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False Choices and Health Care

Steve Silberman recounts an encounter with the British healthcare system whilst traveling, which morphs into a rant against our pay-as-you-go system. In the midst of this, he observes,

One renowned health-care expert who grew up in England recently explained the difference between British and American medicine to me by saying that if he was very rich and had cancer, he would rather live in the U.S. But if he was poor and had cancer, he’d rather live in the U.K. and be guaranteed at least B-minus care.

We can quibble over whether NHS actually delivers B-minus care; many would argue it’s closer to C-minus. And it’s also debatable whether those poor enough to qualify for Medicare receive comparable care here. Regardless, the overall point stands: The United States provides cutting edge care for those lucky enough to be able to afford it, whether out of personal wealth or excellent insurance coverage, and puts those not so fortunate in dire straits whereas the British system provides at least mediocre care for all.

But this is a false choice. An NHS-style socialized system is actually rather rare. Most advanced societies have either a hybrid system of basic care with the ability to have private doctors on the side or a single-payer system with quasi-private doctors paid for by the state or a quasi-state agency. The United States will almost certainly wind up going in either of those directions, rather than maintaining our current patchwork or moving to the extreme NHS alternative, within the next twenty years. Our current model is unsustainable and that which is unsustainable won’t be sustained.

via Zoë Pollock

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About James Joyner
James Joyner is the publisher of Outside the Beltway, an associate professor of security studies at the Marine Corps Command and Staff College, and a nonresident senior fellow at the Atlantic Council. He's a former Army officer and Desert Storm vet. He has a PhD in political science from The University of Alabama. Views expressed here are his own. Follow James on Twitter.

Comments

  1. PD Shaw says:

    As I recall, the British have put a lot more money into their healthcare system to avoid some of the problems of a decade or so ago with dangerous wait times. Now, it might be on a less sustainable path than the U.S. depending on how you map the rate of increase.

    I think the false choice is that there is some system some other country has that need only be inserted on top of the U.S. and we’ll get the same outcomes.

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  2. george says:

    Living in Canada the last decade, I’d definitely go for the hybrid. The basic system here delivers a solid ‘B’ from what I’ve seen, and in fact an ‘A’ for emergency service – if you get into a serious car accident Canadian health care is as good as anything I’ve seen in the US (something I’ve seen personally in both places; Canadians really aren’t left dying on the streets, despite what some in the US say about the Canadian system. Its not accident that Canadians on average live as long or longer than Americans.)

    But non-critical care (hip replacement, knee replacement etc) isn’t as good as the best US care, typically requiring a fairly long wait. The ideal system would be to have gov’t care like the Canadian system (and the per capita expense of the Canadian system is half that of the US), and then allow private health care on top of it. Win-win as far as I can see.

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  3. JayR says:

    But this is a false choice. An NIH-style socialized system is actually rather rare. Most advanced societies have either a hybrid system of basic care with the ability to have private doctors on the side or a single-payer system with quasi-private doctors paid for by the state or a quasi-state agency. The United States will almost certainly wind up going in either of those directions, rather than maintaining our current patchwork or moving to the extreme NIH alternative,

    This is why the health care debate in our country fails. It’s because people who put themselves forward as educated and well-informed (like James) actually talk complete nonsense off the top of their head. The NHS (not “NIH”) is a “hybrid” system. In the UK you have an option to purchase top-off insurance and there is a system of private hospitals/clinics (The Duchy) that offer “private” healthcare. In fact, many specialists consult for both the NHS and the Duchy/other private providers and going private is a way to “jump the queue.” Perhaps James is thinking of Canada, which is truly a pure single-payer system. But if he is he should find a quote from a Canadian expert.

    I’ve lived in both the UK and the US and I prefer the UK system. Of course, I never wanted hip replacement surgery now-now-now but the NHS was certainly good for both the routine and acute care my family needed. It might be “B-minus” care, but the care that private insurance provides in the US is certainly not “A” care for most people.

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  4. DC Loser says:

    James – I think you meant “NHS – the UK National Health System” not NIH – which I think stands for the US National Institute of Health.

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  5. john personna says:

    It’s at least possible that the trade-off George describes, with fast emergency and slow hips, is near optimal.

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  6. James Joyner says:

    @JayR: There’s a private layer on top of the UK system, yes. But NHS is a bureaucracy-delivered system. It’s that which I’m speaking of that’s both rare and what those who oppose major reform are falsely putting forth as the choice.

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  7. James Joyner says:

    @DC Loser: Yes. Fixed!

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  8. DC Loser says:

    Back in the 70s, Benny Hill poked fun at the NHS and contrasted (and exaggerated) it with the pampered care provided by the private health care system for those who were willing to pay for it.

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  9. WR says:

    @James Joyner: The NHS is a bureaucracy-delivered system? Have you ever attempted to deal with a health insurance company here?

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  10. DC Loser says:

    James – I find your remark that NHS is a bureaucracy delivered system. How about military health care in the US? It’s the most socialist system I know. Why do retirees love their Tricare coverage so much? It sounds a lot like one of those bureaucracy delivered system too.

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  11. JayR says:

    @James Joyner

    Your reply is exhibit two of why the health care debate (and other political debate) is so broken. You said originally

    An NHS-style socialized system is actually rather rare. Most advanced societies have either a hybrid system of basic care with the ability to have private doctors on the side.

    But the NHS is precisely that! A system of basic care with the ability to have private doctors on the side. Rather than admit that you don’t know jack about which you speak you fall back on

    There’s a private layer on top of the UK system, yes. But NHS is a bureaucracy-delivered system.

    What is a “bureaucracy-delivered” system? Is that a technical term or just a way of saying “I don’t like the idea of it?” (Because who likes bureaucracy?) Can you come up with an example of a system that is not “bureaucracy-driven?” It’s sure not ours, or have you never had to deal with an insurance company? In fact, both in the UK and also in Australia (where I currently live) the “hybrid” system makes for less haggling with bureaucrats than dealing with private insurance in the US. In the UK my GP’s office had an office staff of one, because getting reimbursement from the NHS was a trivial matter so there was no need to have people to do billing and negotiate with the insurance companies.

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  12. James Joyner says:

    @DC Loser and @JayR: By “bureaucracy-delivered” I mean one where doctors are government employees and the hospitals are run by a government agency. Is there a technical term of art for this?

    @DC Loser: Tricare is after my time, although my parents were one it for some time. As I understand it, it’s just an government-run insurance system. When I was growing up, and even when I was in the Army, soldiers, dependants, and retirees went to military-run hospitals with military officer doctors. I gather those still exist for active duty personnel but that most medical care is now outsourced to the private sector and reimbursed via TRICARE.

    @JayR: I don’t think we’re in disagreement on anything substantive here. My preference is for some sort of single payer system where everyone is guaranteed a decent level of care that’s not tied to one’s employer or driven by profit. I’d like that augmented by a system where the well-to-do and those with better jobs that provide Cadillac insurance have the option for boutique care, skipping to the head of lines, and otherwise premium treatment. That is, preserving the A-plus system that exists now while ensuring that everyone gets at least C-level care.

    I think that would wind up being not only cheaper but providing better care.

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  13. JayR says:

    @James JoynerActually there is a term for this. It’s called “government provided health care” or “single provider.” Which is different than single-payer, in which the government merely pays for the health care and tells doctors how much they will pay. Like Medicare in the US or the NHS in the UK. Nobody forces a UK doctor to join the NHS (although once they do they are obliged to provide NHS care).

    I don’t think we’re in disagreement on anything substantive here. My preference is for some sort of single payer system where everyone is guaranteed a decent level of care that’s not tied to one’s employer or driven by profit. I’d like that augmented by a system where the well-to-do and those with better jobs that provide Cadillac insurance have the option for boutique care, skipping to the head of lines, and otherwise premium treatment. That is, preserving the A-plus system that exists now while ensuring that everyone gets at least C-level care.

    If that’s the case we are in agreement 100%. I just don’t understand why you contrast this aspirational goal with the UK, since you just about perfectly described the health care system there.

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  14. Gustopher says:

    @James Joyner: If your preference is for a form of single payer, I have no idea why you have been voting for Republicans, you big-government loving commie you. You’re not just to the left of your preferred party, you’re to the left of the Democrats too.

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  15. The ideal system would be to have gov’t care like the Canadian system (and the per capita expense of the Canadian system is half that of the US), and then allow private health care on top of it. Win-win as far as I can see.

    The frequently polled statistic that health care in Canada cost half per capita what it does in Canada completely ignores the difference in demographics between the US and Canada. After all, the US government already pays for 58% for healthcare in the US. If you truly believe that the US can achieve Canadian rates, what you are essentially saying is that you believe the government could CUT healthcare spending 14% and fund a complete national healthcare system on the remainder.

    I doubt any of the supporters of national healthcare would actually support such a proposal.

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  16. JohnMcC says:

    Regarding the complaint about waiting times for ‘elective procedures’, I have a personal experience. Had a heart attack in ’07 fortunately with good outcome (Cath Labs are AWESOME). Took my 12 weeks of FMLA recovery time.

    Soon afterwards began having really horrible pain (worse that the MI) in right hip and leg. Virtually immobilized me which is unfortunate because at least 1/2 of my work is on my feet. I’m an RN and the average ‘floor nurse’ walks 5 – 7 miles per shift. Saw a neurosurgeon who offered to cure me but would have had to take time off for a lengthy rehabilitation. Did not have the FMLA (or paid time off). So had to work for months with truly severe pain before my surgery.

    How is that different from the ‘waiting lists’ of Canadian or British health care systems?

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