So various US publications have waded into the health reform debate with comparing the US with the UK’s NHS. These commentary, as many other bloggers and those on Twitter, are of varying degrees of stupidity, ignorance and general lack of insight.
It is worth keeping in mind that for decades, there have been comparisons between Canada’s healthcare system (very similar to the UK’s NHS, but there are very important differences, too) and the US. The Americans have these debates constantly and the various lobby groups are well-equipped to flood the ether with their rhetoric. There is a deep-seated concern about ‘socialised’ medicine, about the role the state usurping individual responsibility, and about power and control.
And the spirited defence of the NHS will no doubt continue apace.
But underlying the debate is the unanswered question of why does the US have so much trouble with reforming its healthcare system in the first place.
One reasons is that Americans seem have a lot of trouble with what are called free-riders. Because their system is insurance based, those who do not take out/cannot afford health insurance, get a ‘free ride’ on the taxpayer, through the federally funded Medicare/Medicaid programmes for instance.
By and large, Americans philosophically are liberal in their outlook, and believe that individuals should make the most of their gifts, so the system rewards, and celebrates success, and while not necessarily punishing failure, ignores it as long you pick yourself up and get on with improving your life. Ideologically, that means that it is hard to grasp that everyone may have an interest in the general welfare of individuals, AND that the responsibility for the general welfare is the responsibility of government. Practically that translates into a political ideological debate about the role of the state.
Why does that matter?
The US politically is a different system from parliamentary democracies. In the latter, political parties stake out ideological territory (left, right, socialist, whatever) and the electorate chooses. In the US, the United States itself IS the ideology. The political parties are interpreters of this founding ideology and the electorate chooses within that ideology from the political parties. That explains in part why there is a narrow range of political choice on offer in US elections, and why, under the skin, all political beliefs flow back to the founding ideology of the US Constitution, and its revolutionary roots. The US believes it is the definition of democracy, so why would one have varying degrees of political persuasion if you’ve already solved the hard problem.
That means that the health reform debate is predicated on historical consensus about the political objectives of the US as a democratic entity. One of these principles challenges the role of government, another principle addresses individual liberty and third focuses on how the US interprets the public interest and general welfare. The third principle is NOT interpreted by the state (as in the US, the state is a creation of the people), as it is parliamentary systems (where the state exists independently of the people — read Hobbes). In the US, the resolution of a political debate amongst competing interests determines the public interest as the state does not have an independent existence and so cannot have its own guiding principles.
Why should this matter?
Because in the US, these debates nourish the democracy itself. The discussion is not esoteric but fundamental to the concept that Americans have of their country. Such debate in UK, France, Germany, Canada, etc, with universal health systems, will invariably invoke principles to resolve the issue, that can not work in the US political arena. The difference, of course, is that while the Americans will have the debate, other countries will sit complacently by while their governments pursue reform policies which should be challenged and debated outside the government. The differences are subtle, but important.