Letters to America: My Appendix Burst - It Cost Me Nothing. Yours Would Have Cost You a House

Hello again, my lovelies 👋🏻

Today I want to talk about those moments when an argument stops being ideological and becomes brutally practical.

Mine arrived with abdominal pain, a diagnostic CT scan, IV antibiotics, morphine, a perforated appendix and emergency laparoscopic surgery.1

It was frightening, painful and inconvenient.2

But it was never financially terrifying.

At no point, while trying to work out whether my appendix was about to make a proper mess of me, did I have to ask whether the scan was in network, whether the surgeon was covered, or whether I could afford to stay overnight.

In the United States, depending on the city, hospital and insurer, the same episode might very well have been financially ruinous.

When I got my favourite AI research assistant3 to do a check for me, its credible estimates for a comparable uninsured emergency episode in New York, Atlanta or San Francisco run from the tens of thousands of dollars into the high five figures once emergency assessment, imaging, theatre fees, surgeon and anaesthetist charges, pathology, inpatient nursing, drugs and follow-up are included.

My friends and clients in the US have confirmed these estimates, yet here in the UK I never even thought about the costs involved.

The basic absurdity

According to the OECD4, the United States spends about US$14,880 per person on healthcare.

The United Kingdom spends about US$5,860.

America therefore spends roughly two and a half times as much per head as we do, without delivering clearly superior overall outcomes. In fact, on broad measures of health-system performance, access and equity, it performs worse than comparable wealthy countries.

If this were defence procurement, infrastructure, software procurement or university finance, Americans would spot the pattern immediately:

Y’all are being overcharged for a badly designed system, with too many intermediaries, too much opacity and far too little accountability.5

The usual knee-jerk response to this observation is that Americans get choice, speed and innovation. American exceptionalism at play again - and for some people, some of the time, that is true.

A well-insured, high-income American with a strong employer-sponsored PPO can get rapid scans, quick specialist appointments and access to world-class hospitals.

But that is not the same thing as saying your system is better.

It is saying the system works very well if you are already winning.

And that, my lovely, is a much narrower - and more self-interested - claim.

America does not spend twice as much money because Americans receive twice as much care - or indeed standards of care that are twice as good - as us Brits.

It spends more because it pays far higher prices inside a fragmented, multi-payer system that generates administrative waste and lets hospitals, insurers, pharmaceutical companies and specialists negotiate in opaque and often inflated ways. And it’s not just me - this is also the view of the respected British Medical Journal.

Now let’s be honest here: both the US and the UK systems ration care.

Britain does it mainly through national and regional budgets, patient waiting time and clinical priority. America does it through ability to pay, insurance status, network access, prior authorisation and a household’s tolerance for debt.

One of these systems, at least , has the merit of honesty.6

Prepaid, not free

The UK’s system is free at point of use😮 Surely that’s “communism” pure and simple, isn’t it? Must be rubbish if you don’t pay for it and everybody can access it…

This is where many American conservatives make a categorical error. They look at Britain and imagine that “free healthcare” means everyone is forced to endure some grim collectivist service in squalid conditions.

Y’all therefore need to understand that Britain’s system is not “free” - and nor are those of most of its neighbours across Europe.7 It is prepaid, through our taxation systems.

And because it is prepaid collectively, catastrophic medical risk is socialised rather than dumped on frightened households at the worst possible moment.

That distinction matters - particularly when the pain is acute, the doctor is using words such as “perforated”, and you have rather more immediate things to worry about than a future invoice and whether you have enough left on your credit cards to pay it.

There’s another fallacy we should deal with here: the UK’s National Insurance is not an NHS subscription, as American commentary often seems to assume. It contributes to a wider national social-insurance model, which includes funding our State Pension (which everyone is entitled to), while the NHS is funded principally through general taxation.

The comparison “conservative” Americans often make is therefore rather disingenuous at best. They compare the entire British tax burden with one American line item: usually the employee contribution to health insurance.

That is a load of bollocks.

A fair comparison between the two countries is much more like this:

• We pay Income Tax and National Insurance into a system that funds healthcare, pension entitlement and all our other public services.

• And yes, the rough rule of thumb is that this works out at around 30% of your gross pay packet - a higher percentage if you’re in a higher tax bracket.

• Your employer also has National Insurance contributions to make8, and since 2012 both of you are obliged to pay into an occupational pension scheme9 that will top up the amount you will receive from your State Pension when you retire.

• You pay federal and state tax, and payroll tax for Social Security and Medicare, all of which are deducted from your salary before the money reaches your account. And yes, in a lot of States (particularly Red ones) the State taxation level can be very low - and (on the surface) extremely attractive.

• But then you also have to pay substantial insurance premiums, deductibles, co-pays, coinsurance and prescription costs. Speaking to colleagues and friends on your side of the pond, your monthly insurance premiums for even half-decent coverage can be - from a British perspective - utterly eye-watering.

• And you still need to make separate and serious private provision for your retirement…

What it actually means is that these costs have been broken up, privatised, disguised and pushed onto your household balance sheet.

The private paradox

There is another point that almost never appears in the American caricature of European healthcare:

• Universal systems do not abolish private medicine. They make it cheaper.

In Britain, private health insurance is comparatively affordable, to the extent that many people have it - or their employers can provide it in a group scheme - the charity that I am Chair of provides this as a staff benefit for all our employees at a cost of around $60 per person, per month.

Now our private healthcare system and hospitals haven’t discovered some miracle efficiency that yours don’t have, but they can offer cheap(ish) private healthcare insurance because the NHS sits beneath the market as the universal backstop.

Our private insurers do not have to price for every catastrophic emergency, every ICU episode, every major trauma, every expensive cancer pathway or every uninsured chronic condition. The state already carries this ruinous tail risk - which everyone pays for through taxation.

That means private cover is usually sold as a speed-and-comfort product: faster elective access, consultant choice and rather nicer facilities. It is an add-on, not the foundation. The truly expensive part has already been socialised.

This is what many affluent Americans would do well to understand.

And yes, the waiting lists

Again some honesty: our National Health Service has a waiting-list problem.

Anyone who has watched a relative wait in pain for orthopaedics, mental-health support, cataract surgery or a specialist appointment10 knows that “free at the point of use” is not the be-all-and-end-all of the matter.

Time is a cost. Pain is a cost. Lost work and worsening illness are costs, and pretending otherwise is foolish. It gives critics the easiest point on the field to throw a big pointy stick at.

But long waiting lists are not a rebuttal of universal healthcare - nor proof that this doesn’t or cannot work.

They are evidence of what happens when a universal system is under strain, under-capitalised and badly managed in places.

America also rations care; it simply does so less honestly, through premiums, deductibles, patchy networks, prior authorisation and the quiet personal or family decision not to seek treatment because the bill may be ruinous.

A long queue is a failure of capacity.

A bill that deters treatment is a failure of social solidarity.

Neither should be treated as inevitable.

Britain’s waiting-list crisis did not emerge because universal healthcare is inherently unworkable. It followed more than a decade in which the NHS was expected to meet rising demand, an ageing population, workforce shortages, capital neglect and then a pandemic, on funding growth well below its historical norm.

Lord Darzi’s independent review of the NHS in England11 found that, apart from the exceptional Covid period, NHS funding since 2010 rose by just over 1% a year in real terms, compared with a long-run annual inflation average of around 3.4%.

Conservative ministers could truthfully say that NHS spending increased each year. But that’s not the point. The real question is whether it increased fast enough to meet both need and in line with other inflationary pressures. The evidence strongly suggests that it did not.

Successive Conservative-led governments also expanded outsourcing and market-style mechanisms within the English NHS. Critics (including myself) argue that this reflected a deeper hostility to democratised healthcare and a wish to open more of the system to private providers. That wider claim is harder to prove cleanly.

What can be said with confidence is that the direction of travel in terms of the Conservatives views of, and plans for, socialised free-at-point-of-use healthcare was not neutral - and remember they held the purse strings for 14 long years12…

It is also true that there is research which indicates that greater outsourcing has been associated with worse outcomes in the areas most exposed to for-profit provision.

All this does not excuse NHS delays.

But it does explain why a waiting-list crisis should be understood as a failure of stewardship, capacity and investment, rather than proof that universal healthcare is a dead end.

So why on earth do any of you defend the US approach?

Some of this is simple self-interest. If you have gold-plated employer cover, a good income, decent health and excellent hospitals nearby, the American system can feel fast, premium and tailored to you.

You have been lucky enough not to meet its sharp edges.

Yet.13

There is also decades of Republican (and to a lesser extent corporate Democratic) party political conditioning. “Public”, “universal” and “socialised” have been made to sound like synonyms for coercion, failure and mediocrity. “Free at the point of use” is translated, in some minds, into communist.

That is branding, not analysis.

But the ugliest feature of the US approach to healthcare is the way the system hides its cruelty in fragments. No single premium, payroll deduction, denied claim, deductible or bill seems quite large enough, alone, to expose the full scale of the extraction.

Add them together over a working life, however, and the bargain looks much worse.

This may be one reason recent Democratic Socialist breakthroughs in American cities matter.

They have not solved healthcare, obviously. But victories by democratic socialist candidates and allies in cities including New York and Seattle suggest that more voters are beginning to question whether your neoliberal habits really make economic common sense when applied to the individual as opposed to the corporate “person”.

What my appendix taught me

I am not suggesting that the NHS is perfect. It plainly is not.

It needs more staff, more capital investment, more competent management and a government willing to treat it as essential national infrastructure rather than an inconvenient line on a Treasury spreadsheet.

But when my appendix perforated, none of that changed the central fact: I went to hospital, I was scanned, medicated, operated on, cared for and sent home to recover.

Nobody asked whether I could afford it. Nobody presented me with a menu of financial risk while I was in pain. Nobody left me to decide whether a hospital bill was worth avoiding.

I didn’t have to create a sodding GoFundMe to pay my medical debts.

What we have in the UK is not socialism. It is a civilised society deciding that an emergency appendectomy should not become a household financial crisis.

America can do far better than the system it has. It just needs to stop mistaking expensive for excellent, fragmented for free, and the ability to pay for the right to be treated.

As for me - I’ll take higher visible taxation on my gross salary every single damn time, if it means that I can rock up to A&E in a medical emergency and know I’ll be treated without worrying about bankruptcy.

I’ll still be paying less per month than most of you, my lovely readers across the pond…

À bientôt, my lovelies