Letter From America: Health Care (and why it doesn’t work…)

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.


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  • Cosmo

    jon, a thoughtful, informative article. Thanks
    You may be familiar already with this writer, Molly Worthen


  • Jim M

    That was a good piece. Will be interesting to hear what the response is if you do discuss healthcare in that school… Your point about the power of employers was a good one; I’ve never thought about it but it’s pretty terrifying.

  • Brian O’Neill

    “The reason they call it the American Dream is because you have to be asleep to believe it.” George Carlin.

  • hgreen

    American dream always seemed like a nightmare to me. This is where the UK is heading.

  • Robin Keogh

    When I lived and studied in California a couple of years ago, an American friend was involved in a motorbike accident. His face was very badly cut and required stitches. I sat with him whilst the Doctor did his excellent work in amazing facilities at the local hospital. When the Doctor finished he told my friend that the nurse would be back in ten minutes to collect ‘details’, and winked at him. As soon as the Doc left the cubicle my friend jumped off the bed and said ‘quick, follow me’. He led me out a back exit of the building, into his car and home. It transpired he had no insurance. Despite the fact he was fully employed and a hard worker he could no way afford health insurance at that time. After further enquiries amongst my group of local fiends in the area, I discovered the majority of them had no insurance despite all being full time workers. Really scary stuff.

  • leoinlisbon

    In the US, people ‘want health care … but not if they have to pay for anybody else’s.’
    The UK is not entirely different. The NHS is under severe pressure. A simple solution would be to increase taxes. All parties with any chance of being in power
    are reluctant to do this. The result is, amongst other things, rationing by waiting list.
    People I know in the in the Irish Republic are far from happy with their health service.

  • SleepyD

    The NHS is broke, financially and figuratively. The sooner we face the fact that “free at the point of delivery” is financially stupid, the sooner we can go about changing some of the NHS fundamentals. Spending double on the NHS than on education illustrates the future of the UK. Raising taxes to prop up a broken healthcare system is just plain silly.

  • Jon Hatch

    Funny how there’s always taxes to prop up Trident…

  • lizmcneill

    Hard to be educated if you’re sick, or dead.

  • lizmcneill

    Wasn’t there a survey not so long ago where people said they’d be happy to have an increase in tax as long as it was ring-fenced for the NHS?

  • Jon Hatch

    I do believe so.

  • Jon Hatch

    It’s interesting that certain politicians declare the NHS, affordable public housing, education, or environmental protection agencies ‘broken’, they say ‘the system is broken, and I won’t waste tax money on a broken system’… but if the military is ‘broken’, they say, ‘The military is broken, and I will spare no expense to fix it!’

  • Zorin001

    Well they wouldn’t want to sell the military to the highest bidder (at least I hope), the rest though is fair game.

  • Abucs

    “………….The American Revolution was built on the fact that they were located on a vast, largely-unexplored continent abundant with natural resources…………”

    The French and Indian wars which surrendered Mississippi to the English Colonies was in the 1760’s and the Louisiana Purchase was in 1803 so the American colonies were restricted to the eastern seaboard coast for most of the 1700’s.

    You might also consider the possibility that the present time we are living in is a bubble that might fail disastrously at some point because the governments lending themselves pretend money cannot work for the long term.

    Those with the power are those who make the law and who control the banks enough to receive endless ‘free money’ on demand through government debt bonds. This theft robs the hard working people of their own wealth and makes it harder for them to raise their own families.

    Those holding the power are the political class, such as those receiving $400k from the financial sector simply for ‘talking to them’.

    It is these people that the following clips are clearly criticising and rightly so.


  • Brian Walker

    Come Home John! The Bengoa report awaits..

  • leoinlisbon

    ‘Funny how there’s always taxes to prop up Trident.’

    I think the UK should abandon nuclear weapons. However, the voters have routinely voted not to do so, right from the 1940s when the Labour Party created the NHS and an independent nuclear deterrent at the same time.

  • BonaparteOCoonassa

    The main problem with US society is that the establishment succeeded in turning Marxism into an obscenity. Thus there is no basic and widely accepted critical analysis of how capitalism might actually work in society. Not that I am saying that Marxism is the be-all of capitalist criticism, but it lays a foundation from which to proceed. Instead all forms of working class solidarity are demonised, and the false-consciousness of individualism successfully distracts the working classes. So no majority support for health care! And semi-fascist intervention all over the world, plus billions to the MI Complex, as Eisenhower predicted.

  • Korhomme

    Interesting thoughts, thanks!

    Trump is determined to get rid of ‘Obamacare’, and some/many of his followers agree.

    If, however, they’re told that ‘Obamacare’ is the Affordable Care Act, they’re not so happy.

  • BonaparteOCoonassa

    They might vote differently if the media got behind it, but the media are incorrigibly part of the establishment.

  • BonaparteOCoonassa

    I think there is a strong case for sub-contracting defence to Russia. They have a very successful and extremely up=to-date and efficient arms industry, and could do with more investment (if you have to invest in arms).

    In contrast the RN has frigates which are well lout of date and new destroyers which have to have their hatches secured with rope because they rattle too much and engines which give up the ghost if it gets too hot. The aircraft carriers have no planes, and when they get them they will be sitting ducks to new Russian radar, (plus numerous other faults, well documented on the internet). The RAF has a third of it’s planes at any time unable to fly for lack of spares.

  • grumpy oul man

    If perhaps we spent our money wisely, on education and health care, nursery’s and library’s, and not on weapons and tax cuts for the wealthy, then we might not collapse.
    Instead of stopping skilled and hard working migrants for entering the west we welcome them and the economic benefits they would bring us.
    The gurus such as your examples always seem to blame the problems on the poor or on benefits aimed at helping people but never seem to place any blame on the greed of those holding the Power.

  • grumpy oul man

    Have they not already got the military working for the oil companies. But the working man/ woman paying for it.

  • Kevin Stewart

    You mentioned Harry Truman had a national health care proposal, not many remember that Richard Nixon did as well.

  • David McCay

    The cost of healthcare and the cost of University are the two things which drive my absolutely crazy here in the US and which may ultimately lead to me leaving. My wife had a one-night stay in a local hospital recently (just to get antibiotics via IV) – $14,000 bill ! Our next door neighbours 10-year-old broke her arm – $75,000 bill !! Average cost of a University education – circa $50,000 per year !!! Complete madness ! The system is beyond broken !

  • SleepyD

    And your point is?

  • SleepyD

    Your point being?

  • lizmcneill

    Healthcare before education isn’t that terrible. As for free at the point of use, look at the mess in the USA currently. Do you want to start down that privatisation road?