The Political Abuse of International Health System Comparisons

Modern medicine, likes to present itself as driven primarily by the desire to adopt best practice and follow evidence wherever it may lead. Treatments proven effective are to be used, while those deemed flawed are to be discarded. Analysts of policy diffusion and adoption often assume their realm should be governed by similar assumptions – and, perhaps, in an ideal world this would, indeed, prove to be the case. Policy is, however, generally the domain of politicians – and politicians often have very different ideas as to what constitutes an effective or desirable policy stance. Across a range of politically-charged issues, policy proven effective in one setting is not adopted unquestioningly elsewhere, but instead becomes a political tool employed by politicians seeking to discredit opponents.

The use of the UK National Health Service (NHS) as a perennial ‘political football’ is a long tradition in USA politics. Nonetheless, both the volume and intensity of attacks against the NHS appeared to increase markedly in the lead-up to the 2008 presidential election and, particularly, during the debate over the Democratic health reform legislation in 2009–2010. While the several decades after the establishment of the NHS were largely used to elicit fears of physician shortages if applied to the USA, this concern was eventually displaced by the current focus on health care rationing. The evolution of the NHS as political foil has broadly followed the contours of the USA health reform debate, reflecting the wax and wane of various stakeholders, with opponents eventually settling on the fear of rationing as a singularly effective political message.

Horror stories of rationing were to be found in USA media reports as early as the 1960s. A short Tribune aside from 1964 bemoaned the fact that an English swimmer who lost her dentures was denied a replacement by her local health council. ¹ Presented without even a semblance of local context, this apparently extraordinary incident is presented as typical of an inappropriately stingy national health care system.

The relative silence on the UK NHS during the 1990s round of reforms is notable. While Republicans were successful in prompting the collapse of the health reform effort spearheaded by President Clinton and first lady Hillary Clinton, they did not do so (by and large) by falling back on NHS scaremongering. Opposition was more focused on the sheer complexity of the plan and the increased role it envisioned for the federal government. Moreover, the system with which it drew comparison was not to be found in the UK, but immediately to the north in Canada.

Canada had, by the early 1990s, itself undergone a period of heath system introspection. Indeed, some critics of Canadian Medicare went so far as to suggest the inspiration for future reforms should come from the USA. Denunciation of such proposals was swift and direct. ‘If Americans had a Canadian-style single-payer health system in place today,’ commentator Milan Korcoc mused, ‘there would be no health-reform debate going on [there].’ ² ‘Ironically, the outdated USA approach is being reformed out of existence by the Bill Clinton administration,’ sniffed the editorial writer at the Toronto Star. ³ While observers could point to some failings, a consensus formed around the proposition that ‘Canadians need to fix a system that essentially works. Americans must replace one that does not.’ ⁴

The Canadian system entered the 1990s debates about USA reforms at an early stage. At the start of 1992, Republican congressional committee staff released a report that purported to show that American adoption of a Canadian-style system would raise health care costs by approximately US$82 billion. ⁵ As the 1992 presidential election campaign approached fever pitch, so did the rhetoric surrounding Canadian health care. Democratic candidate Paul Tsongas of Massachusetts went so far as to assert that, ‘as wonderful as the Canadian system is, if I had been in Canada when I got cancer, I might not be here today.’ ⁶

Such early back-handed compliments by prominent politicians and observers likely helped ensure defeat of the reform plan that emerged under the auspices of liberal Democratic congressman Jim McDermott. While his plan was hardly identical to Canadian Medicare, it drew enough comparisons to make it an easy target for Ottawa-bashing conservatives. The McDermott Plan, like other counter-proposals offered during the course of the Clinton health care debate, never really had a chance.

If Canada displaced the UK as conservative punch bag in the 1990s, opponents of Democratic health reform efforts went back to the UK in 2009–2010. The NHS was most trotted out both before and after reform legislation had passed. In summer 2009, Charles Grassley, a Republican senator, was claiming that the cancer-stricken Senator Edward Kennedy would have been unlikely to receive sufficient care under the NHS. ⁷

The latest round of fear-mongering surrounding the prospect of rationing reached fever pitch when word leaked that the Obama administration was considering the accomplished health care quality improvement expert, Dr Donald Berwick, for the post of administrator of the Centers for Medicare and Medicaid Services. Berwick is well-known and respected by a wide cross-section of health care personnel worldwide. As head of the Institute for Healthcare Improvement, he has a long history of evaluating health systems and health care institutions, plus suggestions for quality improvement. ⁸ Few questioned his credentials or his ability to fulfill the role.

Political operators did, however, question his stated beliefs regarding ideal types of health system and, more specifically, the praise he had previously directed at the NHS. Since the 1990s, Berwick had signaled his approval of its broad ideals, while also pointing to persistent concerns, including the perceived (relative) dis-empowerment of patients and excessive centralization of decisionmaking. Perhaps unsurprisingly, his caveats about the NHS were conveniently swept aside, while his praise of the overall system and what is stood for was duly amplified.

Republican politicians employed Berwick's own words in order to indict the Obama administration in a plot to introduce rationing and, indeed, a Federal takeover of the entire health care system, by stealth. Conservative politicians and sympathetic media outlets engaged in a spirited game of one-upmanship following the White House's announcement of Berwick's nomination. A press release from the National Right to Life Committee screamed ‘Donald Berwick is a one-man death panel,’ a reference to an earlier political kerfuffle over a vastly misinterpreted provision of a draft of health reform legislation. Berwick, the item continued, ‘is also an enthusiastic supporter of Britain's National Institute for Health and Clinical Excellence, the agency charged with determining which medical advances will – and which will not – be made available to the British public.' ⁹ An editorial in the Chicago Daily Herald made Berwick's connection to the NHS even clearer, lest anyone had missed it, with a headline promising, ‘National Health Service: It's Coming to America'. The piece further accused Berwick of advocating rationing of care. The Economist answered this charge in characteristically sober tones, noting how Republican Congressman Paul Ryan had quite rightly pointed out that rationing already occurred in USA health care, with the only outstanding question being who should make such decisions. ¹⁰

Veritable hysteria set in. In a quaintly-titled ‘second opinion’, Senator John Barrasso and fellow Republican legislators sought to draw attention to Berwick's previous statements on the NHS as a means of discrediting him. To drive the point home, Senator Barrasso dubbed Berwick the President's ‘health care rationing czar’, while Senator Orrin Hatch characterized Berwick's views on the NHS as ‘some of the most outlandish statements I've heard in years'. ¹¹ In his own statement, Barrasso managed to first strike fear into the hearts of Americans by citing a Daily Telegraph piece detailing massive cuts across the NHS – while later praising the spirit of the reforms that were driving said cuts. ¹² The Senator referenced the deep cuts NHS trusts across the UK were making in response to government calls for greater efficiencies, while soon after speaking favorably of the ‘decentralization’ inherent in the Cameron government's reform agenda. ¹³

Richard Neustadt and Ernest May once pointed to the rudimentary grasp of history on the part of many policy-makers. Under such circumstances, most were seen to do little more than ‘invoke past events for advocacy and comfort’, rather than succumbing to a form of ‘technocratic determinism’. The same can be said for contemporary and near-contemporary policy developments in other states near and far. ¹⁴ While there are, indeed, examples of effective policy diffusion in health care, there are many others that involve politicians simply scoring cheap rhetorical points. Just as British leaders (and, indeed, large swathes of the populace) express fear at the ‘Americanization’ of the NHS, generations of USA critics of leftish health reform schemes have bemoaned the baleful influence of ideas emanating from otherwise-benign allies such as Canada and the UK.