I am inclined to be snotty about the NHS. Debunking things that everyone else seems to believe in is one of my stocks in trade and I found all that clapping to be a bit North Korean. Moreover the service is the last proud moral possession of the Labour Party, not an organisation I’m fond of. But I was taught to speak as I find and in 2021 I’ve had two sets of procedures which were precautionary, efficient, on time and delivered with friendly charm. This was all despite Covid and it it left me with the conclusion that, at least some of the time, the service works very well indeed.
More interestingly, there is a strictly non-socialist case for the NHS which was put to me by the late Jim Buchanan. (I should explain that this was James M. Buchanan, 1919-2013, 1986 recipient of the Nobel prize for economics and not the fifteenth president of the United States.) He won his prize for contributions to public choice theory which broadly investigates what happens if you apply normal economic assumptions of rational self-interest to salaried public officials and almost as normally reaches some pessimistic conclusions. This makes some public choice theorists recognisably “right wing” in their scepticism about state efforts to improve economies and societies and Jim Buchanan remains something of a diabolical figure for many on the American left. He had actually written sceptically about the NHS in the 1960s. The main issue in these writings was “moral hazard”; though that sounds like something from Pauline theology it is used by economists to refer to people having incentives to do things which in the general interest you would not want them to do. In this case it was the “insurance” argument, in general the idea that people should not be able to avoid the costs of the risks they choose to take and more specifically the implication that with free health care people will take too many risks with their health. (For the record, this was never an argument which convinced me because I always thought that those people who are capable of rational action had a far greater interest in their own health than the mere avoidance of doctors’ bills.)
But imagine my surprise when Jim (as he introduced himself), spotting me as the only Brit in the room, made a point of telling me that he now liked the NHS. This was some forty years after he’d argued against it. When I asked him why the answer was not one a conventional enthusiast for the service would have liked: “Because it kills people”. This was not Swiftian irony, let alone mere sarcasm. What he meant was that the US health care system, including and especially Medicare, the federal provision for the over-65s, is “rights based” whereas he saw the NHS as “utility based”. In other words the NHS could make some attempt to allocate resources where they were most needed and was not committed to pouring them down wasteful channels.
I shouldn’t have been, but I was surprised by Buchanan’s rationality. I had had several conversations with “right wing” republicans in the past and was aware that what infuriated them most about public health care often centred on an image of a committee of salaried and publicly employed officials deciding on whether a person should live or die. I vividly recalled incidents of literal tremblings with rage and the invocation of the names of Orwell, Huxley and Pol Pot at the thought of a committee having such powers. They didn’t care that outcomes might be decided by a market mechanism, a drunk driver or a passing psychopath so long as they were not decided by state officials. This points to an ancient distinction in philosophy, probably best expressed by Rousseau when he said (in the words of G.D.H.Cole’s translation), “The nature of things does not madden us, but only ill will does”. One’s financial affairs look like the nature of things and the decisions of public bodies look like ill will. But, of course, analysis suggests that this distinction is movable and arbitrary.
Buchanan went on to say that the rights-based system created legions of rent-seeking parasites in the form of lawyers and regulators and drug company managers. Better, after all, to have a state bureaucracy where some people, some of the time, are trying to do the right thing. The figures, of course, back up the argument of the later Buchanan: pre-Covid the US spent more than 17% of GDP on healthy care whereas it was under 8% and falling in the UK. There are no obvious and major ways in which the US performed better than the UK as a result. In 2017 life expectancy in the UK was 81.3 years and in the US 78.6 though there are a lot of factors other than health care required in the understanding of those figures.
I think this speaks highly of Buchanan as an open-minded rationalist rather than the “right wing” ideologue that many of his opponents saw him as. But I also think that there is a further Benthamite argument which was not mentioned in our conversation: the sense of security that freely available health care provides removes a major obstacle to human happiness. Having just had a “health scare” I would essay, as one of the grand guesses that utilitarians must make, that people not having to worry about the financial consequences of ill health considerably outweighs the problem of moral hazard.
Lincoln Allison March 2021
(This comment was published by The Critic in April 2021.)