“Free” healthcare?

Dot writes: I was talking to a colleague the other day and was rather surprised to find that we didn’t agree about healthcare being free at the point of access. We are in sympathy about so many things (for example, Old English sound changes being pretty much the most fun you can have on a Wednesday morning) that I tend to assume we will have the same views on any given issue. I grew up under the tender care of the NHS and as a child I was wholly mystified by the idea that, just when you were sick and least able to earn money, you should be required to pay for your healthcare. It seemed a bit like putting people in prison for debt. But my colleague said that she didn’t approve of people thinking they were entitled to be looked after by other people, and that they ought to take care of their health. And she had a point, of course. So that got me thinking.

Then our LRB arrived (how I love the LRB) and there was a ‘Diary’ feature in it from a London doctor writing about two difficult patients he had seen recently: a woman with severe bladder pain probably connected to her abuse of drugs and alcohol (a connection she had uncovered herself by doing some intelligent research on the internet), who took more drugs and drank more alcohol to deal with the consequent anxiety, and a man, her brother, with poorly controlled diabetes. Under current funding arrangements in the NHS GPs ‘buy’ referrals to hospitals, so difficult patients like these are expensive for them; and under new rules practices are going to be allowed to select their patients. It seems to be a system deliberately designed to let the most needy patients slip through the net (as well as being a symptom of the government’s mania for setting up artificial markets because markets are, like, excellent). The doctor writer is clearly distressed by the situation: as a doctor, he sees sick and unhappy people, and he wants to care for them. But isn’t a drug user or a person who doesn’t look after their diabetes an obvious case of someone who doesn’t make basic efforts to preserve their own health and shouldn’t expect to have their problems paid for out of the public purse?

Back when the NHS was first set up, it was sold to the British populace very carefully: this was not charity. Everybody was paying for it. You paid your National Insurance, and in return you got a set of benefits, including a pension when you retired and not having to pay up front for going to the doctor. In fact, it was a similar sort of idea to the one Mitt Romney signed into law in Massachusetts and then found himself opposing when Obama wanted to extend it to the whole USA: compulsory health insurance. Only it was a cheaper and more efficient way of having insurance than going through private companies, because all the money could go into healthcare and none of it had to be hived off as profit. And, the point that has always puzzled me when people oppose such schemes, everybody got something out of it: everybody needs healthcare, more when they’re very young or very old, less at other times, and this way they got it much more cheaply and easily than they would otherwise have done (no worrying about whether the paycheque would stretch to another GP bill this month). OK, some people get ill because they do stupid things. But anybody can be unfortunate. Why oppose free-at-the-point-of-access care to someone who, say, gets breast cancer or is hit by a bus? That could be the person who eats nine portions of green vegetables every day and runs marathons. Or that could be you.

But what about the undeserving? What about the people who get cancer because they smoke forty a day, or indeed have bladder problems as a result of drug use? Well, for a number of reasons I’m not comfortable with the idea of dividing the deserving and the undeserving. First, poor self-care is very strongly connected with poverty – for example, it is hard to maintain a decent diet if you don’t have good cooking facilities, don’t regularly have the bus fare to the nearest supermarket that sells a good range of vegetables, or can only afford white bread when you get there – and I am not someone who believes that the poor should just pull themselves together and get jobs. There aren’t enough jobs, and lots of the jobs that there are don’t pay (which doesn’t mean the poor shouldn’t try to get jobs, just that we mustn’t blame them if they can’t or if they don’t have much money when they can). It takes unusual strength of character to pull yourself up by your bootstraps from a position of social deprivation, and I don’t think we should require unusual strength of character from someone before they’re entitled to get their asthma treated. Second, I’m not at all happy with doctors, or health service administrators, taking on the role of moral judges. How could they possibly know all the relevant facts? How could they avoid being swayed by their prejudices? Third, I believe in complicated explanations: the reasons why someone is a mess are usually much more murky than that person simply being morally limp. Fourth, I agree that individuals have a duty to try to look after themselves, but I don’t think we should turn that around and say that means we have no duty to look after each other. I don’t want to live in a society where we cheerfully ignore others’ suffering. Fifth, it’s better for society as a whole if the sick are treated, the poor supported, and the lowly not rejected: I’m not too happy with the reduction of ‘contribution to society’ to ‘paying taxes’, but the fact is, people are more likely to get jobs and pay taxes if they are well and if they feel that they owe something to their fellow-citizens.

In fact, I’m a bit of a lefty. A soft lefty: I firmly believe, for example, that there should be a favourable tax regime for micro-breweries. But I also firmly believe that there is such a thing as society. And society is well served by a national health service.

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9 thoughts on ““Free” healthcare?

  1. Katimum

    I agree in principle but one of the snags with the Health service which we are experiencing now is that it is too successful – new treatments are developed, both drugs and medical procedures, and these are plain very expensive to pay for. We don’t want to deny them to anyone, but we are way past the stage when medical treatment involved some syrup of figs and a bandage or so. Also people’s perception of what is ‘necessary treatment’ is very variable – to a couple desperate for a child, IVF to them is ‘necessary’, but not to the confirmed old bachelor who wants his hip replacement. And of course, all this successful treatment leads to more children (childbirth costs and even possible fertility problems in future) and people living longer – on a long list of prescription drugs, free after you reach the magic age. It’s easy to say that drug companies shouldn’t make so much profit – but they have to be motivated to carry on the research and pay for the drugs which never got off the ground. A series of horrible moral problems – but having difficult moral problems doesn’t mean that you shouldn’t make moral decisions.

    1. Dot

      You’re right, Mum. These problems don’t take away the principle of universal healthcare provision, but they do imply that some treatments might not be free because National Insurance can’t cover it. This is true of any insurance plan (I have private health insurance, but there are all sorts of things it doesn’t pay for). The important point, for me, is that there shouldn’t be people who can’t get basic healthcare (the stuff the insurance plan would cover) because they are too poor or are not obviously deserving. No-one should have to put off going to the GP because they don’t have the up-front fee. That’s also a way cheap problems turn into expensive problems.

    2. I agree with your post, Dot, and with Katimum’s comments, but I would also add that the NHS needs not only to be free but also to be competent. Ovet the last 20 years I have amassed a long list of complaints, ranging from misdiagnosis and incompetent treatment to being given the brush-off, bullied, and lied to quite shamelessly. I would say around 80% of my NHS encounters fall into one of these categories. And it may just be anecdotal but I hear much the same from many other people I know.

      1. Dot

        That’s awful. But private medicine isn’t immune from bullying or incompetence. All my recent contacts with the medical profession have been in Ireland, where much provision is on a private or semi-private basis and there are fees for things like GP visits and trips to casualty. I felt much more bullied in the fee-paying clinic I attended for my first pregnancy than by the public midwives who looked after me in my second. Privatisation tends to be held up as a panacea for the ills of the NHS, but it clearly isn’t; what do you think ought to be done instead?

  2. mairij

    Hi Dot
    I like your arguments. It seems lacking in both logic and compassion to make someone who is ill or incapacitated to pay for treatment; like kicking a dog when its down.

  3. Liking here too (but I am a self-confessed lefty).
    I’d add a practical suggestion:
    (1) doctors deciding is one thing, but para-medical pseudo-professionals–MBAs, professional “managers”–is another and to be avoided. Mind you, come the Revolution, and people meeting and greeting Walls…
    (2) if such decisions have to be made: bring in the philosophers. A panel of at least three, for every case.
    Thus, by a happy coincidence, creating jobs for philosophers. The move could be extended throughout all spheres of working life. In a move to replace that part of bureaucrats’/administrators’ jobs that involves judgement, judgements, and indeed the exercise of good judgement. Leaving administrators free to do what *they* do best. Everyone’s a winner.

    1. Dot

      I thoroughly approve of jobs for philosophers, but it does strike me that the thing philosophers do best is disagreeing with each other…

  4. Lily Roth

    Interesting. I have experienced private healthcare in the US for 27 years of my life and then the NHS for the past 10 years. Hands down, the NHS has taken far better care of me…both through my very complicated and difficult pregnancy and my breast cancer. And, athough my treatments have been costly, preventative care has been a priority…for example, the NHS found an adrenal tumour (whilst looking for breast cancer) which had been overlooked by my private physicians for 15 years!
    I think your points about deserving and undeserving people are spot on. Many people would look at me, fat my whole adult life, and see and undeserving slob who isn’t properly looking after herself. Yet, in reality I was an athletic, healthy dancer until I developed Cushing’s syndrome at the age of 18 (undiagnosed for 3 years) and gained an enormous amount of weight and developed other dire problems as a result of my rare condition. Since that time, I’ve been on numerous supervised diets and other regimens, but have never been able to return my endocrine system to “normal” (probably partly to do with the adrenal tumour that they’ve just found). Anyway, my ability to NOT lose weight is practically a superpower (as my twin says, fondly). I was in hospital on a drip for a week with neutropenic sepsis during chemo and managed to lose a mere 2 pounds! 😉 Point is, unless you know all of a person’s physical and mental history, you probably don’t know if they’re undeserving or not.
    I can tell you when I was diagnosed with breast cancer, I was pretty devastated…and I was very glad that the NHS meant that I wasn’t going to have to choose between my family having a place to live and my survival! The last thing you need to be worrying about at a time like that is money. So…I love the NHS and I say long life to it!

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