Overton Window watching
Most people in my line of work are obsessed with the concept of the ‘Overton Window’, the range of socially permissible ideas, and in particular, with the way ideas cross the window’s boundaries over time. I share that obsession myself. In this day and age, how could you not?
When I first came across the concept, the examples people would use to illustrate it were examples of attitudinal changes that happened over the course of a generation or so. Then came the Great Awokening, which meant that ideas that had been completely mainstream until 5 minutes ago were now suddenly beyond the pale. More recently, we saw a backlash against ‘wokery’, which means that some of those previously exiled ideas have re-entered the Overton Window. In our time, it has become possible to be an ‘Overton Window watcher’, who sits at the boundary of the Overton Window, and watches ideas arrive and leave.
Inside the Overton Window
My one criticism of our Overton Window obsession, though, would be that by focussing almost exclusively on what happens at the window’s boundaries, we neglect movements within it. These matter too. It is possible for an idea to successfully break into the Overton Window, and then get permanently stuck in its outer layer, rather than moving on towards the centre, where it has a chance to become an actual reality.
The outer layer of the Overton Window contains ideas that you can express in public without everyone freaking out and yelling at you, but which are nonetheless not widely popular. A good example of this is republicanism, the idea that Britain should abolish its monarchy, and become a republic. It is a perfectly respectable opinion. Republicans do not have to fear negative social repercussions for expressing their views. Monarchists will disagree with them, but they will try to persuade them that they are wrong, rather than call them traitors or lunatics.
It has not always been this way. There was a time when expressing anti-monarchy views was genuinely controversial. Republicans have managed to break into the Overton Window – but once they were on the inside, they stopped. They never moved much further than that. No major political party has adopted the abolition of the monarchy, or a referendum on the subject, as an official manifesto commitment. At no point has the UK come close to becoming the United Republic of Great Britain and Northern Ireland.
We could call this the ‘republicanism trap’, or, if you’re one of those impressionable readers who think German compound nouns automatically look philosophical and profound, the Republikanismusfalle. It’s when an idea becomes socially acceptable, but still fails to make an impact, because it gets permanently stuck in the outer layers of the Overton Window.
Social Health Insurance meets politics
There is a possibility that the idea of replacing the NHS with a Social Health Insurance (SHI) system will meet the same fate. This idea broke into the Overton Window about three years ago. You can see this from the fact that the NHS Confederation, the Health Service Journal, the Health Foundation, the King’s Fund and the Nuffield Trust have all published papers or articles critiquing SHI. They would not have done this before. When an idea is outside of the Overton Window, you do not write papers or articles explaining why you think it’s wrong. You just dismiss it, or ignore it. The Royal Geographical Society does not argue with the Flat Earth Society.
Breaking into the Overton Window was a real triumph for SHI supporters. The danger now, though, is that SHI will be stuck in this outer layer for a very long time – and arguably, Reform’s awkward and short-lived flirtation with SHI has been a setback.
In 2024, Nigel Farage must have sensed the vibe shift in the way we talk about the NHS, because he said several positive things about the French health insurance system. What happened next was interesting.
I mentioned the SHI-critiques by the NHS Confederation, the Health Service Journal, the Health Foundation, the King’s Fund and the Nuffield Trust. These are all, in my view, unconvincing, but they are intellectually honest critiques. They critique actual SHI systems, not some silly strawman version of them, and they engage seriously with the idea. This is exactly what that debate should look like.
Politics, of course, is not like that at all. Politics is not about being right, it’s about winning.
So, predictably, Farage’s pro-SHI statements triggered the usual scaremongering about Americanised healthcare. His opponents ignored the bit about France, zoomed in on the word ‘insurance’, and then went on to claim that ‘insurance’ means that you have to pay for every treatment out of pocket. They also claimed that the poor would go without healthcare, and that the prices you would have to pay would be American ones. The Labour Party, for example, claimed that under an insurance-based healthcare system, patients would have to pay £10,958 for an appendix removal, £23,000 for a hip replacement, £1,045 for an ambulance, and £1,368 for an A&E visit. These prices have, apparently, been taken from the US, and just been converted from $ into £.
This is misinformation of the crudest kind – but then, Farage is really the last person in the country who could claim to be unfamiliar with a populist style of politics. He should have anticipated such responses, and he should have had a list of ready-made rebuttals on hand. Instead, Reform quickly dropped the issue, and reverted to reaffirming their commitment to a free-at-the-point-of-use NHS.
Look. I don’t know the first thing about political communication, and would never pretend to. I’m an impractical ivory tower guy, and I don’t do ‘real world’ stuff. But I know a fair bit about manufactured hysterias around the NHS, because I’ve studied the 40-plus-year-history of them, which is why I know that the above strategy never works. Once you have been accused of being an enemy of the NHS, your opponents will never drop that accusation. And if you appear to row back on things you said earlier, they will only interpret that as an admission of guilt. Once you are in that position, the only way out is forward. You have to own every word you said, and double down on it.
I’d normally say that Reform’s communication problems are a problem for their press team, not me, but in this case, they’ve made it a problem for anyone who supports SHI alternatives. If you look at the responses from Labour and others, it’s quite clear that they are not just attacking Farage and Reform. They are attacking the very idea of insurance-based healthcare. Reform have given their opponents an easy opportunity to spread misinformation about SHI, and then they just ran away and refused to clean up the mess.
Basic facts about SHI
Since Reform are neither willing nor able to do it, let’s address these claims here.
At the most basic level – what does ‘insurance-based healthcare’ mean?
‘Insurance’ is the way we deal with costs that are unpredictable from the perspective of an individual, but predictable enough from the perspective of a large group. I have no idea what my healthcare costs are going to be this year: it could be zero, it could be hundreds of thousands, it could be anything in between. But these things average out, so at the level of, say, the borough I live in, the city I live in, or the country I live in, we can work it out in advance with a reasonably high degree of accuracy. It therefore makes sense for groups of people to get together, and pool their resources for that purpose. Everyone pays some money into a common pot, enough to cover the group’s anticipated healthcare costs, and then the ones who get sick get to draw on the pot to pay their medical bills.
If we use ‘insurance’ in this most general sense, even the NHS could be described as ‘an insurance-based healthcare system’. We do not usually think of it in those terms, because the specifics of the system obscure it, but all it would take to make this clear is a few minor accounting tweaks. The NHS is funded out of general taxation, not a specific, earmarked ‘NHS tax’. But we could very easily convert, for example, a part of income tax into a ring-fenced NHS tax. This would not change the nature of the NHS in the slightest, only the financing mechanics would be a little different.
Once we have an NHS tax, we could relabel it ‘National Health Insurance Contribution’ or ‘National Health Insurance Premium’. Again, nothing would have changed. But we would suddenly have ‘an insurance-based healthcare system’.
I’m not trying to play linguistic games here. I’m merely pointing out that there are commonalities as well as differences between the NHS, and the health systems we would normally describe as ‘insurance-based’. They differ in that, in the latter, the insurer does not double up as a monopoly provider of healthcare. Rather, it buys healthcare on a competitive marketplace. If it is an SHI system, there is more than one insurer: there are multiple – sometimes over a hundred – competing ones. Those are important differences. What the systems have in common with the NHS, though, is that there is a pooling mechanism for healthcare costs, such that you pay for it primarily via your premiums, not at the point of use.
It is therefore plainly dishonest to scare people by telling them they would have to pay for their ambulance, their appendix removal and their A&E visit under an insurance-based healthcare system. A system in which you have to pay for everything out of pocket is not an insurance system, it is just no system at all.
If an insurer refused to pay for clinically necessary treatment, that would be a straightforward breach of their contractual obligations, and thus illegal. In fact, insurance-based systems are typically much more explicit about what exactly you are entitled to than the NHS. In the NHS, you are only entitled to ‘healthcare’ in general, but not to any specific kind of treatment.
What about co-payments?
It is true that most SHI systems are not 100% free at the point of use. Small user charges play a supplementary role. However, this is simply because most health systems in general are not 100% free at the point of use. Most tax-funded, state-run healthcare systems also have co-payments, which can be just as high as in SHI systems, or higher. Anecdotally: I used to know a Norwegian who lived in Germany, and who expressed surprise about how low the co-payments were, compared to Norway. Norway has a tax-funded health system, Germany has the world’s oldest SHI system. The question of co-payments is independent of the type of healthcare system you have. It is simply an entirely separate debate. Even the NHS could, in principle, introduce co-payments any day. It would be seen as a violation of its founding principles, sure, but it would not make it a different healthcare system.
What happens to those who can’t pay their insurance premiums, though?
In SHI systems, the answer is: the same thing that happens in the UK to the people who can’t pay taxes, which, as we have established, contain an implicit health insurance premium. Those people are still entitled to treatment, and other taxpayers pick up the tab, which we could think of as an implicit insurance premium subsidy. In SHI systems, that implicit premium subsidy is simply made more explicit. It becomes an actual transfer payment that you can see in the accounts.
So no, you won’t have to pay the (absurdly precise) figure of £10,958 for an appendix removal; and you’ll still get your appendix removed if you can’t pay insurance premiums; and whether there will be a co-payment or not is an unrelated debate.
Where next?
The NHS is no longer the sacred cow it once was. Criticism of it, and advocacy of an alternative, has entered the Overton Window.
But are we at a stage yet where a political party could openly call for the replacement of the NHS with a different system? Or would such a party instantly consign itself to electoral oblivion?
I have no idea. Again, I don’t deal with ‘real word’ politics. But what I do know is that if a party or other political organisation is tempted to do anything of that sort, it cannot do it in a non-committal ‘I’m just asking questions’ way. You cannot just lob the word ‘insurance’ into the arena, and then duck. You have to have a clear idea of what alternative you actually want, you have to anticipate a barrage of misinformation coming your way, and you have to know exactly how to respond to that.
SHI may be in the Overton Window now, but not everyone got the memo, and old taboos die hard.
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Thank you - clear writing based on clear thinking.