Source: Wikimedia Commons Author: Oxyman
It’s been a month since the clamour and bustle about healthcare reform during the US Congress’ summer break in August. The British blogosphere was then alight with spirited defenses of the NHS, like this piece from David Colquhoun. As Congress gets back to work, Obama is countering his critics with speeches on several of his main policy areas. Now that the dust has settled, I’d like to take a closer look at it.
Firstly, it’s worth noting that the NHS is incredibly popular as an instution. People love the NHS, although they often criticise government decisions made about it.
What is bemusing to us in the UK medical field is the way in which the NHS has been held to be an example of
1) An inefficient system
2) An unfair system that restricts access to treatments
3) Socialist or communist
4) The fate that could befall the US if healthcare reforms are passed
None of these are true. Before discussing the merits and drawbacks of the NHS, let’s take point 4 – the US has an insurance-based system and it will in all likelihood remain that way. As Atul Gawande points out in this excellent New Yorker article the healthcare system is like the phone system: you can’t just turn it off for a few months to replace it with something better. Health insurance systems developed naturally at first, with a varying course depending on local context, but now that they are in place they are very difficult and expensive to change by whatever means. It is therefore both highly improbable and probably undesirable for the US system to become like the NHS.
Many valid criticisms can be made of the NHS. As such, it is strange that its US critics have often strayed so far from reality in order to criticise it. The advantages of the NHS of 2009 are simple: free treatment for all with relatively short waiting times and good health outcomes, at a modest national cost of 8% of GDP per capita. Its disadvantages are: patchy funding depending on region for high-tech treatments that have a poor cost-effectiveness or are purely elective (the ‘postcode lottery’), wards with little privacy, and high rates of hospital-acquired infection.
It is pretty efficient, then, and fair to all – since we all get charged the same – nothing (although there is regional variation in service provision, as mentioned above). Although it may have been founded on socialist principles, no-one in the UK ever calls the NHS ’socialist’ or ’socialised’, it is simply not considered as such. And in any case, unlike in the States, most countries in Europe call their mainstream left-wing politicians Socialists, who are considering far milder than Communists (which many in the US seem to consider identical). The NHS co-exists with private insurers, who are still able to sell premium services despite competing with an excellent government-run system. This should have been one of concrete factual argument used by the Democrats for the feasibility of a public option, rather than the counter-argument it became in a fact-free environment.
Then of course, there were the inevitable hilarious ideas such as “Stephen Hawking wouldn’t have been allowed to live under the NHS” when he in fact says he owes his life to it.
By contrast, the US system costs an exorbitant 16% GDP per capita, does not cover a large fraction of the population, and has very little in the way of measures guaranteeing fairness. Half of that 16% is already spent on Medicare and Medicaid – so actually, Americans are spending proportionally just as many of their tax dollars on national healthcare programs as we are already, and see how much more we do with it. So to counter the fears of ‘rationing’, we actually provide more care to more people at the same cost.
It’s a shame that truly intelligent discussion of healthcare has been derailed by scaremongering and one-liners in the US. While we could accuse anti-reform adovcates of disingenuousness, it’s also clear that the Democrats failed to make a clear riposte to their arguments and a convincing case of their own. Intelligent and informed analysis pieces, such as this FT column, have been few and far between.
September 14th, 2009 at 6:46 pm
I can’t understand why Medicare and Medicaid are so stunningly inefficient. Maybe it is because Medicare is only for the elderly who are expensive to treat?
September 14th, 2009 at 6:59 pm
I think it might be a little fairer to compare America with the German insurance system (although no-one in the States seems to be doing so). My understanding is that everyone is registered with one health insurance company or other and your employer, as well as having to pay tax to the government, has to pay part of your health insurance (the rest is covered by the government). Coming from England it sounds quite strange, but according to Wikipedia Germany has the oldest universal health care, and they do very well in terms of life expectancy and patient/doctor ratios and things. I’m guessing Nico probably knows more about this than I do, despite me living in Germany…
September 14th, 2009 at 11:25 pm
This is very well written and explained. I hope you don’t mind, I posted this link to the Wall St Journal in response to their article http://online.wsj.com/article/SB10001424052970203917304574412680569936844.html?mod=googlenews_wsj&mg=com-wsj#articleTabs%3Darticle
Thank you!
September 15th, 2009 at 2:03 am
So much mis-information, so little time to rebut. NHS is apparently fine, as long as you don’t mind limited or no access to “high-tech treatments that have a poor cost-effectiveness” (At what point does paying a lot for a treatment to save your life or your child’s life become “poor cost-effectiveness”?) and “high rates of hospital-acquired infection” – symptomatic of poorly managed, poorly staffed, and unprofessionally operated medical facilities. But hey, it’s free, right, and you don’t even have to make any hard decisions; just let the government do it for you (but that’s not socialism, is it.) As we way in the USA, just keep drinking the Kook-Aid and for God’s sake, try to stay healthy.
September 15th, 2009 at 7:48 am
W Davis. My experience is that you also have limited or no access to high-tech treatments in the USA unless you have health insurance.
The argument about decisions is interesting. How much choice does your health insurance policy give you in the doctors and hospitals you can use? As I understand it, the vast majority of people in the USA get their health insurance through their employer. The employer will typically only offer one scheme. That scheme will specify the doctors and hospitals you can use. As a UK citizen I can register with any GP practice in the country (at is happens my local practice is excellent – about 5 minutes walk away) and I can specify which doctor in that practice I want to use. Should I need secondary care I can choose any hospital in the country – although the GP will typically help me in that choice. Should I be unhappy with those choices I can of course go private or part-private (for example getting the actual operation on the NHS but paying for a private bed)
In practice all the statistics show that we stay as healthy as the US.
September 15th, 2009 at 12:22 pm
W Davis: It becomes poor cost-effectiveness when saving your child’s life means that there isn’t enough money to save five other childrens’ lives. You may think this a heartless situation, wouldn’t it be better for everyone to pay for themselves so no children die? However, one in six people in America doesn’t have insurance (reference
September 15th, 2009 at 5:25 pm
There are a few points to reply to here:
1) You still have the opportunity to take out private insurance with companies such as BUPA to get a premium service if you want to get treatments that are not sufficiently cost-effective to be funded on the NHS. Therefore the freedom of the individual to purchase healthcare is preserved, but the overall cost-effectiveness of the system is high. Cost-effectiveness is also ensured by the use of GPs as the first point of entry for non-emergency care. This is cheaper and ensures better continuity of care than the ever-increasingly hospital-based medicine in the US.
2) High rates of hospital-acquired infections are a complex issue. I agree that the NHS is understaffed on the frontline in many places, and some places have poor managers. However, this is far from the only reason. We should increase the number of frontline nurses, lower bed occupancy rates and build better hospitals. If we were to double spending on the NHS to achieve those goals, we would still be spending only as much as the US does.
3) ‘Let the government do it for you’ is not necessarily a hallmark of socialism. In the modern European sense of socialism meaning social democracy. Rather, it is a hallmark of authoritarianism (the opposite of libertarianism[US]/liberalism[UK]). Either left- or right-wing ideologies can favour an authoritarian approach.
September 16th, 2009 at 2:09 pm
Let’s not forget, that more than 100 NHS doctors and patients leaders have answered a call from Senator John Kerry, the democrat and former Presidential hopeful, who has asked for “lies” about the NHS to be exposed.
The letter, which has been signed by top doctors from across Britain, including Sir George Alberti, the Government’s emergency care Tsar, and Professor Alan Maryon-Davis, the president of the UK Faculty of Public Health, insists that the NHS is “literally a life saver”, especially for patients with pre-existing health conditions.
“In the US, people with pre-existing health problems are rarely covered by private insurance companies for those problems,” it reads.
“Many do not change jobs for fear of losing cover for such conditions from their new insurers. The NHS is literally a life saver for those with pre-existing health problems – they are not denied care.”
“On average, British users of the NHS live longer and have a lower infant mortality rate than the US,” it adds, while “survey after survey” shows high patient satisfaction.
The NHS also give “freedom from (the) fear” of the financial consequences of falling sick.
The elderly are given the same treatment as younger patients, with free flu vaccinations, nursing care visits, and home help on top, it adds.
The letter also points to the case of Prof Stephen Hawking, who suffers from motor neurone disease, who last month insisted that he owed his life to the NHS.
Although Britons can take out private health insurance, only one in eight chooses to do so, the letter adds.
The letter, published in the British Medical Journal, attacks claims that the NHS has “death panels”, in which doctors decide who should continue to receive medication and treatment, a key claim of opponents of President Obama’s healthcare reform plans.
It also refutes one American politician’s assertion that Teddy Kennedy, the senator who died last month, would not have received treatment for his brain tumour in Britain, because at 77 he was too old.