How, and how not, to disagree on healthcare

A while ago, I got an e-mail from someone who had recently finished reading my book Universal Healthcare Without The NHS, which makes the case for replacing the NHS with a Social Health Insurance (SHI) system similar to the Swiss and the Dutch model. That reader offered mixed feedback. They liked parts of the book, but ultimately remained unconvinced by its main conclusion. It said something like:

“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.

Head of Political Economy

Dr Kristian Niemietz is the IEA's Head of Political Economy. Kristian studied Economics at the Humboldt Universität zu Berlin and the Universidad de Salamanca, graduating in 2007 as Diplom-Volkswirt (≈MSc in Economics). During his studies, he interned at the Central Bank of Bolivia (2004), the National Statistics Office of Paraguay (2005), and at the IEA (2006). He also studied Political Economy at King's College London, graduating in 2013 with a PhD. Kristian previously worked as a Research Fellow at the Berlin-based Institute for Free Enterprise (IUF), and taught Economics at King's College London. He is the author of the books "Socialism: The Failed Idea That Never Dies" (2019), "Universal Healthcare Without The NHS" (2016), "Redefining The Poverty Debate" (2012) and "A New Understanding of Poverty" (2011).

2 thoughts on “How, and how not, to disagree on healthcare”

  1. Posted 07/08/2019 at 10:07 | Permalink

    Having benefited from the NHS recently , I am probably inclined to defend it . As an older citizen , my fear is that a private system would render people with pre- existing conditions vulnerable to higher charges.
    However on a less personal note , is there any information to indicate how much the average person’s life expectancy is influenced by the type of health system his country has ? If so , does it vary by age ?
    I think that any answer has to taken into account low hanging fruit such as clean drinking water , adequate food and childhood vaccinations which are presumably prevalent in all first world countries . I would be interested in your views .

  2. Posted 11/08/2019 at 10:22 | Permalink

    The NHS is a relic of the brief period during which socialist (as opposed social-democratic) ideals were put into practice in the UK. Hand in hand with a variety of nationalizations.

    State intervention is only legitimate in order to address market failure, according to economic liberalism (maybe a strict liberal would not even consider market failure as something tha should cencern the state). For communautarians (socialists, communists, certain types of conservatives) the role of the state can be (or must be in the case of marxism-derived ideologies) much wider.

    The Dutch system is one whereby the chief role of the state is to regulate, in order to mitigate abuse of power, ensure quality and mimimize the cost of health care to society as a whole.

    One cannot seet the Dutch system as separate from its origins as a mixed socialized/private system. Helath care providers were always (since the German occupation at least) regulated and “private practice” in the English sense only existed hand in hand with equally “private” health insurance. The social/state component was a means tested free insurance system that would pay for a basic level of service (private patirnts could pay more for more luxury, not for better treatment) . The state system did not have a deductible.

    That system was becoming too much of a burden for the state and a major reform took place whereby there would be a single level of service, a single type of compulsory insurance (with some ability to add packages for treatments not condidered part of the basic package and a supplement that would allow the insured to select their own providers) , explicit insurance premiums and an explicit deductible (the higher the deductible the lower the premium) and a subsidy to those who in the past would have enjoyed a premium-free scheme.

    Helth providers like hospitals may have an operating surplus but are not allowed to distribute earnings. The same applies to health insurance companies.

    Finally, rates and pharma prices are negotiated between the state, insurance providers and care providers.

    The state has two incentives to keep costs low: (1) the level of subsidy and (2) the fact that the government/public sector is the country’s largest employer hence also the largest provider of employer-subsidies.

    All in all this scheme functions pretty well, despite complaints from pharma (especially the providers of expensive, exotic medicines that tend to be kept uninsured for a while) and certain specialists. One indicator is patient satisfaction (a bad indicator inn this area) and a much better indicator, the number of patients that seek treatment in (very nearby) neighbouring countries where waitinglists may be shorter or exotic treatments more readily available.

    My expectation is that this system will not appeal to the Uk’s next trade patron, the US because it has an enormous institutional bias against expensiveness hence a consumers’ paradise, the exact opposite to the US system, a suppliers paradise. The more likely trajectory for the UK would be to keep the NHS as a single payer/insurer, have a separate regulator and let the provision of services become more private, but for profit private, a critical difference.

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