American politicians can’t help bragging: everything they have is the best in the world. Every state, no matter how backward, racist or decrepit, is introduced as “the great state of X”; the essential prefix when schmoozing politicians on a visit to any part of the country is “I am so proud to be here in the great state of Y”. Flattery, in the US, is as important as bragging.



It is this attitude that, until recently, had most of their politicians insisting that US healthcare was the best in the world. In reality, the World Health Organisation ranks it 38th, behind Colombia (22nd) and Saudi Arabia (26th) and just above Cuba. The No 1 cause of bankruptcy in the US? Medical debt. And with more than 250,000 deaths a year, medical errors are the third leading cause of death, behind heart disease and cancer. Obamacare has made things somewhat better, but there are still 27 million people without health insurance because they can’t afford it, and millions more who can’t afford the co-payment on prescriptions.

Rightwing Christian fundamentalism has had a devastating effect on women’s health. There’s little care for poor women or children once they’ve been born; according to the Centers for Disease Control and Prevention, 25 other industrialised nations are better than the US at keeping babies alive. Americans who say they are pro-life merely mean they are pro-birth. Republicans want to slash Medicaid – government help for those who cannot afford to pay – which pays for nearly half the births in the US.

Like George Bernard Shaw, whose plays and prefaces I loved when growing up, I have always wanted to write things that made people both laugh and think. After working on Yes Minister and Yes Prime Minister, I had the opportunity to go to the US to make films. My Cousin Vinny was a statement against capital punishment; The Distinguished Gentleman was about the power of the lobbyists, in which a cheap Florida con man (Eddie Murphy) runs for Congress in order to extract a fortune from the lobbyists. At the time, Congress seemed the best con in the US because the bribes are legal. The best con, of course, is now the presidency.

US healthcare astonishes me, and I’ve long wanted to write something about where the country’s money was going (armaments) and not going (healthcare, inquality) – and I wanted whatever it was to be funny. Comedy attacks the institutions of society in a way that’s agreeable to read. It’s anarchic. It’s the best way I know to make social and political ideas accessible.

So I wrote Samaritans, a novel set in a fictional hospital in Washington DC, a struggling institution beset – like most hospitals – by rising costs and poor management. In desperation, the board hires a hotel man from a Vegas casino as the new CEO: Max Green, a man with no interest in healthcare, but an eye for profit. He can see a way to make a huge profit on hospital care: potentially billions. Healthcare, of course, is the biggest lottery of all.

While writing it, I remembered the NHS as it was in the late 1980s, before it was hopelessly understaffed and overstretched, before general practitioners and foundation trusts were responsible for their own borrowing and spending, before there was an internal market. Before, in other words, so much of it was privatised. Britain is blindly lurching down the same calamitous path as the US. Successive governments have slowly dismantled the beautiful idea that healthcare should be free at the point of delivery. Now, amid much secrecy, 87% of Charing Cross Hospital has just been sold off in a real estate deal.

The problem with running healthcare like a business is that patients are not customers. They don’t choose to be sick. But in the US, healthcare is not a human right, it’s a privilege. “People can’t have what they can’t afford,” explains Max. “That’s what got America into this economic mess – people wanting something for nothing. There’s no morality in that.” Is this Britain’s future too?

While I was writing Samaritans, life began to imitate art, as it used to sometimes with Yes Minister. Gary Loveman, the CEO of a bankrupt Vegas casino, Caesar’s Palace, was appointed by Aetna, one of the US’s biggest insurance companies, to run its health insurance division. Donald Trump, once just a TV reality star and real-estate man with whom no US banks would deal because he never paid his bills (he still owes around $300m – £230m – to Deutsche Bank), suddenly became a serious presidential candidate. I had envisaged the story as an allegory for modern America – and then it came true. I hope that, like Yes Minister, people find it enlightening as well as entertaining. And scary too, so that they do something about it all, before it’s too late.