Thursday 10 January 2008
Johann Hari: Public services and a sweet twist of history
For decades now, we have been lectured by the right that two of our biggest national institutions – the NHS and the BBC – are rotting old relics, rendered increasingly obsolete by the forward march of technology. How can the institutions of 1948 and (wipe off the dust) 1922 survive in an age of digital high-precision hyper-choice? Privately, Conservative MPs explain that these "monoliths" will inevitably be broken down and sold off.
But a funny thing happened on the way to the future: technological developments are making the NHS and the BBC more necessary, not less.
Let's start with the health service. The NHS is, in effect, a very wide health insurance scheme. Everyone pays in through general taxation, and everyone takes out when they need it. Risk is pooled across every resident of Britain. The alternative is some model of private insurance, where risk is pooled among smaller groups: the people who can afford to buy into your private health plan.
Technology is not rendering the NHS model out-of-date; instead, it is rusting up the private insurance model. Why? It is becoming easier and easier to predict who will become ill, and who will – barring accidents – remain healthy. So private insurance companies are responding by insuring the healthy, and offering unaffordably high premiums – or a flat "no" – to the people who need insurance most: the sick or likely-to-be-sick.
There was the first whisper of this shift on British shores last week. Medical insurers Pru Health have set up a system by which people who refuse to allow their attendance at the gym to be monitored, or to wear pedometers, have to pay up to four times as much for the same cover. My fellow stubborn fatties are punished for opting out. Dr Penny O'Nions of health care adviser the Onion Group says this is a harbinger of a private system where "unhealthy people are relegated to the bottom of the pile and high premiums". But the Association of British Insurers says that "such policies are likely to grow".
This has already been taken much further in the US, where private health insurance firms turn away 12 per cent of applicants, and more than 30 per cent of people over 60. This has created a growing class of the uninsurable – people like Cynthia La Morgese, a 29-year-old teacher in California. She works out three times a week, has a vegetarian diet, and practices pilates. There's no history of high cholesterol, high blood pressure, or pretty much anything else in her notes. But three years ago she injured her knee while working out, and when she quit smoking, she took Wellbutrin, an anti-anxiety drug that helps you give up. So that's it. She's out. "I can't get insurance," she says, after trying dozens of companies. "It's horrible."
When your country has a private insurance system and you are locked out, what happens? One result is that 18,000 die unnecessarily in the US every year – and millions are anxious. Becky Malke was a call centre worker who had to talk people through health insurance applications, and she tearfully explains in Michael Moore's documentary Sicko: "Sometimes you know ahead of time they'll be declined. One time I had a couple [on the phone]. The husband was late for work and the wife said, 'Don't worry baby, it's OK, we'll have health insurance now'. And I could tell they were going to be declined because of their health conditions. They were so happy and I thought, oh god, in a few weeks they're going to get that call telling them they're not eligible for insurance." Private health companies in the US have a 37-page list of conditions that can debar you from receiving insurance, ranging from anaemia to varicose veins.
Crucially, as genetic technologies become better and better at predicting which of us has the propensity to become ill, the ranks of the uninsurable will grow considerably. Gordon Brown, in an intellectually dazzling defence of the NHS model two years ago, saw this: "People with a predisposition for a particular disease will find it impossible to obtain private insurance. Advances in genetics make the case for the widest possible pooling of risk. The more accurately you can predict risks, the greater the case for risk-pooling."
In the coming decades, private health insurance will increasingly go the way of America's private disaster insurance industry. Companies like Risk Management Solutions in Silicone Valley now have computers with mathematical models of every major US disaster since the 1812 earthquake. They can tap a zip-code into their computer and calculate how likely any house in the US is to be blown away, drowned out or fall down. The companies they advise only insure the safest, and the result is clear. As Texas Insurance Commissioner Mike Geeslin puts it, "The risk-transfer mechanism at the heart of insurance is breaking down." George K Bernstein, who was Richard Nixon's administrator for the US government's programmes, agrees, warning: "There's not going to be much left they do insure by the time it's all over." With disasters, only the very low-risk are being insured privately – so the state has to step in for everyone else.
If we ditched the NHS, we would have to recreate it inch by inch as private firms refused to insure more and more people. So, far from being an ideological hang-over, the NHS funding model is the most rational option for today. That's why systems as diverse as the US and France are moving our way, paying for ever-more people's healthcare from general taxation.
Technology is similarly making the case for the BBC all over again. Soon, a majority of TV viewers will have automatic recording technologies such as TiVO and Sky Plus, so your favourite programmes are sitting there waiting for you when you switch on the box. One of the many advantages is that you can simply fast-forward through the adverts: I don't think I've watched a single one since I got mine six months ago. TV advertisers are waking up to this drying up of their audience, and demanding lower rates. Commercial television is going to have drastically smaller budgets as this trend deepens – and the quality will inevitably deteriorate.
So how will good TV shows be paid for in future? One alternative revenue-stream was going to be phone-lines on shows like The X-Factor – but the British TV industry just tossed that option into the shredder by famously ripping off their callers. Then there's the option of subscription channels you have to pay for monthly. But if we're going to do that, doesn't it make more sense to retain the ultimate high-quality subscription channels for just 36p a day, through the BBC licence fee?
This is a neat, sweet twist of history. It turns out the broadcasting funding model of 1922 is the smartest choice for 2022, and the health funding mechanism smelted in 1948 is the smartest choice for 2048. Can you hear that noise? It's the low, satisfied chuckles of Nye Bevan and Lord Reith, echoing over 21st-century Britain.
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