Can someone explain to me what it is about paying for healthcare that gets Americans so riled up? It’s one of the three things about this country that still totally baffles me after 30+ years — the other two being their attitude toward guns and the death penalty. (“Keep the government away from healthcare and guns, but it’s OK for the government to kill people.” Um…)

Expensive But Broken

When it comes to healthcare, the statistics from the OECD are telling: the USA is the only developed country with no single-payer national healthcare system; it has the highest rate of infant mortality in the developed world; and it has the lowest life expectancy. It also has the highest obesity rate and the highest proportion of people aged over 65 with two or more chronic health problems. Yet actual spending on healthcare per capita far exceeds that in other countries.

As someone who grew up with a flawed-but-functioning national health system, it’s pretty obvious that the delivery of healthcare in this country has gone seriously awry. If you’re employed in a job with a halfway-decent wage and benefits package, you (and, likely, your dependents) will be covered by some form of private insurance scheme. These can cost you little-to-nothing in premiums (if you’re lucky enough to have snagged the kind of public sector job that comes with crappy pay but great benefits); or, they can cost hundreds of dollars every month to cover you, the spouse, and the kids. Coverage varies: some plans only cover ‘basic’ care; some don’t cover mental health treatment; some only cover 75% of the cost of an in-hospital stay. Even with insurance, you’ll be paying some kind of copay for every doctor visit or prescription; and often there’s a deductible that you have to meet first each year, before the insurance coverage kicks in.

Here, the private insurance companies reign supreme. Some on the political right get hysterical at the notion of the government ‘controlling’ access to healthcare, saying it will lead to rationing. I don’t know what planet they live on, because the insurance companies already control and ration. Just because your doctor may have prescribed a particular drug or procedure doesn’t mean the insurance will cover it; and given the staggering cost of healthcare here, very few can afford to buy services ‘out of pocket.’

Still, if you have insurance and a doctor recommends an MRI, or you have to get one of the kids an X-ray because that ankle is swelling up alarmingly after he fell off his bike, you don’t think twice. The care will be first rate, the diagnosis almost-certainly accurate, and you’ll get clear instructions on what to do next.

But if your job doesn’t come with health insurance? Or it did, but you got fired? Or the spouse is fighting cancer and you start a new job and the health insurance plan won’t cover pre-existing conditions for the first year? Well, then you’re screwed. Yes, there is Medicaid, but only for the poorest. Eligibility and coverage varies by state, but can be defined by an annual income as low as $11,000 for an individual or $24,000 for a family of four. Yes, there is Medicare, but only if you’re 65 or older, or disabled, and even then you may want to buy some form of supplemental plan because Medicare isn’t always as comprehensive as you’d think.

Some Healthcare History

When Obamacare (the Affordable Care Act) went live in 2016, about 24 million people finally got access to health insurance. You always could buy individual plans, but they tended to be staggeringly expensive. Now, companies have to offer plans that cover pre-existing conditions, and government subsidies make the monthly premiums affordable for most on low incomes. It isn’t perfect, but the problems are the kind of thing that can be fixed, and the payoff has been huge. I know a number of people in their twenties who work two or three jobs in the service world (choreographers, hairdressers, writers) who were ecstatic to finally be able to afford the peace of mind of insurance. “Next time I get a really bad cough, I can go to the doctor before it turns into pneumonia!” That was a real conversation I had last year, with a 27-year old dancer.

So why the hell does America not look after its people with some form of national health insurance? When Medicare was first introduced in the mid-1960s, the intention had been to create a universal, national scheme. But facing resistance from some in Congress the government at the time first focused on the relatively-uncontentious proposal of insurance for the over-65s. The intention was to then introduce a similar scheme for children and pregnant women, but it never came to pass.

Far as I can tell from some superficial research, introducing coverage just for the over-65 crowd backfired massively because — surprise, surprise — it quickly became a very expensive scheme. Given the rudiments of how insurance works in ANY marketplace — payment by all to provide coverage for a few — that shouldn’t be a surprise. Older people tend to be sicker. In any event, by the late 1970s the “it’s too expensive” narrative had become enshrined and national health insurance was dead in the water.

Healthcare as Commodity

So here we are in 21st century America, a country with excellent care that’s not available to everyone. A country where private insurance companies, not doctors, dictate what prescriptions or procedures are worthy of coverage. A country where prescription meds are widely advertised on TV and doctors’ offices spend inordinate amounts of time processing insurance payments. A country where people with chronic conditions spend hours sending in claims, arguing with the insurance company over what treatment will be covered, and forking over small fortunes in copays. A country where one awful accident can literally push your family into poverty, or where people have to sell their homes to pay the healthcare bills. A country where the cost of healthcare is the number one cause of personal bankruptcy.

Yes, I know the NHS (Britain’s National Health Service) is far from perfect. Some prescriptions or procedures aren’t available and wait times for appointments to see specialists can be absurd. But, no one asks you to fill out forms about your insurance information when you’ve just rushed the kid to the hospital emergency room.

Healthcare in America is widely seen, especially by the political right-wing, as just another consumer good. For many of the current crop of Republicans in Congress (who, incidentally, get great coverage with their own insurance plan), it’s something you ‘choose’ to buy, and if only the government would get out of the way the competitive marketplace would ensure it would be affordable for anyone. Which is, of course, rubbish. Suppose you slip and fall on the ice and break your leg in four places and can’t work for three months; or, one of the kids is diagnosed with cystic fibrosis; or, that odd-looking mole on your thigh turns about to be stage two melanoma that is on the verge of metastasizing. Think you can afford to buy the care you need? Think again. The commoditization of health care just doesn’t work (re-read that comparative OECD data in paragraph two if you don’t believe me.)

Perhaps the furor over the Republicans’ deeply-flawed plan to ‘replace’ Obamacare — a plan that would deprive 24 million people of health insurance and allow companies to once again deny pre-existing conditions — has awoken more people to the staggering iniquities of the system. Perhaps, in a few years, we’ll finally get a universal single-payer system here. But I doubt it.