How, and how not, to disagree on healthcare
“I take your point that countries with SHI systems seem to achieve better outcomes, on the whole. But you haven’t persuaded me that they achieve those outcomes because they are SHI systems.
If we could start from scratch again, there would be a lot to be said for your system. But given where we are starting from, I don’t think it’s worth the hassle of switching to such a system today. Why not compare the NHS to systems that are more similar to it? Why not go for smaller, but more realistically achievable reforms?”
Why do I remember this?
Because in the two and a half years since the book was published, this was pretty much the only non-hysterical criticism I have received. Apart from this outlier, I have only received two types of responses: agreement, and hysterical, rage-fuelled denouncement. Nothing in between. No “You have a point, but…”. No “You may be right about X, but you’re dead wrong on Y and Z.”
That reader is my hero, because they, uniquely, have managed to come up with a perfectly reasonable critique. They demonstrate that it is perfectly possible to disagree with the book’s main conclusion, without misrepresenting the argument, without accusing me of being bribed by American healthcare corporations, and without claiming that my “true” motive was hatred of the poor and the sick.
Which raises the question: why is it that in this day and age, we still cannot sensibly discuss the pros and cons of different healthcare systems? Why can’t we just disagree with a proposal without freaking out about it?
I don’t know the answer, but we can narrow it down a bit by clarifying what this is not about.
One of my colleagues believes that this is simply the result of a lack of exposure to alternative healthcare systems. When we travel abroad, we sample foreign cuisines, beers, wines, and many other things. But unless we live somewhere for a prolonged period, or in the case of an emergency, we usually have little to no experience of other healthcare systems. Combined with our natural – and when it comes to healthcare, quite understandable – risk aversion, this makes us more possessive of the system we know, and are familiar with. It makes us more suspicious, and less open-minded about alternatives than we would be in other areas.
It sounds plausible. But I don’t believe it. Because none of this is specific to healthcare. It is generally true that we usually do not know a lot about how this policy area, or that policy area, is organised in other countries. Why would we? It is not something that is of great use to us in our everyday lives. And yet, this does normally not make us hostile to the suggestion that we should learn from international best practice.
Suppose somebody suggested that we should emulate the Finnish school system, or the Austrian social housing system. (These are not entirely hypothetical examples; I vaguely remember reading articles which more or less made that case.)
My guess is that unless you have a professional interest in one of those areas, or unless you have lived in one of those countries, you will know very little about either schooling in Finland, or social housing in Austria. (I certainly know very little about it.) But I am nonetheless sure that you would not react with anger, indignation or hostility to such a proposal.
You would react with some curiosity. You would ask that person to tell you more about it. How do those systems work? How do they differ from ours? What’s good about them? Would they work here? What are the downsides? Where’s the catch?
Maybe you would be sceptical. Maybe you think that our current school system, or our current social housing sector, is pretty good, and does not need wholesale reform. Maybe you think that conditions in those countries are too different from British ones to offer useful lessons. Maybe you think that you don’t need any lessons from abroad, because you already know what changes ought to be made. Or maybe you would simply listen for a few minutes, learn a bit about that proposal, and then decide that you don’t agree with it. Maybe you would decide, on the basis of that information, that you prefer the system we currently have. And fair enough.
But be that as it may – here is a short list of things that you would definitely not say:
- “Our school system taught me how to read and write. Without it, I would be illiterate. I will not hear a word said against it.”
- “Why are you denigrating our brilliant, dedicated teachers?”
- “I don’t know about social housing in Austria, but I heard that it’s really bad in Ukraine. What if we end up with the Ukrainian system instead?”
- “Easy for you to say. Presumably, you got private housing. If you relied on it, you wouldn’t be so dismissive of our social housing sector!”
- “In the Victorian age, children had to sweep chimneys, and the poor lived in workhouses. With people like you constantly attacking our schooling/social housing system, we are in danger of going back to that!”
- “Our school system/social housing sector is based on an ethos of solidarity, and caring for other people. Maybe you just don’t understand that.”
All of this sounds self-evidently absurd. Yet propose an alternative healthcare system, and you will be inundated with responses along those lines.
What’s the difference?
I don’t know. But maybe pointing out the absurdity in this way is a first step towards challenging it.
Dr Kristian Niemietz is the author of the book “Universal Healthcare Without The NHS”. Download it here for free, or buy the Kindle version here.