Initially, the standard accusation used to be that I want a system like in the US, where healthcare spending is almost twice as high as in the UK, and yet millions of people are uninsured. For a while, this used to work quite well for my detractors. Adopt a pose of moral outrage, shout “America!”, and bathe in the ensuing applause.
But fortunately, in the meantime, a few people have read the book, and know that this is simply not what it says.
The book makes the case for a social health insurance (SHI) system of the type that currently exists in the Netherlands, Belgium, Germany, Switzerland and Israel. Those systems are market-oriented, in the sense that people get to choose between competing health insurers and competing healthcare providers. They are market-oriented in the sense that health insurers and healthcare providers enjoy a sufficient degree of autonomy, and are thus sufficiently different from one another. But those systems are also fairly egalitarian, not just in the sense they cover everybody, but also in the sense that you could not tell someone’s socio-economic status from knowing their health insurer or their family doctor. (This is quite different from the US, where Medicaid acts as a designated “poor people’s insurer”.)
It’s a good thing that those who misrepresent the book online are now more likely to get called out by people who have actually read it. In response, however, some of my detractors have come up with a bizarre new line of attack. They now claim that what I describe in the book is not my true agenda. They claim that I secretly do want to introduce the US system, but that I am reluctant to admit that openly, knowing that it would put people off. So I use those benign examples of market-oriented healthcare systems as a smokescreen. I hide behind the systems of the Netherlands and Switzerland, in order to lure my readers into a false sense of security. But don’t fall for it – it’s a Trojan horse. It’s the American system, even if it’s wrapped in a Swiss and a Dutch flag.
It is, of course, true that people with unpopular, socially stigmatised views do not always reveal their full agenda. Imagine, for example, that you’re a xenophobe. You want to severely limit immigration, because you dislike foreigners. Would you say that openly, in a public forum? Probably not. You would hide behind more socially acceptable arguments. You would say something like: “I feel no animosity towards immigrants whatsoever, quite the opposite! Some of my best friends are immigrants, and I actually think that immigration has enriched us, in many ways. But the problem is that Britain is full. We don’t have the physical capacity to accommodate more people. We don’t have enough houses, we don’t have the appropriate infrastructure, and our public services can’t cope. So it is with a heavy heart that I have come to the conclusion that we must curtail immigration.”
However, while such a person might not be sincere about their motives, they would still be entirely sincere about their policy agenda. They want to curtail immigration. That’s what they’ll tell you they want, and that’s what they truly do want, in their heart of hearts. They’re sincere about what they want, just not about why they want it.
Which makes sense, because presumably, they want to make that agenda more popular. They want you to support it too. Whether you support it because you share their stated motive (“Britain is full”), or whether you support it because you share their true motive (xenophobia), makes no difference to them. Both motives lead to the same policy agenda.
But my case isn’t like that at all. My detractors are claiming that my stated policy agenda is different from my true policy agenda, and I have no way to prove them wrong, short of connecting myself to a lie detector and filming it. But the problem with a secret agenda is that as long as I keep it secret, I cannot win anyone over to it. Suppose I publicly promote policy X, but secretly believe in policy Y. Suppose I can reach 100 people, out of which 30 are open to X, 10 are open to both X and Y, and 60 are implacably hostile to both. Now, if I do a really good job at promoting X, I might manage to persuade the 40 people who are open to it. I would have won 40 X-converts. But I wouldn’t have persuaded anyone of Y. Because I wouldn’t have made the case for it. So if Y is what I truly want, winning X-converts is not much of a victory.
This would, of course, be a different story if I were a politician running for office. I could then promise you X before the election in order to get elected, and once in office, I could break my promise and enact Y instead. But since I don’t have any power to implement anything, I can only try to persuade you, and I can’t persuade you of something, and I can’t do that if I don’t make the case for it.
If I secretly wanted Britain to adopt the US healthcare system, what could I possibly gain from praising the healthcare systems of Switzerland and the Netherlands? This would, at best, be a needless distraction from my “true” agenda. Sure, the case for an SHI system is easier to make. But it’s also easier to get to Gatwick Airport than to Stansted Airport, from where I live: if my plane leaves from Stansted, that doesn’t help me very much.
There are examples of countries replacing single-payer systems with SHI-type systems, for example, the Czech Republic and Slovakia did so after the end of socialism. But there is not one example of a country trying to introduce an SHI system, and accidentally introducing the US system instead. It doesn’t work that way.
So if I have a secret agenda to introduce the US system, then I must have been hiding it really well. So well, in fact, that by hiding it, I’m also defeating the entire agenda.
 Obviously, a lot of people genuinely believe those arguments; and want to curtail immigration for those reasons. They do not have to be an excuse. It’s just that if somebody is looking for an excuse, this is the kind of argument they will make.