To charge or not to charge – Fandango’s Provocative Question #48

Wednesday. I am just on my way to do some charity stuff (fittingly at my local hospital) but hopefully I can blast out a meaningful paragrath and come back later. It is time for Fandango’s Provocative Question.

In his question this week, he notes that the USA does not really “do” public healthcare, and asks us whether this is a good or a bad thing.

First of all, we need to be clear on the exact difference between the two systems – where they are alike and where they differ.

The USA does private healthcare to a very high standard, probably the highest. So, it’s not a difference in quality. Rather, the difference is a case of how we pay for it – whether we pay through taxes or through premiums. So, all we’re really talking about here is just the funding model.

I say just – because we’re not really talking about healthcare at all, we could apply our argument to many different areas – healthcare just becomes an example. Public healthcare is funded every bit as much by people, because a state’s only assets is its citizenry, except in the form of taxes, not in premiums.

Also, each system has a beginning and an end. Some things are covered, others not. We can argue about whether certain treatments should be available – a common example is IVF, but that same debate might be had under both systems. Even in the UK, smaller than many countries, there are variations about what is funded and what is not, so different people have different ideas about what makes the best health service. That’s true also when you compare the public and private systems. There’s no guarantee that one allows you to offer more than the other.

One aspect of difference, however, is how much we pay. Certainly, in the UK model, what you pay is pretty flat throughout your working life. And because it is out of taxes, it is a certain proportion of what we earn, just like income tax. With a private system, one would expect premiums to be much more bespoke – there will be times when you’re a lesser risk, others when you’re a greater risk. So there will be fluctuation in your premiums.

I prefer the flatter model, simply because none of us plan to get ill. In my own case, I had my stroke at forty-eight, unusually early. I was at the hospital yesterday and heard of a woman, thirty something, five children already, pregnant with her sixth (six!), who also had a stroke. More unusual still. None of us plan to be ill, and a flatter model takes us less by surprise when it does happen.

Private health insurance can also cover unplanned illnesses, I hear you say. Of course it can, provided you have bought sufficient cover. And that’s the heart of the debate. In a private system, you pay for the cover you can afford, or, if you’re lucky, the cover you wish to pay for. Whereas in a public health system, your “premium”, obligatory, is a percentage, is based more on your ability to pay. And when you’re covered, you’re covered, period.

So, it boils down to your overall politics in the end. You might wonder about a system where one person pays thousands, and the next person pays nothing, for the same cover. Or you might recognise that the reason somebody pays thousands is precisely because their income allows them to do so. I say again, this is just like income tax. People who question the use of tax dollars to pay for healthcare, they probably also question the use of tax dollars to pay for education, roads, defense etc. If they claim that healthcare is different, we should ask why they think it’s different.

I can only really finish this piece with a personal anecdote. Once upon a time, I was in the top few percent of UK earners. It was never silly money – it was a good salary, but not really any more than hundreds of thousands of other people. I saved my money, I built a stash. I decided to take a break and set myself up as a bicycle mechanic. You know, Lance Armstrong and all that. Boy, that was hard, trying to pick up something new in my forties, especially when (as I realised later) my eyesight was going. So the stash got smaller. Then, the stroke. Almost four years, and I haven’t had a “proper” job since. The state has made it quite clear that it desn’t really expect me to work again. Maybe I will, maybe I won’t. And that stash is now almost gone because I still have to pay the bills. And I’m only in my fifties. Now, I don’t want this to be a sob-story, but my point is that circumstances do change. Whilst people might be healthy and paying what they consider to be way over the odds for their healthcare package, they should be aware that this is a lifetime committment, and that there might well come a time when the tables are turned.


  1. Disease doesn’t discriminate, we shouldn’t too.
    Everybody can get ill, everybody pays.
    I understand the positives of a private healthcare system but I also learned about many stories of people dealing with mental struggles or addiction who needed to find out that their insurance doesn’t cover this or that treatment.
    People suffering from mental illness are sometimes excluded from insurance. When in crisis I can’t have the clarity to compare possibilities in terms of insurance. When in need you need to go to whatever doctor there is and act.
    I think that that is a big big difficulty if government expects us to ‘self-care’ to prevent worse (and save them money).

    Liked by 1 person

    • Yeah, you touched on a few things which indicate to me what a big topic it is. You have to have some safety net with private healthcare, because what if someone either opts out of insurance, or cannot get insurance. Either that, or you decide that you let those people die. The trouble is, there are many people who think like that – look after myself and stuff the rest.
      I think that ultimately you judge a society on how well it treats its sick, its elderly, not how well it treats its billionaires.

      Liked by 1 person

  2. Unfortunately many in the UK forget that the government does not have any money other than that collected in taxes, or borrowed. If we are to expect greater resources in any area then we have to be prepared to pay more, all of us. We cannot leave an ever increasing debt for our future generations to deal with. There is a price to be paid for living longer, for producing too many offspring, for eating and travelling unhealthily and so much more. I do not have any answers, and am as reluctant as the majority to give up my cosy lifestyle.

    Liked by 1 person

    • I agree, and with something like the Health Service, it will always be underfunded, just because there will always be more to do. There will always be that tough decision, yes it is covered, or no it isn’t, which we make somewhere. As you say, there is no bottomless pit, and in fact we’ve seen that in practise by how the NHS has got smaller over the years – prescriptions, dentistry, opticians etc. I’d be hapy to start by diverting money away from vanity projects but sooner or later, we’d hit a buffer anyway. Plus, the NHS is just one ball of many that we need to juggle.

      Liked by 1 person

  3. “…we’re not really talking about healthcare.” You’re right, we’re not talking about healthcare per se. We’re talking about access to affordable healthcare, and if you live in the US, way too many citizens don’t have access to affordable healthcare.

    Liked by 1 person

    • More fundamental. We could apply the same principles to education, say. Something unrelated to health. Whether we all send out kids to private schools (or, if we can’t afford to do so, to leave ’em uneducated), or whether we evolve to have public schools. I think it boils down to somebody’s view of how much they take responsibility for themselves, and how much society does for everybody. How much we value a society of educated, healthy people, that actually makes our own environment better as a result. That’s a sliding scale, depending on someone’s overall politics – and yes, unfortunately, a lot of people don’t give a rat’s ass.

      Liked by 1 person

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