A family dressed in white runs across an open meadow with glistening Colgate smiles. Fade to a tanned couple, embracing as they slowly rock on the dance floor at sunset. "Ixekizumab 80mg/ml injections" appears in bold font on the screen -- a new immunological therapy for psoriasis -- with a raw price-tag more than $4000 a fortnight.
"Ask your doctor today!"
But just as we are warned that ixekizumab can alter immune response and increase the risk of serious infections, we switch to an animated parrot advertising a Caribbean cruise with a rooftop pool and a free unlimited drinks package. Television in the U.S. is different.
It does not take long for other healthcare commercials to appear -- ads for hospital networks spruiking their special brand of personalised care, for health insurers offering to go that extra mile, for special financing to pay overdue medical bills, even for malpractice lawyers to quench your dissatisfaction.
A job-search commercial shows a man rejoicing that he finally got health benefits after using their platform. And the upcoming college football game is advertised with sponsor logos underneath -- a local hospital... and Pepsi.
The strange thing is how smoothly these health commercials blend in with ads for hatchbacks and holiday packages. One could easily assume that health in the United States is a middle-class luxury, to be desired and purchased like a Caribbean cruise. Scratch the surface and we find a complex commercial machinery whose mission is to sell healthcare to those who can afford it.
Many Americans have come to conceptualise healthcare as a commodity -- as a product to be advertised and bought.
Ever since that sleight of hand 80 years ago that linked health insurance to employment, blurring the lines between healthcare and remuneration, there has been a slow shift from patient to customer to consumer. Consumers who are today accustomed to astronomical healthcare bills -- the average raw cost of a three-day hospital stay in the United States is $30,000. A deeply foreign concept for Australians who live in the lap of a high-quality public health system.
The recent political whirlwind around dismantling Obamacare, which was dealt a terminal blow last week, must be viewed in the context of this peculiar capitalist experiment that is American healthcare.
The Patient Protection and Affordable Care Act, now nicknamed Obamacare, passed through Congress in 2010 with the goal of increasing healthcare access. At that time, over 18 percent of the U.S. population was uninsured -- 50 million lives unable to access healthcare without huge out-of-pocket expenses.
Obamacare tried to reduce that statistic by expanding eligibility for government-sponsored insurance plans for the elderly and low-income populations, by incentivising employers to provide health benefits, and by forbidding discrimination based on pre-existing conditions.
The long-term economic argument for Obamacare was to curb the overall healthcare spend by facilitating preventative medicine -- a vision that is yet to be fully realised. However, the real success story is that as of 2017, the number of uninsured Americans has almost halved.
Nearly 20 million people now have healthcare for the first time. The biggest gains have been felt in the hidden corners society. People with chronic illnesses can now access reasonably-priced insurance.
Almost two thirds of the newly insured population come from minority groups. In the words of David Cutler, a Harvard economist, "These are people who blend into the background of the economy... The law has helped this population enormously".
And yet, not a single Republican voted for Obamacare in 2010, and in the ensuing years there have been over 60 attempts to repeal it. In 2013, a prominent state republican called it "as destructive to personal and individual liberties as the Fugitive Slave Act of 1850". There are complex historical reasons fuelling this republican vitriol, but the core criticism is around wealth redistribution -- that taxes and private insurance premiums must increase to subsidise healthcare for the less wealthy.
President Trump rode to office promising to "repeal and replace" Obamacare, and on the same day as his inauguration signed an executive order that put a freeze on all of the Obamacare reforms still rolling out nationwide.
By early March, an alternative piece of legislation, the American Health Care Act (aka Trumpcare) had been drafted. Among other things, this new Act removes tax penalties encouraging individuals and employers to purchase insurance, reduces government support for the low-income insurance plan (Medicaid), and gives states the ability to opt-out of the pre-existing conditions clause. Obamacare, with all of its accessibility reforms, disembowelled.
Ever since March, in the halls of Congress and on the walls of Twitter, Trump and his allies have been on this 'repeal and replace' crusade. They came tantalizingly close in late July, as the Senate cast a final vote to repeal Obamacare.
In one of the most incredible political spectacles, Senator John McCain, who had just returned to Washington a few days earlier following brain surgery for glioblastoma, ambled to the front of the Senate, extended his hand like a Roman emperor, wavered for a minute, and then gave a thumbs down to seal a 51-49 vote against the repeal. A weathered Republican now reinterpreting healthcare as a patient and voting no.
After a few further skirmishes, last week Senate leaders finally announced there would be no further repeal votes. Obamacare, albeit in a handicapped form, looks like it is around for a while longer.
As the dust settles, we reflect again on why accessible healthcare -- something that most Australians regard as a foundational responsibility of government -- has proved so controversial. Trump's hostility throughout has been couched in this notion that Obamacare increases costs and reduces choice for the individual. We have become familiar with tweets like this:
I will sign the first bill to repeal #Obamacare and give Americans many choices and much lower rates!— Donald J. Trump (@realDonaldTrump) October 17, 2016
This argument feels more like a salesman selling a cruise with multiple buffet options and a 20 percent early-bird discount, rather than a finessed approach to health system design.
Atul Gawande, an American surgeon and author, put it beautifully in his recent New Yorker piece:
"Pitchforks have their uses, but crafting health-care policy calls for more delicate instruments."
However, the reason why this rhetoric seems to resonate is that many Americans have come to conceptualise healthcare as a commodity -- as a product to be advertised and bought. The whole architecture of the health system reinforces this -- from the hospital with valet parking and a sponsored football team, to the deluxe benefits packages offered by elite employers.
Healthcare is for sale, and you have to buy your slice of the pie. The unavoidable consequence is that, just like for that Caribbean cruise, there are first-class customers in the captain's lounge and economy travellers in windowless rooms.
And then people whom you don't see, who stayed at home.
The American healthcare dream.