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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”)

Catalonia Again

I’m sitting here trying to write an article about the election in Catalonia on Wednesday, because there’s nothing else to write about. It would be more interesting if the African National Congress, South Africa’s ruling party for the past 23 years, elects a new leader who is not Jacob Zuma’s ex-wife, but the results on that won’t be in until tomorrow.

Apart from that there’s nothing except more stuff about Donald Trump’s Russian links. So it has to be Catalonia – and the problem is that I don’t care what happens in Catalonia.

One more smallish group defined by some tiny distinction of religion or language or history wants to break away from some other, bigger group – ‘Spaniards’, in this case – that is defined by slightly broader and more inclusive distinctions of the same kind, and I simply couldn’t care less.

Maybe, after all the nonsense that happened in the past six months – big demos for independence, an illegal referendum that was designed to provoke the Spanish state into over-reacting (and succeeded), and various pro-independence leaders jailed or going into voluntary exile to avoid arrest – a majority of people in Catalonia will be so fed up with the turmoil that they vote to remain part of Spain. But I don’t think so.

Maybe a majority will be so enraged by Madrid’s blundering over-reaction that they vote for their independence from Spain, and actually get it.

Then most of the larger companies in Catalonia will move their headquarters elsewhere (several thousand have gone already), and they will have a new currency nobody trusts (because they will no longer be in the European Union), and the people running the place will be the single-issue fanatics who managed to put this issue on the agenda in the first place. They don’t seem to have many ideas about what to do next.

As H.L. Mencken said, “Democracy is the theory that the common people know what they want, and deserve to get it good and hard.” But I don’t think the Catalans are going to vote decisively for independence this time either.

Instead, they are going to split their votes in a way that leaves no clear majority for or against independence, and makes it hard even to form a coalition government. (What is happening in Catalonia this month is actually an election, not a referendum, although everybody is treating it like the latter.) So we can look forward to months, years or even decades more of the same.

On a somewhat larger canvas, this is exactly what is happening in the United Kingdom, too. Just as the Catalans complain that they are paying too much tax to the Spanish government, which transfers it to poorer parts of Spain, so the ‘Little Englanders’ complain that the UK pays too much to the European Union (which spends a lot of it raising standards in the poorer parts of eastern Europe).

Just as the Catalans (and especially younger Catalans) are far less different from other Spanish citizens than the separatists imagine, so the English (and especially the young English) are far less different from other Europeans than the Daily Mail-reading older generation of English nationalists imagines. It is the ‘narcissism of small differences’, in Sigmund Freud’s famous phrase.

But just as the Catalan mess is guaranteed to run on for years, now that it has reached this stage of obsessiveness, so will the British mess. If the UK actually leaves the European Union, the British will be much the poorer for it, and the nationalists who foisted it on the rest of the population will spend the next generation blaming the wicked Europeans for their own mistakes.

And if, by chance, the British end up not leaving (rationality doesn’t often win, but occasionally it does), then the country will spend the next generation contending with a non-violent insurgency waged by the disappointed nationalists.

Obviously, not every separatist movement that appeals to nationalism is wrong. The anti-colonial struggles for independence in the 20th century were fully justified and necessary because the injustices were great and the gulf between rulers and ruled was immense. The American war of independence in the 18th century was justified because great questions about human rights and democracy were at stake.

But when all parties concerned subscribe to democratic values, it generally makes more sense to stay together and try to work out the differences. Separatist pro-independence movements in democratic countries tend to be driven by the ambitions of politicians who want to be bigger fish in a smaller pond.

As former Canadian prime minister Jean Chretien put it (in a broken half-English sentence calculated to insult his fellow French-Canadians who were the separatist leaders in Quebec), they want to drive up “dans un gros Cadillac avec un flag sur l’hood” (in a big Cadillac with a flag on the hood). Enough said.
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To shorten to 700 words, omit paragraphs 11 and 12. (“But just…nationalists”)

Brexit Blues

Politicians never lie. Well, hardly ever. They’re not into full disclosure, as a rule, but they know that if you lie, sooner or later you will be caught out, and then you are in deep trouble. So just change the subject, or answer a different question than the one you were asked, or just keep talking but saying nothing until everybody gets bored and moves on.

British prime minister Theresa May had a bad day with the truth recently. She got her job when last year’s referendum came out narrowly in favour of leaving the European Union – Brexit – and the previous prime minister, David Cameron, had to resign. Her task is to lead the country out of the EU, and it’s been a nightmare, with her own cabinet evenly split between Leavers and Remainers.

But then a talk radio host called Iain Dale asked her live on air the question she must have been dreading: would she now vote Leave if there was another referendum? She couldn’t say no, because she is leading the negotiations with the EU about leaving. She couldn’t say yes, because that would be a lie. So she waffled and dodged.

Dale heard her out, and then, very politely, asked her the same question again. She dodged again. So he asked her again. And again. After four goes, it was perfectly clear to everybody that she would not vote Leave, and probably didn’t in the first referendum either. It’s hard being a politician sometimes.

The United Kingdom is now halfway out of the EU – or rather, May’s government has now used up half the time that was available to negotiate an amicable divorce settlement and decide on the post-separation terms of trade with the EU, Britain’s biggest trading partner by far. Unfortunately, it has not settled half the issues that need to be decided, or even a quarter. Maybe one-tenth.

The delay is almost entirely due to the deep divisions in her own cabinet. Half of them are Brexiteers, some of them quite fanatical about the need to Leave, while the other half secretly wish the referendum had come out the other way. And if they do have to leave, they don’t want to go very far.

It’s all about ‘hard’ and ‘soft’. The fanatics want a ‘hard Brexit’ in which the UK crashes out of the EU without so much as a post-Brexit trade deal, while their opponents want to stay in the customs union and even the ‘single market’ (where all the EU countries adhere to common standards for goods and services).

May couldn’t afford to alienate either side by taking a stand, because the consequent war within the cabinet would probably bring the government down – and the Conservatives would probably lose the subsequent election. But if she couldn’t tell her own colleagues which way she was going to jump, she couldn’t tell the EU negotiators either, and so eighteen months have passed with very little accomplished.

Now she has been forced out into the open – by the ‘Irish question’, of all things. The one land border between the United Kingdom and the EU is in Ireland.: Northern Ireland is part of the UK and on its way out of the EU; the Republic of Ireland is staying in the EU. So obviously, there will have to be customs posts and other controls on that border post-Brexit.

But there must not be that kind of ‘hard border’ or the war in the North is likely to start up again. Part of the deal that persuaded the fighters of the IRA to lay down their arms 20 years ago was the guarantee of a ‘soft border’ between the two parts of Ireland, with no passport checks, no customs controls, no barriers of any kind. Break that deal, and it probably wouldn’t be long before the killing started again.

Theresa May couldn’t go on ignoring this question, because she depends on the support of a small Northern Irish party for her majority in parliament. In the end, she had to agree to what she called ‘regulatory alignment’ between the UK and the EU in order to keep that border open. For all practical purposes, that means the UK must stay in the EU customs union and internal market, although it will no longer have any say in how they are run.

This does reduce the whole Brexit enterprise to a complete nonsense: the UK will pay 40 billion euros in compensation to ‘leave’ the EU, and end up approximately back where it started. It’s still better than crashing out without a deal, and it may be what May secretly wanted all along, but there is going to be a rebellion by the Brexiteers in the cabinet sooner or later.

So it’s all up in the air again, really: hard Brexit, soft Brexit, or even drop the whole idea and stay in the EU. It was always a stupid idea, and the grown-ups are definitely not in charge.
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To shorten to 700 words, omit paragraphs 1 and 7. (“Politicians…on”; and “It’s…services”)

The Irish Border

History never leaves Ireland alone. In the late 19th and early 20th centuries the lethal alliance of the Conservative Party in Britain and the Unionist Party, which represented the Protestant minority in Ireland, made it impossible for the British parliament to pass a Home Rule Bill for Ireland.

A Home Rule Bill might have let the two countries take their distance peacefully and gradually, while retaining close links – or maybe not, but it was worth a try. Instead came the Easter Rebellion of 1916, the Irish War of Independence, the partition of the island between the independent Republic and Northern Ireland (part of the UK), the Irish Civil War, and three decades of terrorist war in Northern Ireland that only ended 20 years ago.

Well, the Conservatives and the Unionists are back in coalition now, and another war is brewing on the border between Northern Ireland and the Republic. At the moment it’s practically an invisible frontier, with no border posts or customs checks, because both the United Kingdom and the Irish Republic belong to the European Union. Brexit, however, will put an end to that, and probably to peace as well.

In principle, Britain flouncing out of the EU shouldn’t hurt anybody except the British themselves, but the UK’s Irish border is a nightmare. Prime Minister Theresa May has sworn a mighty oath that the United Kingdom will leave both the ‘single market’ and the customs union, but that will turn this ‘soft’ frontier into a ‘hard’ EU border with a non-EU country: border guards, customs checks, passports, queues and all the rest.

What made the Good Friday peace agreement of 1998 possible was the promise that the border between the two Irelands would practically disappear, which allowed the Catholic nationalists of the Irish Republican Army (IRA) to believe that their war had not been just a futile struggle that killed 3,000 people. They could dream that with all the coming and going across an open border, the two parts of Ireland would grow closer and eventually reunite.

Recreate a hard border and they will feel cheated. Not all the militants of the IRA will pick up their guns again, but some almost certainly will. It was very hard to stop the first time, and there is no particular reason why a renewed war couldn’t last another thirty years and kill thousands more.

Presumably Theresa May does not want to see this, and the EU recently offered her a way out. If you must go, they said, then leave the inner Irish border open and put your customs and immigration controls between Northern Ireland and the rest of the UK (which are conveniently separated by the Irish Sea).

Northern Ireland would remain in the EU’s customs union and nobody would be stopped at its land border with the Republic. Customs and immigration checks would only happen at Northern Irish ports and airports, when people or goods have crossed or are going to cross the Irish Sea. It makes as much sense as anything can within the context of Brexit – but May has to reject it.

She must reject that offer because she lost her parliamentary majority in the election she needlessly called last June, and remains in power only thanks to the votes of the Democratic Unionist Party – i.e., the hard-line Protestants of Northern Ireland. And the DUP, always terrified that Britain will abandon them, simply will not allow any kind of border, however soft, to be put between Northern Ireland and the rest of the UK.

May cannot defy the DUP on this or her government will fall – and the Conservatives would probably lose the subsequent election, putting her nemesis, the dreaded Labour leader Jeremy Corbyn, in power.

However, if May insists on leaving the EU customs union, there will have to be a ‘hard’ border – and if there is, says Ireland’s Prime Minister Leo Varadkar, he will veto any negotiations between the EU and the UK on a free trade deal after it leaves the Union.

Theresa May is finally cornered, and the United Kingdom may end up ‘crashing out’ of the EU with no deal at all. The UK can then spend the next decade trying to renegotiate on less favourable terms the 59 trade deals it now enjoys with other countries as a member of the EU – and, more likely than not, dealing with a renewed IRA insurgency in Northern Ireland.

Or May could aim for a deal that keeps the UK in the customs union. Then the border would remain open, and there would be no Irish veto, and a reasonable deal on post-Brexit trade would be possible. But that would split the Conservative Party, and avoiding that is far more important to her than all these other issues.
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To shorten to 725 words, omit paragraph 8. (“Northern…it”)