The blogosphere is erupting with criticism and praise for the NHS, which divides along national lines. One thing you have to understand is that the NHS is one of the most sacred things to British identity. We love whingeing about it but we love it and believe it to be better than the alternatives. I'm not sure what a US equivalent would be, maybe Congress, in that they complain about it all the time but say bollocks like that it's the only true democracy in the world.
I'll be honest, some people are better off in the US system then in the UK system. The main people who are better of are:
Very rich people, because they will use private health care in both systems and in the UK system they pay twice, although this depends on how rich they are compared to how sick they get. The NHS effectively subsidises private healthcare in the UK because the moment something goes seriously wrong the patient can be transferred to an NHS hospital for them to pick up the pieces.
People who make money out of the US system e.g. people with shares in health insurance companies, medical staff probably get paid more in the US etc.
People who might benefit from expensive treatments with low success rates. Extremely premature babies are more likely to survive in the US, because US hospitals better, much more expensive treatment for them. All the extra money Americans spend on health care per capita does improve the outcome of some people at the margins.
You might be better off if you've got good, particularly employer based cover, as long as you don't get too sick. However, on average Americans pay more for their insurance than Brits do for our NHS and insurance companies put a horrific amount of time and energy into finding reasons to avoid paying out (more on that later). It also causes problems in that one's options to change jobs or marry and divorce are restricted by the effect it will have one's health coverage.
I think that I take this discussion a bit personally because my family is one of the groups of people who are much better off under the UK system. My husband has a chronic health condition (well actually a couple of them) and don't think he'd be able to get insurance in the US. As there's a strong genetic factor to it, I'm not sure if our children would either.
Anyway, what I really want to talk about, and the inspiration for the title of this post, is rationing in healthcare. Here is the uncomfortable truth: all healthcare systems involve rationing
. The amount of money we could spend on healthcare tends toward infinite, or at least exceeds the per capita GDP of any country. Even if we spent the bare minimum on housing and food and every other penny on health care, we'd still have to ration healthcare in some way, and our health would be worse because access to good food and housing have a much bigger impact upon health than access to MRI machines. I'm at peace with that. I honestly prefer to have a MacBook and a house with a garden, to the couple of months my life expectancy might be extended by spending more on healthcare. If I felt differently, in the UK I'm free to purchase private healthcare and the only limit would be the amount of money I was willing and able to spend. All systems require some way of deciding which treatments, which might improve a patients chances, aren't worth the extra expense.
One of the arguments being used against a UK style system is the bogey man of healthcare rationing, which led to the amazingly stupid statement that “scientist Stephen Hawking wouldn’t have a chance in the U.K., where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless.” Of course, the (sadly for my faith in humanity not deliberate) mistake is that Stephen Hawking is British has lived in Britain for the majority of his life (his being a professor at the University of Cambridge is a clue) and regular relies upon the NHS for healthcare. Maybe they were confused because he his speech box has an American accent.
The picture being spread by opponents of healthcare reform is of Orwellian panels before which people will have to justify their existence to receive healthcare. That's not actually how it works in the UK. We have an institution called the National Institute for Clinical Evidence, or NICE for short. Their job is to decide what treatments are cost effective to provide. They do this by comparing a treatment to the number of QuALYs (quality adjusted life years) it can be expected to provide a patient. Here is where the tiny grain of truth in the likes of Palin's criticism of the NHS comes in. As the years are quality adjusted, treatments which return a patient to full health are more likely to be paid for than a treatments which leave a patient in pain or with a disability.* This is a much discussed paradox in healthcare economics, it intuitively makes sense that a treatment which saves your life is better than a treatment which saves your life and leaves you blind, and patients faced with two treatments, one of which is slightly more risky but one of which may lead to a serious disability, may well prefer the more risky treatment. However, we don't like the result that saving the life of a blind person is worth less than saving the life of a sighted person. Happily most of the time these kinds of concerns aren't very relevant to NHS rationing decisions. Most treatments which don't get approved by NICE don't get approved because they're not very effective, or even have negative consequences which outweigh the positive ones, or there are alternative treatments which are cheaper and just as good. The big one which has made the headlines are certain very expensive cancer drugs. The thing which really stopped NICE approving them was that they only had quite a low chance of extending life a few months. We could get all sentimental about doing everything possible to extend someone's life, but if you give someone with terminal cancer the option of a 5% chance of an extra three months with end stage cancer or the equivalent money's worth of really good palliative care, such as 24 hour nursing in their own home, they might not pick the drugs.
And as a stated above, all healthcare systems involve rationing, even in the US. In the US rationing takes the form of whether your insurance company or you yourself will pay for it. I think maybe Americans get more squeaked by the government making life of death decisions than by leaving them to the private sector. Some insurance policies have explicit exclusions. A lot of the time they do it through rescission. Rescission is the process by which an insurance company declares a policy invalid, without having to return the premiums paid, usually under the legal reason that they was a misrepresentation or mistake on the patients original application forms. I say 'legal reason' because if you want to make a profit, there's not much point dropping clients whose medical costs are less than their premiums, even if they have made a mistake on their forms. If they're motivation were purely legal they'd explain it as "rescission is essential for combating fraud" rather than "it is one of many protections supporting the affordability and viability of individual health insurance in the United States under our current system" as Don Hamm’s (CEO of Assurant) said. He also said that rescission only effects less than 0.5% of the people Assurant covers, which sounds pretty small until you take into account that 90% of the US population use less healthcare each year than the cost of the average insurance premium. There's not much point in an insurance company rescinding their policies, given that they're making a net profit. So that 0.5% becomes a 5% chance that your insurance will cancel your policy if your healthcare costs more than that year's premium. If they target the rescissions at the 1% most expensive patients you're looking at a 50% chance of rescission if your healthcare costs go over $35,543. Here's blog a cribbed most of this off
. It also features a great video in which no one in a commerce subcommittee, including the CEO of Assurant, can work out what their "easy to fill in" form means. Insurance companies have a really strong financial incentive to make sure that you don't fill in your form correctly so that they can get out of it if you get too sick. Rationing happens in all healthcare systems. In the UK it's done by government agencies; in the US it's done by insurance companies. I prefer a system in which these decisions are made transparently by people who answer to the people I elect.
Which brings me back to Stephen Hawking. Today, Prof. Hawking would receive great healthcare in either country because he's famous and eminent. However, if he'd been a US grad student when he was diagnosed with his condition at the age of 21 how likely would he have been to one of those 0.5% of patients who face rescission?*Just to clarify, this doesn't mean that you're less likely to receive a treatment just because you have a disability. NICE makes decisions about treatments not patients. The only way in which patients pre-existing conditions work their way into the maths is when they impact upon the likely effects of the treatment, for example, there's not much point treating someone's prostate cancer if their going to die from kidney failure long before the cancer spreads from their prostate. The only place I see rationing based upon pre-existing conditions really biting is in donor transplant, where your chances of receiving an organ is lower if your life expectancy is lower or your condition makes the transplant less likely to be successful. I'm not sure of a way private healthcare could get around that other than the even more distasteful idea of organs going to the highest bidder or buying organs.