Henry Hill is a British Conservative and Unionist activist, and author of the blog Dilettante.
Watching the battles between the Obama administration and the Republicans over Obamacare is a slightly surreal experience for a Brit. After all, over here the National Health Service is a national shibboleth, an apparently fundamental part of our British identity, and those who challenge it – such as Daniel Hannan – earn themselves something akin to pariah status amongst political polite society.
So warped is the discourse on health in Britain that our incoming Conservative government was compelled to ring fence NHS spending completely from the austerity drive, necessitating vital cuts in other sectors whilst dis-incentivizing healthcare efficiency. One can decry wasteful spending on a bloated bureaucratic class, but actually cutting it is politically impossible. Every increased NHS cost has to be referred to as an ‘investment’. Really, it isn’t the terms of the American debate about healthcare that puzzles the British: it’s the phenomenon of having a debate on the subject at all.
Yet the dialogue is so one-sided in Britain that the evidence filtering across the Atlantic is unlikely to be balanced. When it comes to healthcare the testimonies of most British politicians are akin to Soviet tractor statistics – it would be electoral suicide to other than burnish the halo of this last surviving relic of our post-war flirtation with a command economy. To try to redress the balance, below I examine some of the fundamental differences between British and American cultures regarding that paramount American virtue, freedom, and the cultural impact of the UK’s largely socialized medical system.
Since the trajectory of Obama’s healthcare policies has been in a “British direction,” if you will, American policymakers would do well to consider the cultural effects of those policies.
This won’t be an article about health outcomes per se. Certain individuals continue to courageously challenge British assumptions about healthcare, with Hannan’s column and James Bartholomew’s excellent The Welfare State We’re In being but two examples, and these men make the arguments about the NHS’s inefficiency, failings and returns entirely incommensurate to its astronomical costs far better than I can in a short article such as this. Instead, I want to examine the impact the NHS has on individual freedom, and what the state and other agencies feel mandated or entitled to do with it. This article was sparked by this piece on Smitten by Britain, a “Britophile” American blog, which reports that the Royal College of Physicians is lobbying British lawmakers to ban smoking in cars. This one example is enough to demonstrate several of the deplorable side-effects of the impact of an NHS-style universal health system on political and civic life.
The most obvious impact becomes apparent when you consider what your car actually is. It is a personal space that is (usually) your private property, and access to it is at your discretion. Your home also fits this description. Your car is not a public space, and if the government can legislate to prescribe how you behave in your car (for reasons other than ensuring you drive safely) then it can prescribe your actions at home without any leap in logic. This is a prime example of how the area of your life that the government feels entitled to meddle with is constantly expanding, even in a society as over-scrutinized and over-managed as the UK.
Where does this sense of entitlement spring from? This expansion of governmental influence stems from the second consequence of universal health care on the British model: nearly every action anybody undertakes or choice they make comes with a bill for the taxpayer. Where once an individual could make a choice and bear responsibility for the consequences of that choice – for example, by eating a poor diet and paying higher insurance premiums – the state is now mandated to foot the bill for the consequences of poor decisions “free at the point of delivery”. When something is ‘free’, and especially if you think that it is ‘free’ because the money is being squeezed out of someone else through taxation, you are less likely to appreciate the healthcare you are receiving – the negative health impacts of your lifestyle choices or the actual price you’re paying in higher general taxation – and thus you’re much more likely to indulge in irresponsible behaviour. Moreover, because the government can cast irresponsible behaviour with what were once only personal consequences as a cost to taxpayers, the general population are more likely to be inclined to support prescriptive legislation if they think it will save them money.
Once the government has, in its munificence, removed the natural consequences that encourage responsible behaviour, it has to pay for the consequences of irresponsible behaviour (higher taxes for you), try to legislate new disincentives to replace the ones it has disposed of (punitive duty on alcohol and cigarettes, heavy restrictions on the marketing and sale of these products) and outright ban behaviour that costs the state money (smoking ban and, if one continues the logic, prohibition). In Britain, the worst part is that there is no escaping this. Even if you choose to pay substantially extra for private healthcare from the likes of Bupa, the state is still fundamentally liable for your wellbeing, you still pay all the taxes levied to pay for the NHS and your choices are still restricted or penalized.* The Conservative Party once campaigned on an ‘opt-out’ scheme for people with private healthcare, but dropped it after the 2005 election.
Nor is this behaviour confined to the government. The smoking in cars example above also demonstrates how once a prescriptive culture develops, it can extend beyond government and into third parties such as the Royal College of Physicians, effectively turning professional medical organisations into authoritarian lobbyists. Rather than simply getting you better, doctors can come to think it would be much simpler if they simply banned all the things that make you ill – which is true, if you can momentarily forget the frightening consequences of such logic. But where does it end? If too many idle hours in front of the computer or television increase our chances of falling ill, why not legislate limits on these activities or mandatory exercise? It sounds absurd, but it is entirely consistent with the logic being demonstrated by the RCP.
This paternalistic attitude can be seen even beyond organisations that have any formal link to the healthcare profession. Alongside the rise of no-win, no-fee legal practices, the idea that it is acceptable to prescribe behavior to avoid even the smallest of risks lies behind the mutation of health and safety – at its heart an entirely laudable doctrine designed to stop machine operators losing fingers or miners choking on gas pockets – into the grotesque edifice it is today. It might look like private companies are treating adults as children, but the government did it first.
The common thread running through all these examples is that once the government removes responsibility from people (or rather, agrees to foot the bill for their irresponsibility), people will have less reason to act responsibly. As the costs climb, and the bill comes to be presented as a collective burden on all of us, both the government and the people lose any incentive to let people manage their own lives and, over time, perhaps lose the belief that they ever could. The general public is saddled with more laws, more taxes and less freedom in exchange for a healthcare system that is a long, long way from being, in the words of innumerable British politicians, “the best in the world”.
In Europe, we have always struck the balance between freedom and security differently to America. However, in the UK the political consensus surrounding the fundamental goodness of the NHS is so absolute, and the debate so muted and warped, that the general public can scarce imagine a market-based system being anything other than a cruel, social-Darwinist nightmare. Those voices that do oppose the NHS tend to argue on the basis of measurable results and medical outcomes, and often do so very well. Arguing against universal healthcare on the basis of individual freedom is extremely unlikely to work in Britain, but it is a warning worth making to Americans who cherish and tangibly enjoy their liberty-oriented culture.
Having tens of millions of American citizens without healthcare provision is wrong, but US lawmakers should be careful that they design a safety net to catch people when they fall, rather than a padded cell wherein they are confined and prevented from climbing at all.
*Incidentally, the fact that private healthcare only makes sense as a high-end product in the UK surely explains how ordinary British people came to think that private or semi-private health provision could never cater to them.