As I watch American media outlets debate the merits and feasibility of single-payer healthcare, I tend to get a little frustrated. I am not American myself—I am Irish and, regrettably, British—but I have plenty of American friends and colleagues, and hearing about their relationships with their healthcare system is often agonizing.
It’s not agonizing in quite the same way as hearing about, for example, climate change, which is terrifying in its magnitude and tremendously difficult to deal with. Quite the opposite: It’s agonizing because the answer is so simple, and yet treated by establishment politicians and media as an impossibility. Every other developed country has had a universal healthcare system in place for a long time, in some cases for well over a century. All countries’ systems are different, and all have encountered problems in finding the balance between cost and quality, but they are all cheaper than the U.S. system, and all comparable countries have better across-the-board outcomes. Universal healthcare is also popular across the political spectrum. Ask the average right-leaning person in Europe if they want a U.S.-style healthcare system, and they will look at you as though you are mad. In the U.K., a favorite tactic of right-wingers is to fraudulently frame themselves as defenders of the National Health Service, even as they make cuts to healthcare budgets, because they know how much everyone cares about it. To most non-Americans—excepting perhaps those who own a lot of shares in private health corporations—there’s no question here. Universal healthcare is the way to go.
Americans who are suspicious of universal healthcare have a response to this argument. Sometimes they will dispute that other systems are cheaper, or popular, or have better outcomes for most people, but since the data is pretty clear on this point it’s not a terribly easy position to defend. So instead, they will often make an argument that is less empirical, and more philosophical: They will tell you that universal healthcare is un-American. It might well be the case, they admit, that Europeans and Canadians and Australians like their healthcare. But, they say, we’re not Europeans or Canadians or Australians. We’re Americans, dammit, and what makes us American is our independent spirit, our belief that the government shouldn’t control our lives, our ability to choose our own healthcare on an individual basis. In a word: freedom.
I understand why this rhetoric is persuasive. Americans greatly value their freedom, and it’s a part of the American spirit I have a lot of admiration for. Many non-Americans, and American leftists too, will criticise this approach by arguing about the difference between procedural and substantive freedom: In other words, having the theoretical right to do whatever you please is all well and good, but you won’t actually be able to use that right if you’re limited by your material circumstances. It’s an important thing to consider, but for many Americans, this argument will not work because it seems beside the point. Freedom, in the American tradition, does not mean you get to have everything handed to you (which is what the establishment of a strong welfare state sounds like to many right-leaning Americans). Instead, freedom is all about making choices: Americans get to choose the healthcare plan that’s right for them, either by choosing to work hard and getting a job with good benefits, or by comparing insurance plans on the market and choosing the one they like the best (or if they don’t get insurance at all, well, that’s also a choice). This is the American way, we are told, and much more suited to the fierce individualist spirit of the U.S. than a public system imposed on the people unilaterally. When you hear criticisms of universal healthcare, over and over again you will hear that Americans want to decide what type of care is right for them, that they don’t want bureaucrats running their lives, that they value freedom and choice.
Well, I totally agree. Americans do value freedom and choice. And if you love those things, you should hate the American system and love universal healthcare.
I’m not here to argue that the American healthcare system is substantively worse than other systems (although it is). I’m also not here to argue for or against any particular universal healthcare system—I’ve lived in three different countries with three very different systems, which all had their advantages and disadvantages, so I’ll leave it to the policy experts to decide which specific model would best suit the U.S. Instead, I’m here to argue that the current American healthcare system is completely and utterly un-American, full of qualities totally anathema to the American spirit, and that universal healthcare systems are much better at embodying the things Americans value. Observe:
Americans hate dealing with bureaucracy. (Forgive me, we are entering the world of generalities, but I do think there are some tendencies that are broadly applicable to American political philosophy and cultural self-imagining, if not every single American.) One of the main things Americans associate with government is the figure of the pen-pushing bureaucrat: some stony-faced suit you have to line up to talk to, causing you a headache, with no interest in being helpful so long as he follows the rules and does his job—a figure that is about as far from the wild frontier as it’s possible to get. Well, I hate to break it to you, but those bureaucrats already run the American healthcare system. It’s just that the buildings they work in say “Aetna” or “Blue Cross Blue Shield” on the front instead of “Department of Health.” And it might surprise Americans to know that in universal healthcare systems (at least the several I’ve experienced), you basically never deal with bureaucrats. Your interactions with the healthcare system are pretty much entirely with (a) medical staff and (b) the receptionist at the front desk who helps you book your appointment. Obviously there are administrators somewhere keeping everything running, but they’re not part of your personal experience. You do not have to call them. You do not have to justify yourself to them. The only people you have to talk to are the people who are directly involved in your care.
Americans don’t want strangers getting involved in their business. Why do you have to tell some insurance employee about your personal health issues? Every year, countless Americans find they’re not covered for services they need, and have to spend hours on the phone begging multiple strangers with no medical expertise to understand their most painful and private situations: reproductive health issues, disabilities, physical and sexual violence, miscarriages and stillbirths, mental health crises. There are people who attempt suicide, are saved by emergency services, and then find that the first thing they have to do in the aftermath is argue about their hospital bill. Americans have a powerful streak of independence running through them; people will passionately defend their right to shoot people who invade their private space just by stepping on their property. In America, people have a strong sense of the private sphere, and that you have a right not to let some total stranger get involved in your private affairs. So why accept this totally unnecessary intrusion into your personal life? It’s tough enough talking about these things with a trusted doctor—it seems sickeningly un-American to me that you would need to discuss your private health information with an employee of an insurance company sitting at a desk somewhere (especially considering their job is often to find a way to explain why you don’t actually need what you say you need).
Americans don’t like their lives being cluttered by nonsense if they can just keep it simple. Deductibles, co-pays, pre-existing conditions, exchanges, the whole messy patchwork of programs, the interminable paperwork, the inscrutable bills, the endless phone calls where tinny classical music plays down the line for half an hour until you finally talk to someone…every other system has shown this stuff to be unnecessary. You know how it works in other systems? You walk into whatever clinic you want. If you’re new, you spend 10 minutes filling out a form. Then you book an appointment with the clinician you want, you go to the appointment, you leave. If you don’t like the clinic for whatever reason, you switch by going to another one and spend 10 minutes filling out the form there. You’re very sick and need to go to the hospital? You go to the hospital. When you stop needing to be in the hospital, you leave. No muss, no fuss. Some systems might require you to enroll in insurance, but this is a somewhat different process than in the U.S. Because healthcare is recognized as a right, and quality and accessibility is prioritized over profit, requirements are placed on insurance providers to ensure that coverage is comprehensive and affordable, and that the enrollment process is simple and mostly worry-free for residents. (This is not to say there are no injustices in other health systems—the NHS demands surcharges from non-citizens, for example, and access to mental healthcare lags behind physical care in most places— but these imperfections, while they should be fixed, are small compared to the issues with the American system).
Americans believe in negotiating the best deals. Take a look at this neat little guide to the most common medical treatments and their cost to the U.K.’s National Health Service. Remember that these services are free at point of access, and paid for by progressive taxation, so these are not upfront costs, but rather how much it costs the NHS to provide each service, taking into account how much it costs to pay the staff, purchase the equipment, and so on. These same services are typically billed several times higher in the U.S.—sometimes 10 times higher or more for the exact same products and services. (I specify “the exact same” because often enough, people against universal healthcare will try to claim that despite lack of access, the “quality” of healthcare in the U.S. is better. While “quality” is a tricky thing to gauge—mortality rates might be a little lower for one type of cancer, a little higher for another, and so on—the general trends show that even aside from access issues, “quality” is generally about the same or lower in the U.S. than in comparable countries.) Read this well-known article from Time Magazine in 2013, which analyzes the reasons behind the massively inflated and near-random costs of U.S. healthcare. Simply put, the NHS has massive negotiating power, because they purchase equipment and medicine for the whole country, and can therefore negotiate low prices, which is reflected in the low costs to taxpayers (British healthcare spending per capita is less than half of the U.S.’s). In the U.S., on the other hand, individual hospitals, insurance companies, and pharmaceutical/medical equipment companies are caught in a messy battle, with each of them incentivized to inflate their costs. That’s why consumers are left with a confusing and wildly inconsistent pricing system that does not benefit them in any way, because they are individually not powerful enough to negotiate much themselves, and no-one in the system is charged with working in their interests. Trying to create a “market” for healthcare has resulted in a system completely opposed to what markets are theoretically supposed to do, causing prices to spiral out of control, become totally irrational, and leave the little guy impotent and squished. To put it simply, you’re getting screwed. The American healthcare system is a bad deal, folks.
Americans value freedom. Advocates of the American healthcare system will claim that it gives people more freedom, because you get a choice of insurance plans. Leaving aside the fact that in many cases, you might only have one insurance company available to you, it’s important to note the sleight of hand here—it is implied that the way you practice freedom of choice in the healthcare system is through choosing your plan, but a choice of plan is not the same as a choice of goods and services. To see what I mean by this, try and imagine the American insurance system applied to, for example, groceries. Imagine that instead of just going to the store whenever they needed, Americans were forced to choose from a selection of “grocery plans,” which specified which groceries from which brand you could have access to (after deductibles and copays, of course). Imagine you need some cranberries, so you can make some delicious white-chocolate cranberry cookies, and instead of just going to get the damn cranberries, you first have to check your grocery policy, because you’re worried that cranberries aren’t covered. After 20 minutes of reading, you figure out that your plan covers up to 40 packs of dried fruit per year (and only from specific brands which have agreed to accept your particular grocery plan). Your nearest store isn’t covered by your grocery plan, so you have to drive an extra 10 miles to one that is, and pick up the cranberries. Later, you receive a bill that’s much higher than you expected, and you have to make a 40-minute phone call to the grocery insurance company, so you can ask them: Why was I charged $172 dollars for a pack of dried cranberries? Cranberries were covered under the dried fruit policy, surely? You could switch to another grocery plan, but all the others cost more, and none of them cover everything you want. This illustrates what it means to have a choice of plans, without necessarily having freedom of choice in goods and services. (Also this analogy does not work perfectly, because people need chemotherapy a lot more than they need cranberries).
At the moment, insurance plans are the means by which Americans try and exercise a modicum of influence over what actually matters to them, which is getting to see the practitioners they want, and receiving the services they want. An insurance plan in itself is not healthcare. It’s basically a big document controlling what healthcare you can and can’t access. It limits you to certain clinics, medical practitioners and services, and in many cases, it may not even be clear to you what services are covered until after you get the bill (in economics, this is called information asymmetry, and is considered one of the biggest factors behind market failure).
By contrast, universal healthcare systems generally allow you to sign up to whatever clinic you like in your area, and see the primary care physician of your choice (some, like Japan’s, even allow you to go directly to whatever specialist you want without a referral from a primary care physician). You and your preferred medical practitioner decide together what treatment is right for you, and you get the treatment with no middlemen involved. There are some practical limits, of course—if a doctor or clinic is too popular, they might put people on a waiting list or prioritize patients who live closer, or if an experimental treatment has not yet been proven effective, it may not be provided in some countries without additional private coverage (other countries, like France, choose to spend more to allow for these choices). But these practical limits on resources also exist in the U.S. The difference is that in other countries, the goal is effective patient care, whereas in the U.S., the goal is extraction of profit. And if insurance companies can extract more money from you by restricting where you can go, who you can see and what you can take, they absolutely will, and do.
The American healthcare system is an imposition on freedom-loving Americans. It is restrictive, invasive, unnecessarily complicated, full of red tape, extraordinarily bloated, and wasteful. Though each universal healthcare system is different, and of course none are perfect, they are leaner, more effective, and give their beneficiaries far more freedom of choice than the American system does. I think Americans know this, too: Most Americans support Medicare For All, including about half of Republicans, and polling has consistently shown that Americans dislike and fear their own healthcare system.
There are some issues where I’m unsure I could ever find common ground with American conservatives, but here’s one: Replacing the current system with universal healthcare is as American as apple pie and the Super Bowl. It’s the logical conclusion to a belief in life, liberty and the pursuit of happiness, and should be treated as such. Universal healthcare should be viewed as patriotic. The national anthem should play every time single payer is mentioned. Every ridiculous insurance bill in the land should be snatched up by a majestic bald eagle and used to line the nests of its soft, downy eaglets.
And most importantly of all, when it comes to the 2020 Democratic candidates who shy away from a universal healthcare plan, they should be asked why their values are so un-American. A bit of a tacky approach, sure, but it would be fun to watch them squirm.
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