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Universal Health Care

Nothing is perfect, and that definitely includes health care. On the 70th anniversary of the first full-coverage national health care system that is ‘free at the point of delivery’, Britain’s National Health Service, English people have been marching in the streets demanding better funding for the NHS, and Donald Trump naturally got the wrong end of the stick again.

Back in February, as part of his war against Barack Obama’s attempt to improve the coverage of the rudimentary US health care system (‘Obamacare’), Trump claimed that the marchers were protesting because the British system is “going broke and not working.”

It’s tough trying to defend the existing US system when every other developed country provides universal health coverage for its citizens, but Trump battled bravely onwards, later tweeting that the Democrats in the United States “want to greatly raise taxes for really bad and non-personal medical care.” Like the British allegedly suffer under the NHS.

In fact, the English National Health Service (Scotland and Northern Ireland have separate but similar systems) is, in former Conservative cabinet member Nigel Lawson’s words, “the closest thing the English have to a religion.” It is almost universally loved, and the protests were about government under-funding of the NHS.

Even the Conservative government that has strictly limited funding increases for the NHS over the past seven years, despite rising demand due to an ageing population, has now been forced to yield to popular demands. Prime Minister Theresa May announced last week that the NHS would get a funding increase of 3.4% per year over the next four years, giving it an extra $27 billion annually by 2023.

But are the English right to love their health-care system – and are the French and Germans and Russians and Japanese and the people of almost every other developed country right to revere their own similar systems? The United States may be the odd country out, but it does spend far more on health care than anybody else.

The United States spends 16% of its entire Gross Domestic Product on health care, almost twice as much as the average (8.2% for Japan, 8.4% for the UK, 8.5% for Australia, 10.4% for Germany). In theory, that ought to mean that Americans are healthier than everybody else and live longer. In practice, it’s just the opposite.

The United States is the only developed country where the average life-span is less than 80. In fact, it’s barely 78 years in the US, whereas everywhere else it’s in 80-82 range. The US also has the highest ‘preventable death’ rate of any developed country, and the highest infant mortality rate by a very wide margin. Americans spend more on health, and get less back, than anybody else.

They also spend far more of their time worrying about health care. The principal cause of personal bankruptcies in the United States is ‘catastrophic’ health emergencies, and all but the very rich have to devote much time to finding affordable medical insurance. Elsewhere in the developed world, nobody really thinks about that. The care will be there when you need it, and nobody goes bankrupt.

The model that was pioneered by Britain’s NHS on July 5, 1948 has been so successful that it is now spreading into many developing countries as well. India is still a poor country, but its National Health Policy 2017 goals include a commitment to “progressively achieve Universal Health Coverage.” China is working to provide affordable basic healthcare to all residents by 2020. And so on.

Attitudes change over time. In the 1930s nobody thought that there was some sort of basic human right to health care. The well-off paid for their own, and the rest depended on charity (which wasn’t very dependable). What changed that attitude was the Second World War, a time of great national solidarity and sacrifice in every country.

It was the worst war in history, but it produced a generation who believed that the people who had shared in the sacrifice (in both the countries that won and those that lost) must not be left behind in the peace that followed. The will was there to do new and great things, and they did them.

It is no coincidence that the same year of 1948 saw the signing of the Universal Declaration of Human Rights, which said (among other things) that “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services.”

The world had turned, and what had been a privilege became a right. One that is still widely abused or neglected, of course, but it has nevertheless spread across the entire planet in the past 70 years. Why did the United States miss out?

The answer is probably a free-market ideology so strong that it enabled the insurance companies and the medical profession (which opposed the idea of a national health system in every country, at least initially) to win the political battle in the US and strangle the idea in its cradle. It keeps coming back even there, but for the moment Americans must go on paying the costs of their ideology.
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To shorten to 725 words, omit paragraphs 5 and 9. (“Even…2023”; and “They…bankrupt”)

Universal Health Care – a No-Brainer

It began, as so many things do these days, with a Donald Trump tweet. Frustrated by his inability to kill the ‘Obamacare’ expansion of public healthcare provision in the United States, Trump seized on a protest about the under-funding of Britain’s National Health Service (NHS) in London last Saturday to trash the entire concept of universal healthcare paid out of taxes and free at the point of delivery.

“The Democrats are pushing for universal healthcare [in the US] while thousands of people are marching in the UK because their system is going broke and not working,” he tweeted. It was an awkward moment for Britain’s Conservative prime minister, Theresa May, who tries to avoid criticising Trump whenever possible, so she let her health secretary, Jeremy Hunt, respond instead.

Hunt tweeted back that while he disagreed with some of the protesters’ opinions, “not ONE of them wants to live in a system [like the US] where 28 million people have no cover….I’m proud to be from the country that invented universal coverage – where all get care no matter the size of their bank balance.”

It’s true. The British population is growing older and needs more health services, but Conservative governments over the past seven years have not raised spending on the NHS to match. As a result, many people are dissatisfied with the growing delays in treatment, but the NHS is the most beloved institution in the United Kingdom. Not one person in a hundred would want to replace it with a privatised, insurance-based system.

A huge controversy rages permanently in the United States over public vs. private spending on healthcare, with the Republican always trying to cut the share paid out of taxes by federal and state governments (currently about half). But there is no equivalent controversy elsewhere.

Every other developed country has a universal healthcare system – and in an eleven-country study published by the US-based think-tank The Commonwealth Fund last summer, the United States came dead last in terms of safety, affordability and efficiency. The contrast is particularly stark in the differences between the United States and the United Kingdom.

Americans spend twice as much per capita as Britons on healthcare. Health services account for an astonishing 17.2 percent of American GDP (the highest in the world), compared to 9.7 percent in the UK. Yet the British system delivers better results: life expectancy at birth is almost three years higher in UK (81.4 years, compared to 78.8 years for Americans).

To be fair, it’s not only the NHS that enables British people to live longer. They are less obese than Americans (23 percent of English adults have a body mass index of more than 30, compared to 32 percent of Americans). The murder rate in the US is five times higher than it is in the UK. But even if average life-spans were identical in the two countries, Americans would be paying twice as much for the same result.

There really is no controversy: universal healthcare is better. Since half of that enormous American spending on health goes to profit-making enterprises like insurance companies, there is an immensely rich and powerful lobby fighting to keep the public-private controversy alive in the United States, but elsewhere, even in much poorer countries, it is a no-brainer. Like in India, for example.

India, which recently overtook China to become the world’s most populous country, is still relatively poor (although its economy is now growing at over 7 percent annually). Last week in the Indian parliament, Finance Minister Arun Jaitley announced a new government initiative that will provide the poorest 100 million families (half a billion people) with up to $7,800 annually to cover hospitalisation costs in case of severe illness.

“This will be the world’s largest government-funded healthcare programme,” he told parliament. “The government is steadily but surely progressing towards a goal of universal health coverage.” People are already calling it ‘Modicare’ (after Prime Minister Narendra Modi), and it does bear more than a passing resemblance to Obamacare.

India currently spends only one percent of its GDP on healthcare, so there’s still a very long way to go – and as always in India, the tricky bit is actually implementing the programme, especially in the rural areas. (Free government hospitals are mostly in the cities.)

Diagnostic tests, doctor follow-ups, basic medicines (like statins for heart disease or diabetes control) and post-operative home care are not covered by the $1.7 billion scheme. Private hospitals and clinics are still not properly regulated, and frequently overcharge. Poor families dealing with a major illness often end up in the hands of money-lenders, and even in government-run hospitals bribes are sometimes necessary to get good treatment.

All that said, the direction of travel is clear, and maybe in a couple of decades India will have a universal health service like the NHS. Beloved, in other words.
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To shorten to 725 words, omit paragraph 8. (“To be…result”)

India: Changing Identities

When India got its independence from Britain 70 years ago this week, it was founded as a secular democracy – secular because it acknowledged the status and rights of Muslims, Sikhs, Christians and other religious minorities as equal to those of the Hindu majority. Mahatma Gandhi, the great hero of the independence movement, was a devout Hindu, but he was murdered by a Hindu fanatic for defending Muslim rights after Partition.

It was one of the most fortunate assassinations in history, because Hindu radicals had been using Pakistan’s declaration that it was a “Muslim state” to demand that India be declared a “Hindu state”. After Gandhi’s murder, Jawaharlal Nehru, the country’s first prime minister, was able to round up tens of thousands of Hindu extremists and exploit popular reverence for Gandhi to nail down India’s identity as a secular state.

India is still a democracy, but a portrait of one of the men who conspired to assassinate Gandhi now hangs in India’s parliament. The prime minister, Narendra Modi, leads the BJP (Indian People’s Party), which was created as the political wing of the RSS (National Volunteer Organsation), a Hindu supremacist paramilitary organisation. And secular is now spelled “sickular” by the Hindutva trolls on Twitter.

Hindutva is Hindu exceptionalism of the kind that gives rise to the trope that “to be Hindu is to constantly take offence.” It sees India as a “wounded civilisation” because it has spent most of the past thousand years under the rule of various foreign invaders (hardly a unique experience), and proposes to remedy that with a highly simplified, almost kitch version of politicised Hinduism.

It’s just another brand of populism, in other words, but its chief Indian proponent, Narendra Modi, must deal with far deeper divisions in society than his American counterpart, Donald Trump. He is a much more disciplined man, however, and he does not waste his time in tweeting insults and picking fights with random people.

Modi is relentlessly focussed on economic growth, and in particular on raising the living standards of the lower-middle-class Indians who are his strongest supporters. But to get and keep the parliamentary majority that would let him carry out his programme he must appeal to a broader audience.

For more than half a century India got along with the secular principle that religion is a private matter, but Modi supported a national ban on cow slaughter (many states already banned it) when he took office. More recently he banned the slaughter of buffalo as well. So it’s hardly surprising that “cow protection” vigilantes have been attacking people suspected of trading in beef; half a dozen have been beaten to death in the past couple of years.

Modi supports the ban because high-caste Hindus (the group from which the BJP draws most of its support) believe that cows are sacred and must not be eaten. However, lower-caste Hindus, the so-called Dalits (untouchables), do eat beef, and they make up about a quarter of India’s voting population. This poses a serious political problem for the BJP.

Muslims, who dominate the beef and leather trades, make up another 14 percent of the voters, but Modi doesn’t worry about losing their votes because they were never going to vote for the BJP anyway. He cares very much about the Dalit vote, because they are the key to making the BJP the natural party of government.

Modi won a landslide majority in 2014 in the Lok Sabha (the lower house of parliament), but he did it on only 31 percent of the popular vote. The first-past-the-post system regularly delivers such lopsided results. But the Rajya Sabha (upper house or senate) is elected by the state legislatures, where Dalits are often quite prominent politically. The BJP will never get a majority in the senate without Dalit support.

So Modi walks a tightrope on the issue of sacred cows, promoting their protection to appeal to his upper-caste voters, while weakly condemning the murder of butchers and leather workers by “cow protection” vigilantes (who are backed by the RSS, the BJP’s parent organisation).

Indeed, Modi’s whole take on Hinduism is quite ambivalent. Two years ago, for example, talking about health care in India, he got off track and started talking about the elephant-headed god Ganesha: “We worship Lord Ganesha. There must have been some plastic surgeon at that time who got an elephant’s head on the body of a human being and began the practice of plastic surgery.”

It is certainly not Hindu orthodoxy to suggest that Ganesha was a chimera created by ancient plastic surgeons. On the other hand, the idea that India led the world in plastic surgery a few thousand years ago will appeal to the more naive Indian nationalists. It’s a bizarre mixture of ideas, but not untypical in populist politics.

The bottom line, alas, is that the “sickular libtards” are in retreat, the religious minorities are being marginalised, and the people who define India as a “Hindu country” are in charge. It’s too early to say that this is an irreversible change, but it’s a radical departure from the country’s founding values. It’s still a democracy, but it’s starting to look a lot more like Pakistan.
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To shorten to 725 words, omit paragraphs 12 and 13. (“Indeed…politics”)

Coal is Dead

“My administration is putting an end to the war on coal,” said Donald Trump, surrounded by the usual gaggle of officials and (in this case) coal-miners, as he put his super-size signature on the Energy Independence Executive Order. But coal is dying as a major energy source in the United States for reasons far beyond the reach of executive orders.

“The miners are coming back,” Trump boasted at a rally in Kentucky last week, but no less an authority than Robert Murray, founder and CEO of Murray Energy, the biggest US coal company, promptly rained on his parade. “I suggested that (Trump) temper his expectations,” he said. “He can’t bring them back.”

Trump’s latest executive order is not just about coal, of course. It’s a frontal assault on all the Obama-era regulations that aimed at curbing climate change. But while it will slow the decline in US greenhouse gas emissions, it will not have a major impact on global emissions.

That is partly because US accounts for only 16 percent of global emissions. Compared to China’s 29 percent, it doesn’t matter all that much, and China remains committed to big cuts.

In January China scrapped plans for 104 new coal-fired power plants, and it intends to invest $361 billion (equal to half the US defence budget) in renewable energy between now and 2020. The Chinese government is spending that kind of money because it is rightly terrified about what global warming will do to China’s economy and above all to its food supply.

Like the Indians, the Europeans, and pretty much everybody else, the Chinese remain committed to the climate goals agreed at Paris in December 2015 even though the United States has defected. Their own futures depend on meeting those goals – and they know that the American defection does not destroy all hope of success. Globally speaking, it’s not that big a deal.

It would seem like a much bigger deal, however, if they were not confident that American greenhouse gas emissions will continue to decline under Trump, though not as fast as they would under a less ignorant and less compromised administration. Coal provides an excellent example of why.

In 2009, when Barack Obama entered the White House, coal provided 52 percent of US electricity. In only eight years it has fallen to 33 percent, and the decline has little to do with Obama’s Clean Power Plan. First cheap gas from fracking undercut the coal price, and then even solar power got cheaper than coal – so 411 coal-fired plants closed down, and more than fifty coal-mining companies went bankrupt.

Half the 765 remaining big coal-fired plants in the United States were built before 1972. Since the average age when American coal-fired plants are scrapped is 58 years, half of them will soon be gone no matter what Trump does, and even he cannot make it economically attractive to build new ones. (Only 9 percent of American coal-fired plants were built in the past quarter-century.)

Coal is by far the most polluting of the fossil fuels, producing twice as much carbon dioxide as gas does for the same amount of energy, but that alone wasn’t enough to turn the energy industry against it. It’s the cost per per kilowatt-hour of electricity that matters, and coal has simply been overtaken by cheaper forms of energy.

Even in India, the most heavily coal-dependent of the big economies and a country with vast amounts of coal, solar energy prices are now on a par with coal. Sheer inertia means that India will go on expanding coal-fired generation for a few more years, but its National Electricity Plan projects no further increase in coal-based capacity after 2022. King Coal truly is dead.

You don’t need good intentions to do the right thing for climate safety any more; just common sense. From fuel efficiency in automobiles to replacing coal-fired plants with natural gas or solar arrays, saving money goes hand-in-hand with cutting emissions. The economy is not your enemy; it’s your ally. So Trump won’t do nearly as much harm as people feared.

President Obama promised last year to cut US greenhouse gas emissions by about 26 per cent from the 2005 level by 2025. About half of that 26 percent cut would have come in Trump’s first and maybe only term (2017-20), so say 13 percent. The US accounts for 16 percent of global emissions, so do the math: 13 percent of 16 percent equals about 2 percent of global emissions.

That’s what would be at stake over the next four years if Trump’s presidency stopped all the anticipated reductions in greenhouse emissions that Obama based his promise on – but it won’t. A lot of those emission cuts are going to happen anyway, because they just make economic sense. At a guess, around half of them.

So how much damage can Trump do to the global fight against climate change over the next four years? He can keep global emissions about one percent higher than they would have been if the United States had kept its promise to the Paris conference. And that’s all.
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To shorten to 725 words, omit paragraphs 10 and 11. (“Coal…dead”)