5th July
1948, the National Health Service (NHS) opens its doors for the first time in
hospitals and surgeries around Britain under the supervision of Labour Health
Minister Nye Bevan. Following the election of Clement Attlee’s Labour
government in 1945 it was agreed that Britain, recovering from its second World
War, was in desperate need of social reform, summarised by William Beveridge’s report
on welfare. The establishment of the NHS as part of the wider reforms to the
Welfare State was initially sponsored by taxation and continues to be so today.
Sixty four years later, the NHS is seen as one of the great pillars of British
society (Marr, 2007).
The history of modern
American healthcare has been somewhat different. Unlike Britain the United
States has never and continues not to provide universal healthcare for its
population, leaving the market economy to provide health services (Mclintock
Roe & Liberman, 2007). However, a recently passed Health Bill has initiated
the first phases of compulsory health insurance for all American citizens, a
much debated and hotly contested prospect.
Despite these seemingly
opposing attitudes to healthcare within the United Kingdom and the United
States there is much to compare and contrast as recent, current, and continued policy
implementation on both sides of the Atlantic appears to bring the two nations
with a “special relationship” closer together.
In July 2010, two months
after its election, the UK’s collation government, led by Conservative Prime
Minister David Cameron, presented a whitepaper to the House of Commons
proposing top-down reorganisation of the NHS. The subsequent Bill, the Health
and Social Care Act, was submitted in January 2011 and proposed that the
allocation of patient care be removed from NHS Primary Care Trusts and placed
in the hands of General Practitioners (GPs). GPs could then choose between a
variety of both public and private options on behalf of their patients. The
move was described by its supporters as removing the bureaucratic red-tape of
healthcare and providing greater options for improved services. The proposal
was described by the Daily Telegraph as the “Biggest revolution in the NHS for
60 years”. Andrew Porter, the newspaper’s Political Editor wrote:
“The plan…is designed to place key
decisions about how patients are cared for in the hands of doctors who know
them… At present, funds are given by the Government to primary care trusts,
which pay for patients from their area to be treated in hospital. Under these
plans, GPs — who are currently not responsible for paying for hospital
referrals — would receive the money instead and pay the hospitals directly.”
(Porter, 2010)
A second key aspect of
the Bill was the revision of the amount of income hospitals are allowed to make
from private patients, rising from 2% to 49%. Andrew Lansley, the Conservative
Health Secretary described the strategy as positive for NHS patients, he said "If
these hospitals earn additional income from private work that means there will
be more money available to invest in NHS services” (Briggs, 2011).
Opposition leaders,
including Liberal Democrat members of the coalition cabinet refuted both key
aspects of the Bill, describing them as a systematic privatisation of the
Health Service, opening the door to American style competition in British health
care. Deputy Prime Minister Nick Clegg, leader of the Liberal Democrats,
threatened to veto the Bill in the wake of its proposal and vowed there would
be no “back-door privatisation of the NHS”
(The Telegraph, 2011)
The Bill was subsequently
subject to amendments in both parliamentary Houses, as well as public and
professional outcries. One month prior to the Bill’s assent, Dr Richard Nicholl
of the Royal College of Physicians (RCP), collected the signatures of 20 RCP
members signalling an extraordinary general meeting to stop what he described
as a “dangerous” Bill. He said:
"The bill is bad for the
country's health and healthcare and will increase inequalities. None of the
hundreds of amendments the government has had to table so far deal with the fundamental
flaws of the bill"
(Campbell & Helm, 2012)
As well as criticising
the abolition of Primary Care Trusts, Nicholl and other members of the RCP
opposed the planned extension of competition within the NHS. Suggesting
patients would suffer as a result of coalition plans for hospitals to earn up
to 49% of income from private patients. In an interview with the Guardian newspaper
Nicholl warned of longer waiting lists for NHS patients as a result of
prioritising private patients, Nicholl continues:
“…why the hell are the government
forcing this through? Market theory is a disaster in health. People need to
stop this bill; it's plain dangerous."
(Campbell & Helm, 2012)
Following the
extraordinary meeting on Monday 27th February 2010, the RCP polled
25,417 fellows and members asking for their opinions on the Health and Social
Care Bill, the results proved damning with 6% of respondents declaring their
acceptance of the Bill and an overwhelming 69% rejecting it (Royal College of
Physicians, 2012). Despite heavy
opposition the Bill received Royal Assent in March 2012 and many key aspects of
the legislation are expected to be implemented by 2013.
Whilst Britain’s
National Health Service appears to be shifting towards increasing privatisation
amidst claims of widening inequalities, America is seemingly moving in the
opposite direction, all be it from the opposite end of the health care
spectrum.
In July 2009, six months
after President Obama’s inauguration, Democrat leaders presented a series of proposals
on health care reform to the House of Representatives signifying Obama’s intent
on change. Significant proposals included the mandatory expansion of health
insurance to all American citizens, as well as the establishment of a
government insurance plan known as the “public option”. Two federally funded
insurance schemes were already in existence; Medicare, supporting the elderly,
and Medicaid, supporting the poor. However the “public option” proposed to
create a government backed insurance scheme available to all with a view to
competing with the private sector. Further proposals included subsidies in the
form of tax credits for those most incapable of accessing health insurance and
certain reforms of the health industry itself, such as the illegalisation of
certain medical insurer activity- such as “dropping” ill patients or denying
coverage to those with pre-existing conditions (MacAskil, 2009). The plan also
outlined a number of tax increases for both the health industry and wealthy Americans,
including a rise from 1.45% to 2.35% of the Federal Insurance Contributions tax
for individuals earning $200,000 and couples with incomes over $250,000.
President Obama’s
described the proposals as a way of reaching out to the 45 million American’s
without health insurance, he said:
"After decades of inaction, we
have finally decided to fix what is broken about healthcare in America. We have
decided that it's time to give every American quality healthcare at an
affordable cost."
(MacAskil, 2009)
Opposition to reform was
led by Republicans throughout Capitol Hill, disapproving of the President’s
plans to raise both taxation and public spending in order to alter the American
health care model. Senator Jon Kyl of Arizona discussed his party’s opposition
with the New York Times stating:
“I think it is safe to say there are a
huge number of big issues that people have… There is no way that Republicans
are going to support a trillion-dollar-plus bill.”
(Hulse & Zeleny, 2009)
Professional opposition
was also aired by medical experts across the United States. Troy M. Tippett
M.D., President of the American Association of Neurological Surgeons stated in
December 2009:
"The Senate bill inappropriately
expands the role of the federal government in health care decision making, and
undermines the doctor-patient relationship that is critical to a health care
delivery system that works for patients."
(Physicians United for Patients, 2010)
Joseph D. Zuckerman,
M.D., President of the American Association of Orthopaedic Surgeons reiterated
his colleague’s fears:
"We urge the Senate to take a step back,
and make essential changes to this bill before a rush to reform leads to a bad
outcome for patients across the country."
(Physicians United for Patients, 2010)
Despite much opposition
and after ten months of hard fought amendment and Democratic compromise in both
Congressional Houses, a final piece of legislation was agreed upon and ratified
by President Obama in March 2010. The Patient Protection and Affordable Care
Act introduced many of the reforms proposed by Democrats almost a year earlier,
including obligatory health insurance, medical tax credits for the poorest,
increased regulation of the health care industry and higher taxation of the
wealthiest to directly support both Medicare and Medicaid. However, the Bill did not include the “public
option” as proposed by President Obama in July 2009, jettisoned by Senate
dealmakers to create a passable piece of legislation (Bonnett, 2010) The changes implemented via the
Patient Protection and Affordable Care Act 2010 are proposed to extend medical
coverage to a further 32 million American citizens. President Obama described
the changes as “reforms that generations of Americans have fought and marched
for and hungered to see” (Durando, 2010. Sky News’ Foreign Affairs Editor, Tim
Marshall summarised the reforms as not being universal, but “the closest
America will ever get” (Bonnett, 2010).
Principally, the United
States continues along a path of private health care with no universal public insurance
policy yet established, whilst the United Kingdom continues to provide
healthcare free at the point of access in 2012, as it has done since the dawn
of the National Health Service in 1948. However, as we have seen, recent
changes in British and American health policy have been both widespread and of
great significance, with the United Kingdom entering a phase of partial
privatisation whilst the United States has categorically increased access to
health care.
As liberal democracies,
the political processes of the United States and Britain are open for scrutiny,
as are the policies each respective government wishes to legislate. And although
both American Congress and British Parliament operate on a bicameral basis,
differing challenges were faced by David Cameron and Barack Obama throughout
their respective drives for health care reform.
As the first Prime
Minister of a coalition government since the Second World War, Conservative
David Cameron faced vigorous opposition to his party’s health reform proposals
from within his own cabinet. Liberal Democrat ministers, such as Deputy Prime
Minister Nick Clegg questioned the degree by which the Bill would privatise the
NHS (The Telegraph, 2011). Unlike the United Kingdom, the Executive Branch of
American government revolves solely around one man. As such, due to the design
of American politics, enshrined in the constitution, President Obama did not
face the internal competition his British counterpart did. However, both
premierships had to fight to pass legislation once it was opened to the
legislature.
Following the general
election of May 2010, Conservative MP’s accounted for 305 of the available
House of Commons seats, defeating their nearest rivals, and current incumbents,
New Labour by 52. The subsequent establishment of a Conservative-Liberal Democrat
coalition, with their 57 seats provided a large enough majority to formulate a
government capable of passing legislation such as the Health and Social Care
Act 2012 (Parliament UK, 2010). Similarly
to the Conservative majority within the House of Commons, President Obama’s
Democratic Party also held a majority in the lower-House following his election
in 2009. Of the 435 available seats within the House of Representatives, 256
were elected to members of Obama’s party, with 178 in favour of Republican
candidates.
Despite similar levels
of backing within their respective legislature’s lower chamber, both
governments faced different prospects with regards to passing reforms through
the upper-House. Britain’s House of
Lords, with a Labour majority, is constrained to rejecting a Bill a maximum of
three times in one year (Heywood, 2007). As such its role in the creation of
legislation is largely limited to the recommendation of amendments, as was the
case throughout the introduction of Cameron’s health reforms. Conversely to the
House of Lords, the American Senate is not constrained on its rejection of
Bills and as such the importance of its composition is vital to any President
hoping to pass legislation. Unlike the unelected House of Lords, where peers
are either granted status through birth-right or appointment, the Senate is a
fully elected chamber with two senators representing each state (Heywood, 2007).
During the period of time immediately preceding the introduction of the Patient
Protection and Affordable Care Act in 2010, 57 of the 100 senators represented
the Democratic Party as opposed to the Republican’s 41. This slim majority
proved to be a key factor affecting the redevelopment of Obama’s original
health reform suggestions. Such fundamental changes to the American health
system not only split Democrats and Republicans, but also split certain
sections of the Democratic Party itself, leaving those responsible with pushing
the legislation forward a difficult task. Final key amendments included the
abolition of the proposed “public option” and insurances that federal money
would not be used to fund abortions.
We can see that the
paths of both Prime Minister Cameron’s and President Obama’s health reforms
have led through two legislative chambers respectively, however the influences
of each nation’s upper and lower Houses have proven to be converse. Legislation passed within the United States
must truly be approved by both the House of Representatives and the Senate, as
was the eventual case for the Patient Protection and Affordable Care Act in March
2010. However, the power divide between
Britain’s House of Commons and House of Lords is not so evenly balanced, with
the lower elected chamber able to force legislation through due to its
neighbour’s inability to consistently reject Bills.
Furthermore to these two
nation’s processional disparities is the composition of the respective
Executive branches. As American President, all power of the Executive Branch is
vested in Barack Obama, who also acts as Head of State and Commander in Chief of
the Armed Forces. All other members of the Executive, including the Vice
President, Cabinet and Executive Office are regarded solely as advisory bodies
(The Whitehouse, 2012). Unlike the President, Prime Minister David Cameron is
not Head of State, and instead, as the leader of the party with the largest
majority within the House of Commons following the General Election in May
2010, was asked by the Queen to formulate a government. As Prime Minister he is
regarded as primus inter pares or
“first among equals” with regards to his role within the Cabinet. He is
regarded as the leader of a group of decision makers, rather than acting as the
sole decision maker himself (Heywood, 2007). The collective accountability of
Cabinet ministers can be difficult enough to galvanise within a single-party
government, however Prime Minister Cameron faced a much greater test within the
Conservative-Liberal coalition with the debate surrounding health reforms,
battling not only to convince Ministers of his own party but Ministers of a
party much associated with opposing the privatisation of nationalised services.
Superficially, the
American and British political models appear similar as liberal democracies
with bicameral legislatures. However, we have discovered many great differences
in the operation and mobility of these two nation’s political systems. This
trend of partial similarity is something reflected in the comparison of further
political concepts within these two countries.
The democratic system of
government within United Kingdom and the United States is keenly protected, not
only by differing styles of constitution, but also through external
participation by both the general public and professional representative
bodies, such as Trade Unions, Interest and Pressure Groups.
This interaction, as
displayed by both the British Royal College of Physicians and the American
Association of Neurological Surgeons alongside the American Association of
Orthopaedic Surgeons with regards to their own nation’s recent health reforms
exemplifies modern liberal democracy as more than the right to vote. James
Laxar writes:
“Essential features of contemporary
democracy are the rights to free speech and assembly. Democracy also extends to
the rule of law, to the right of those accused of crimes to fair and speedy
trials, to freedom from arbitrary detention and the right to legal counsel.”
(Laxar,p10, 2010)
By upholding the
“essential features of contemporary democracy” as described by Laxar, both
Britain and the United States allow their own political cultures to flourish.
The protection of
democracy is a key similarity when comparing the political culture of these two
countries; however there are many great differences also. The great American
belief in “rugged individualism”, the notion that citizens thrive with little
government interference was summarised by Republican candidate, Herbert Hoover
during his Presidential election campaign in 1928, at New York’s Madison Square
Garden he said:
“When the war closed… we were
challenged with a peace-time choice between the American system of rugged
individualism and a European philosophy of diametrically opposed doctrines –
doctrines of paternalism and state socialism. The acceptance of these ideas
would have meant the destruction of self-government through centralization of
government. It would have meant the undermining of the individual initiative
and enterprise through which our people have grown to unparalleled greatness.”
(Cohen, 2008)
Twenty years later following
a second World War, actions taken by Britain under the guidance of Clement
Attlee and at the recommendation of William Beveridge, establishing the
National Health Service, optimised the European-state paternalism discussed by
Hoover. However, although met by some
scepticism, one former chairman of the British Medical Association described
the move as “the first step, and a big one, to national socialism”, the
National Health Service as part of the wider Welfare State in Britain went on
to be widely endeared by a nation recovering from the effects of two World Wars
(BBC News, 1998).
The impact of
Beveridge’s report on welfare in Britain has gone on to impact the political
culture of the United Kingdom throughout the 20th into the 21st
century. Within his article “Attitudes
to Welfare”, Peter Taylor-Gooby describes British support for the Welfare State
as “strong and enduring in the main” going on to state:
“The NHS, pensions and education command
mass support because they meet mass demands.”
(Taylor-Gooby, p77, 1985)
The defining features of
political culture within the United States and Britain have clearly played a
key role in the development of health care policy in recent years. Whilst President
Obama’s contemporary Democratic Party would widely be regarded as opposed to
the hard-line individualism discussed by Hoover, the sentiments displayed by
the former Republican President still underline much of the overwhelming
American attitude. Similarly, modern British attitudes towards the National
Health Service remain widely alike to those surrounding its establishment; supportive
of the public model. As such Prime Minister Cameron and President Obama both
had to fight to pass legislation largely opposing the views of the popular
national political culture.
As such we understand
the political cultures of both America and Britain to be of great importance
with regards to policy implementation. Summarising Almond and Verba’s study
into political culture, Hague and Harrop write:
“Mass attitudes towards government
will of course reflect what the government has done in the past but- and here
is Almond’s point- these sentiments will in turn affect what the government can
achieve in the present and the future. In this way, political culture connects
government not just with society but also with its own history.”
(Hague and Harrop, p105, 2007)
In conclusion, the
passing of both the American Patient Protection and Affordable Care Act 2010
and the British Health and Social Care Act 2012 has signified major changes to
the health services in the United States and the United Kingdom. Both countries
have displayed close similarities within their political systems, models, and
cultures, however vast differences have also been apparent between these two
liberal democracies from the composition of their legislatures to the wider
political attitudes of the electorate.
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