A National Health Service? The Migrant Levy – and Why Citizens Should Care

Should foreigners pay to use the NHS? At first glance, it’s not so unreasonable. After all, as Health Secretary Jeremy Hunt points out, it’s a National Health Service. And as the Department of Health’s consultation paper, released today, asks: why should “temporary” migrants receive “free” treatment, unless it’s a public health issue or an emergency? After all, tourists’  hospital visits  are already chargeable: this – the argument goes — is simply an extension of already-existing policy, designed to protect the NHS.
The Department of Health’s consultation document, for all its delicate wording, is a toxic combination of two of this Government’s favourite pastimes: migrant bashing and privatisation. The former is convenient cover for the latter, especially when whipped into a frenzy by tabloid columnists.   The language of nationalism tells citizens they shouldn’t care about this, but that’s a dangerous slight of hand.
First, the evidence: or rather, the lack of it.  The Consultancy Paper claims “we know [health tourism] is a significant problem”.  Jeremy Hunt has argued health tourism – costs the NHS £200m a year, though he hasn’t offered any evidence explaining this figure and as George Eaton points out in the New Statesman, the cost could well be as low as £12m, or 0.01% of the NHS’annual budget.  Compared to the £50bnthat the NHS owes for Private Finance Initiatives (for infrastructure that cost just £11bn to build), the financial rationale for this “coordinated crackdown” seems pretty thin.  Especially when you also consider the £16.3bn (net) the OECD estimates that migrants contribute to the UK economy annually (that’s 1% of GDP).  Given the paper admits there’s a need for an audit to first understand the scale of health tourism on page 5, and no costing of the administration that would be required to process such a scheme, it’s hard not to escape the conclusion that this is a case of policy before (or regardless) of evidence.
But of course this isn’t primarily financial: it’s political.  It’s appealing to Britain’s rising tide of anti-migrant popular righteousness in the hope they won’t notice how privatisation is writ large across this Consultation document. 
The most significant proposal is that all those migrants who do not have Indefinite Leave to Remain in the UK – something you can normally only apply for after five years – should be asked to pay an annual Migrant Health Levy to access non-emergency treatment, of no less than £200 (‘an appropriate charge might be higher than this’).  Students, foreign spouses, skilled workers (including those nurses and doctors staffing your local NHS hospital): all charged more, even after several years in the UK.  It’s  also increasingly difficult to qualify to qualify for settlement in the UK, (even assuming you’re able to enter in the first place).   The Paper estimates that the average annual cost of providing healthcare to someone aged 15-44 (like most migrants) is £700.  Yet someone who meets the current minimum salary requirements for a worker’s visa — £20 300 – will already pay over £3500 in tax and National Insurance contributions in their first year of work. Is asking them to pay twice ‘Ensuring Fairness?’
There is a danger in following the taxation = entitlement link too far, for in discriminating on the basis of wealth, the very reasoning behind a national health system – equality of citizenship – is eroded. Of course, that’s unlikely to bother Hunt and co. too much. There’s a barely disguised assumption that any immigrant worth their salt wouldn’t deign to use the NHS anyway, but ‘may  want their healthcare needs to be met by private healthcare’.  When the rich opt out of citizenship, none of us gain – apart from the Health Industry. Let’s not forget BUPA made $604m in profit last year.
The Paper starts off with heady promises that the migrant levy will not see anyone refused ‘timely treatment necessary to prevent risks to their life or permanent health’.  Yet if you read on, ‘we want to consider further the possibility of charging for emergency treatment’, because it seems, some people ‘expect to pay’. Where this leaves those who can ill-afford to, and who wait till the last moment to seek care (risking poorer outcomes), is an awkward problem – as the document at least has the grace to admit.  Buried in the details are other outrages: the suggestion that pre-existing pregnancies should not be covered by any levy charged, for example.  So women married to British citizens and who come to the UK to give birth to British citizens may well be expected to pay out-of-pocket for the privilege (given that health insurers tend not to be keen on pre-existing pregnancy either).
Charging migrants turns GPs in unwilling border police, in pursuit of political objectives that only make sense if they’re framed by the wider privatisation project, and the nationalism that distracts from its hard logic. Yet in the end, after all the outrage at East Europeans’ arrival, their rights to use the NHS won’t change. We are European citizens, and we benefit from freedom of movement and access to their healthcare too:  not least from Poland’s dentists.
Part of the reason why I’m so angry is that since March I’ve been living in the US. Now, I’ve seen what privatised healthcare looks like first-hand, and it’s not pretty. Expensive insurance policies that still demand extra payments for such fripperies as appointments or prescriptions; over-medicalised middle classes; some of the worst health outcomes in the developed world, for twice the money. But plenty of competition, plenty of choice, plenty of glossy brochures.  If you can pay.
The NHS is one of the greatest accomplishments of the twentieth century.  Along with those other audacious achievements of that post-War government – national insurance; free education at all levels; child benefit – the NHS is evidence that, sometimes, governments can govern for the people. This narrow-minded petty nationalism is no fit legacy for the ideals that drove those reforms forward.  Time and time again the Consultation paper calls the NHS one of the ‘most generous’ health systems in the world.  We should be proud of that, not contemptuous. Yet it’s hard to escape the conclusion that we are witnessing the slow dismantling of the NHS. 
Jeremy Hunt claims that he’s just protecting our national health service. But while it may be only the foreign mothers of unborn British citizens, the high-skilled migrant tech workers (upon whose shoulders rest chances of British economic recovery), and the overseas students whose inflated fees keep British universities solvent who are billed this time, it’s another low blow undermining the principle of universal health care.  And it’s hard not to fear that pretty soon, there won’t be much of a health service left for anybody.
Anti-migration populism does not (whatever David Goodhart and others might claim) protect “our” poor.  It’s a smokescreen for policies that intend the very opposite: in this case, profits and private medicine.  It doesn’t have to be like this. The consultation is open until 5pm on 28 August 2013: please, read the paper, and make your voice heard.

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