It would appear that we're in for a major legislative battle over the future of American health care. And while it's still not exactly clear what the administration's plan will look like
, it does seem that -- Rahm Emanuel notwithstanding
-- the president is committed
to having a public option as part of the package.
The specter of "socialized medicine" looms large in some corners
of the American public, inspiring an almost Orwellian fear. In practical terms, however, most Americans have little familiarity with universal health care. As an American who's lived in the U.K. for the past three years, I've relied exclusively on the National Health Service (NHS) for all of my family's medical needs. In what follows, I enumerate some of the differences, large and small, that I've encountered across the two systems. My purpose is not to advocate for one form of insurance over another, although our experience with the NHS has been largely positive. Rather, I hope to shed light on the kinds of things Americans could expect on a day-to-day basis were our country to move toward a more British-style system:
1. You don't pay to see a doctor
. Whether you're treating a migraine or replacing a heart valve, you don't pay a dime. Ever. This may sound great -- and it is -- but it's also very disorienting if you're used to pulling out your insurance card or haggling with your insurance company over exactly what percentage of your bill it will cover for a given procedure. I remember the elaborate accounting gymnastics my husband and I went through at our last jobs over precisely how much to allocate to our Flexible Spending Account
each year so we could avoid being taxed on things like eyeglasses, dental visits and the like. No more. And in that sense -- and contrary to many of the criticisms
about socialized medicine -- it's a much less bureaucratic
system simply because there's less paperwork.
2. The co-pays for prescriptions are much lower
. In fact, children's prescriptions are entirely free. Adults pay a set fee that is usually somewhere around six or seven pounds (at today's exchange rate, roughly $10). I was back in the States recently, and my daughter came down with pneumonia. Because we lacked insurance, a pediatrician friend of my brother's graciously agreed to see her for free, and administered both an instant-strep and flu test on the house. (Our savings right there: about $150). But when we paid for her antibiotics, it cost us $50. I made a point of asking the pharmacist if that medication would have been cheaper if we'd had insurance and she said no. So, depending on how many prescriptions your family uses on a regular basis (we use quite a few), this can be an area of enormous savings.
3. Pharmacists play more of a triage role
. Pharmacists here act more like quasi-doctors. They are not only equipped to treat minor problems -- rashes, coughs, eye infections and the like. Increasingly, they also offer advice on things like quitting smoking and losing weight as well as early screening for long-term problems such as diabetes and heart disease. This has been a deliberate strategy
on the part of the British government. The idea is to give pharmacists a greater role in health promotion, medication monitoring and the treatment of minor ailments so as to reduce the burden on doctors. The ubiquity of pharmacies also means that they are much more accessible to traditionally underserved communities such as the elderly, the unemployed and mothers of young children.
4. Doctors are less alarmist and prescribe fewer drugs
. No matter what's wrong with your child, the first question a doctor here will always ask is: "Do they seem ill?" Basically, unless the kid has a high fever and is vomiting all over you, the rule of thumb is that they probably don't need to be seen by a doctor. Take something like strep throat. If you grow up in the States, you develop a real anxiety around strep throat. In fact, strep only accounts for about 10 percent of all sore throats
. Nonetheless, anytime one of my kids had a sore throat in America, I was always advised to take them to the doctor immediately to do a throat culture. Often, I was given antibiotics before the results even came back from the lab. In contrast, the attitude here is "wait and see": watch the symptoms, see if their condition deteriorates and, most of all, gauge their overall behavior. This holds true for most illnesses.
The logical corollary to less alarmist doctors means that you're also going to be given less medication. Some of this stems from scientific evidence, as in the case of strep. (The new thinking is that even with bacterial throat infections, antibiotics don't necessarily combat
this bug any better than home remedies.) It's also the case that the fear of malpractice lawsuits fuels over-treatment in the U.S., whereas a fairly strict standard
for medical negligence lessens such concerns in the UK. But differences in treatment also underscore a fundamental difference in philosophy across the two systems. It's no secret that over-use of antibiotics
lowers the population's immunity to drug-resistant super-bugs. In a system like the U.K.'s -- which is built around addressing the needs of the population -- a doctor is likely to be much more sensitive to this population-wide effect than his/her counterpart in the American system, which centers around the health needs of the individual. Consequently, less drugs.
5. Doctors are paid per person, not per treatment.
Which brings us to incentives. In the U.S., doctors are paid by the treatment. This creates a powerful incentive to prescribe medication, if for no other reason than to feel that they've covered all of the bases. Under the NHS, in contrast, doctors are paid by the government according to the number of people they see (per capita). So there's much less of an incentive
to "over-provide" service because there's no additional financial reward for seeing the person more than once. Per capita payment also means that you will almost invariably spend less time with your doctor during an average NHS visit, which can be quite frustrating.
6. You do fewer preventive screenings
. One of the hardest things to adjust to as an American
is that screenings for diseases like breast cancer start later and occur less frequently in the U.K. So, for example, the NHS does not begin routine mammograms until age 50 and then only every three years. In the U.S., the recommended age
is 40 and once every one-two years. The rationale behind the NHS strategy -- bolstered by a recent study
in the British Medical Journal -- is that over-diagnosis of breast cancer results in unnecessary treatment and surgery for one out of three women diagnosed with this disease. A similar story
is emerging about prostate cancer screening (PSA) tests, which are routine for many American men over the age of 40 but are not done regularly in the U.K. or the rest of Europe. So if you're generally risk-averse and want to rule out this sort of disease on a regular basis, you need to go private over here.
7. You take more responsibility for your own health.
The standard critique of socialized medicine is that it's the government -- not the individual -- that's making decisions about our health. But as I've argued elsewhere
, that's not quite right. In fact, I've found that you end up taking far greater responsibility for your own health under universal care. For example, just because you're fair-skinned doesn't mean that you're eligible for an annual skin cancer check over here, something you might be advised to do in the U.S. Unless you've got a bleeding mole, the dermatologist is likely to take a few pictures and tell you to compare your freckles to the pictures on a regular basis. Similarly, younger women are also taught how to test themselves
for a variety of sexually transmitted diseases, a procedure that is thought to be
more efficient (because it avoids a pelvic exam) and possibly more effective in identifying disease. Much like the pharmacist example noted above, this emphasis on DIY health care is the byproduct of a system where the government needs to focus its resources on those who are truly ill. But it is also -- at least as explained to me on more than one occasion -- about cultivating a sense of independence in which citizens are put in charge of their own bodies and learn how to monitor and care for them.
8. You see fewer specialists
. Much like an HMO in the U.S., your first port of call in a U.K.-style system is always your general practitioner (GP), who then refers you on to a specialist if the situation calls for it. The difference is that GPs in the U.K. treat a much wider range of problems than they do in the U.S. So, for example, in the U.S., any kind of women's health issue is generally handled by an OB/GYN, while children generally see pediatricians. Here, in contrast, your GP could theoretically give you a pap smear, tend to your son's ear infection and treat your daughter's asthma all in one visit. This "one-stop shopping" model is thus in some ways more efficient
than the American one, which for a host of reasons privileges specialists
over general practitioners, necessitating more doctor visits. Which brings us to seeing a specialist.
9. There are longer delays
. Unlike a GP, whom you can almost always see the same or next day, visiting a specialist in the U.K. can take considerably longer. Current NHS guidelines demand that all patients be seen within 18 weeks of a referral, and evidence suggests
that those targets are being met, if not shortened. But you hear all sorts of anecdotal stories about referrals getting lost in the mail, appointments getting cancelled, etc. Which is probably why -- in his most recent speech on health care - Prime Minister Gordon Brown announced
a switch from "targets" (the Tony Blair mantra) to "entitlements." Among those entitlements is the right to be seen within two weeks if you're diagnosed with cancer, as well as a free health check-up at the age of 40. A lot of the difference regarding wait times between the two countries appears to stem from whether the surgery is elective. While cross-national data are not available, one survey
suggests that the U.S. had the second-shortest wait times for non-emergency surgeries (even while overall wait times appear to be on the rise
). But this just takes us back to the population-based rationale: anything that you can "live with" in the U.K. will by definition have to wait.
10. There is more after-hours coverage
. On the other hand, most national health care systems make it much easier to see a doctor at night and on weekends. I think we've all been caught in that tricky situation of having a sick child on a Saturday night and weighing the costs -- economic, emotional, logistical -- of going to the emergency room or just taking our chances and waiting until Monday. If my child falls ill on the weekend in London, I simply make an appointment with a local health care cooperative, Camidoc
, and can be seen nearby at any hour, day or night. They will even make house calls. In the United States, in contrast, only about 40 percent of doctors
provide after-hours care, and as many as half
of all emergency room visits are estimated to be non-urgent.
In the end, there are pros and cons to both systems, though I hope that this quick review has revealed that the public option is considerably less monolithic than it is often made out to be. Given the nature of the American political system, my guess is that we won't adopt anything near the sort of "pure" tax-financed universal health care that exists in the U.K. But there are a range of models
out there, with lots of different bits and pieces to choose from.