Following on from the Recommended Diary from my European neo-compatriot, I thought I'd pen a few lines on the British experience, and realistic lessons that can be learned regarding the US HCR bill.
Clearly a fully nationalised system is less-likely in the short-term than even a more modest Single Payer system, but there are lessons nonetheless to be learnt from the European model more generally. I hope some of this might prove useful for American activists and strategists looking to move the debate forward from here. Some of the ideas are a bit odd, but I thought they deserved an airing.
I should state that I am somewhat on the fence regarding the US HCR bill (but I live in New York, so have some vested interest), so none of this should be read as implicit support or opposition to the bill that President Obama will probably sign.
The British NHS is a fully nationalised system of universal healthcare. Not just a public insurance option, not even a Single Payer system where all privatised options are paid through the government, a system where healthcare is delivered by the Government as well as paid for through general taxation. This is what real socialised medicine looks like, and contrary to theory and expectations on the Right, it works reasonably well. It could be better, and it is probably a little bloated in terms of the massive investment that has been pumped in without sensible structural reform over the last few years, but on the whole, there is no system I would rather have.
It works to the extent that if the Conservative Party win the next election, not only is the NHS safe from privatisation, but David Cameron has promised to maintain funding levels set by this Labour government in this area. No serious Conservative politician would dare tinker with the NHS, because in spite of occasional horror stories (many - like the MRSA scare - exaggerated, others simply the feature of its size and scope) it is probably the most beloved institution in the UK, followed by the BBC.
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The NHS was founded by the Labour government that followed the Second World War, and the key opponents at the time were doctors, who feared for their livelihoods. Aneurin Bevan, the minister responsible, was asked how he ever got them to agree, and his quote has become famous "I stuffed their mouths with gold".
LESSON ONE: if you want doctors to support reform (and they are the best conduit to patients who have healthcare that they fear they will lose), you need to "stuff their mouths with gold" - find a solution to massive cost of medical training, introduce tort reform to limit medical liability, etc. Now we all know that the major impediment in the US isn't doctors, but insurance companies, so here's my tuppence-worth on applying the same lesson to that industry:
No-one who works for an insurance company really cares about that insurance company in any meaningful way. A patriot longs that his country should survive and prosper long after his death, the family man cares for the futures of great-grandchildren he will never meet, the Catholic cares for the future of the Church in perpetuity. Not so the CEO of an insurance company. He cares about the company for as long as it is his responsibility. How many CEOs would accept happily that their company would be destroyed in 100 years in return for an extra $1 million a year, for life? How many would turn down a 7-figure sum in return for the demise of their company after their term had finished? How many shareholders in insurance companies would refuse doubel the market rate for their shares on ideological grounds?
There are always mouths to stuff with gold, and I suggest that those at the very top of the insurance companies, and their shareholders, will need to be over-richly compensated in return for giving America healthcare it can afford. Buy them off at the start, a better-than-fair deal - let the GOP try to inhibit the next healthcare bill, if it promises gold-stuffed mouths for every shareholder and executive. Watch them accept anything, upto and including full nationalisation, if they get a return richer than could ever have been believed. Some might even campaign for it. Offer gold and more gold, until their stewardship and burgeoning share price rests on an inflated offer from the government. At that point, they will not stand on ideology to oppose you. If we want a public option, how better than by buying and merging the insurance companies?
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The reforms of the 1940s have survived any number of governments of a Conservative bent, not least the 11 years under Margeret Thatcher, and the 7 that followed under John Major. The NHS survived these for one major reason - when you give something as valuable and as intrinsically vital as healthcare to a population (even if they oppose the manner in which it is introduced), such measures are almost impossible to overturn.
LESSON TWO: if you want a platform for more reform, make sure it expands the entitlement. However this is done, no-one will support a government that threatens to take away something people already enjoy - the prejudice for the status quo. Even if the HCR bill is bad, giving the entitlement to people is an irreversible step that can be used as a platform. The debate becomes about how to adminster, how to manage costs, but as soon as that entitlement is given, it can never be revoked by a party that wants to keep power. Opponents of HCR need to win each and every time, Progressives only need to win this battle once - but win it any which way. Dare to use dangerous means, like the destruction of the filibuster, to win this battle because success in the larger war will follow, however harsh the short term consequences of the immediate battles.
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I've spent some time looking at comparative politics across the UK/US/France/Germany/Sweden this year, and one element of the European Social Model of delivering healthcare screams out its irreconcileability to the US model. In one word, the key to progressive healthcare, and the major lesson for US progressives, might be this:
In Germany, in France, in the UK, the cost of a visit to the doctor, the cost of an operation, or the cost of delivering a baby are rarely cited. Someone works it out for the occasional article in a newspaper, or reports it internally to the NHS, but it is not a front and centre calculation. Nobody thinks about the cost of their operation in the UK, unless they are one of a tiny minority (about 6% I believe) who elect to have supplementary private medical care (they have already paid for, and have a right to, NHS treatment too). It is easier for people to accept healthcare as a right when they are not made to think of it as a commodity that costs money and can be compared to other consumer goods.
In the US, or so it is said, healthcare is still spoken of as a commodity - with associated costs per procedure and per drug, which allow the 'value' of helthcare to be ascertained. This is the primary impediment to a more European model - the language in which healthcare operates, the values given to the various parts, are all facets of an unequal consumer market-place where it is always possible to opt into a more expensive version if you have the cash. My point is this: any time that a dollar-figure is put on healthcare, progressives lose.
It is difficult to manage a social shift in language, but the decommodification of healthcare in Europe (it now exists only as a nebulous 'right' of unspecified scope) is precisely what has protected institutions like the NHS from the vicissitudes of political government.
LESSON THREE: do whatever is possible to decommodify healthcare, so that the language of utility (cost-benefit) is depopularised and the language of rights and healthcare as a holistic concept (rather than the sum of procedures and drugs) is made the currency of the debate. Be that cutting the patient out of the billing loop (so only hospitals and insurers see the costs), introducing flat rates for certain classes of prescription drugs (even if those rates are high and don't cut into drug company profits), expanding Medicare wherever possible.
Most of this is already on the lists of US activists - I've seen the campaigns run, and none of it needs to lead to anything as radical as a European model, but to move in that direction I think a change in language and thinking needs to occur. Any time we commoditise healthcare, and time we reference costs and talk about it as another sector of the consumer marketplace (with variable costs for variable levels of quality) we trap healthcare in the realm of the inequal-consumer market-place, rather than allowing it to move into the decomodified realm of the rights of the citizen.
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I don't know how practicable any of this is, but as well as the really important tactical and strategic political campaigning that goes on, I think we need an eye to the sort of language that will encourage a way of thinking that facilitates the progressive side of the debate.
Just as winning campaigns is less about having the best answers, and more about setting the right questions, so I think the policy debate is won not by those who have the best solution, but by those who frame (often through setting the language of the debate) the solution-set most amenable to what they want to achieve. I believe that as long as America talks about healthcare as a commodity, progressives have ceded the most important territory in this debate.
It might be a long time before another healthcare bill comes along - let's use that time wisely, and start reconfiguring the way we think and talk about healthcare, so that when next time comes, our solutions are more in-tune with the way the debate is framed.
"Healthcare is not a commodity" - let's make that the next win on the road. Your thoughts?
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UPDATE: first time on the Rec List (must be the time of night) so thanks to all. I should add that this was conceived as some starting thoughts as to the next HCR bill. As I said, I'm on the fence as to what to do about this HCR bill - I can see both sides - so for me it's largely about which option (killing the bill or passing it) will have the most chance of seeing another (more radical) bill brought in the next 5-10 years. If passing this puts off reform for 30 years, but killing it forces the issue to a head in 5, I'd lean towards killing it. If killing it makes it a toxic issue for a generation, but passage would keep reform alive, I'd support passing it. It is now about what comes next, and I think that's where we should turn our attention. I'd be interested in people's thoughts on when the next HCR bill might be brought depending on what happens with this one.