If the cornerstones of your culture include the world’s most famous spy, its best-loved wizard and the band that redefined pop music, it might seem like a desperate piece of state propaganda to celebrate a health care system at the same time.
But the opening ceremony of the London Olympics in 2012 underlined a truism: Brits love the National Health Service. Alongside trumpeting James Bond, Harry Potter, and The Beatles, director Danny Boyle found space in his show to pay tribute to the doctors and nurses that help provide the universal, ‘free’ service.
Perhaps more surprising still is the cross-party support for this single-payer system that is reviled elsewhere, notably among the political right in the US. Sure, Conservative Party MP Aidan Burley tweeted how it was “the most leftie opening ceremony I have ever seen”. But Burley, who is no longer an elected politician, was shunned by his party elders. The party line is clear: UK conservatives believe in the NHS as much as anyone else.
It’s not a recent conversion either. Nigel Lawson, Margaret Thatcher’s free marketeer Chancellor of the Exchequer, described the NHS as the nearest thing that modern Britain has to a religion in an increasingly secular society. This was the 1980s.
To Republicans in the US, currently engaged in a bruising fight over the future of health care, this must be baffling.
How could the Conservative Party, which holds dear the same principles of market preeminence, stand by something so left-wing? After all, Nye Bevan, the 1940s Labour Party health minister seen as the NHS’s founding father, described a ‘free’ health service as “pure socialism, and as such it is opposed to the hedonism of capitalist society”. And yet, the prospect of the US having to consider a system akin to the UK’s ‘socialised’ care, while unlikely to happen, is in vogue.
When Republican leader Paul Ryan’s plan to repeal and replace Obamacare collapsed last Friday, America reached a fork in the road. The Affordable Care Act was simultaneously hailed and condemned for providing cover for 15 million Americans who didn’t have it, chiefly through an extension of Medicaid, the taxpayer-funded health care plan devoted to low-income families. But it is poised to “explode”. At least that’s Donald Trump’s view, referring perhaps disingenuously to the unstable private insurance market that underpins the system.
But the same President has also vowed “insurance for everyone”. The pledge has unintended echoes of Bevan. In the face of divided Republicans bringing down Ryan’s plan to torch Obamacare, Bernie Sanders, Vermont senator and big beast of the Democrat left, has announced he will introduce a bill to create a single-payer system. His “Medicare for All” has its roots in the NHS.
HuffPost UK has spoken to politicians and experts to find out why there’s consensus in the UK on the NHS and why they think US Republicans loathe it. The Conservative Party and the G.O.P. are not so different in their support for small government. But the Conservative Party appears convinced that the state is best-placed to provide care for its citizens. “I’ll cut the deficit, not the NHS,” was the Conservative Party election slogan emblazoned on billboards in 2010, alongside David Cameron’s face. Put in context, UK conservatives embrace the kind of single-payer system that even some liberals in the US wouldn’t support.
While the London Olympics demonstrate it would be bad politics for the Conservative Party to make state-funded health care its enemy, Tories point to evidence on cover, costs and results - and personal experience - to justify backing ‘free’ care. American observers may think the UK is less burdened by ideology and takes a more kindly view of the state’s ability to run things. But that would overlook the sell-off of publicly-owned assets that began in earnest thirty years ago and continues today. Perhaps the prospect of off-loading a ‘religion’ is just too daunting.
So how did we get here? There are generally two ways to run a health service: either the taxpayer finances it or the individual takes out insurance, with most being a mix of the two. While presidents Franklin D Roosevelt in the 1930s and Harry Truman in the 1940s flirted with publicly-funded health care programmes, the US opted for private insurance as its mainstay. If cover isn’t provided by an employer, people buy health insurance as they would a policy for their house or car. But it’s not cheap. Annual premiums reached $18,142 (£14,533) in 2016 for an average family. And despite Republican protestations, Obamacare is no NHS by the backdoor: 27 million Americans are still uninsured.
“British politicians perceive the US health care system to be ruinously expensive, patchy in its coverage and erratic in its outcomes”
- Warwick Lightfoot of the think-tank Policy Exchange
The NHS, by contrast, was founded by the post-war Clement Attlee government as the cornerstone of the welfare state. Decades later, 99 per cent of care is paid for through general taxation and National Insurance. In short, there is no prospect of the eye-watering bills for care that strikes fear among millions of American families.
Speaking to HuffPost UK, ex-Conservative Party health minister Alistair Burt explained it would be “suicidal” to suggest the party does not support the NHS. “Accordingly the pledge that the NHS should be ‘free at the point of delivery’ is absolute,” the MP said.
The Conservative Party manifesto three years ago spoke volumes. It pledged an extra £8 billion of taxpayers’ money to fund the NHS each year until 2020. Questions remain over whether the promise was genuine, and whether that’s enough to fund a system under pressure. There are stories daily about underfunding, targets missed, and more patients suffering. But it was the party’s clearest and most striking policy promise in the document, a move to outflank Labour Party claims the Tories wanted to destroy the NHS. Winning the argument on the NHS was not only central to general election success. A promise of securing more money for the NHS was at the heart of the successful Vote Leave campaign to quit the European Union.
The Labour Party claims ownership of the NHS, but Burt points to the “broad national consensus” that was accepted under the Winston Churchill and Harold MacMillan Tory governments of the 1950s. “The notion of ‘free’ access to health care is now untouchable,” he says.
“My father is a family doctor, now 94 years of age,” he adds. “He remembers debt collectors still operating when he joined his practice in 1949, a hangover from pre-NHS days. He is as Conservative as you get. But he says ‘never again’.”
The appetite in the UK to adopt anything similar to the US is almost zero. “A hundred per cent of our population has free access to medical care, from accident to cancer to mental health,” says Burt. “There is no call for a wholesale move to health insurance. Everyone would need to be covered, as now. So why should we?”
That’s not to say there is no private sector involvement, or that it lacks US influences. Privately-run hospitals and treatments are popular among those who choose to pay. Big businesses run out-of-hours family doctor cover and provide non-urgent operations to reduce waiting lists, which Tony Blair’s Labour government in part introduced. The current NHS chief executive, Simon Stevens, was a senior executive with UnitedHealth, the US giant. But Burt stresses the difference when business is involved in the NHS: care is “paid for by Government, but free to patients”.
“The left of the Labour Party are quite fanatical about anything which could be termed ‘privatisation’,” says Burt. “These extremes make it difficult to give modern health the scrutiny and answers it deserves.”
In a CNN town hall debate in February, Republican senator Ted Cruz pointed to the UK’s waiting lists for operations, and the US delivering more operations, as evidence for single-payer health care being inferior. On why US conservatives take a different view, Burt emphasises it’s hard to compare conservatives in an individual country, let alone those from different continents. UK Conservative Party MP Simon Burns campaigned for Hillary Clinton, for example. In any case, he’s dismissive of Cruz’s critique. “It is not fair. Comparisons are notoriously difficult between health systems, and there are a number of reasons for poor outcomes, beyond the payment system.
“We have an overworked and quite efficient system, but it is creaking under the pressures of finance and above all an ageing population. All health systems have difficulties. How you measure the NHS deficiencies against the agony of facing a bill for cancer care you cannot pay, I just don’t know.”
“How you measure the NHS deficiencies against the agony of facing a bill for cancer care you cannot pay, I just don’t know.””
- Ex-Conservative health minister, Alistair Burt
But don’t the Republican and Conservative parties share a view that the market delivers the best results? “This opens a can of worms,” Burt admits, pointing to the NHS’s ‘internal market’ that provides competition. “Pure market forces, however, are very unlikely to gain acceptance if there is any serious risk of ‘losers’ or an extensive ‘two-tier’ system based on wealth or privilege.”
Conservative policy experts also think there is little to suggest the UK right would nudge anywhere close to a US-style insurance system, even if the faults in the US system are overblown.
Warwick Lightfoot, director of research at the modernising conservative think-tank Policy Exchange, explained how Tory devotion to the NHS was renewed even when it let capitalism rip in the 1980s. In that decade, the government sold off Jaguar, British Telecom, British Aerospace, British Gas, British Steel, British Petroleum, Rolls Royce, British Airways, and water and electricity utilities. Margaret Thatcher’s advisers had written a paper suggesting that some health services might be charged for, and a story was leaked to The Economist magazine. “She was swift to squash any suggestion that the ideas in it had legs, saying ‘the NHS is safe with us’,” he told HuffPost UK, adding how it set the template for her successors.
David Cameron’s commitment to the NHS was as much personal as political. He came to rely on the state to help care for his disabled and seriously-ill son, Ivan, during his short life. “Cameron saw the very best of the NHS,” says Lightfoot. “He joined the ranks of a number of very privileged rich people who had to deal with a potentially ruinous chronic health condition within their own family if it were handled by private insurance and any substantive element of co-payment.”
Key to Conservative Party loyalty is not just the NHS’s popularity - more cherished than the monarchy and the army - but that it doesn’t cost that much. The UK spends less on health than European neighbours, including Germany and France, and much less than the US. In return, the UK achieves comparatively good health results. Lightfoot points to the Commonwealth Fund health study in 2014 that suggested the UK offered the best overall health provision out of 11 western nations it studied. The report also showed the UK had the second-cheapest health expenditure on the list, spending $3,405 per capita - less than half the $8,508 spent in the US.
While noting the criticism of the Organisation for Economic Co-operation and Development, which says the UK’s ‘command and control’ system means it is slower to respond to patient demand and new technologies, he says: “The NHS has been very effective in providing comprehensive health care at a reasonable cost.”
But Lightfoot thinks UK politicians sometimes overstate the US’s deficiencies. “British politicians perceive the US health care system to be ruinously expensive, patchy in its coverage and erratic in its outcomes,” he says. “They often share the naïve perception that there is little in the way of a health safety net for elderly people or low income households and do not fully appreciate the range of care available through Medicaid and Medicare.”
Publicly-funded care is often less strictly rationed in the US through Medicaid and Medicare than compared to the UK, he says. “This partly explains the cost of the US system,” he adds.
It’s rationing of care US conservatives really abhor. The US-owned right-wing website Breitbart News has written about patients being the victim of ‘death panels’, an infamous phrase evoked by one-time Vice Presidential candidate Sarah Palin to describe Obamacare. “Conservatives in the US dislike the NHS because of Nye Bevan’s expression,” he said, making clear it is the ideology of a state-run system “supplanting the market provision of health care that American conservatives fear”.
Not that every UK conservative holds the NHS in such high esteem, and many also resist the binary choice of UK or US. The Institute of Economic Affairs think-tank argues the NHS would save thousands more lives a year by emulating more mixed systems in Switzerland and the Netherlands.
Daniel Hannan, a Conservative politician who represents Britain in the European Parliament, has long characterised the NHS as a “relic”. From his vantage point in Brussels, he sees no mainstream socialist party in Europe proposing a “state monopoly in health care” based on the British model. The NHS is only beloved of “some Green and Marxist parties”. He suggests few would adopt an NHS model if the UK stopped short of full nationalisation in the late 1940s.
Not that US-style private insurance is the way forward. He told HuffPost UK: “It’s odd that people in both countries hold up the other’s model as if it were the only alternative. In fact, neither the US nor the UK has the best system. There are plenty of alternatives out there that produce better outcomes at lower cost.”
He backs individual health care savings accounts, deducted from salaries, which contain a small insurance component in case of catastrophic illness, but that otherwise pay out as needed. The system operates in Singapore, and has critics, but has been ranked the most efficient in the world by Bloomberg.
Of course, many of the left are not willing to give the Conservative Party the benefit of the doubt, and argue it would have sold the NHS by the pound if not curbed by public opinion and repeated protest. New figures this week showed that roughly half of new cash pumped into the system was spent on private sector treatment.
In an unlikely twist, Bernie Sanders’ brother has an informed view on both the UK and US systems. Brooklyn-born Larry Sanders has lived in the UK since the 1960s, and is the Green Party’s national spokesman for health care. He argues the “extraordinarily expensive” US system is a result in part of the surfeit of profitable yet unnecessary operations and scans, a counter to one of Ted Cruz’s key arguments.
“Bernard (his brother) is right, there’s so much extra money spent in the US. You could be so generous to everybody because of all those extra hundreds of billions. You could have a Rolls Royce system,” he told HuffPost UK.
Two things hold back the US, he argues: ideology and the profits the private sector makes. “There are large groups of people who think the government is a problem and they can’t do anything right. There are vast amounts of money to be made from having that viewpoint - you don’t have to be very corrupt to be inclined to a system which is very good to you financially.”
Sanders does, however, fear Conservative Party enthusiasm for more private sector involvement. “The NHS is very strongly rooted, but in some ways it’s fragile. We could be near a tipping point. If the service gets poor, you will get people who can afford it will use private care. Then you begin to weaken the NHS.”
But a US-style system where universal care free at point of care is abolished? “I don’t think they could do that, but I think they could weaken it.”
When in the UK, Trump likes to celebrate his British lineage thanks to his late Scottish-born mother. If Trump made American health care more British, it would stun commentators - perhaps more than the fact he was elected to do it in the first place.