Private insurance and the NHS

Bob Watcher has a great post on the relationship between the NHS and private health insurance that jives with my understanding of how the two work together based on my post-doc at the University of Manchester in the mid-1990s, and my interest in that system ever since (h/t Brad Flansbaum, on twitter @BradleyFlansbau). Go read the post for a description of the many subtle details. A few big picture thoughts on the NHS and what it means for the U.S.:

  • All citizens have a stake in the NHS running as well as possible since they all use the NHS for primary care (everyone using the NHS is the best quality control program possible).
  • They explicitly acknowledge a tiered system and embrace the idea that those with private insurance or enough money can choose to go outside the NHS for specialty care to avoid waits, etc. This is often understood as helping to relieve pressure on the public system.
  • Access to the cheaper part of the system is easy, but much harder to the more expensive part.
  • They invented the system for themselves; it wasn’t imposed on them.

When Americans peer in and imagine “copying” that system, we rightly say “that won’t work here!” Of course it won’t, it is their system constructed by them for them; we have to come up with our own way of acknowledging limits and running the system. It is a matter of how we will ration, not if, but we do not seem to be able to acknowledge this and have a forthright conversation about how we will deal with this reality. It is interesting and even useful to look at how other systems work, especially to understand how incentives function in practice, but in the end, but we cannot and should not copy another nation’s health care system. We have to figure out how to make our system work for us.


NHS Reforms

Richard Hoey in the Health Care Blog on the latest iteration of reform of the NHS in England (reforms don’t apply to Scotland, Wales or N. Ireland). The system remains tax financed, with health care mostly free at the point of service, with a few exceptions, which has been the organizing principle of the system since its inception in 1947. The big reform ideas are:

….hugely controversial. Firstly, it abolishes a whole tier of NHS management and hands its powers instead to the family doctors at the frontline – the general practitioners, or GPs, as they are known here. Secondly, it loosens the constraints on the NHS’s internal market, providing scope for private companies to compete to run many more NHS services. The two reforms are intended to work together to drive efficiency across the health service, and the efficiencies required are pretty frightening – 4% a year for the next four years. (emphasis mine)

One of the knocks on the U.S. system of government is that it cannot make big changes like parliamentary systems can. The government in the U.K. is of course a parliamentary coalition between the Conservatives and Liberal Democrats, and due to shared power, no one got exactly what they wanted. As Hoey notes, that should sound familiar on this side of the Atlantic:

Just as with President Obama’s legislation, however, the real question will be whether it can achieve, in rather diluted form, what it was intended to do.

Constant Tinkering

Rudolf Klein with an interesting discussion of the most recent round of reforms in the NHS, and how there is nothing new under the sun in the constant tinkering with the health system.

As an aside, reading this post took me back to when I was a post-doc at the University of Manchester (U.K.) in 1995-96, and got a chance to meet Dr. Klein on a trip to the University of Bath. He graciously talked with me about health policy and my research at the time. The discussion went to the role of culture in shaping what is politically feasible in terms of cost control. He made an observation comparing the U.S. and the U.K. along these lines: the U.K. is an original sin nation; they expect things to be bad and to likely get worse, be it the weather, waiting lists for knee replacements, or England’s chance of winning the World Cup. In the U.S., it is the opposite. We believe in the perfectability of humankind, and expect that with enough effort, money and energy, we should be able to fix anything.