year: by late September she’s got to the limit of what the scheme will reimburse. The pharmacy assistant suggests which of her diabetic medications are essential, which she can eke out a bit or forego till next year, and which prescriptions she might get cheaper at Walmart.
My English accent catches Mrs O’Hare attention: I empathise with her having to choose which prescriptions to take today, saying I’m lucky to live in a country where older citizens like herself would get them all, and for free. “Yeah”, she says, “but who’d want commie health care? Why would you want to pay for other people’s illness?”
In the Southern states of the US, the depths of scorn for ‘socialised’ health care can be breath-taking to European sensibilities, especially from those who would be net ‘winners’ from such a system. And it’s not just from the odd rural patient, routinely sceptical of foreign ways. On the interstates, every visitor centre has a free newsletter for the tourists. Advertising local theme parks, country music museums and Apple Butter Fairs, they all end with a letter from the local Mayor: and most of these bizarrely condemning ‘Obamacare’ along with welcoming you to the County. These local Mayor’s welcome letters criticize the complexity of the proposed health care reforms: it is, claim many commentators, impossible to know what was proposed, or what would happen. But, as Daniel Skinner, in an eloquent critique of the debate on the Affordable Care Act in Critical Public Health points out, beneath such criticisms are “ideological games, not assessments of reality”. As he notes, the Act will do little for the poor and insured in States which have refused to expand Medicaid, such as Texas. It is hardly a radical restructuring of the political economy of health care in the US.
But, like the freedom to bear arms, the freedom to take and manage your own health risks is deeply and passionately held on to here – and, like antipathy to gun control, antipathy to health care reform can be hard to fathom for a foreigner.
Back in the UK, we take for granted that heath care is a right not a benefit: that we are entitled to care from the NHS as part of the post-war settlement between a democratic State and its citizenry. This is a pact that requires a high degree of trust in both an elected government and in your fellow citizens. In the Appalachians, Washington seems remote, geographically and culturally, but so too does California, or Florida. Beyond the distance of other citizens, though, is a deep cultural unease with the paternalism of welfare: a distrust of those who know best what is in your interests. And in this, despite the overblown right-wing rhetoric of ‘death panels’, or ‘communist’ withdrawal of choice, the Obamacare detractors perhaps have a point. Most Americans cannot afford the best health care their country can provide; and even those with good coverage are often tied to cost-conscious HMOs which offer little choice either. But there is in principle a choice: of treatment regime, of the best medications (even if not generic), of provider, or specialists. Freedom lies in that principle, if not the actuality.
As with the right to bear arms, arguments about the public health rights and wrongs of who gains and who loses miss the point. It is not about whether (on balance) gun control or socialised health care are good for the public health: both undoubtedly are. It is about what individual freedoms are sacrificed for that ‘public’ health. It is perhaps churlish to name them, but NHS patients do not have the freedom to go directly to a specialist, or to choose our own brand medications, or even to use primary care services without signing up for endless intrusive preventative clinics and checks.
In return for what most see as these small sacrifices, we have taken it for granted that catastrophic health care costs will not ruin us if we need treatment. We have taken it for granted that the NHS will look after us from cradle to grave. A visit to the US suggests the fragility of this trust. The current dismantling of socialised health care in the UK risks skewing the very contract on which the system is based. We make sacrifices (and largely unconsciously) because, on the whole, socialised health care is good for the public, and for all of us as individuals within that public. Competition, contracting and choice will spread like poison ivy rash: once broken out, they are impossible to contain. And once the NHS is no longer a taken for granted part of the public realm, that fracturing may be hard to repair.
About the Author: Judy Green is based at the London School of Hygiene and Tropical Medicine and has researched and published on methodology, risk and the sociology of health.