For advocates of universal healthcare, the last four years in American politics have been exciting ones. The dream of universal coverage — the idea of an insurgent, fringe candidate only one cycle ago — is now among the most popular policies in the nascent 2020 Democratic field. This proposal has many iterations and comes under many names (Medicare-for-all, single-payer, public option) but the emerging principles are clear: Americans shouldn’t go bankrupt because of health issues and healthcare should be available to everyone, regardless of their ability to pay.

Recent news that the Trump administration is preparing a renewed legal assault on Obamacare is yet another reminder that what progress has been made towards universal coverage is often fragile. As the battle lines are drawn in this new fight, many on the right are keen to tear down the ideas that progressives say America is falling behind on. Last year, the White House released a 72-page report denouncing (among other things) “Nordic Socialism.” Trump and his Fox News allies regularly attack Europe’s preference for larger social safety-nets and “big government” programs. Pictures of a continent not exactly having the best decade have only made their message more powerful.

In my experience, progressive Democrats should be wary of how powerful this right-wing messaging has been. I’m currently writing a book about rare diseases, and in many of my interviews with people who have them, we drift onto the topic of the health system in their respective countries. Since I aim to talk to as many English-speaking people as I can, a lot of them are Americans. In almost all cases, my American interviewees are unhappy with the system as it currently is. Many complain of unsympathetic specialists, high costs, long waits for diagnosis, stubborn insurance companies, and other things that litter the complaints of most hospital frequenters, regardless of what country they call home.

It is notable that not a single one is sympathetic to a Medicare-for-all, or “government-run healthcare” (as many of my interviewees called it). Even though their health conditions were chronic and expensive, most favored only modest reforms of the system. (It is worth noting that most of those sharing a similar opinion have told me they are politically unaffiliated.) My observations are obviously not scientific, and indeed many polls do show majority in-principle support for universal health coverage. Nonetheless, it should serve as a warning to progressives who assume those most in need of comprehensive healthcare will always be their staunchest supporters.

“Government-Run Healthcare”

While I encountered a large degree of skepticism towards “government-run healthcare,” I also saw confusion about what such a system would actually mean. For example, one man — let’s call him Peter — voluntarily offered up a story he had read in the press about government death panels in the UK refusing treatment to a small and very sick baby boy. The reality was far more complex. In the case of 11-month old Charlie Gard, his parents were requesting a treatment for his rare mitochondrial condition that had not even been trialled on mice. His medical team were convinced there was no treatment that would improve his condition, despite the parents’ disbelief. The subsequent decision to prevent further treatment was made in an independent court of law as it was judged to be in Charlie’s best interest.

Others simply recall terrible stories of things they’ve read about overseas and conclude that they mustn’t let their country go the same way. Peter’s other concerns largely fell in line with other anxieties people had shared with me: The number of bureaucrats will explode, it will infringe on their privacy, and “I can’t trust [the government] to avoid pocketing the money.”

A common misconception about British healthcare that I see perpetuated by the American right — and one that Peter himself shared — is that you are “locked” into treatment in a public hospital, with publicly funded doctors and nurses. The reality is very different.

Were I fortunate enough to earn a higher salary, in the UK I could opt for one of the many private insurance providers — whether to cut waiting times, acquire a private room, or improve the quality of the food. I would not lose my right to be treated in a public hospital, nor the right to be picked up by a publicly-funded ambulance in an emergency. In fact, private practice in the UK relies on the NHS in key respects; indeed, if something goes badly wrong in a private hospital, a patient is transferred to an NHS facility, where the most advanced resources reside. And in the UK, having an NHS post is a mark of qualification for a private doctor. In addition to this, there is nothing preventing any UK resident from seeking paid-for treatment elsewhere in the world. As I came to learn during the Obama years, moral panics about the perils of British healthcare are nothing new in American politics.

Since being diagnosed with a neuromuscular condition, and a number of other related ailments, I have had many, many thousands spent on me by the NHS — funded by the taxes we Brits pay in order to pool our risk and keep our health costs lower. I am in my mid-twenties, but already I’ve had approximately two years out of work since finishing my education, and the work I have done in between hasn’t exactly earned me a particularly high salary. The British exchequer doesn’t salivate at the sight of my tax returns. I am receiving treatment I could not pay for myself, that is for certain. Were I in many other countries, including the U.S., I might have many times the average annual salary in medical debt, or worse.

In summarizing the NHS, I’ll quote The New York Times, who I think have provided a pretty fair evaluation:

The service is known for its simplicity: It is free at the point of use to anyone who needs it. Paperwork is minimal, and most patients never see a bill. … No one needs to delay medical treatment until he or she can afford it, and virtually everyone is covered. … According to data from the Organization for Economic Cooperation and Development, the United States spent 17.2 percent of its economic output on health care in 2016, compared with 9.7 percent in Britain. Yet Britain has a higher life expectancy at birth and lower infant mortality.

Essentially, healthcare in the UK only excludes visitors and illegal immigrants. It is because of these high ideals — the equal treatment of all regardless of wealth or status, and the principle that being poor in health shouldn’t make you poor in wealth (or vice versa) — it is near-impossible to overstate the affection the UK has for its National Health Service. We put it in our Olympic opening ceremonies, set up minor political parties about it, and tell pollsters it’s what makes us most proud to be British. Eighty-seven percent of people are “proud” of it as a public institution. Since its foundation in 1945, it has taken on a holy quality in the national consciousness, bearing witness to the beginning and end of millions of lives, across every class, race, age group, and gender. Seventy years of this relationship has had an indelible effect on the nation’s psyche. We are — to put it mildly — a little obsessed with our National Health Service.

It’s a system the vast majority in Britain is fearful of losing. In 2012, the Conservative-led coalition could only sneak past the biggest piece of NHS legislation in decades by breaking an election promise to leave it alone; deliberating keeping quiet throughout their campaign about their plans to introduce “choice and competition” into the service — putting General Practitioners (or “family doctors”) in charge of commissioning care and treating hospitals more like businesses competing for patients. After the white paper “Liberating the NHS” was released, it was panned by most health service professionals and proved deeply unpopular with the public.

The Brits are right to be defensive, because they get a pretty good deal for what they pay for, too. The UK provides universal coverage to all legal residents and spends less than half as much per capita than their friends over the pond. Despite fears that universal coverage will swell healthcare costs, as a percentage of GDP the U.S. already spends more on “socialized medicine” than the UK — with nowhere near the amount of coverage (see chart). By removing the excess connective tissue of a healthcare system that constantly (and unnecessarily) evaluates the cost and validity of a claim, a single-payer system like the NHS can actually be far more efficient. In a study of 10 other developed nations, the American Journal of Medicine found that the U.S. spent 8 percent of their healthcare costs on administration, far ahead of other countries who paid between 1 and 3 percent. If it is a ballooning bureaucracy Americans fear, it is already upon them.

The same study also showed how the U.S. spent more on prescription drugs than the other countries: $1,443 per capita. Spending elsewhere ranged from $466 to $939. The reasons why are clear: the United States government allows drugmakers to set their own prices for a given product, and then leaves individual companies to bargain for those drugs on behalf of patients from a position of weakness — hence increasing prices. Vox has a good explainer on why the U.S. spends so much on prescriptions, and the complex effect drug-prices have on R&D, but in terms of costs to patients, Americans lose. This doesn’t have to be the case.

For an American audience, it is hard to overstate how little effect my health problems (which are both serious and numerous) have on my financial situation. There simply isn’t any effect. I am free to worry about the million other petty grievances that litter my day, and that is a tremendous relief. Prescriptions are free for inpatients, the elderly, the young, those in education, and anyone with a chronic illness, so only my travel to and from the appointments causes me any inconvenience — and I could claim money back for that, too, if I weren’t so lazy. I wish this were the same for my American interviewees, for whom illness is wrapped up in a litany of loans, bills, and expenses. An experience my British counterparts and I simply do not share.

Recent Challenges for the NHS

While there are many good reasons to admire the UK system, that does not mean it is above criticism. The UK’s profound love for its NHS can be unhealthy, not unlike other obsessions. The institution’s status as a bulwark of our country’s self-image — namely a beacon of civilized and humane individualism — has made it exceptionally difficult to have a constructive conversation about reform. Any mention of potential change is quickly interpreted as a path to Armageddon and a slippery slope to an American-style system (cue blood-curdling screams). For an institution that has been visibly struggling to cope for most of this decade, the reluctance to have frank and honest debate about what the future holds is doing more harm than good.

As a very regular user of the NHS, I feel I can talk with more authority than most about what its weaknesses are. For one, there are simply not enough nurses and doctors to service patient needs quickly and effectively. Higher access means higher demand, and when multiple crises on a ward hit, the less acute patients can suffer. This can mean delayed access to pain-relief, or much-needed treatment. In rare cases, this can lead to serious deterioration or death.

The lack of provision for treating the very elderly and chronically ill outside of hospitals, known as “social care,” is another problem. There simply isn’t enough care in the community, and as a result the quality is often poor. In a problem known as “bed blocking,” nearly a million extra patients per year are sat in hospital beds when they shouldn’t be because social care simply isn’t there. These patients are often the most needy, which exacerbates the problems on hospital wards that I described earlier. Last year, satisfaction with social care services was only 26 percent, according to the King’s Fund. The growing list of treatments for the ever-expanding inventory of chronic illnesses present a serious cost to all healthcare systems, but particularly those like the NHS which avoid passing the devastating costs onto the patient.

The failures are not inherent to a “socialized” system, but are the direct result of a lack of cash — not to mention the recent Tory Party competition reforms mentioned earlier, which create expensive and cumbersome tendering processes for the NHS.

The UK has fewer doctors per head of the population than most of the OECD countries. (The UK has 2.8 doctors for every 1000 people, less than the average. Austria has 5.1 doctors for every 1000 people. Lithuania, Switzerland, Germany, Italy, Norway, and Switzerland all have more than 4.) Waiting times in Accident and Emergency have been getting worse for years; a problem exacerbated by an aging population, and the closing of local doctor’s surgeries, which are crucial in providing front-line care and diverting patients away from much-needed hospital beds. As a result, avoidable hospital admissions are high; conditions that can be successfully treated in primary care settings, like Asthma and Chronic Obstructive Pulmonary Disease, are ending up in Accident and Emergency far too often, and it’s hampering the service.

Again, a lot of this is down to money. Since the foundation of the NHS, its budget has increased by 3.7 percent annually (on average) every year, according to the Institute for Fiscal Studies. Between 2010 and 2015, in an era of austerity following the global financial crash, that number had been close to 1 percent. In 2018, public satisfaction with the NHS was at 53 percent; a 3 point drop from the previous year and the lowest level since 2007. Despite this reality, a clear majority of British voters would like spending to increase, and would be willing to pay more in taxes to fund it. Like all polls, this number changes slightly depending on how exactly you ask the question, but the message is clear: ask us, and we will pay.

In my years being fascinated with American politics, I have tried to understand the complex web of insurance that runs healthcare provision in the United States. I am still learning. But one thing is glaringly obvious: a system that means financial difficulty regularly accompanies much-needed medical care is not an ethical one. Many uninsured Americans have died, and millions have gone bankrupt due to medical bills — although we don’t know exactly how many as those filing aren’t made to state the reason. (An inconvenient fact that pushes the issue further away from the minds of policymakers.) Comparable statistics about medically-induced bankruptcy are hard to find in other developed countries, although for different reasons — it is simply not a big problem.

There are alternatives, and not all of them come in the mold of Britain’s single-payer NHS. Other options include compulsory insurance like France, Japan, Australia, and Germany. Each has varying degrees of government involvement, but all accept the principle that being sick is a burden enough, without adding financial horror into the mix. If one good thing comes of the 2020 primary, I hope it is that Democrats (and through them, America at large) can finally decide what system is right for them. Because to my mind, the current one certainly isn’t.