What’s So Scary About Socialized Medicine?
No one could blame you if you just wanted to stop thinking about health care now. The issue and the laws that govern it have been at the forefront of the national conversation since the first mumblings about Obamacare, and the pace of news on the topic has reached near-absurd levels in recent weeks. Whether the government does or does not have a moral obligation to provide its citizens with baseline health care has been discussed ad nauseam, and all legislative evidence indicates that no minds have been changed. The passage of the Affordable Care Act in 2010 seemed like an indication of a trend toward more government involvement in health care, but the election of Donald Trump and healthcare bills proposed in both the House and the Senate since the beginning of 2017 have brought us pretty much back to where we started.
It’s not hard to see why health care is such a flashpoint. It has the unique distinction of being incredibly personal as well as essential to a well-functioning society. Even among the staunchest proponents of health care for all, Obamacare has been met with frustration. In reaction, Republicans have decided that the solution is less inclusive health care — fewer people on Medicaid, less incentive to get insured. But what if, instead, the answer to the problems of the Affordable Care Act was a more inclusive healthcare system? As politically and culturally unlikely as this proposition may be, it could actually go further to solve the issues of the ACA than a return to the pre-2010 status quo, and it’s not nearly as scary as it sounds.
I’ve lived in the UK for several years now, and I’ve been a beneficiary of socialized medicine since the moment my plane touched down. I first moved for a master’s degree, and by the time I arrived at my student halls I had already been registered with a primary care physician. This came as quite a pleasant surprise after spending my early 20s moving around the US and repeatedly struggling to find a doctor who took my insurance through the haze of tonsillitis, strep throat, or whatever else I’d managed to pick up.
My subsequent interactions with the National Health Service (NHS) were nearly as seamless as the first. A couple months after arriving in London, a friend got sick in the middle of the night and needed to go to the hospital. She and I, both Americans, gathered her documents — passport, NHS card, papers proving she was enrolled as a student. When we arrived at the waiting room, she sat down and I took these items to the counter. I received blank stares in return. None of it was needed. Everyone, including tourists, has access to emergency care through the NHS.
The following summer, just after my 25th birthday, I received a letter inviting me for a cervical screening, free of charge of course. This screening, which is offered to women between the ages of 25 and 64, is just one of a battery of screenings the NHS can institute country-wide throughout the lifecycle. Other tests include annual eye screenings for people over the age of 12 who have diabetes and two types of tests for early signs of bowel cancer, one of which can be completed at home and mailed in (yes, it’s what you think). These types of screenings are not unique to the UK. Indeed, many of the same screening services are offered in the US under the Affordable Care Act. But under the NHS, it’s easier to institute them across the whole population, which helps to provide early intervention and improve overall health outcomes.
People often express concern that such a comprehensive healthcare system would make taxes skyrocket. The UK does have higher taxes than the US, but data from the Organization for Economic Cooperation and Development (OECD) and World Bank show that the US spends far more per capita on health care than any other wealthy nation and still has worse outcomes in terms of life expectancy and child and maternal mortality. This not only points to inefficiencies in the American system, it also demonstrates that despite the UK’s higher taxes, the NHS (and comparable systems in other countries) is cheaper overall than health care for an American.
This is true not just on the societal level, but on the individual level as well. I know this for a fact, because in the spring of 2015 I was back in California, where I grew up, for three months — just long enough that I had to get health insurance or risk being penalized on my taxes. I paid a premium of $211.72 per month, after which I still had a co-pay of $60 for primary care visits and $70 for specialist visits. My in-network deductible was $5,000. My premium alone was about 6% of my income during those months. By contrast, I paid an average of approximately £71 ($91) per month for health care in the UK during the 2016/2017 tax year, or around 3% of my salary*. By consequence of birth, I also paid £500 ($641) for two and a half years of NHS care as part of my visa application. That adds just over £16 ($21) per month to my NHS bill, still vastly lower than my American health care, and not a fee any British citizen would pay.
There is a short list of items a patient might have to pay for beyond her normal tax contribution. Dental visits, eye tests, some prescriptions, and some long-term care all make the list. But each of these is vastly cheaper than its American counterpart, and each is provided for free to certain groups based on need, age, and pre-existing condition. All prescriptions that carry a fee cost £8.40 ($10.77). Birth control pills are free, as are other long-term contraceptives such as the implant and the IUD. The most expensive bracket of dental payment listed on the NHS website is £244.30 ($313.27). That’ll get you a crown, a bridge, dentures, or other complicated procedures. Each of these services is more expensive in the US by hundreds or even thousands of dollars on average. You can get a full dental exam and a cleaning in the UK for just over £20 ($25).
The differences between US and UK healthcare policy boil down to founding principles. The NHS was founded on the idea that health care is a right, not a privilege. The NHS website states:
The NHS was created out of the ideal that good healthcare should be available to all, regardless of wealth. When it was launched by the then minister of health, Aneurin Bevan, on July 5 1948, it was based on three core principles:
· that it meet the needs of everyone
· that it be free at the point of delivery
· that it be based on clinical need, not ability to pay
These three principles have guided the development of the NHS over more than 60 years and remain at its core.

More than six decades after the NHS was founded, the Department of Health published a constitution to guide the further development of the body. Principle 1 of this document reads, in part, “[The NHS] has a duty to each and every individual that it serves and must respect their human rights. At the same time, it has a wider social duty to promote equality through the services it provides and to pay particular attention to groups or sections of society where improvements in health and life expectancy are not keeping pace with the rest of the population.” This approach to healthcare provision starts from the idea that health care is a human right and a societal good, and builds itself around the need to balance the interests of the individual and those of the society.
By contrast, healthcare.gov describes the goals of the Affordable Care Act like so:
The law has 3 primary goals:
· Make affordable health insurance available to more people. The law provides consumers with subsidies (“premium tax credits”) that lower costs for households with incomes between 100% and 400% of the federal poverty level.
· Expand the Medicaid program to cover all adults with income below 138% of the federal poverty level. (Not all states have expanded their Medicaid programs.)
· Support innovative medical care delivery methods designed to lower the costs of health care generally.”
The law clearly recognizes the individual and societal benefits of a strong healthcare system, but it has a narrower definition of who deserves protected access to care. These principles influence the theory of who is responsible for the provision of health care, which in turn influences how it is paid for. In the US, health care is the responsibility of the individual; in the UK, health care is the responsibility of the whole society.
With the individual mandate of the Affordable Care Act, the US got closer to the UK system than it has ever been before. The idea was that if everyone was forced to get insurance, costs would be shared evenly throughout the system, which would make health care available and affordable to everyone. The UK system functions on the same theory, but in a markedly different way. As a single-payer and (mostly) single-provider system, all UK residents pay for health care based on their earnings and everyone receives the same quality of care. Costs are kept down in this system because the NHS does not have to spend money on marketing and can set prices for drugs and other treatments.
The NHS is by no means a perfect system. Hospitals across the country are stretched to their limits and the last year has seen a series of strikes by junior doctors concerning pay and working conditions. There seems to be a constant struggle over funding and other resources. It can take longer to get an appointment, particularly with a specialist, than it might in the US (though not always). Still, it brings healthcare access to every UK resident, and many of the pitfalls are seen in the US as well — who among us has not spent hours in the ER waiting room? Moreover, there’s still private health care in the UK. No one has to use the NHS if they don’t want to, but they do have to contribute to it, kind of like how property owners in the US pay for the public education system even if they don’t have kids in it.
The problem with the Affordable Care Act wasn’t that it went too far in providing health care to Americans, it was that it did not go far enough. The individual mandate and the expansion of Medicaid were half-steps toward single-payer health care that left many people frustrated and out of pocket. Instituting a single-payer health care in the contemporary US political environment seems infeasible in comparison to 1948 Britain. The Labour Party had come into power on a “landslide” victory of 48% over Winston Churchill’s Conservative Party, which received 39.8% of the vote. Still, there’s no structural or natural reason why the US couldn’t move to a similar system. The reasons, instead, are primarily dogmatic. “Socialism” is a dirty word that our post-Cold War brains cannot abide. We are allergic to tax hikes of any kind, regardless of what they would pay for. Our individualistic mindset gives primacy to autonomy and choice, unless of course you have a uterus.
As our president said, “Nobody knew that health care could be so complicated.” There is no simple fix to the challenges we face in this area. Any solution will require not just a legislative overhaul, but also a frank dialogue about how we define ourselves and our relationship to one another. However, there is more than one way to skin this particular cat. With so much at stake, we owe it to ourselves to consider all of them.
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*Calculation based on approximate spending of 18% of Income tax and NI contribution on NHS.

