The American Sickness

The United States is sick.

I do not mean Americans are physically sick. They are physically sick, but every other nation knows that already. Sickness is a part of life. Barring accident, most of us expect to succumb to sickness sooner or later. Sickness in America is worse than in other rich nations, though the US is the richest of all. The US spends an extraordinary amount on healthcare, both in absolute terms and as a percentage of its GDP, yet still fails to deliver even modest levels of care for large swathes of the population. 47 million Americans have no insurance, and many more are underinsured. But I do not mean to emphasize America’s physical sickness. Yes, the US tends to rank lower than other rich countries, like the UK, on many measures of health. Comparing the US to the UK, the American life is shorter. The American infant is more likely to die. Americans are more likely to have HIV or AIDS. Americans are less likely to have a health professional present at a birth. Per capita, Americans have more dentists, slightly more doctors, but far fewer nurses. The meaning of the per capita measures is undermined, however, because the distribution of access is so different. Most Brits have very similar access to health professionals, whilst Americans enjoy, or dread, varying levels of access. In short, we all know that the US, on average, spends a lot on being well, but still manages to be, on average, sicker than the inhabitants of the UK and other rich European countries. But when I write that the USA is sick, I am not referring to the sickness, often untreated, that lies in American bodies. I refer to the sickness in the American soul.

Let me write one thing about freedom. Freedom is not worth dying for. Dead people are not free. Dead people have the least freedoms of all. However much we honour those who fight, and die, for our freedoms, most of us recognize that exchanging death for freedom is no kind of a bargain. To enjoy freedom, we must be alive to enjoy it. Moreover, illness and incapacity is the most debilitating kind of constraint on our liberty. Pain and infirmity leaves us imprisoned, trapped in a cage of our own bodies. Health, then, is a vital constituent of freedom.

Paradoxically, Americans want to die for their freedoms, or at least pay over the odds for it. The measures are straightforward. They know that inefficient healthcare is crippling their nation. Whether it is the unfathomable burden on unionized businesses, or the loss to the labour market of so many potential workers, or the astonishing waste on administration of insurance, or the wealth creamed off by ambulance-chasing lawyers, Americans know their healthcare is in a mess. But they cannot do anything about it. They cannot do anything about it, because they are worried about losing their freedoms.

In the US right now, there is a hate campaign about Britain’s National Health Service, nationalized provider of healthcare to all Brits. Britain’s NHS is being demonized. According to Conservatives for Patient’s Rights, a US pressure group, the UK suffers from lots of waiting lists. They also say that Britain suffers from rationing. Both are true. Both are natural by-products of efficiently providing universal healthcare. Waiting lists are a consequence of not spending money on having surplus resources, including healthcare professionals, lying around and doing nothing until somebody needs them. Waiting lists mean everybody waits a period of time, instead of having a system where some people can jump ahead whilst others wait longer, or a system where some go untreated to focus more resources on those who do qualify for treatment. As for rationing, even the free market rations scarce resources. A world without rationing is a world with infinite resources – in other words, a fantasy. People can say a human life is priceless, but that is only because they are not paying the bill. A simple thought experiment should clarify. Imagine somebody suffers from a disease, and the drug to cure it is very expensive. Imagine it is so expensive, it costs the entire combined GDP of all the nations on earth. What would happen? We would let the person die. Spending the entire world’s wealth on saving a single life would make no sense. Though difficult to measure these things on a scale, the benefit of a prolonged life for one person would be tiny compared to the loss of the rest of the world of sacrificing everything for the cure. So there are always decisions about who gets what treatment, and there will always be people who are denied treatment because of a limit on resources. The NHS is a system that rations healthcare based on the judgement of health professionals and a collective evaluation of the price to pay for health. America’s mess of insurance and private healthcare and hodgepodge of public provision and law also rations healthcare, but rations it based on a much less straightforward interplay between the wealth and economic value of the richer patient and the arbitrary rules and luck that befalls the poorer patient. Americans are only free of waiting lists because they pay the price in much more expensive care. Americans are not free of rationing, but because the rationing is a complicated jumble, and because it favours some over others, an alliance of the winners and the easily-confused now live in fear. They fear they will be less free if professionals are allowed to decide priorities.

Americans love to laugh at British smiles. Crooked old bad British teeth. Wonky smiles. Americans find British teeth to be an endless source of humour. There is also something else that Americans find odd about the British, though this attribute is less often on display. British men, ignoring those of a religious persuasion, have foreskin. I mention both dentistry and dicks because they both reflect a fundamental truth about the differences between American health values and British health values. Any idiot can judge a smile. Any idiot can see if a penis has been circumcised. Both are superficial. Both are to do with aesthetics. Braces do not make someone healthier, and there is no connection between circumcision and genital health. A nice smile and a cut cock can be judged by an ignoramus with no knowledge of medicine. In contrast, the knowledge of what makes for a good immune system, what reduces the risk of cancer, how to treat a disease and how to alleviate infirmity all belong in the domain of the expert. Americans idolize the Ben Franklins of the world: self-reliant generalists. But trusting an authority is more likely to deliver good health than trusting your own ignorance. Modern medical science is complicated and needs to be administered by people who are highly educated. Trust in authority is why British penises are not circumcised – because no money is wasted on an unnecessary procedure. Trust in authority is why British smiles are crooked – because resources have been applied to more important goals that prolong life and alleviate pain. That keeps the cost to the taxpayer down, whilst preserving the health of the people who keep the country running. In contrast, Americans trust their own judgement above all others. In the American deal, they can see how superior they are, thanks to the straighter smiles and aerated willies, but they must avert their eyes to fellow citizens who live life in pain or who die too soon. And to finance that deal, Americans spend double the amount that we spend in the UK.

The American evisceration of the NHS shows that the American people have souls in turmoil. For all the supposed flaws in Britain’s NHS, one truth keeps getting overlooked. The NHS is not a monopoly provider. The British state has not banned private medicine. Nobody is forced to pick state treatment. Nobody is denied the right to private treatment. The American obsession with freedom misses the essential truth that British healthcare is free. By the laws of demand and supply, nothing impedes private healthcare in Britain, other than the economics of inefficiency. Brits are free to get their healthcare supplied on a private basis. The NHS was deliberately designed to enable private care. Doctors were guaranteed the right to work privately, as well as the opportunity to work for the NHS. Many do both, guaranteeing that a free market is preserved within the provision of British healthcare. Put simply, Brits are at least as free as Americans. What Americans mistake for state oppression is nothing of the sort. The reason why the NHS often looks like a monopoly is not the product of state control, whether control of patients or doctors. The reason why the NHS looks like a monopoly is because most people chose to use it. Only 10% of Brits have private healthcare insurance. If more Brits wanted private healthcare, with more expensive doctors, in more exclusive hospitals, they could have it. They do not want it. They do not want it because, by and large, it is a poor deal. People would rather rely on the efficient provision of healthcare delivered by the NHS in preference to paying for private care.

There cannot be a better expression of freedom than Britain’s healthcare. Every Brit is free to survive. Every Brit is free to be treated. And every Brit is free to pay for a better supplier, if they choose. The vast majority chose not. In the American soul, the British system is something to fear. Fear is the American sickness. What Americans fear, more than anything, is the realization that they are already imprisoned, not by an authoritarian state, but by the labyrinth of ‘freedoms’ they constructed for themselves.