The quality of American politics and policy seems to be going from bad to worse. Neither Republicans nor Democrats are offering compelling and optimistic visions of the future that are supported with popular enthusiasm. Trump’s approval ratings are unusually low for a president at this point in their tenure, but Democrats aren’t exactly getting people excited either, as demonstrated by series of recent special elections in which the Republicans, however narrowly, hung on to their seats.
No issue illustrates this better than healthcare. Most Americans are at least sceptical of Obama’s Affordable Care Act (ACA), which partly caused the Republican landslide in the 2010 midterms. Many believe that even if they received insurance under the ACA, the deductibles and premiums are so high, it is scarcely worth being insured. The individual mandate, which Obama saw as necessary to bring young and healthy people into the insurance pools, is widely resented as an infringement on individual liberty. For a significant minority of Americans, their opposition to the ACA derives from a belief in small government, and therefore the conviction that the ACA represents a federal overreach. Why the ACA constitutes ‘big government’ but not Medicare or Medicaid is hard to understand. But that sentiment is nevertheless real, not purely an elite phenomenon.
But Republican alternatives to the ACA are even more unpopular. Conservatives often point out that once a government programme is introduced, it is impossible to abolish. This is particularly true with the ACA. Having grown accustomed to the subsidies and federally enforced insurance standards the law provides, like a ban on denial of coverage for pre-existing conditions, people are reluctant to go back to the pre-ACA of high uninsured rates and more frequent bankruptcies from high healthcare costs. Regardless of Republican pretensions, it is clear the level of federal intervention in the healthcare industry is only going to grow- the public demands it, even if they don’t like some of the consequences of the ACA.
If repealing the vast majority of the ACA’s provisions is unrealistic, then the only question becomes how to improve it. The Republicans haven’t provided a serious answer to this question, because they believe the law is fundamentally flawed. The Democrats, however, are divided. On the one hand are centrist Democrats who want to improve the mechanics of the ACA to move towards universal coverage. They would expand and strengthen the mandate, bringing more young and healthy people into the system, reducing costs overall. They would increase federal funding for Medicaid, to compensate poor people living in states that refused the Medicaid expansion. They would also enhance the ACA’s marketplaces to make healthcare more competitive.
Many Democrats would go much further, supporting a system called single-payer. For an American audience, single-payer is best described as Medicare for all. Anyone could get government-sponsored insurance if they wanted, paid for through the Medicare levy. But this is where my knowledge and experience as a Brit comes in. Britain has had an extreme form of single-payer since 1948, called the NHS. In Britain, not only does the government pay for everyone’s healthcare, it also nationalises the vast majority of the hospitals and doctors’ surgeries. People can buy private health insurance if they want to. But unlike in America, there is no employer tax deduction for private insurance bills. So the vast majority of people are insured by the state, simply because private insurance is too expensive in addition to paying more taxes.
There are three key advantages to the NHS above the American ACA model. The first is that it guarantees universal coverage, the ACA doesn’t. The second is that it is much cheaper. America spends almost as much taxpayer’s money as a proportion of GDP on healthcare as the UK, but it doesn’t come close to achieving universal coverage. Nationalising the means of healthcare delivery helps keep costs down, because it reduces the amount of paperwork needed when hospitals charge insurers. The other advantage is that it is simple. Everyone is automatically insured, and so doesn’t have to worry about how they are covered and for what.
Having said that, most Americans would not be satisfied with an American NHS, even if it is preferable to the current system. American healthcare is generally better quality. Waiting times are lower, people are more likely to get their own bed, there is more access to expensive drugs, etc… The NHS engages in a lot of healthcare ‘rationing’ to keep costs down. This can be a brutal process, where people who need non-emergency treatment can wait for months to be seen. Once you consider that the American state is a fair bit more inefficient than the British one, it is highly unlikely that America could expand quality healthcare to all and spend significantly less than what is does currently. Britain spends unusually little on its healthcare- it’s not a route I would advise America to follow.
The best solution for America would be to allow anyone to buy into Medicare, by giving up a much higher proportion of their income to the government. This would essentially give the country universal coverage without needing the individual mandate. Unlike the ACA, it wouldn’t increase the deficit, because the programme would pay for itself. It would retain the ACA’s non-denial of coverage for pre-existing conditions. It would expand the Medicare insurance pool to include younger and healthier people, improving public finances. It also has the advantage of not interfering with the private market; people who like their current insurance should be able to keep it without fearing that government regulations and taxes will force them to change plans. Moreover, private insurers would no longer be forced to cover people with pre-existing conditions, because those people could just buy into the government system.
Britain could learn an awful lot from this ideal American system of a regulated, competitive private healthcare industry existing alongside a government-funded insurance scheme for those who can’t go private. The problem with the NHS is that it leaves the vast majority of people with no alternative. I know friends and family who have suffered considerably from this system. They have been forced to ‘pay double’- high taxes in exchange for a system that doesn’t work, and private medical bills to get the treatment the government should have given them in the first place. To remedy this, Britain ought to lower taxes for those who want to be privately insured. The NHS is fantastic at insuring universal healthcare, and the nationalised nature of healthcare delivery keeps taxes lower than if the government had to pay private entities. But the NHS isn’t the only good deliverer of healthcare. It would benefit from competition from private insurers, even if the NHS itself should remain fully public. The British left denies any advantages of private competition, arguing that if the government increased funding for the NHS, the problem would be solved. An increase in funding may improve the state of affairs overall, but many people will still be let down, and need somewhere else to go.