What’s so scary about the NHS?

Civitas, 18 May 2009

As President Obama pushes ahead with his plans to reform healthcare in the United States, announcing a proposal that would vastly expand federal regulation of insurance and the healthcare industry as a whole in order to guarantee all Americans access to affordable coverage, he is facing some equally determined opposition. Conservatives for Patient Rights (CPR), a right-wing advocacy group, last week launched a $500,000 television advertising campaign to promote free-market health care. The campaign’s message? Obama’s proposals could turn the U.S. healthcare system into…the NHS!

The advertisements present interviews with British and Canadian patients (the ‘victims of government-run healthcare’) who talk about different barriers they have faced in accessing care, and physicians who lament the restrictions placed on their autonomy by state-run healthcare systems. UK patients include Katie Brickell, who was diagnosed with terminal cervical cancer at age 23 after being refused a routine pap smear test on three occasions (the NHS currently allows the test beginning at age 25), and Kate Spall, who tells of her mother’s death from renal cancer after she was repeatedly placed on waiting lists for surgery. Her cancer metastasised during this time, and she was then told her local primary care trust (PCT) would not fund a potentially life-prolonging drug. Kate shows the denial letter from the PCT, which states: ‘This may seem harsh for individuals but the PCT has to balance the costs of individual treatment against the needs of the wider community.’

Also appearing is Professor Karol Sikora, who, as an oncologist, speaks about the heartbreaking situation of prescribing treatments he knows his patients may not be able to obtain because they have not yet been recommended by the National Institute for Health and Clinical Excellence (NICE), and therefore PCTs have the option not to fund them.

There is another side to this, however.  CPR and much of the US republican political party want to publicise the failings of government-run health care primarily because they have close ties with the healthcare industry (insurers, private provider chains, pharmaceutical companies), whose structure and finances may be greatly affected by the proposed policies. CPR is led by the ex-CEO and chairman of Columbia/HCA (a hospital management company that collapsed after being forced to pay $1.7 billion in fraud compensation to the US government). If you have doubts, check out the introduction to Regina Herzlinger’s book Who Killed Health Care?, which documents the countless times Congress and large health insurers have blocked moves to increase transparency and consumer power.

But this is a smart political campaign. As an American, I understand how such sentiments hit at the heart of the fear of the single-payer system, or what opponents such as CPR dub ‘socialised medicine’.

In the United States, there is a deep cultural resistance to the idea of ‘rationing’—rooted in the nation’s founding ideals of individual independence and payoff for hard work, growing through the terror of communism in the 1940s and 50s and further instilled by the Cold War. Rationing, parents and teachers have always told their children, is what happens in poorly run, dictator-lead countries—not in a free-market, capitalist nation like ours.

As an economic concept, however, rationing is unavoidable wherever any collective responsibility is taken.  No government administration would dare use the term, but rationing is of course already taking place in US health care; the allocation of resources is such that those with the most wealth can and do receive the best (often most expensive) treatment, and health insurers frequently dictate to doctors what they can and cannot do in the care of a patient. It is fair to say that with some 47 million uninsured, the highest healthcare costs in the world, and repeated bottom-level rankings on international league tables of health outcomes, the current US system of rationing is indeed in need of reform.

CPR and their supporters are right in that problems do also arise in highly centralised, political health systems like the NHS.  The health service here too easily frowns on the pluralism that would support innovation and clinicians tailoring services to individual patients.  But instead of fighting for the status quo in America, why not take a look at some other European systems that are equally committed to universal health care, and which often have even higher outcome rankings and patient satisfaction levels than those of the NHS?  In Bismarkian systems (which have policies the US might more  easily adopt, due to American system’s existing insurance function) certain principles apply almost universally.  All individuals are obliged to pay into a social health insurance plan from a menu of insurers; insurers are obliged to accept all the applicants that choose them; and the government goes someway to defining the mandatory minimum package while paying subsidies for those on low incomes or with excessive health risks.  In Germany and France this is done through the wage packet, an earmarked health tax that goes straight to a patient’s insurer. In Switzerland and the Netherlands it is achieved largely through health premiums (similar to paying for private health insurance in the UK, but with comprehensive top-ups for those who cannot afford it), and this provides the advantage of detaching health care from employment and the fluctuations of the labour market.  Either way, the consumer (the patient) controls the purse strings, not the government or (particularly in the case of Switzerland, Germany and the Netherlands) health insurers.

No healthcare system is without its faults. Our focus of reform should instead be on learning from each other’s successes and shortfalls. Ironically, the NHS is currently trying to figure out how to garner further benefits from working with the private sector.

However, most developed nations have long ago decided that basic healthcare is a right. The question is whether the U.S. wants to re-allocate some of its resources from the hold of the powerful healthcare industry and put them toward improving equity, even slightly, in population health.

CPR and their supporters are saying no. And that’s scary.