It would appear that certain British politicians, and some MPs in particular, favour a private healthcare system. There are those who cast a wistful glance across the Atlantic and imagine that the United States has discovered a superior model of healthcare: a sleek, privately run machine whose efficiency and choice puts the NHS to shame. Yet anyone who has spent time looking inside that machine, even with insurance in hand, knows this image bears little resemblance to reality.
Political scientists sometimes talk about ‘framing’: the idea that public debate is shaped less by the sensible centre than by the most polarised voices at either edge. The extremes dictate the boundaries of the conversation, leaving everyone else to spar within those lines. So it is with discussions about the future of the NHS.
No mainstream party proposes dismantling it, yet the gravitational pull of those who admire the American model exerts a quiet influence. In some of their rhetoric, one hears the faint suggestion that the grass is greener on the other side.
Yet when it comes to healthcare the green glow is mostly the colour of money and for some, the anxiety that comes from endlessly spending it in an attempt to become well again.
A system without universality
To understand the American system is to appreciate its contradictions. In 2023, the US census reported that around 305 million Americans, roughly 92% of the population, had some form of health insurance for at least part of the year. One might be tempted to see this as comprehensive coverage. But in the United States, the phrase “having insurance” does not guarantee access to care, nor even the certainty that one’s policy will remain valid when needed most.
Private insurance accounts for just over 65% of coverage, public programmes for about 36%. The most common arrangement is employer‑based insurance, covering more than half the population. These policies, offered as workplace benefits, vary wildly in quality and cost. Losing your job often means losing your healthcare.
A postcode lottery on a grand scale
Next come Medicaid and Medicare, each covering around 18.9% of Americans. They are vast entitlement programmes designed to offer a safety net for low‑income, elderly, and disabled citizens. Their funding is shared between federal and state governments, which means that eligibility, benefits, and even the willingness of hospitals to accept patients vary markedly from one side of a state border to the other. An illness in one state might be covered; the same illness in another may not.
Medicaid, aimed at low‑income families, pregnant women, seniors, and people with disabilities, also pays the premiums of those who qualify for both Medicaid and Medicare. It is the financial backbone of many hospitals that serve America’s poorest, a quiet, unglamorous pillar without which entire communities would lose access to care.
Medicare, meanwhile, is structured more like private insurance, and it comes in alphabetised sections. Part A covers inpatient care and is available to people from the age of 65. Part B, which requires enrolment, covers medically necessary services and preventive care. Part C offers additional benefits, and Part D covers prescription drugs. It is comprehensive in theory, but in practice it covers only some of the cost of some of the care, some of the time.
Then there are the smaller streams: direct‑purchase insurance for the self‑employed or those who can afford to purchase additional cover, and military‑related programmes such as TRICARE and Veterans VA coverage. Together they create a system that resembles less a healthcare service than a sprawling patchwork quilt, intricate, at times beautiful, but prone to leaving gaps.
Insured, yet exposed
Those who manage successfully to navigate this labyrinth, however, may discover at the moment they need treatment that insurance does not guarantee approval.
And even when treatment is approved, the costs rarely disappear. Most American insurance policies require patients to pay ‘deductibles’ – similar to the ‘excess’ on a UK insurance policy – meaning a fixed amount must be paid out of pocket before insurance begins to contribute. In many plans this deductible runs into thousands of dollars, leaving patients responsible for a large share of their care before coverage even starts.
After that threshold is reached, patients are usually still expected to make ‘co-payments’: charges applied to many forms of care. A typical doctor’s visit may carry a co-pay of $20 to $40, while a specialist appointment might cost $40 to $75.
Prescriptions often require additional payments of $10 to $60 depending on the type of drug, with some very expensive medicines requiring patients to pay a percentage of the price instead.
In 2023, 19% of claims to Medicare and Medicaid were rejected. Estimates for private insurance rejections run between 10% and 20%. Fewer than 1% of rejected claims are appealed: the system is simply too complex and opaque, and leaves applicants exhausted.
The emotional toll is one thing; the financial toll is quite another. Medical debt accounts for around 40% of personal bankruptcies in the US. It is possible, in the world’s wealthiest nation, to recover from a heart attack only to lose your home.
A system under strain
Americans from across the political spectrum increasingly acknowledge that their system is in crisis. Medical – and therefore insurance – costs continue to rise; federal funding wavers, employers shift providers and more of the burden slips onto the workers. For millions, access to healthcare feels less like a right than a precarious subscription service, one that can be rescinded for the smallest administrative misstep.
From the UK, we often see only the NHS’s imperfections, its long but falling waiting lists, its staffing crises, its missteps. Yet compared with its American counterpart, our health system remains a triumph of equity and clarity, a rare institution built on the radical idea that health is a public good, not a commodity.
If the British system is ailing, the American one is already deep in chronic illness. Before we allow the framing of political debate to narrow our imagination, it is worth remembering that not all envy is grounded in understanding. The NHS, for all its flaws, remains a reminder that some forms of civilisation are measured not in profit, but in care.
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