This Day in British History (National Health Service Law Goes into Effect)

July 5, 1948—Diving into an area of socioeconomic reform that was bypassed by its transatlantic cousin and former colony, Great Britain instituted cradle-to-grave health care for all citizens, no matter what their level of means, with the National Health Service (NHS).

Fourteen years ago, on a vacation in Toronto, I sprained my ankle, then cooled my heels for several hours at St. Michael’s Hospital before its overworked staff could get a look at it the problem. Upon my return to the states, my podiatrist came into his examination, grinned and asked me, “So, I hear you were in the socialized medicine capital of the world!”

Luckily for me, my doctor was as fine at his profession as he was firm in his capitalistic beliefs. But if he regards Toronto as the capital of “socialized medicine,” then he probably regards the U.K. less as the cradle of the Magna Carta than as the incubator of The Communist Manifesto.

Students of economics and international politics have had field days over the years explaining why the U.S. and Great Britain both proposed landmark health care legislation right after the end of World War II, but only the latter managed to pass it. My own explanation for the difference in outcomes is threefold:

1) The U.S. was not riven with the kind of longstanding class-based, hierarchical (all those dukes, earls, etc.!) society of the United Kingdom, and therefore American voters were less inclined toward radical means to redress the inequities.

2) The American Medical Association (AMA) adopted one of the most ruthless, shameless—but effective!—campaigns ever seen in American political history to defeat the legislation.

3) The major political players backing the reforms occupied different levels of strength in their countries. In the U.K., the Labour Party, under Clement Attlee, had just come to power, backed by a union movement finally coming into its own. In the U.S., the Republican Party had rebounded (and would eventually gain control of both houses of Congress in the 1946 Congressional elections). A major force behind Harry Truman’s proposed national health insurance program, the labor movement, possessed less credibility and electoral clout than it had in a decade. (Strikes across the board as WWII came to an end accounted for the credibility loss; its electoral punch dissipated after the GOP passed the Taft-Hartley Act.)

Ideological revolutions require two types of individuals to bring about change: practitioners of hard-boiled politics and theoreticians.

In the first class, as far as the NHS goes, was Aneurin Bevan, Attlee’s Minister of Health. Churchill nicknamed the fiery Welsh miner’s son “The Minister of Disease” probably because of rhetoric like this in the 1945 general election: “We have been the dreamers, we have been the sufferers, now we are the builders. We enter this campaign at this general election, not merely to get rid of the Tory majority. We want the complete political extinction of the Tory Party.” (Substitute “Republican” for “Democrat,” and you’ll have a typical post from Daily Kos!)

There are two figures that fall into the theoretician class in terms of influencing the NHS:

1) William Beveridge, a civil servant, economist and academic, was the only member of a wartime committee to put his name on the Social Insurance and Allies Services Report (which came to be called—naturally!—the “Beveridge Report”) that declared the need to “abolish want by ensuring that every citizen willing to serve according to his powers has at all times an income sufficient to meet his responsibilities.”

2) If Beveridge translated the health-care movement into a bureaucratic framework, another figure provided it with a moral one. In Citizen and Churchman (1941), the Archbishop of Canterbury, William Temple, stated that it was the state’s responsibility to help those in need, particularly the poor, sick, elderly, disabled, and those unable to work. Temple came up with a term for all this—the “Welfare State”—that has assumed a far more pejorative tone than when it was first coined. Certainly, the NHS is considered the cornerstone of the British welfare state. (In the U.S., one near-contemporary counterpart to Temple was Monsignor John Ryan, who came to be known as the “Right Reverend New Dealer” who provided crucial Catholic support for the idea of a “living wage.”)

The aim, and the perceived glory, of the NHS was its unprecedented achievement: the most up-to-date health care freely available to all. Over the years, expectant mothers, for instance, were able to avail themselves of anesthetics, relaxation techniques, hypnotherapy, aromatherapy, and birthing pools.

While British doctors hated losing lucrative private work following the introduction of the NHS, nurses loved the new institution, because it freed them from one of their most irksome responsibilities—collecting fees from patients. Twice the Tory Party voted against national health insurance. When they were promptly put into the political wilderness—twice!—it learned to make its peace with the popular program.

Still, for all its virtues, the NHS has, to a certain extent, become the behemoth that critics suggested. It might have been the kind that Churchill had in mind during one memorable urinal encounter with Attlee. The bemused Labour Party leader inquired of his Tory counterpart why he seemed to be standing so ostentatiously alone while they performed their respective functions. “Well, whenever you see anything big and functioning, you always try to nationalize it,” Churchill responded.

With a workforce of 1.3 million, few other employers rival the NHS in size, ether perhaps Communist China and Wal-Mart. And it is indeed in a budgetary black hole, forcing it in recent years to look at cuts. Even Manchester’s Park Hospital (now called Trafford General) has not been immune, with a recent round of cutbacks forcing the loss of 38 beds, 210 workers and two operating theaters.

The American experience with health care has been far different. In a speech to Congress on Nov. 19, 1945, President Harry S. Truman proposed a national health insurance fund to be operated by the federal government. Participants would pay monthly fees into the plan and, in turn, would have the cost of any and all medical expenses covered in time of need.

While participation in the plan was optional, this did not stop the AMA from launching one of the most disgraceful public relations campaigns in American history. In the 21st century, WMD stands for “weapons of mass destruction”; in the mid-1940s, the acronym represented the three Congressional Democrats who sponsored Truman’s health proposals in the form of a Social Security expansion bill: Senators Robert Wagner (N.Y.) and James Murray (Mont.), along with a young Rep. John Dingell (Mich.).

Well, the AMA made the Truman-era WMD almost as controversial as its later military counterpart, calling the bill “socialized medicine” and claiming that it had been put over on the American people by White House staffers who were “followers of the Moscow party line.” If this wasn’t McCarthyism in a white coat, I don’t know what was.

Truman’s ability to pass the legislation was hampered, of course, after the GOP regained control of Congress in the November 1946 elections. Then, with the outbreak of the Korean War, he not only had to concentrate on foreign-policy issues but knew that the drawn-out conflict was further eroding his stature with the public, so he had to give up the legislation.

Lyndon Johnson signed Medicare into law at the Harry S. Truman Library in 1965. Still, four decades later, health care remains an issue here in the U.S.

While the Republicans have a point about the nightmare that a big national bureaucracy can cause (the NHS had 1.2 million patients on waiting lists in the 1990s, a figure that has dropped down to 591,000 recently), the party has not done itself any favors by insisting that we simply allow the medical marketplace to work.

There’s only one problem with this, in my view. Wall Street works--to the extent that it does--only because of the concept of transparency—investors’ ability to see a company’s true financial picture in the form of publicly released annual reports, audited by major accounting firms.

Do you really believe that the medical profession operates in a similar way? Then why is it so hard for patients to obtain elementary information such as malpractice suits in which their surgeon might have been involved? How much do we know of the necessities and risks involved with certain procedures?

The medical profession’s past role in health care insurance puts paid to the notion that men of science are experts into whose hands we should trust decisions that concern all of us. This anti-democratic notion simply doesn’t work when those supposedly objective figures have a huge vested financial interest in maintaining the status quo.

Once Americans trust that these figures will work in their interest and not their own, they—and whatever market-based health care proposals the GOP cares to propose—deserve attention. Until then—let the health care buyer beware.