Editor's note: This story, originally appearing on August 20, 2009, is reprinted here as part of our Best Crosscuts of 2009 series.
There is a lot of talk of 'êsocialized medicine'ê in the current political debate about health care. Some politicians assert that the Obama Administration and the Congressional Democrats want to destroy the US health care system and replace it with something on the lines of the British National Health Service.
I have lived most of my life in Britain. I have used the British Health Service on and off for over 60 years and the US health care system here in Seattle equally for the last 15. In my main career I worked as a senior Civil Servant in the British Health Department where for a while I was the Under Secretary responsible for negotiating the health care budget with the Treasury. I have used 'êsocialised medicine.'ê I have observed it at close quarters. And I have helped to run it.
It'ês no boast but a statement of fact to say that I can recognize it when I see it and know what'ês good and what'ês bad about it. I am equally confident that none of the proposals now before the US public amount in any serious sense to 'êsocialized medicine,'ê and that an informed and rational debate around these proposals should lead to real improvement in the way health care in the US is paid for.
In spite of some of the absurdly distorted things you can hear about it in the current US debate, Britain has a good health care system. It helps the population to live longer than people on the average do in the US. It delivers a notably lower infant mortality rate. It costs around half of the US system. It covers the whole of British population, with few and relatively low co-pays. It has low administration costs. Because it is financed largely from general taxation it does not burden businesses, or push up the costs of employing staff. And contrary to what you hear in some quarters, no politician or 'êbureaucrat'ê has control over doctors'ê clinical work with individual patients.
My wife and I have just come from a consultation with her National Health Service internist near our central London home. We made the appointment on the Web before leaving Seattle. We sat for a moment in the waiting area of the newly built and beautifully decorated office. We were summoned to the consultation room at exactly the appointed time. The doctor was a model of courtesy, insight, and helpfulness. The consultation was unhurried. There was no paperwork for us before or after the visit and hence no clerical staff to handle it. There were no co-pays for the consultation or the three months'ê worth of medicines that the doctor prescribed for my wife. And to judge from the vehicles parked in the spaces reserved nearby for doctors (two Mercedes and a Lexus) the doctors are decently paid.
We experienced the system at its best. There is another side, however. Accessing the hospital and specialist services can be a frustrating business. There can be delays in getting appointments and further delays in getting treatment. Britain'ês survival rates for some cancers lag behind those of the U.S. and some other countries. British general practice is a strong and effective specialty, but is physically and organizationally separate from the specialist services. You do not find in Britain the full-service medical providers such as Minor and James, The Polyclinic, and Group Health in Seattle where in one organization patients can with relative ease and promptness access internists and all the mainstream diagnostic and specialist services.
With all its qualities and failings, the British National Health Service might be described as a 'êsocialized'ê or 'ênationalized'ê health care system because though the health professions practice independently within it, the Government both provides the money from taxation, and is responsible for managing and running most of the services. It is this double role — in providing both the money and the services — that makes the British system unique amongst developed countries and, if you don'êt mind the pejorative language, makes it 'êsocialized.'ê
The nearest U.S. parallel is the Veterans Administration, which is both funded and provided by the Federal Government. And the VA is an interesting subject for study. There have recently been questions about its quality control — for example in prostate cancer treatments. But in a review of US health care systems done a couple of years ago by the independent Rand Corporation, the Veterans Administration scored higher than any other on five of the six criteria studied. This points up the danger in crude stereotyping of health care systems by the degree of government involvement.
There is no question of moving to a government-run system for the generality of U.S. health care. None of the proposals emanating from the House or the Senate would lead to a single monolithic health care service or increase the federal government'ês role in the direct provision and management of health care. There is good reason for this. The U.S. consumer'ês expectation of promptness and choice of access and the American voters' traditional dislike of government combine with extremely powerful and well entrenched health care and insurance provider interests to mean that any efforts to recreate a British-style health care system in the US would be politically insane. Whatever its virtues and defects in its own context, the British system is not a viable export.
The main thrusts of the reforms on the table in the U.S. are to change the regulation of the private health insurance industry so that people with existing serious health problems are not cut out of the system; to increase the opportunities and incentives for uninsured people to get insurance; and perhaps also to create a government-run insurance scheme, akin to Medicare, to cater for the needs of the working-age population alongside or in competition with the existing private insurance schemes. Whatever the merits or faults of these proposals, their adoption would retain the individual'ês right of access to and choice between a wide range of providers, and the provider side of health care would remain in the private sector.
One fear expressed is that if the public insurance scheme were created it would be so popular and successful that it would destroy the existing private schemes. To judge from recent statements, the leaders of private insurance firms seem to think this would happen — though whether in the event they would prove so lacking in competitive spirit and business enterprise and would so quickly and feebly throw in the sponge must be doubtful. But even if it did happen, it'ês not clear that disaster would ensue (except of course to the profits of the defeated competitors). Medicare is a popular program, and is widely thought to combine low administration costs with a generally sympathetic approach to coverage and individual need.
If a Medicare-type system were to become the norm in the U.S. for the working-age population, the European parallel would not be Britain but France. There, most health care is paid for through a branch of Social Security through which individuals are insured and are free to make their own choices of health care provider. Work on international comparisons done by the OECD and the World Health Organization suggest that the French arrangements are among the most successful in combining reasonable cost restraint with a high degree of consumer satisfaction. The French are demanding consumers and are not the people to suffer in silence. I can see no reason why the same could not be achieved in America.
A new U.S. public insurance scheme for people of working age would of course mean that more of the money for health care would be channeled though a government agency. But provided the actual delivery of health care remained independent of government, there would be no 'êsocialized medicine.'ê
In the US we tend to think that the health care system is based on the private sector. So it is, on the delivery side. But on the financing side, federal and state governments are already massive players. In only a few years, without any of the present reforms being adopted, one dollar in every five spent in the U.S. will go for health care, and nearly 50 cents in each of those dollars will be channeled through government. Given the size of the U.S. population, and its very high spending on health care, the federal government must already be the largest source of money for health care in the world. If channeling money for health through government agencies is 'êsocialized medicine,'ê then the USA is already, and irrevocably, its global capital.
The British health service may have something to offer as a model in the strong role of general practice, particularly in the management of chronic disease. It also has purchasing disciplines which are tough, though not destructively so. In other respects, on any rational analysis, the scares about socialized medicine and the British experience are just red herrings drawn across the track to inhibit proper debate.
