DOI: 10.13140/RG.2.1.2772.5923

~ 1 ~

The Great Atlantic Divide: Freedom-first or Equality-first?

Ralph Fevre

School of Social Sciences, Cardiff University, United Kingdom, CF10 3WT

fevre@Cardiff.ac.uk

In the summer of 2014 Dr Jen Gunter was on holiday in London with her family. They were in

Parliament Square when a gust of wind blew some grit into 11 year old Victor’s eye. What Dr Gunter

did next was exactly what my wife and I did when this happened to one of our children. She tried to

get the grit out but failed and took Victor to the nearest NHS hospital. They were seen quickly and a

young doctor took the grit out. Perhaps there were a couple of differences in our experience, mainly

to do with our lack of medical training. We never flipped our daughter’s eyelid and irrigated her eye

with Evian and my wife nearly passed out when the doctor was examining her. Before that we

waited a day to see if whatever was in our daughter’s eye would disappear and we made her wear

sunglasses to school. But it was essentially the same story: grit in the child’s eye followed by the

accident and emergency department at the local NHS hospital and happy ever after.

So why do I know about Dr Gunter’s uncannily similar experience to that of thousands of

British parents? I know because I read her story in her blog, in just under 1000 words. Even more

remarkably, the blog earned her 800 comments! The reason why her story was blog-worthy whereas

ours were not does not lie in our incompetence. Dr Gunter expected to pay for her son’s treatment

(about a $1000 dollars she guessed) but had not yet had a bill when she posted her blog. We did not

pay for taking our children to hospital either, and never expect to, because the NHS is a universal

health care system which is funded through taxation but free at the point of use. Dr Gunter is an

American and is used to paying for treatment, no matter how minor, but it was not really the

generosity of the hospital towards tourists that she wanted to bring to our attention (though a

handful of the 800 comments focused on that part of the story). The main point of the blog was to

tell other Americans that, even though it was free, the treatment Victor got, and the hospital

facilities, were no worse than they might have encountered back home in the US.

One of the first comments on the blog missed the point (Britain is not a third world country

and how could Dr Gunter be so condescending?) but was soon put right. Other posts explained, and

Dr Gunter confirmed, that the point of the blog was that Americans are told that they get what they

pay for especially where health is concerned. If a service is free to anyone (though perhaps not

tourists) it must be pretty terrible. That was the point of the blog: it was for Americans to see that,

despite what they are told, a discerning consumer like an American gynaecologist can tell them the

DOI: 10.13140/RG.2.1.2772.5923

~ 2 ~

NHS is actually ok. Dr Gunter was the first one in the ocean telling everyone else to come on in the

water’s lovely, really. Most of the people who posted comments agreed with her. There were some

differences between hospitals and regions – some colder water here, a few sea urchins there – but

perhaps these variations were no different to those in other countries including the US. In fact many

of the Britons who posted comments seemed pretty proud of, and grateful for, the NHS.

There is certainly a strand of these comments which recalls Danny Boyle’s NHS segment in

the opening show for the London Olympics. The common theme is that the NHS is an incredible

service, the envy of the world, but we take it for granted. If Britons like me do take it for granted we

would expect this to be reflected in opinion polls but in 2012 nearly three quarters of us thought

Britain's National Health Service was one of the best in the world. The majority agreed that quality is

at the heart of the service and both measures had been rising for several years.1 The people who

posted comments on Dr Gunter’s blog may have romanticised the NHS a bit, but they also seemed

pretty well-informed. They often had extensive experience as patients or were NHS insiders of one

kind of another, including quite a few doctors and nurses. Many of them claimed that the NHS

provides a higher quality service than systems which are not available to everyone, regardless of

their ability to pay. Several of them had experienced the US system as patients, or as clinicians and

other professionals, and said that system has built in drivers which depress the quality of care

people actually receive. People got no, or sub-standard, care if they had no insurance and, even if

they had insurance, the quality and cost of treatment they received depended on the whim of the

insurance companies. Moreover, the same quality of care was delivered at much higher cost

because the American system builds in incentives to over-treatment and price-inflation.

Is Dr Gunter’s expectation that quality might suffer because the NHS is free at the point of

use shared by other Americans? As far as I can tell (spotting nationality is not always easy) most of

the Americans who posted on her blog reported very similar experiences either on vacation in the

UK or after relocating there. These few were as ready to praise the NHS as Dr Gunter but when

Britons say the NHS is the envy of the world, they must be counting out most Americans. As one post

explained, ‘I have recently moved from the UK to the US and am saddened by the overwhelming

negative attitude to the NHS over here, mainly from middle class people who can afford health

insurance. My heart goes out to those who can’t.’

Why do Americans who have not used a British hospital assume that a system like the NHS

must provide inferior health care? Perhaps because she had not expected so many comments from

other nationalities, I think Dr Gunter was surprised that many of the people who commented on her

blog did not seem to know the answer. As other comments indicated (and Dr Gunter concurred) the

best way to answer puzzled enquiries about American attitudes was to direct people to the

DOI: 10.13140/RG.2.1.2772.5923

~ 3 ~

arguments made in the US against the Patient Protection and Affordable Care Act, otherwise known

as the ACA or Obamacare. Even the most superficial analysis of these arguments suggests that

Americans expect poor quality care from a system like the NHS because they believe such systems

restrict the freedom of individuals.

To understand the arguments, it is necessary to know the main provisions of the ACA. It has

been rolled out over four years but it means that all Americans are meant to have medical insurance.

An insurance market had been set up to keep costs affordable and there is also regulation to stop

some of the more obvious abuses by insurance companies. Middle and low-income families get help

with the costs of insurance through tax credits. The means-tested Medicaid state insurance program

has expanded to cover more low-income Americans. The elderly and disabled get cost-free

preventive services and a discount on brand-name drugs. Yet the ACA is more unpopular than it has

ever been.

There is no disagreement between different polls on the main points of public opinion so we

can take just one, well-regarded, poll from the Kaiser Family Foundation which tracked answers to

the same question from 2010 when the ACA was signed into law. At that point the ACA got its

highest rating with 50 per cent rating it favourably but this figure trended down for the next four

years dropping to just over a third in January 2014. In July 2014 those polled who were unfavourable

to the ACA reached its highest level yet, at 53 per cent. This figure had risen 8 per cent in a month,

mainly because those who are not sure how they felt about the ACA had now made up their minds.2

All of this negative opinion appeared to run counter to solid evidence that the ACA was

reducing the numbers of uninsured Americans. It seems the unfavourable judgment of the Act is

deeply rooted in principle rather than poor expectations of its effectiveness. To get at what these

principled objections are we have to acknowledge, first of all, that most Americans do not think that

the system they had before was all that great. Thus CBS News Polls have reported approval for the

state tackling insurance abuses like insurance companies not covering pre-existing conditions or

kicking grown children off their parents’ plans. Most do not want to turn the clock back and about 6

in 10 want to keep the law but improve it. This includes a big majority of Democrats (86 percent),

most independents (58 percent) and almost a third of Republicans.3 That said, the majority do not

like the basic premise of the ACA: ‘Still, the most controversial component of the law - the

requirement that nearly all Americans obtain health insurance -- does not sit well with the American

public.’4

Americans apparently choke on the idea of the state preventing people looking after their

health (or not looking after their health) in the way they want to. They are certainly encouraged to

choke by the opponents of ACA who continue to spend a great deal of money trying to get rid of it.

DOI: 10.13140/RG.2.1.2772.5923

~ 4 ~

In the Kaiser poll for July 2014, most people said they still heard negative things about the law.

People who said they discussed the law were five times more likely to say what they had heard was

mostly bad. Just over half of the people polled had come across political ads about the law and the

great majority of them said the ads were mostly against the ACA. Much of what was done in these

ads was about building on that gut-reaction to state compulsion that is shared by so many

Americans. The main elements of this strategy were helpfully summarised by Karen Harned from the

National Federation for Independent Businesses on the Fox News website5 and with this help we can

see why most Americans think that state compulsion is not just bad in itself but inevitably means

worse care.

Karen Harned listed the ‘Top 5 freedoms at stake if ObamaCare is upheld’ as individual

liberty; freedom for consumers; freedom for small businesses; freedom to decide what is medically

best; and ‘the economic future of the country’. Some of these threats to freedom speak to other

issues than the quality of health care. Individual liberty is guaranteed by the constitution and, on this

interpretation if gives Americans the right to decide when, and to whom, they want to give financial

assistance. There is a big difference between choosing to donate to charity and having the state take

higher taxes to fund the ACA. This is especially problematic if those taxes are used to pay for birth-

control to which you have strong religious objections. But it is the middle three of the five freedoms

listed by Harned that are most relevant to the quality of health care.

Freedom for consumers is meant to ensure bad provision goes to the wall and the quality of

care is driven upwards. If this drive is led by rich consumers this is fine as their spending power will

force innovation in treatment which will ultimately benefit all. If rich consumers find they are not

well served by expensive treatment they can sue the providers and force change. Freedom for

businesses means they can respond to market demand and change and innovate to give consumers

what they want. Freedom to decide what is medically best is no longer possible if the state takes

over the interface with health care. The state over-rides people’s ideas about what is best by

capping spending, rationing care and stifling innovation. This last point needs a bit of elaboration

and there was, fortunately, a comment from an American on Dr Gunter’s blog which did just this.

This comment explained that a simple problem like Victor’s that could be easily diagnosed and

treated at very little cost. A universal health system like the NHS could cope with this kind of

problem but not with elective treatments or things that were harder to diagnose and/or expensive

to treat. The author of the post was sure this meant quality would fall as the state would be under

pressure to keep costs down.

It must now be clear why, when Dr Gunter was telling her fellow Americans the water was

lovely, this meant she was asking them to question common knowledge. Her experience was out of

DOI: 10.13140/RG.2.1.2772.5923

~ 5 ~

kilter with their knowledge of their rights as Americans and of the relationship between these rights

and the quality of goods and services, including health care. Their knowledge tells them the water

cannot be lovely and that any child of theirs who ended up in an NHS hospital would run a high risk

of being shaken about like a rag doll by a Great White.

The British posts on Dr Gunter’s site included dozens of personal histories and some

statistical evidence intended to show how mistaken these fears are. We need to understand that the

great majority of Britons do not see the freedom of the individual as the starting point of any

argument about universal health care. Their starting point is quite different and it is has something

to do with the fact that, when asked what they think is most important about delivering public

services in general, nearly twice as many say the government’s priority should be what is good for

society as a whole (50 per cent) rather than the amount of tax people will have to pay (28 per cent).

The quality of the individual services comes in third (at 20 per cent). Moreover, almost two-thirds

(63%) want the standards of public services to be the same everywhere in Britain.6

The commitment to uniformity in public service does not vary with party affiliation but of

course not all Britons are equally egalitarian. British society splits more or less down the middle on

whether the ideal society is one which ‘emphasises the social and collective provision of welfare’ and

one ‘where individuals can look after themselves’. There is a slight majority who favour ‘a society

which emphasises similar income and rewards for everyone’ over one ‘which allows people to keep

as much money as they can’ but there is no denying that individual freedom and responsibility have

always featured in British debates about health and welfare. The NHS is, however, seen as

something of a special case. Even those Britons who are committed to individual rather than social

responsibility approve of the goal of providing treatment for all regardless of means and free at the

point of use. Indeed, nearly three-quarters of the public think the NHS should provide drugs and

treatment no matter how much they cost.

Quality worries are a relatively low priority for the public services as a whole and much the

same applies when people are asked specifically about the NHS. Less than one in ten (8 per cent)

spontaneously mention the low quality of services, treatment or care as the biggest problem facing

the NHS. As already suggested by their readiness to say the NHS should provide drugs and treatment

irrespective of cost, people are far more likely to identify the biggest problem the NHS faces as lack

of government funding. For many years they have believed the biggest problem is lack of resources

and investment (spontaneously mentioned by 39%) and 20% believe the NHS is understaffed and 8%

think there is a big problem with overworked staff.7

Britons have very mixed opinions about whether drawing on the resources of the private

sector to extend NHS capacity can help to alleviate these problems. The majority (61%) approve of

DOI: 10.13140/RG.2.1.2772.5923

~ 6 ~

treatment for NHS prices in private hospitals to ease capacity problems and believe the private

sector has a role to play in reducing NHS waiting lists (62%). On the other hand, people are not at all

sure whether this will be good for the quality of care: just over a third (35%) think it will, but 31%

think it will not.8 About four out of ten people express indifference as to whether a private company

provides health care as long as the care remains free of charge but there is no sign that this

proportion is increasing and in 2013 nearly half of the British public said they would prefer not to

farm NHS services out to the private sector.9

For many people, distrust of the private sector overlaps with dissatisfaction with the way

successive governments have tried to reform the NHS. Although concerns about quality remain at a

low level, there is evidence of much greater concern about the impact of government changes. In

the recent past this was focused on the way governments had increased the size and influence of

NHS bureaucracy and management, but this worry now seems to be receding as the public is

persuaded that government has seen the error of its ways. There is, however, still real concern

about privatisation. In 2012, nearly three-quarters of Britons who thought privatising the NHS was

on the cards thought it would make services for patients worse.10

It is time to move on from statistics, and qualifications to statistics, because we know

enough to be confident that there are deep philosophical roots to differences in British and

American attitudes towards the provision of health care. Britons think the NHS is wonderful because

everyone is able to use it whereas Americans think the NHS must be worse than their own system

for the very same reason. Where the roots of the American philosophy lie deep in the idea of

personal freedom, British attitudes grow out of a deep commitment to equality. It is not just that

there is a level of health care they do not want to see the poorest fall below, most Britons want

health care to be available to all on the same terms. The deepest roots of these principles lead us

down to the idea that all human beings are equal and deserve equal care. Upon this assumption of a

fundamental equality Britons erect what academic philosophy calls positive freedom. Positive

freedom is the freedom to do something, to actually be able to do it, not just think about it or know

that nobody would object if you did it. If you combine positive freedom with equality then everyone,

no matter what their means, can go to the nearest accident and emergency department and get that

speck out of their eye (and their cancer and their type two diabetes and their heart disease treated).

The British philosophy starts with equality and leads on to (positive) freedom. For the

majority of Americans the right approach is the mirror image of this. Of course it has to be freedom-

first, but this is freedom of the different, negative kind, freedom from interference, as specified in

the constitution, for example. This is not the freedom to actually be able to do something since what

you do with your freedom is up to you. Thus the American constitution confirms the rights that the

DOI: 10.13140/RG.2.1.2772.5923

~ 7 ~

state cannot interfere with. You can carry a firearm on the street if you want11 but the state will not

give you one for free, unless you are in law enforcement. That would, technically, be a positive

freedom because toting a gun is then something everyone can actually do. The mirror image is

completed because equality comes second in the American philosophy: since the constitutional

guarantee of freedom applies to everyone this also underwrites equality.

From the American point of view, it looks as if Britons do not have these freedoms (after all,

they have no constitution and they lavish money on an unelected head of state) or, even more

perversely, they willingly throw them away so that everyone can be in the same leaky boat together.

From the opposite side of the Atlantic, the American freedoms look selfish but this mutual

incomprehension arises from the different logics of positive and negative liberty. It is sometimes

suggested that negative freedom is the hobby horse that teenagers like to ride: ‘I have the right to

do what I like and you can’t stop me’. Positive freedom is the justification for put-upon parents who

provide those teenagers with the wherewithal to enjoy their negative freedom. Negative freedom

does not give those teenagers spending money or transport but parents sometimes do.

But I do not want to be caught arguing that the British national character is more mature

than the American one because this kind of contrast trivialises a difference that we need to

understand more thoroughly and deeply. Think for a moment about the role of limitations in

debates about positive and negative freedom. The latter is very attractive to teenagers because it is

open-ended. Positive freedoms are attractive to parents because they have to be specified and so

there is plenty of opportunity for drawing the line: no, tonight is a school night. The same applies in

the NHS of course: you can have a heart-bypass but if you think you are looking your age you can pay

for that face-lift yourself. And again, yes to the gastric band but if you want to get rid of all the loose

skin when you lose 140 pounds the taxpayer won’t help you.

Every time we agree on a positive freedom we are enacting a belief about what we think is

the right thing to do. Negative freedom is open-ended because it is based in one solid conviction

rather than a series of value judgments. Thus libertarians are fond of saying negative freedom

extends to cocaine use but you rarely hear a positive freedom argument in favour of free cocaine.

There is however a positive freedom argument for the state providing free methadone to addicts to

get them off smack. Few people who make this case argue we all have a right to methadone. Instead

they believe that the poor souls who have are addicted to heroin deserve the chance of getting back

on their feet and we would want the same chance if we were in their place. This analysis points

towards a difference in where our convictions that we have positive and negative freedoms come

from. That same difference also explains why Britons are so attached to equality and Americans to

freedom.

DOI: 10.13140/RG.2.1.2772.5923

~ 8 ~

American philosophy is based on sound (and sometimes ‘self-evident’) knowledge: I know I

have a right to do what I like because it is in the constitution. There is no doubt of my freedom

because it is a right that is published in one of the most famous documents in the world. Nor is there

any doubt about equality in the American system. It too is only a matter of knowing the constitution

which guarantees equality before the law. As any pitying or bemused American knows, the poor

Brits do not have a constitution (just the European Human Rights Act which some of them

apparently want to do without!) so how do they get by? The answer is that they make do with faith:

not religious faith but belief in something rather than knowledge about something. This is the real

source of the differences that we are seeking to understand.

The British philosophy is based in shared beliefs about the equality of human beings that are

rooted not in the constitution but in history, particularly the history of popular social movements

like the nineteenth-century campaign to abolish first slavery and then the slave trade.12 Just as in the

American version, the foundation of freedom is the same as the foundation of equality only here

that foundation is made of things we must believe in rather than things we just know. The British

belief in positive freedom has the same roots in popular social movements as the belief in equality. It

was this belief that drove the construction of the welfare state and, of course, the NHS.

There is one more important thing to remember. In the British, faith-based version, equality

comes first: we believe we are all equal so we all deserve the same freedoms. If fortune has given

our sisters and brothers less resource than us they are nevertheless still equal and deserve the same

freedom. Of course the American version is the mirror image once more: freedom-first (just as so

many slogans proclaim) and equality is a consequence. This means that a reform like the ACA which

targets equality first is going to be in for a rough ride. Even a seemingly innocuous idea like lowering

the threshold for exemption on estate tax below $5 million falls into the same category. As British-

born satirist John Oliver pointed out on HBO, only 1.4 in every 1000 estates paid any estate tax in

2013: ‘Basically, if you’re not comfortable calling your accumulation of shit an estate, the estate tax

probably doesn’t fucking apply to you!’13

In Britain the equivalent threshold in 2013 was £325,000 (just short of $500,000 not $5

million). Although British inheritance tax was still only paid on 3 in every 100 estates14 this is

evidence of the salience of the contrast between freedom-first and equality-first. All the same, the

flurry of statistics a few paragraphs ago included some data suggesting Britons are worried that

successive governments might be ignoring their preference for equality-first, particularly in policy on

the NHS. Some of the British posts on Dr Gunter’s website said they even thought that governments

had been using public policy to move Britain towards the American model.

DOI: 10.13140/RG.2.1.2772.5923

~ 9 ~

There have been a lot of changes in the NHS in the last thirty years and not all of them have

favoured freedom over equality but there is, nevertheless, a discernible trend in this direction.15

Quite often the major rationale for policy shifts has been increased negative freedom for individuals.

Very often this has been expressed, as one would expect, in rights language. At the same time, the

belief in equality which powered the construction of the NHS has been turned into an after-thought.

At the beginning of the period, politicians who wanted to copy the American model were

extremely wary of frightening the horses. Thus in 1982, in the middle of her first term, Prime

Minister Thatcher told her party that ‘The National Health Service is safe with us’. She said she stood

by ‘The principle that adequate health care should be provided for all, regardless of ability to pay’

but she also said growing private health insurance was welcome (‘it helps to reduce the waiting lists,

and it stimulates new treatments and techniques’).

The following year Prime Minister Thatcher told the country ‘People talk about a "free"

service. It is not free. You have to pay for it’ thus reminding electors that there might be other things

they would rather spend their money on than the NHS. She then offered them the possibility of

making this possible by shrinking the NHS, or at least making sure it stuck to its budget and did not

waste taxpayers’ money. The attempt to make people think of the NHS as taxpayers rather than

patients was an essential component of the quiet revolution that was being instigated but it was not

until 1985 that the structural changes being planned for the NHS became a little clearer.

In that year an American economist, Alain C. Enthoven, wrote a Nuffield16 report which

argued that bringing market forces into the NHS would improve the quality of care. Professor

Enthoven subsequently built his career on elaborating the idea that markets and choice were the key

to improving standards in different healthcare settings around the world. The ‘experimental’ internal

market for the NHS that he proposed in 1985 was a neat fit with the Government’s focus on getting

the NHS to stick to its budget and use taxpayers’ money efficiently. For the next five years,

successive Conservative Governments worked all of this up to full-scale leading to a 1989 White

Paper with proposals which Kenneth Clarke, Secretary of State for Health, said would create ‘a

better NHS, providing the type and standard of service a patient has a right to expect’.

In the following year the proposals became the 1990 NHS and Community Care Act which

created an internal market and a purchaser-provider split. The purchasers were mostly health

authorities and they were given budgets to use to buy services from providers (mainly acute

hospitals plus services for people with mental health problems, learning disabilities and the elderly).

In addition, GPs were encouraged to take on their own budgets and buy services from hospitals and

other providers on behalf of their patients. Later in 1990 Thatcher was replaced by John Major as

DOI: 10.13140/RG.2.1.2772.5923

~ 10 ~

Prime Minister and leader of the Conservative Party and in the first Major administration attention

switched from the internal market to the reinvention of patients as consumers.

The Patient’s Charter, introduced in 1991, declared that from this point on the NHS had

customers who had various rights which they could use to demand that their needs be met in the

way that best suited them. A new Secretary of State for Health, William Waldegrave, declared that

‘Every household should know its rights under the NHS’. These rights covered quality as well as the

receipt of treatment and included waiting times for hospital treatment. When New Labour took over

government in 1997 they retained the waiting times and the idea of doctors buying health care from

hospitals on behalf of patients. The internal market was out of favour but free choice was still seen

as the key to improved standards. GPs, nurses and other workers were brought together to

commission care on behalf of their local communities using the majority of the NHS budget.

In the 2001 Health and Social Care Act the New Labour Government intensified the focus on

decreasing waiting times by making them performance targets and brought private money into the

NHS. The Private Finance Initiative used high-interest loans to design, build and operate hospitals

that would swallow up a huge amount of taxpayers’ money that might have gone on services.

Subsequent changes increased the freedom of the NHS Trusts that run hospitals and switched the

emphasis in public health strategy to people’s freedom to choose, personalising services and

working with the private sector.

By 2004, it was clear that there were at least four senses in which freedom-first had

challenged equality-first in NHS policy. Taxpayers were told they had the freedom to bring the NHS

to heel (though overbearing non-clinical oversight was eventually abandoned). Patient freedom, or

customer choice, was driving up quality. Practitioner freedom was channelling the response to

patients’ demands to the providers. The providers of health care benefitted from increased

independence (for example in NHS Foundation Trusts). All four types of freedom were augmented

by the proposals for the English NHS made by the incoming Coalition Government (between

Conservatives and Liberals) in 2010.17

Taxpayers got a new commission to monitor the quality of healthcare and another body to

promote competition and regulate prices. Patient choice and involvement were reinforced by

increasing information, easing access to data on patient experience and service quality, and more

control over their health records. Most spectacularly, provider freedom was increased by giving

private providers increased rights to compete with the NHS to meet health needs at public expense.

Within the NHS the trend to independent Foundation Trusts was to be accelerated.

The 2010 White Paper which included these proposals used the word freedom 18 times (and

at most key points in the document). This was three times as frequently as it used the word equality

DOI: 10.13140/RG.2.1.2772.5923

~ 11 ~

and most of these mentions were to do with the protected grounds covered by the 2010 Equality

Act. Socio-economic equality was not mentioned in relation to the NHS but only in relation to the

Government’s Department of Health which was now expected to take the lead on public health.

How did American and British philosophies diverge in the first place? This is a story worth

telling because it will help us later on when we wish to reach a decision about whether the

dominance of freedom-first over equality-first is welcome. Two centuries ago, the most influential

voice in the development of the visions of equality and freedom in Europe and America was Tom

Paine’s.18 He wrote for a mass audience, producing some of the most popular works of non-fiction

ever published in English in the course of an extraordinary life. He was born in Norfolk, England in

1737 and received little formal education. His wife and child died when he was in his twenties and

he was later sacked from his job as an excise officer because he agitated for higher pay. He moved to

the US in 1774 after having the good luck to meet Benjamin Franklin who advised him to emigrate

and gave him letters of introduction. A year after his arrival he published an anti-slavery pamphlet.

A year after that, as military conflict between Britain and the American colonies began, he published

a pamphlet called Common Sense which argued for full independence from Britain. An appointment

to a Congress committee followed Paine’s participation in the war as an assistant to a general in the

continental army, but Paine was removed following his disclosure of secret information. After being

instrumental in raising finance for the Revolution in the US and France, Paine returned to Britain in

1787 and, in response to Edmund Burke’s attack on the French Revolution two years later, he

published his most famous work, The Rights of Man between 1791 and 1792. For this he was

charged with treason but escaped to France where he was at first welcomed to great acclaim but

subsequently imprisoned for a year for supporting imprisonment rather than execution for the

deposed king. While in prison he began work on the controversial book The Age of Reason.

It might be over-simplifying19 but I think you can see in his publications that Paine’s political

philosophy began as freedom-first but matured into equality-first when he saw that negative

freedom was ruling out equality rather than facilitating it. In his writings at the time of Common

Sense, Paine argued that a commercial society like the US was perfectly capable of running itself

without interference from the parasites of the British crown. This argument was all about the

obvious benefits of negative freedom: get the parasite off our backs and we can all live in peace and

prosperity. Equality came second as a benefit of independence, peace and prosperity. Freedom

meant removing obstacles which prevented each citizen pursuing their goals in whatever way they

though fit (including saying what they liked and making themselves rich). Each citizen had an equal

right to determine their own fate as long as they did not trespass on other citizens’ rights to self-

determination.

DOI: 10.13140/RG.2.1.2772.5923

~ 12 ~

By the time The Rights of Man was published, Paine had decided that in an old country like

Britain the poor and powerless had no hope of self-determination without government intervention

on their behalf. He proposed positive freedoms in education and welfare that did not guarantee

equality but made the chances of rich and poor achieving equality more even. The proposals he

made for a proto-welfare state applied specifically to Britain but the influence of French events on

his writing makes it clear he was proposing a European model. Paine thought the model of equality-

first and positive freedoms applied to all those old societies with their histories of regal and

aristocratic drones rather than as a self-organising commercial society.

Around the time of The Age of Reason, Paine came to the conclusion that this European

model was not just appropriate for old societies like France and England but also for new

commercial utopias like the US. It seemed that unregulated capitalism could not help making people

more and more unequal. Equality and freedom could not be understood only as abstract rights

framed in a constitution because a capitalist economy made it much harder for some people to turn

abstract rights into real freedom and real equality. Thus the rich and powerful enjoyed more actual,

concrete freedom because they were rich and powerful. In the European model equality and

freedom were not understood as abstract rights. From the point of view of Common Sense Paine’s

mature thought implies a restriction of negative freedom since the European model limits the

freedom of the rich in order to increase the freedom of the poor. But this is a necessary

consequence of the combination of Paine’s belief in the equality of human beings combined with the

observation that existing society, capitalist society tended to increase inequality.

Paine’s ideas had an enormous influence on people across the world and not just in America,

Britain and France. It was nevertheless in Britain that his writings had the most direct influence on

popular political ideas, becoming the inspiration for nineteenth-century movements for political,

social and economic reform. But Paine’s proto-welfare state proposals did not mention universal

health care, so what has this to do with the NHS? If you think capitalism generates inequality you

know it is inevitable that this will generate inequalities in health because people will not have the

same access to the means of living healthy lives and paying for health care. If you believe in the

equality of human beings, universal health care offers every human being in a capitalist society the

same chances of health and a reasonable quality of life. In this way the NHS, or something like it, is

devised to make up for the inequalities capitalism creates. But why does it now seem Britain is

backtracking on Paine’s vision?

Enough Britons eventually lost their belief in the equality of human beings that their support

for a European model of public policy with equality-first broke down. This process began in the

1970s but we have already seen some of its consequences in the series of NHS reforms described a

DOI: 10.13140/RG.2.1.2772.5923

~ 13 ~

little earlier. Of course evidence of this is not confined to politics and the mass media has often led

the retreat from equality-first. Its weapons have included the concept of ‘political correctness’ which

signals we have to pretend that everyone is equal when they plainly are not. There has been a lot of

campaigning in the media for negative over positive liberty too. For example there has been a

decades-long campaign against ‘the health and safety culture’ and ‘the nanny state’. In different

ways, both of these campaigns imply that personal freedom is being restricted by the state because

it thinks it knows best. At the same time positive liberty is derided: prisoners have LED TVs and

voting rights, and large families get welfare benefits and help with housing costs.

From the mid-1980s, parties of all political persuasions have paid attention to these

campaigns but they had, in any case, determined that public policy must include more freedom-first

and less equality-first. Something similar has happened in the US, although of course there equality-

first was pretty scarce in the first place, but in the UK politics dramatically changed tack. Successive

governments sang from the same hymn sheet and the first line of the hymn might as well be O say,

can you see by the dawn’s early light …. In 2002 Lady Thatcher told dinner guests that her greatest

achievement was ‘Tony Blair and New Labour. We forced our opponents to change their minds.’ She

was right. Her electoral success shifted the centre of gravity of British politics to the right and this

meant moving away from the European model which Tom Paine had helped to devise and towards

the American alternative which can be derived from his early works.20

The aim of the New Labour project (from the 1990s) was to win electoral success by

maintaining the trajectory of public policy towards freedom-first that Prime Minister Thatcher and

the Conservatives had initiated a decade earlier. In 2002, key New Labour figures spent a weekend

brainstorming with Bill Clinton, the American President usually associated with moving the

Democrats to the right and abandoning equality-first. They included the prime minister, Tony Blair,

the chancellor, Gordon Brown, and one of the people most often described as the architect of New

Labour, Peter Mandleson, who declared ‘we are all Thatcherites now’. Tony Blair added, more

recently: ‘Values unrelated to modern reality are not just electorally hopeless, the values themselves

become devalued. They have no purchase on the real world’.

One corollary for the convergence of British politics in pursuit of the American Archetype has

been steeply-rising inequality.21 The top five most unequal OECD countries measured by GINI

coefficient are now Chile, Turkey, the US, Israel, and the UK, but the UK and US feature in the top

five most unequal countries whatever measure you choose. It is hard to over-play the significance of

this because, throughout the previous two centuries, the UK played a key role in implementing

policies designed on the model of equality-first. It was not only the NHS that Britain brought into the

world but also an end to the slave trade and to slavery itself. Britain achieved these goals decades

DOI: 10.13140/RG.2.1.2772.5923

~ 14 ~

before the US, as it did in respect of electoral reform, the reform of working conditions and

employment relations, public education and the welfare state.

The only point at which equality-first might have led the US policy agenda was in the brief

Progressive Period up to the start of WWII. In the US in the 1930s unregulated, uncaring capitalism

was blamed for the Depression and the response was some regulation and Roosevelt’s New Deal for

welfare and public works. This was a brief, and rather weak, European-style response to the

perceived failure of the American model to deliver happiness and prosperity for millions of citizens.

This attempt to follow Europe did not last and the US still lags far behind other nations in providing

protections for its citizens. What kept rampant inequality at bay until the 1970s was not the US

government but rapidly rising productivity that funded rising wages.

In the UK and the US the financial crisis in 2008 did not lead, in due course, to a latter-day

New Deal. Instead massive state hand-outs were awarded to bankers and years of cuts in public

services were set out for everyone else. But there still are differences between US and UK public

policy and the biggest difference is probably health care. As I mentioned, many Americans still hope

to repeal the ACA and most hope to get rid of its restriction of their (negative) freedom to spend

their money however they like but the ACA is, after all, primarily aimed at increasing enrolments in

insurance schemes. It is no NHS and, indeed, much less of an equality-first measure than its failed

predecessors: the 1948 reforms of President Harry Truman and Republican President Richard

Nixon’s 1972 proposals.

The differences are not limited to policies since they also extend to how people feel about

the things the policies are designed to address. We know from the earlier flurry of statistics how

passionate Britons are about the NHS, how fearful they are for its future and how suspicious they

are of Government intentions towards it. The NHS is always in the top two most important items for

politicians to deal with according to the polls. This is not always the case in the US and, when it

features, health care is often far behind the economy. In 2011 CBS news reported that Americans

were nearly ten times more likely to identify the economy and jobs as the most pressing issue. At

the start of this paper we learnt of one American doctor trying to alter American minds on the

question of the quality of care in the NHS but it then became clear that this depended on a more

fundamental change in American hearts.

What makes healthcare an abiding issue in the UK is the fear and suspicion that attach to the

future of the NHS. Many fear that politicians intend to foist US-style health care on the UK. This was

why there were so many British comments on Dr Gunter’s blog, and so few American ones. It was

not just that they would not be able to get the health care they needed if they had to pay for it out

of their own pockets. It was not just that they suspected that bringing in private providers would

DOI: 10.13140/RG.2.1.2772.5923

~ 15 ~

mean paying more for the same, or worse, services that the state once provided. It was not just that,

when they were feeling particularly cynical, they wondered how much of this money would find its

way into the pockets of the very rich, including some former politicians. It was that they could not

put their trust in freedom-first because they still see the world as the older Tom Paine did.

Capitalism generates inequality and, despite everything that has happened since the 1970s, they feel

that human beings are equal and they all deserve a chance. What are the odds of their view carrying

British public opinion and reversing thirty years of creeping Americanisation of British public policy?

1 Ipsos Mori Public Perceptions of the NHS Tracker Survey (Spring 2012 Wave Report) 23/10/2012. Other polls

produce very similar results for example YouGov reported three-quarters of Britons thought the NHS was one of the UK’s greatest achievements YouGov Healthcare Choices: NHS versus Private, 2013. 2 The Washington Post ‘wonkblog’ 1 August 2014.

http://www.washingtonpost.com/blogs/wonkblog/wp/2014/08/01/suddenly-obamacare-is-more-unpopular-than-ever/ 3 ibid.

4 http://www.cbsnews.com/news/public-opinion-of-the-health-care-law/

5 http://www.foxnews.com/opinion/2012/03/23/top-5-freedoms-at-stake-if-obamacare-is-upheld/

6 All the statistics in this paragraph and the next are from Ipsos MORI What do people want, need and expect

from public services? Published by the 2020 Public Services Trust in partnership with RSA Projects, March 2010. 7 All statistics in this paragraph and the next are taken from Ipsos MORI Public Perceptions of the NHS Tracker

Survey (Spring 2012 Wave Report) October 2012. 8 YouGov Healthcare Choices: NHS versus Private, 2013

9 47%, up from 36% in February 2011. Ipsos Mori poll for King's College London The Guardian, Friday 29

November 2013. 10

Seven out of ten Britons who believed the Government had plans to privatise services thought this would make things worse for patients – an increase of 10 percentage points on the previous year. This and the other data in this paragraph are from Ipsos Mori Public Perceptions of the NHS Tracker Survey (Spring 2012 Wave Report) October 2012. 11

And over 11 million Americans have the right to carry a concealed handgun (something foreign tourists might bear in mind). 12

See Ralph Fevre, Inequality and Individualism: the Future of Work and Politics, Edward Elgar: forthcoming. 13

http://www.offthechartsblog.org/john-oliver-debunks-some-estate-tax-myths/. Also see http://www.mediaite.com/tv/john-oliver-destroys-americas-blind-optimism-in-face-of-income-inequality/ 14

‘Inheritance tax: when facts and politics collide’ The Telegraph February 11th, 2013 15

The advent of devolution half-way through the period complicates the issue because the political complexions of Scottish and Welsh administrations have retarded the move away from equality-first in Scotland and Wales. Some of the analysis below does not apply to these countries or, at least, not to quite the same extent as it does in England. 16

Most of the following information on the changes in the English NHS comes from the relevant Acts and White Papers or the Nuffield Trust. 17

Equity and Excellence: Liberating the NHS. The Prime Minister, Conservative leader David Cameron, subsequently made a habit of aping American attacks on the quality of the NHS in his own attacks on the devolved NHS run by a Labour administration in Wales. As in the former case, the evidence for this attack on the quality of care provided in the Welsh NHS was hotly disputed. 18

For more discussion of Paine and eighteenth-century thought in general see Fevre, op cit.,. 19

For a more sophisticated account see Gregory Claeys, Thomas Paine, Boston: Unwin Hyman, 1989. 20

A more academic discussion of the ideas in the remainder of the paper is elaborated in Fevre, op. cit.,. 21

All figures from the OECD.