Debating the NHS: A Rejoinder
I’ve had some interesting replies to my last post on this, so I thought I’d put down a bit more here. Just from the outset, though: I wrote the original piece out of bemusement that everyone had given up whinging about the NHS for a day. I was hoping to strike my usual balance of being critical of something while still supporting it overall.
The estimable Shiro Ota wrote this:
Perhaps the NHS does constitute some semi lack of freedom (to be as detrimental to your own health as you like, although most people who live in such a way don’t seem to worry too much about their moral responsibility not to strain the system); but surely that’s more than offset (by a long way) by the benefits of aiding those who are genuinely, unavoidably, unhealthy; and those who are upstanding; hard-working citizens who could, nevertheless, not afford equivalent private care.
Randian objectivism is an understandable system that would oppose an NHS. But without subscribing to that (which I don’t), I can’t see a case for opposing its institution. In post-war Britain; or at present.
The question of the balancing act returns, of course - do we derive a greater value (of freedom or whatever else is at stake here) from the existence of the NHS as we do from the potential state of its non-existence?
It’s hard to prove anything from a counterfactual (and I should know). I suppose that all I can say in reply to this is that I don’t feel the only alternative to socialised health-care is its polar opposite. This is reflected in the fact that a Labour government has been spending the last decade and more tying the NHS to private interests, partnerships, and investment. I don’t think it’s working – actually I think it’s disastrously half-arsed.
Coming from another world, though, where we never had an NHS, I think that state intervention would be perfectly acceptable in a system that is, for the most part, operated in terms of a free market of health-care. So I don’t think that Randian Objectivism is the only recourse, or that, indeed, it could be any sort of improvement.
Obamacare may be basically the right synthesis, in the end – I’m sure we’ll find out.
My sainted mother, Dani Kaye, wrote this:
And why don’t you mention what you would put in its place, given the relative poverty of such a massive proportion of the British population compared to, say, Switzerland, where we have mandatory health insurance?
Well I think I made clear that I wouldn’t do anything like remove the nhs… it’s too well-established. But if I was starting from scratch?
Subsidies delivered to essential, first-level health services and medicines, mandatory insurance with certain benchmarks of assistance based on personal income, anti-monopoly laws for hospital ownership and licensing permissions so there wouldn’t be too much geographical overlap… basically a really, really well-regulated market scenario. Rather than the current approach, which is to try to de-regulate, localise and set up PFIs etc. over the top of a state monopoly. No NICE, either: individual health establishments make their own decisions about their services, above a certain level. They compete, improved services are incentivised, and thus we’re hardly dealing with some anarchistic nightmare realm.
Another particular friend asks:
Is it just me or are the Daniel Hannan NHS comments pretty reasonable?
Well, Hannan clearly thinks the whole project was misguided, though he seems to agree that people have always meant well in instituting the NHS. I don’t actually have a problem with this guy. He’s mainly saying things that most people say every day: we spend too much money on it, it’s over-regulated, and it has crazy little breakdowns in its own special ways. It’s a perfectly reasonable point of view.
A few points about the general Fox coverage, though: Doctors over here are paid PLENTY. There’s no argument to be found on that. I truly believe that. Could they be paid more? Sure! But I don’t think their pay levels are in any way part of any of the problems that our system has.
The bottom line is that free healthcare is a basic human right and it’s morally abhorrent to deny someone treatment because they can’t pay for it.
Privatisation of healthcare does not work because the companies are not loyal to the needs of their customers, they’re loyal to their shareholders, and if there’s no public alternative to drive costs down and make them provide a higher quality service then healthcare will just get more expensive and worse because it’s better than nothing.
Oh, and can we please stop pretending that Randian Objectivism was anything other than a stillborn adolescent philosophy for wannabe sociopaths and people who thought Catcher in the Rye was “like, totally about me and shit.”
I dispute that free healthcare is a human right, on the grounds that we can’t define the limits of ‘healthcare’ and that it’s not possible for it to be free. The only questions here are “when and how much do you want to pay for it?”.
I do think that successful companies need to provide good services in a proper, competitive marketplace. Alternatives don’t need to be public.
I also think that a certain minimum level of healthcare should be absolutely fee at the point of use, for everybody. So we’re in agreement. But there are plenty of ways of ensuring that.
Randian Objectivism was fun but, of course, too extreme to be politically interesting. But that doesn’t mean that classical-liberal ideas aren’t useful guidelines here.
FROM FACEBOOK: SHIRO SAYS…
The estimable (though yet to be esteemed) Shiro Ota here. You are quite right that I presented my reply as something of a false dichotomy, although that was due to my own misconstrual of your comments as a suggestion that you’d favour an American-style private system over our national one.
Having read your rejoinder to your wise mama, I now see … Read morethe compromise you have in mind. However having said that, one more niggling question: in your original article you wrote: “So if you’re going to oppose the NHS, do it properly, from the ground up: do it because you think it’s a signpost on the road to decreased freedom”; and I took that decreased freedom to be referring to mandatory tax payments by which (most people) spend more than they (personally) gain; however in your alternative suggestion you suggest mandatory insurance payments. Now surely that’s just as much a sacrifice of freedoms as NHS tax payments, only with the surplus payments going to insurance companies rather than the health service. Surely that’s worse, isn’t it?
Additionally, you’re quite right that the present NHS suffers many faults, however in basic principle – would you really not favour some form of national socialised health service over some form of privatised equivalent? I know you’ve already answered this question in a sense, however just out of interest, in the basic principles of each – is private health really what you’d opt for?
Nevertheless, a fine response again Mr. Kaye.
Aha – my freedom argument (or should I say my depiction of a possible argument from freedom?) wasn’t based on the unfreedom of tax payment, but the unfreedom of no longer completely ‘owning’ one’s own health and responsibilities to it.
FROM FACEBOOK: SHIRO SAYS…
Aha. So what would be ultimate freedom of health ownership – the right to choose when; where; and if you seek health care? And would it include funding options at all? Surely mandatory insurance payments would still oppose this freedom, wouldn’t they? Still seems like anarchism (or a naive Randianism) would be the only way to ensure this freedom to me – but freedom’s not the be all and end all.
The phrase ‘naive Randianism’ seems redundant, somehow.
Healthcare is a right in the same way flood defence or a fire service ought to be a right in any urban civillisation. Classical liberalism had a historical tendency to fail when large scale social problems were uncovered – the “i’m glad those people in the slums had the choice to pay for food instead of a private fire brigade. Now, if only some one had put out that blazing inferno hurtling towards my house before it got too big for anyone to handle…” factor.
A failure of Healthcare anywhere represents a serious threat to society as a whole, hence ‘Miasma’ panics in the Victorian era and pandemic scares now. Quite aside from anything else, it creates a culture of fear which reinforces existing boundaries in society – a cursory glance at the history of the relationship between the City of London and the East End proves that.
Secondly: how is health care in the hands of bureaucrats appointed by an *elected* government more coercive than one in the hands of bureaucrats in the payroll of an unelected, unappointed corporation? Healthcare isn’t a ‘choice’ issue. You either have a disease that requires treatment or you don’t, and a bureaucrat is a bureaucrat whether he works for the Repubic of Generistan or Medisurance GmbH. The difference between a government bureaucrat and a corporate apparatchik is that a government bureaucrat gets his mandate and job directly from your taxpayer cash and so doesn’t have nearly so much of a license to fuck you about when it comes down to the wire.
1. Flood defence and fire services are bloody important, but I’d stop short of saying that anyone has a human right to them. And since when are the only plausible guardians of anything we decide to categorise as inalienable rights our governments? Classical liberalism certainly was tempered for generations by the social problems you describe, and I think we can agree that’s a good thing.
2. Pandemics aren’t a failure in healthcare, though. Throw as much central money, technology and willpower at a flu virus, and you’ll still get your nice regular three-times-a-century flu contagion sweeping the land. We can limit and respond to it better than before, but perfect healthcare does not equal perfect health.
3. Everything can be a ‘choice’ issue if your choice is between competing services. But someone with as much awareness of the workings of the various branches of our civil service as I know you have, Richard, knows that the argument that a centralised bureaucracy is more accountable doesn’t really hold water. I’d suggest that simple, emergent competition structures are usually a stronger safeguard for the individual interest than the other thing.
1. Yeah, you’re probably right on the word ‘right’. Perhaps, a different way to state that would be that any responsible community has a duty to try and solve those issues…
2. I’d argue that you’re wrong in the regard. The truly major flu viruses have tended to occur at times of major social dislocation and movement of people – 1919 being one example, the spread of the Black Death in relation to roving nomadic hordes being another. I suppose that major social dislocation and mass movement of people is a condition of the modern age, but even with Swine Flu the worst hit locations are mostly slums.
AIDS is another case in point. One of the most compelling reasons I’ve read in the scientific press for it’s appearance and rapid spread has to do with the rapid spread of ungoverned, infrastructure free cities in Africa. (Mogadishu and Lagos being Libertarian paradises!) Without food and health infrastructure, when European and Asian factory fishing ships devastated the food supply situation in those regions a lot of people turned to bush meat and we saw the sudden spread of disease after the disease after disease, incubating in these places.
I agree, you can’t guarantee you’ll prevent a pandemic, but the better our infrastructure is, the better our healthcare is, the less we’ve had. The story of city councils in this country is really the story of a fight against, and defeat of, disease in this country. We’ve not had anything comparable to the Cholera, Typhoid and Smallpox outbreaks since that great effort to get clean water into every house in the country. It removed a large part of the incubators. Universal Healthcare ensures new ones don’t occur in poor neighbourhoods. Because once these things start, they cut across social class faster than any politics.
3. You know what, my views on that have changed. They’ve become, well, more nuanced. The British Civil Service – well into the 1980s, in most cases right up to 2000, was the most secretive in the democratic world, far more so than in most cases. The biggest issues we’ve faced came from the desire of the CS to keep itself secret ‘for the good of the country’. Most of those barriers, cultural, systemic, etc etc have actually come down over the last 20 years – partly by choice (under John Major), partly thru fuzzy conviction (Blair), partly because the EU forced them to be transparent (Thatcher – to be fair to her, some of the efficiency drives helped). It’s no surprise that classical liberalism found it’s most effective arguments in the UK, when people were dealing with such a bizarrely opaque organisation without precedent anywhere outside the Sovbloc… we have far fewer elected officials, far fewer means of representation, and frankly a far less democratic system than anywhere else in the First World in many respects. It lacks a proper representative system, especially at local levels.
BUT – my argument isn’t that a government centralised bureaucracy is great, it’s just that it isn’t any different from a corporate centralised bureaucracy. If i’ve learnt anything from the last year’s study it’s that theory falls apart in the face of general human folly and hang-ups. A corporate bureaucracy has all the same inefficiencies – just start A talking about his recent efforts – all the same elitism at higher levels, all the same people problems.
The difference is – in a representative democracy (the kind you get in France, in the US, Germany, places were local government is properly served) the government has a bureaucracy has a mandate directly from the voters and the users, not just some shadowy shareholders who may never use the service at all. And if they fuck up, you can choose to vote them out. That, in a situation like healthcare is a far more real choice than which unaccountable corporate entity to get screwed over by.
It’s a negative thing – i’m not saying that the centralised bureaucracy is *more* accountable, i’m saying that it’s no worse than the other kind. Happy times!
I still believe you have a right to the best healthcare available, and that socialised medicine is key to the notion of an advanced society. In America, the reason we’re evening debating this, Remote Area Medical Clinics, designed for use in the third world, now operate frequently in the most prosperous nation on the planet, often catering to people who do have insurance but their insurance has found a way of weaseling out of paying for something essential. There is no way in which that is not wrong.
America is completely fucked-up on this issue, but fully exploring and explaining the American situation would require an extremely long diversion about the frontier spirit, the ideal of the self-made man, the red scare and the death of American socialism, healthcare industry lobbying, the protestant ethic and the spirit of capitalism, the seizing of the political narrative by the right, the tax revolt of the late 70s, wedge issue politics, the American dream (the big one), astroturfing and many other contributory historical and political factors and concepts all of which lead to the fucking ridiculous situation we’re in today.
The people who are arguing against this are not rational people staking a philosophical position, they’re nutcases screaming about Hitler and Obama killing their baby. An American friend of me likened the American political discourse to a game of football (well he said soccer) in which one side use their hands and refuse to acknowledge that they’re doing anything wrong and the other side gets portrayed as wimps for protesting about it. There are no reasoned debates. It’s screaming and howling and crying and theatre.