Taking legislative steps to establish a National Health Insurance (NHI) scheme is a principled, progressive and necessary move if South Africa is to continue working towards a more just, equitable, prosperous and healthy society. The most successful social democracies in the world established national/public health systems, and their societies have benefited enormously.
In the case of South Africa, today, the effort to establish a publicly funded national health system is a necessary step, but it is insufficient. The next, more difficult step is to expand the middle class – often ill-defined – who are the most important part of the revenue base. An even more difficult step will be to build trust in the state, the government and the ruling elite – the axis that has brought the country to where it is.
Before we even get to that, we need to have a serious look at the ideological opposition to an NHI, an opposition that is driven by a seriously flawed set of ideas, beliefs and values imported from the US.
The monetarist, decidedly conservative politics and policies that took shape in the early 1980s and gained traction among free marketers and market fundamentalists began to erode belief in national health systems.
It is clear that this terribly conservative outlook seems to be the basis of opposition to an NHI in South Africa. Without purposeful support from the state, South Africa may drift further towards “the American model”, which is a product of ideological opposition – the power of corporate influence over the legislative process and a concern about “a nanny state” manufactured over time, and reproduced by various means of coercion and consent. It is worth looking a bit closer at these processes in the US.
Myths, misconception and corporate lobbying
The US never quite put a national health system in place, mainly because of extreme individualism, that old dog Classical Liberalism with its (axiomatic) opposition to the state, and because of consent manufactured by large sources of funds from corporate lobbies, especially “big pharma”, to the media and legislators.
To be sure, it is not in the financial interests of the largest corporate donors to change the system, and society has, by and large, accepted this system as normal (it is the status quo) and, therefore, unchangeable.
“Big Pharma is trying to buy maintenance of the rigged status quo … The breadth of these contributions shows drug corporations have no intention of doing anything to lower their prices — they are lavishing millions in campaign contributions to protect their power to dictate high prices for prescription drugs,” said Ben Wakana, executive director of the advocacy group Patients for Affordable Drugs Now.
For what it’s worth, in the UK, the Conservative Party, especially, but also the Liberals (and Tony Blair’s Labour), have effectively been chopping up Britain’s NHS, with customary support from conservative corporate and ideological allies.
In both cases, “public opinion” is swayed by influential groups who peddle stories about “abuse” of the healthcare system by the poor (and more recently by immigrants and refugees) and who tell tales about people who are lazy or unwilling to just “get a job” or to work harder. And then there is the horror of the “nanny state”.
The so-called “nanny state” is largely a right-wing trope rolled out by Classical Liberals. The concept has some of its origins in distinctly sexist stereotypes and misogynistic references about “grand-maternal government” or a “grandmotherly government”, all of which helped shape lies and just awfully bigoted ideas about women in the 19th century. Women can simply not be trusted, or so the story goes… After that the argument was raised whenever the state instituted anything from speed limits to social welfare.
The “nanny state”, however, has been good for society. Simon Chapman, Professor of Public Health at the University of Sydney, identified at least 150 ways that the “nanny state” has been good for society.
He concluded, from his research and observations, that “nanny state critics are almost always self-interested. They’re rarely motivated by the freedoms they purport to defend. And invariably their arguments crumble under scrutiny”.
This makes it always important to open knee-jerk resistance to an NHI to scrutiny.
Myth of free and independent markets
In South Africa, opposition to an NHI is largely ideological. It rests on beliefs in free markets and innovation unrestrained by the state. It is also about race, entitlement and sanctimony. It’s that old set of beliefs – “we work hard for our money” and “why must we pay for them” to have a better life.
There is, also, opposition to a “nanny state” – terribly sexist, as it always has been,and simply just a smear. In South Africa, there is a bloc that tends to bang on about “lazy people” or people who supposedly don’t want to work (referring to black people usually) and who are dependent on “a nanny state”, and the misconception or convenient, partial panic that whites have to pay (tax) for (black) social benefits.
This is misleading, disingenuous and deeply ideological. It is misleading, mainly because working-class people also pay taxes, and the middle class, even the most impressive entrepreneurs rely, themselves, on state support.
For instance, in the US, everything and everyone – from the late Steve Jobs to Elon Musk – has relied on direct or indirect state subsidies and interventions. The South African bloc’s favourite scion, Musk, has received billions of dollars in support from the state, and continues to rely on state concessions. Actually, Musk simply adopted a system that preceded him.
As Dean Baker, an economist and founder of the Centre for Economic and Policy Research, explained in his excellent book The Conservative Nanny State, conservatives and right-wingers (and those darned Classical Liberals) have always used the state to advance their own interests. Baker’s book opens up for scrutiny the enormous government interventions in the market in areas from trade, monetary and intellectual property to immigration policies. Most conservatives have aspired to making the wealthiest people in the US even wealthier.
Baker’s opening gambit is this: “Conservatives want to use the government to distribute income upward to higher-paid workers, business owners and investors. They support the establishment of rules and structures that have this effect. First and foremost, conservatives support nanny state policies that have the effect of increasing the supply of less-skilled workers (thereby lowering their wages), while at the same time restricting the supply of more highly educated professional employees (thereby raising their wages).”
It is what some of us have described as socialism for the wealthy…
The actual problem is lack of trust in the state-government-ANC axis
While all the above are important and, of course, open to tantrums and conniptions, there is an opportunity missed. A legitimate concern is the almost complete lack of trust in the state-government-elite axis to manage effectively anything more than rinsing a tumbler. It is tragic that one may make that claim without pairing it with evidence.
While some of us don’t mind paying tax – it is never about personal, pecuniary gain and more about what type of society we want to live in – we cannot, not even for a moment, trust the axis to govern by consent and in the interest of the governed.
The “market” or private healthcare providers are barely to be relied upon to extend their services to the indigent, the unemployed or those who simply cannot afford healthcare. It is these citizens whom the state has a duty to protect – unless you’re a Classical Liberal who believes that the state has no business interfering in the lives of persons, except, so it seems, to provide benefits, concessions and support to the likes of Musk or Apple – notably when they were starting out.
Data has shown that the inability to pay medical bills is the primary cause of bankruptcies in the US, and an estimated 61 % were caused by medical issues, with people losing their homes because of medical debt burdens. This is the wealthiest country, with the “most advanced” and “sophisticated” democracy; yet it cannot take care of the poor, the weak – and the middle class.
The mild panic and hysteria around the NHI driven by ideology, misconceptions, misrepresentations and entitlement are a ruse to conceal opposition to paying for a public health service that others may use. This panic diverts attention from the need to put pressure on the axis. The real problem is not an imaginary “nanny state”. It is also not about lazy others.
All of these things have been proven to be rather specious. The overriding problem is the lack of trust in the state-government-elite axis.
Establishing a national health system as part of a more just, equitable, prosperous and healthy society is absolutely important and necessary, but the real battle, for the public, is trusting the axis; and for the axis, it is creating conditions for expanding the middle class.
If the past two decades are a prelude to the future, the axis is not worthy of trust – and we should probably stop before we end up like the US, and send people into bankruptcy and homelessness because they cannot pay their medical bills. DM