16 August 2012

Surprisingly, many
Americans do actually
admire Britain's NHS

Charles Lewis

Jill Stephenson made some great points in her recent article (31 July) on the NHS and fairness. She also made some comments on the approach to healthcare in the USA that merit comment. As a US resident, I thought it might be of interest to readers if I added my own perspective.

When Jill states that 47 million Americans are condemned to a 'precarious life without health care provision' she is not being especially accurate. Laws brought in by the Reagan administration ('Emergency Medical Treatment' and 'Active Labor Act') require hospitals to provide care to anyone needing emergency healthcare treatment regardless of citizenship, legal status or ability to pay.

Hospitals have a legal responsibility to stabilise their condition. ER rooms are used to such an extent by the uninsured that some 55% of US emergency care is not paid for by the user. Not that this is a particularly desirable way to provide healthcare and, indeed, one of the objectives of Obamacare was to move them out of the ER and into doctors' waiting rooms. However, the situation is not quite as dire as Jill Stephenson describes.

I don't want to understate the gravity of a situation whereby many of those 47 million simply cannot afford insurance, but it is worth noting that some others, often young and feeling healthy, choose not to carry it. Some 10 million uninsured are under the age of 30. At a time in their lives when their earning power is often low, there is a trade-off between the cost of healthcare and the anticipated use of it. Some will take that risk especially given the high cost of insurance that gives better than catastrophic coverage. This is one group that Obama was targeting with the requirement to buy insurance. As it is well established in most health systems that healthy young people subsidise healthcare for older, less healthy people then you really want to make sure that they are paying in to the system.

For many of us in the USA who favoured healthcare reform and a move towards universal healthcare provision, 'Obamacare' was a huge disappointment. President Obama had the electoral mandate, the political capital and the Congressional majority to make some substantive reforms to a system that has some real issues. Instead, he caved in to special interests, papered over a couple of cracks and added a raft of new taxes. Those who had signed up for 'hope and change' quickly discovered that it was Washington politics as usual.

Certainly, getting rid of health insurance restrictions based on pre-existing conditions, stopping insurance companies from dumping sick patients and extending health insurance to some young people, were worthy and popular reforms and have been well received across the political spectrum (yes, even by Republicans). But Obama failed to address the fundamental problem with healthcare in the USA: the issue of cost.

Jill Stephenson is right when she says that healthcare is not cheap. Compared to other developed countries, healthcare in the UK looks fairly inexpensive which may explain the waiting lists and other problems. If you want to fix that then you are probably going to have to start paying more for your care. However, by the same comparison, the USA looks outrageously expensive. Despite the rhetoric, Obama has failed to address this.

The 250 million Americans who do have coverage get pretty good healthcare. However, cost inflation continues apace and there is no evidence that Obamacare is going to slow this in the decade to come. In a system that still relies to a large extent on employer-provided health insurance, inflation is accelerating the move to high deductible insurance plans that shift cost from the employer and onto the employee. Already, illness can cause financial hardship to those Americans who do carry health insurance. As costs increase, people will take that into account when taking decisions about their healthcare. Going forward, the challenge is not just in ensuring coverage for the uninsured. It is also about protecting those who do have insurance.

While the UK has decided that paying for healthcare from general taxation is their preferred way forward, other countries have shown that a health insurance model can also work. But to ensure that such a system works in the public interest requires strict government regulation. Unfortunately, in the USA, Obama has demonstrated that special interests continue to be more important than the public interest. Obama's performance in this area contrasts with that of Romney who actually did sign a form of universal healthcare into law when he was governor of Massachusetts. Romney has other impediments when it comes to the forthcoming election but healthcare is not one of them.

Given the noise coming from the right-wing of American politics, many in the UK would be surprised to know that there is considerable admiration in the USA for the NHS achievement. Especially when they understand that the opportunity to augment basic services with private insurance exists. While many Americans are instinctively suspicious of government, there are parallels with the UK. Just as the NHS appears to be 'sacrosanct', attempts to privatise Medicare may well have electoral consequences.

In 2011, Democrats won one of New York's most conservative Congressional districts in a race that largely turned on the Republican plan to overhaul Medicare. As healthcare costs continue to eat into the budget of ordinary Americans, the debate is likely to intensify and some politicians could discover electoral advantage in a cheaper and more equitable system.

Charles Lewis retired two years ago from the accounting industry where he specialised in systems audit and the audit of controls over financial reporting. He has lived in the USA since 1998.