For the past several years, I’ve been a guest speaker in our local high school’s ‘Culture Week’, when they ask people from overseas to come in and give presentations on life in their home country- food, sport, politics, art, and history- and the student’s then write reports on what they’ve learned.
A frequently recurring question each year is, ‘What’s something you miss from there?’ When I started doing this, I tended to give light, fun answers- Tayto cheese and onions, a really good black pudding, chocolate that doesn’t taste like candle wax, televised football…
Not this year. If they ask again, my answer is ‘health care’.
Health care in America is a nightmare. It’s spectacularly inefficient, mind-bogglingly expensive, bewilderingly complex, and- unless you are very healthy and rich- icily cruel. And unbelievably, that’s not by accident or incompetence, but by design. American health care is, well, distinctly American.
Many outside America stare at the torturous political battles over the Affordable Care Act, as well as the single-minded determination by so many on the right to kill it and replace it with something that will cost much more and protect less and ask, Why can’t the US manage to insure a basic level of health care for all of its citizens? Why is that so difficult?
To understand why, you have to go back to the beginning, to the nation’s founding narrative, to the creation myth. Unlike European revolutionaries, the American revolutionaries of the 1700s never contemplated either the redistribution of property or universal material equality of all citizens. The American Revolution was built on the fact that they were located on a vast, largely-unexplored continent abundant with natural resources. It was on that untapped promise that they planned to build national- and individual- prosperity. The Revolutionary founders demanded independence from England to realize their new nation’s right to expand and become prosperous; all of the political reforms they proposed- individual liberty, freedom from persecution, equality before the law, limited governmental interference- were seen as the best way to get there.
What this means implicitly- again, according to the unconscious national myth- is that America is ‘the land of opportunity’; there are no limits to what an individual with vision, purpose, direction, and a love of hard work can accomplish. The myth is sustained by regular re-tellings of accounts of the plucky, frugal, self-sacrificing, hard-working individual who overcomes all obstacles and is now a success. Schools are festooned with encouraging messages urging students to never give up, kids, you can do it!
For the believers in the myth, the Federal government’s job in this process is to get out of the way. The US government is seen not so much as a provider of materials and benefits, but as the protector of each citizen’s opportunity to attain materials and benefits for themselves. Indeed, assisting people who are demonstrably not succeeding is seen as grossly unfair. You won’t be in this country long before you hear someone say, ‘Why should my taxes pay for (insert benefit here) for someone else? They need to get off their asses and get to work!’
How the national myth affects health care is that the majority of Americans get their health care through their employer (after the Second World War, President Truman floated the idea of a tax-funded national healthcare system, much like what was being designed all over Western Europe, but the idea died a quick death in the Congress). If you’ve got a good job that provides a decent health care plan, chances are you are in a very good position.
However, there are three problems with employer-provided health care. The first is that it gives enormous power to employers over their workforce and their unions. Remaining employed- with the pay and benefits that an employer is willing to give- particularly if you or a family member has a chronic health issue, becomes more than a matter of livelihood but potentially of life itself.
Secondly, there is no universally-agreed-upon ‘base level’ of health care; the quality and extent of the health care in the US can fluctuate dramatically from one employer’s plan to the next. Whether or not you get eye care and glasses, dental care, prescriptions, this or that medication, or this or that procedure is by no means guaranteed. Your plan might not pay for the one medication that’s 97% effective against your illness; the most effective procedure for your child’s illness might not be covered; a ‘pre-existing condition’ might not be covered; your co-payments (the amount you pay before the coverage kicks in) might be thousands of dollars, leaving you deep in debt before the insurer has even begun to cover you.
Finally, employer-based coverage subtly equates having health care with having a job or, to tie it in with the creation myth, being willing to work hard and succeed. People without health care, then, risk being seen as lazy spongers, unwilling to work and content to be supported by those who are. In my case, I have a job, but my employer- our local school district- doesn’t provide health benefits for supply teachers. I took the job because the flexibility in work hours allowed me to home school my daughter, who has autism. Before the Affordable Care Act, I had no insurance; now I have some; it’s not great- nothing like what the NHS gave me- but it’s something.
In recent election seasons, when local media questioned candidates about whether they supported the Affordable Care Act, Democrats naturally did. Republicans, again naturally, didn’t but their rhetoric was interesting: they said their solution was to scrap the ACA and create jobs, get people off unemployment, and thereby give people health care.
Again, there was the assumption that people with no health insurance had no job; I did have a job, but no health care. Millions of Americans are in the same situation- their employment gives them substandard coverage, no coverage, or their Republican-controlled state (like mine) refused to accept the funding that the ACA provided to them to give their uninsured coverage. And incidentally, the jobs that Montana-based Republicans want to create involve opening up protected land and drilling for oil, fracking for gas, mining for metals, and clear-cutting the forests.
Of course, like all national myths, the American one hides many historical contradictions. It wouldn’t be until a hundred years on from the Revolution when one of the greatest contradictions became unavoidable and America tore itself apart over the ‘land of the free’ being a slave economy;
The failure of the post-Civil War ‘Reconstruction’ to deliver freedom, safety, or opportunity to African-Americans would fester for another century;
The Great Depression and the ecological disaster of the Dust Bowl destroyed the lives of millions, many (like the protagonists of John Steinbeck’s classic American novel The Grapes of Wrath), fleeing west to pick fruit in California, found themselves hated, unwanted, and persecuted by the police;
The collapse of the financial and mortgage markets in 2008 further exposed the myth’s weaknesses, as millions found to their horror that their pensions and savings were gone, squandered by financial sector multi-millionaires, and that the Federal government was prepared to use billions in tax dollars to bail out the culprits… who then ploughed the bailout money back into their personal fortunes.
But despite all this, the myth persists. It persists mostly among elderly working-class whites, who remember a time when the myth worked- at least for them and people they know. They elected an administration that promised to restore the damaged myth. Trump insisted that the myth was ruined by immigrants, Muslims, feminists, liberals, China… ‘others’…
It will take a seismic social and political shift for the majority of Americans to see health care as a universal right, to agree to look at health care in a different, more inclusive way.
At the moment, they all want health care… but not if they have to pay for anyone else’s…
That’s not part of the myth.