To explain why the UK voted to leave the European Union, commentators have zeroed in on four potential reasons: fear of immigrants, voter dissatisfaction with a weak economy or the status quo, loss of national autonomy, and age.
The first three explanations are intuitively powerful, but they seem to be contradicted by a whole host of evidence. The fourth — age — is quantitatively persuasive, but it still leaves us searching for a story about how years-lived affects opinion.
All the while, the issue that received the most coverage during the campaign seems to have been entirely forgotten in the post-Brexit analysis: health care.
For some reason, the post-Brexit analysis, particularly in America, has ignored this aspect of the story. But choosing to ignore the politics of health is a risky proposition. For although this conflict has remained latent for quite some time, as our societies have gotten older, it has become a highly salient divide in our democracies.
The older members of society want more of the increasingly expensive medical treatments that extend their lives, whereas the young are on average healthier and they resist paying for large health systems or seeking out health insurance.
What did not cause Brexit (at least, not totally)
Before I explain the role of health politics in Brexit, we must consider why the alternative explanations are insufficient for explaining the outcome. It is useful to provide this corrective, because attempts to draw out lessons from Brexit for the current US presidential election have largely drawn on these three somewhat false narratives.
First, economic concerns always appear to be part of political rhetoric; but it seems a stretch to attribute Brexit to a sense of either national or personal economic distress. For one thing, UK unemployment is currently at historically low levels (hovering around 5 percent).
And in surveys, large pluralities of Brits have — over a two-year span — consistently thought that exiting the EU would make the UK economy worse off. In the most recent pre-vote survey, only 23 percent of respondents thought that the economy would get better if the country left the EU (40 percent thought things would get worse!).
With regard to personal finances, the picture is also muddled: Almost half (47 percent) of surveyed Britons believed that leaving the EU would make no difference to their personal finances; only about one in five thought that Brexit would have a positive impact on them.
Second, xenophobia was undoubtedly a part of the Brexit mentality. However, the exit campaign preceded the recent influx of Muslim refugees, and the districts that voted most heavily in favor of remaining (London and Scotland) also have some of the highest proportions of Eastern European immigrants.
In general, there was no relationship between size of immigrant population in a region and Brexit vote. So it seems unlikely that Eastern European immigrants, who compete for scarce jobs, and Muslim refugees, with their "subversive" religious beliefs, are the main cause of Brexit.
Historical trends in YouGov surveys on the main concerns of Britons further support this. As the chart below shows, Brits have increasingly ranked health as the most important problem facing their country — steadily overtaking both the economy and immigration:
Clearly, both economic concerns and anti-immigrant sentiments were important lenses through which the Brits understood the status quo, but they were both decreasing relative to health as a national concern.
Third, the media has focused on the "take our country back" argument, comparing it to the appeal of Donald Trump in America. There is no doubt that taking control back from the EU was a part of the Brexit campaign.
But according to surveys, average Brits did not see the EU as the main threat to their nation. For instance, in an April 2015 survey that asked Brits to pick the most important issues facing the country, far more chose the economy and health than chose Europe:
Finally, age was a clear line of division: Almost 75 percent of voters age 18 to 24 voted to remain, whereas only about 40 percent of those age 65 and up did. But this doesn't explain why older voters were less likely to vote to stay in the EU. Rather, commentators use age as an indicator of other beliefs, typically claiming that older people are more xenophobic, economically insecure, or nationalistic.
But, as noted above, these arguments are incomplete. And they ignore one of the most common aspects of getting older: the need for more health care. As the table above shows, there is a rough relationship between age and health concerns: The older the person, the more likely they are to mention health as the most important problem for the country.
Saving the NHS by leaving the EU was the core argument of the Leave campaign
It is difficult to overstate the importance of the NHS in the UK consciousness. The NHS is the fifth-largest employer in the world (only the US Department of Defense, the Chinese army, Walmart, and McDonalds have more employees). In a recent poll, Brits voted the NHS to be the number one "symbol of what is great about Britain and we must do everything we can to maintain it." It ranked higher than the monarchy and the British army.
It is no surprise, then, that when the Leave campaign began to make its argument, it seized on the NHS.
Indeed, one only needs to superficially examine the Leave campaign’s official propaganda to see the importance of health care to their simple and clear argument — the cost savings of leaving the EU can be used to the National Health Service, Britain’s publicly funded health care system.
This argument was the number one reason offered for exit, both on the Leave campaign’s official leaflets and on their infamous buses. "Save our NHS" and "Help protect your local hospital" posters were the only issue-specific positions plastered on the "Vote Leave" website and were often handed out at the campaign’s rallies.
Indeed, the use of the NHS logo was so pervasive in the Leave campaign that the Department of Health, which owns the trademark to the brand name, threatened litigation.
The first volley came in January, when UKIP made a pledge to invest £3 billion into the NHS. Where would the money come from? Easy: "Instead of paying the up to £20bn a year to the European Union … why don’t we use some of this money to help our NHS."
In April, the Leave campaign published a highly publicized letter signed by over 50 health care workers that argued that the NHS was in financial crisis. Their proposed solution was simple: "If we Vote Leave on 23 June we will be able to spend more on our priorities like the NHS. If we put the billions that currently go to EU bureaucrats into the NHS instead it would hugely improve patient care." When Boris Johnson, the former mayor of London and newly named foreign secretary, joined the Leave campaign, he further added that Brexit would reduce waiting times at accident and emergency centers.
And these arguments actually seemed to be having an impact: By the end of April, for the first time since the question had been asked, a larger percentage of Brits believed leaving the EU would improve the NHS than the percentage of those who thought it would be bad for the NHS or have no effect at all.
At first, the Remain campaign didn’t really provide an organized response to the Leavers’ claims, seemingly assuming people would recognize their inaccuracy. And when the Remain campaign did finally recognize the threat, they framed their response in a way that appealed more to young people than the older people who were the ones most immediately concerned with the state of the NHS.
The Remain campaign framed the EU as a kind of alternative to the NHS: a panacea to guarantee better health. For instance, the Royal College of Physicians argued that the EU should be regarded as a "social determinant of health." The EU would not necessarily fix the NHS, but it would help produce better health in spite of the NHS’s problems.
First, they argued that the EU allowed Brits to engage in "medical tourism." They pointed out that 27 million individuals have a European Health Insurance Card, which allows them to travel to and seek treatments in other European countries — outside the NHS.
Second, they argued that the UK would lose influence over the European Medicines Agency, the organization that approves drugs for use within the EU (basically the EU’s equivalent of the US Food and Drug Administration) and which is currently based in London. They also noted that the UK would lose access to EU funding for health and drug research (the UK receives 16 percent of the EU’s research budget).
Finally, they argued that being outside the EU would make it harder for the UK to deal with pandemics as well as other emerging diseases. Without EU cooperation and coordination, the UK would have to engage in its own surveillance of emerging diseases and maintain its own databases.
All three arguments positioned the EU as an alternative provider and guarantor of health. So, not only did the argument against Brexit come too slowly, when it arrived, it really only appealed to one group of people: the young.
Across the world, young people tend to be more enthusiastic about medical tourism. And the same is true of Great Britain. In a recent 2012 survey, while 29 percent of people over 50 years of age said they would "definitely never" travel to another country for cheaper medical or dental care, only about 16 percent of those under 35 were similarly pessimistic.
Moreover, in the UK, it is the youngest people who show the most enthusiasm for more medical research and who want to use medical research activities as means of improving the NHS. In surveys from the renowned Wellcome Trust, only about 11 percent of adults ages 18 to 35 thought that the UK spent too much on medical research, compared to about 21 percent of adults over 50.
This general skew of Remainer arguments toward health policies preferred by the youth of the nation seemed to have two consequences for the views of the NHS. First, the young were less satisfied with the status quo. In a 2015 survey released by the NHS, about 57 percent of the young (18 to 34) were willing to say that they were satisfied with the current version of the NHS, compared to 71 percent of the old (over age 70).
Second, the version of the NHS augmented by the EU appealed more to the young than the old. In a large survey of Britons right before the vote, there was a large age gradient in the effect of Brexit on the NHS: The young (67 percent) were far more likely than the old (37 percent) to think that the EU’s role in the NHS was positive:
Putting these facts together reveals a simple story. The Leave campaign seized on the peculiarly British love of the health care system, stoking fears that the NHS was in trouble, and that Brexit was the solution. The Remainers were slow to take this strategy seriously. And, when they did, their messaging and argumentation was oriented to the youth of the nation.
By the end, both sides managed to convince their constituencies of their cases: The young thought the EU was indispensable to the NHS, and the old thought the NHS would be better outside the EU. The old turned out to vote, and they won.
The future of NHS politics in Britain
Just moments after the Brexit vote, Nigel Farage admitted that the NHS promises would probably not be fulfilled. An exasperated reporter who confronted Farage responded: "So you’re saying that after 17 million people have voted for Leave, I don’t know how many people have voted based on that advert, but it was a huge part of the propaganda, you’re saying that’s a mistake?"
Brexit will surely have destabilizing consequences for the health care of Britain; but, moving forward, it should be remembered that Brexit is only one instance of the use of the NHS in UK politics. Because the NHS is important to Britons both as a supplier of health care and a symbol of British culture, it often shows up in other realms of politics.
Consider, for instance, current debates in the UK over funding of the nuclear weapons program. The Labour Party has argued that the money spent on "Cold War weapons" should instead be diverted to the NHS. And so we go again. Like the use of the foot to measure distance, the money spent on the NHS is likely to persist as a strong English reference point for the measurement of governing priorities.
As aging Brits continue to demand that the government provide more access, lower out-of-pocket costs, and better quality of health care delivery, more and more will have to be sacrificed in the name of the NHS.
Mateusz Tomkowiak is a PhD candidate in politics at Princeton University who studies American politics from a historical and international perspective. Follow him on Twitter @itomkowiak.