A visit to the ‘land of freedom’ with its catastrophic health care costs is a warning not to be complacent about the NHS …
Where it’s brushed against poison ivy, Kelly’s skin is badly blistered, a rash slowly spreading down her back. But with no job, and no health insurance, there is no money for a doctor’s appointment or a prescription, so we try to find something over the counter that will work. A year into a job, her friend SallyAnn is luckier to have just qualified for health insurance when a gynae problem means several investigations are needed. The $2500 dollar excess is going to be tough to meet, though. At the clinic, ahead of her in the queue for pharmacy, Mrs O’Hare is trying to navigate the Medicare ‘donut hole’ that hits many by this time of year: by late September she’s got to the limit of what the scheme will reimburse. The pharmacy assistant suggests which of her diabetic medications are essential, which she can eke out a bit or forego till next year, and which prescriptions she might get cheaper at Walmart.
My English accent catches Mrs O’Hare attention: I empathise with her having to choose which prescriptions to take today, saying I’m lucky to live in a country where older citizens like herself would get them all, and for free. “Yeah”, she says, “but who’d want commie health care? Why would you want to pay for other people’s illness?”
In the Southern states of the US, the depths of scorn for ‘socialised’ health care can be breath-taking to European sensibilities, especially from those who would be net ‘winners’ from such a system. And it’s not just from the odd rural patient, routinely sceptical of foreign ways. On the interstates, every visitor centre has a free newsletter for the tourists. Advertising local theme parks, country music museums and Apple Butter Fairs, they all end with a letter from the local Mayor: and most of these bizarrely condemning ‘Obamacare’ along with welcoming you to the County. These local Mayor’s welcome letters criticize the complexity of the proposed health care reforms: it is, claim many commentators, impossible to know what was proposed, or what would happen. But, as Daniel Skinner, in an eloquent critique of the debate on the Affordable Care Act in Critical Public Health points out, beneath such criticisms are “ideological games, not assessments of reality”. As he notes, the Act will do little for the poor and insured in States which have refused to expand Medicaid, such as Texas. It is hardly a radical restructuring of the political economy of health care in the US.
But, like the freedom to bear arms, the freedom to take and manage your own health risks is deeply and passionately held on to here – and, like antipathy to gun control, antipathy to health care reform can be hard to fathom for a foreigner.
Back in the UK, we take for granted that heath care is a right not a benefit: that we are entitled to care from the NHS as part of the post-war settlement between a democratic State and its citizenry. This is a pact that requires a high degree of trust in both an elected government and in your fellow citizens. In the Appalachians, Washington seems remote, geographically and culturally, but so too does California, or Florida. Beyond the distance of other citizens, though, is a deep cultural unease with the paternalism of welfare: a distrust of those who know best what is in your interests. And in this, despite the overblown right-wing rhetoric of ‘death panels’, or ‘communist’ withdrawal of choice, the Obamacare detractors perhaps have a point. Most Americans cannot afford the best health care their country can provide; and even those with good coverage are often tied to cost-conscious HMOs which offer little choice either. But there is in principle a choice: of treatment regime, of the best medications (even if not generic), of provider, or specialists. Freedom lies in that principle, if not the actuality.
As with the right to bear arms, arguments about the public health rights and wrongs of who gains and who loses miss the point. It is not about whether (on balance) gun control or socialised health care are good for the public health: both undoubtedly are. It is about what individual freedoms are sacrificed for that ‘public’ health. It is perhaps churlish to name them, but NHS patients do not have the freedom to go directly to a specialist, or to choose our own brand medications, or even to use primary care services without signing up for endless intrusive preventative clinics and checks.
In return for what most see as these small sacrifices, we have taken it for granted that catastrophic health care costs will not ruin us if we need treatment. We have taken it for granted that the NHS will look after us from cradle to grave. A visit to the US suggests the fragility of this trust. The current dismantling of socialised health care in the UK risks skewing the very contract on which the system is based. We make sacrifices (and largely unconsciously) because, on the whole, socialised health care is good for the public, and for all of us as individuals within that public. Competition, contracting and choice will spread like poison ivy rash: once broken out, they are impossible to contain. And once the NHS is no longer a taken for granted part of the public realm, that fracturing may be hard to repair.
About the Author: Judy Green is based at the London School of Hygiene and Tropical Medicine and has researched and published on methodology, risk and the sociology of health.
2 Responses
Karen on Jan 25, 2014
Here is just a brief account of the joys of ‘private’ insurance and the freedom of choice. I am an American, who had the privilege of living in the UK for several years, and am thankful for having had access to the NHS. I currently have insurance. I am covered. What does this all mean?!? Freedom of choice? No, not really. Can I still see the doctors I was seeing across state lines in NC? No. Well, I can, but insurance won’t cover it. What does it cover? Almost nothing, until I have met my $2500 deductible. I can have a mammogram at no cost because I am now over 40 and it will cover the labs from a women’s health check (but not the actual office visit). How much does this fabulous plan cost me? $104 per month – my employer covers the other $104. My employer also kindly contributes to an HFA fund ($42 per month) that I can use towards medications. Do I have prescription insurance? No. Would a normal ‘healthy’ person ever meet their deductible? No. Would they bother even trying? No. Most clinics will offer a 20% discount to cash paying customers without insurance. Why not go with Obamacare? I do not qualify. Does it make any sense, really? No. Apparently, if your work offers insurance, and it costs less than 9.2% of your wages, then you must take your work’s insurance. But it looks like the plan that I could have afforded with Obamacare would be pretty much the same. Useless. Will my insurance cover the cost of scans? Only if it is preapproved and deemed necessary by some half-whit on the other end of the line working for the insurance company. How much will I pay AFTER I meet my deductible? 20% of each visit, until I go over $5000, then it will cover 100%. Until I go over $10,000 – then I pay 100%. Can I go to a specialist? Only if I am referred, and only if that specialist is within the list of preferred physicians. Will it cover labwork? 50% after I have met my $2500 deductible. Had Obamacare not kicked in, I would have to wait 18 months for insurance to cover anything towards preexisting conditions, of which I have many. Thankfully, that has been quashed, otherwise, again, what would be the point of insurance, when it won’t cover what’s already wrong with you? Dr X says I need surgery – will insurance cover that? I must call ahead and get authorization – blue cross blue shield will let me know if it really is necessary, and will also let me know, if approved, which surgeon I can use (which is totally ridiculous, because the specialist who insists on surgery IS the surgeon I wish to use). Can I take a gun to a bar and get my drink on? Yes. Will my insurance cover me if someone shoots me? Probably not. Makes sense, doesn’t it? Now, keep in mind, I’m one of the ‘luckier’ ones, as there are others out there with insurance coverage, who must meet a deductible of $8000 or more – I feel as I have no room to be whining about this, as my deductible is tiny compared to theirs.
I also recently found out that many states had the option to expand their Medicaid programs, but they opted out (TN opted out, stating it was just too much to help the poor people and that enough people were abusing it already). I would have qualified for that program if it had been expanded, and would have enjoyed a bit of freeness in the land of healthcare. Instead, they have cut food stamps out and shortened unemployment benefits. Already, unemployment numbers have dropped significantly. How, you might ask? Because those who have been unemployed longer than 13 weeks are no longer in the system, therefore, it looks like everyone is working again. Yet, somehow, the foodbanks are crying out for more donations because they are inundated with starving people. The republicans feel that charities will step in to help the hungry – uhm, where are all these charities supposed to get their money from when the very people that donated to said charities are needing to use them, themselves?!? TN is also proposing that if a child receiving benefits has poor grades in school, those benefits will be cut. Dumb kids? No money. Now, call me crazy, but is that not setting poor kids up for even more failure, apart from crime? But I guess, what really gets me the most, is that these dumb people are voting for the republicans…the very ones who will cut all benefits if they get their way. I’m just waiting for 3rd world country status.
A family friend passed away. She had a gastric bypass years ago, and wasn’t given proper aftercare. She’d suffered great health issues. She was a nurse, but had been unable to work for several years, because of her size and health problems. Her husband was ex-military, so is able to use the VA hospital (she married him after he came out of the service, therefore was not entitled to military benefits). Anyways, Medicare would only cover a certain amount of days for her to reside in a care home. She was sent home. Her husband also suffers from a heart condition, and, considering her size (350lbs –25stone), he was simply unable to care for her. She was paralyzed from the waist down, therefore, couldn’t even roll herself over in bed. She did not have control of her bodily functions, and was constantly soiling herself. Thus, leading to further infections, etc. She was hospitalized, then sent back to the care home, of which Medicare would not cover. It cost $2500 per week to stay there. $2500 seems to be the magic number these days. My parents and the church they attend covered most of that bill. Doesn’t really seem fair, that someone who provided care to the sick and elderly for so many years, was denied such care in her time of need.
I think back to my childhood and how I NEVER went to the doctor. I certainly never went after I was out of school. The first time I personally took myself to see a doctor was when I was 23 years old. Because I had health insurance for the first time. I was in the early stages of shingles – something that could have been incredibly painful to have not had medical care. I did not see another doctor until I was in the UK. I think about how great it was when I came out of hospital, not owing a penny. How my prescriptions only cost me 7.10. Sure, that hospital stay scared the daylights out of me (an angry boyfriend murdered his pregnant girlfriend – but, I guess it turned out to be a win for me, as I got to move to the cushier ward because her death freed up a bed). Being in the elderly, we don’t know what is wrong with you ward, was quite daunting, but again, it was free….I still had a bed, was hooked up to IVs, was given medication, had access to what I think was food, and was checked on every 15 minutes. I had xrays and 2 different ultrasounds. I can only imagine how much that would have cost me here, in the land of freedom of choice.
I was shocked to find out that many are wanting the NHS to disband, as they feel care is not adequate. This baffles me, because you can receive some sort of care without the fear of becoming homeless or going to jail because you can’t afford your medical bills. You don’t have to make the decision of which is more important – insulin that is imperative to keep you alive, because you suffer from Type I diabetes – which costs near $1000 per month – or being able to feed your children and keep a roof over their heads.
Think long and hard, Britons, because, unless you are one of the small percentage of super wealthy citizens, privatized insurance is the WRONG decision. You may hear about all the brilliant health care advancements that are available to Americans, but at what cost? A large majority of us can only dream of winning the lottery to receive such ‘brilliant’ care. We rely upon being able to get care from government funded entities (which I might add, are being cut as I type this), and then, we can barely afford to go to those. Those facilities, in turn, are less helpful than the NHS surgeries currently available to yourselves. The only winners here in the health care race would be the insurance companies and pharmaceutical companies.
Chris on Jan 30, 2014
Thank you for trying to return the favour. The British NHS was there when you needed it. Thank you again for being there when it needs you.