Wednesday, August 12, 2009
Now, this may seem like, if anything, a feel-good story. But readers will surely apprehend the quiet menace of the totalitarian state machine behind it all. After all, as I have been hearing people say in shrill American accents for quite some time now, it means that some bureaucrat gets to decide whether I live or die. I mean, don't you think they call their bosses in the nanny state before operating? How the hell else are they supposed to check whether you fit into one of their communistic quotas? And, on top of being menacing and diabolical, the system is also an inefficient shambles. First of all, the toilet seats are always up, there's no flat-screen television, and you have to share a dormitory with other people. And these nurses - talk about attitude. Eat this, drink that, swallow these, would you like some water, etc etc. Ooh, la-di-fucking-da, look at you. Don't they realise who they're working for? If there was any concept of customer service in these wretched hospitals, they would say 'you have no insurance, so as soon as you can walk, you're out the door'. This so-called 'service', by the way, isn't free: you pay through the nose with your hard earned tax money. In a single year it costs $2815 (or £1706) per person. I could have bought a new nose with that. How dare some bureaucrat tell me how to spend my money? And... wait a minute... someone has just told me that America spends $6719 (or £4072) per person on healthcare every year. You fools! You bloody fools! You've only gone socialist without realising it!
Well, so much for that. In the drive to crush Obama's extremely modest healthcare proposals, much of the US health industry and the Republican right have struck on the original idea of saying that any offense against the holy profit is both foreign and communist. Hence, the debate becomes a spurious, contrived contest not between the actual proposed changes and the actually existing system, but between America and the UK. For example, one of the points that American rightists make about the NHS, amid much paranoid drivel, is that in some of its health outcomes, the NHS underperforms compared to the US system. The obvious answer is: so what? One could retort that on the most important health outcome that matters - health adjusted life expectancy - the UK outdoes the US. But this is beside the point. The NHS is not perfect, and has suffered long periods of underinvestment. Germany and France spend approximately 12% of their GDP on healthcare, but Britain only rose above 6% to approx 8% in the first half of this decade, and you can be sure that's about to fall again. To prove that free and equal access at the point of delivery is a superior system, it is not necessary to prove that the NHS excels on every point. There are also some comical misconstructions, as when Sean Hannity warned viewers about some poor sod from Merseyside who had to resort to supergluing the crown to his tooth because he couldn't find an NHS dentist. Hannity warned that Obama would reduce Americans to such a state if his proposals were passed. He did not realise, or did not care, that the reason for the dearth of NHS dentistry is because of the expansion of the private sector in dental care. Dentists are allowed to operate privately, and make far more money doing so (because they can charge more for basic operations). The reason the guy was looking for an NHS dentist is because he couldn't afford the exorbitant costs the private dentists charge for routine work. Another comical moment arose when a right-wing US investors magazine tried to claim that Stephen Hawking would be considered 'worthless' by the NHS, because of his physical handicap. Hawking retorted: "I wouldn't be here today if it were not for the NHS. I have received a large amount of high-quality treatment without which I would not have survived."
Of course, there is another way of approaching this, which is to consider why the private sector is so scandalously inefficient and wasteful. The NHS has historically had very low administration costs, with about 5% of the overall budget going to admin. Only after the internal market was introduced did it rise significantly, to 12%. In Britain's private hospitals, the administration costs are closer to 34%. (David Rowland, Allyson M. Pollock & Neil Vickers, 'The British Labour Government's Reform of the National Health Service', Journal of Public Health Policy, Vol. 22, No. 4, 2001)
In the United States, 'after exclusions', administration costs amount to 31% of total expenditure, although the overhead is much lower in schemes like Medicare than in private insurance. (Steffie Woolhandler, M.D., M.P.H., Terry Campbell, M.H.A., & David U. Himmelstein, M.D., 'Costs of Health Care Administration in the United States and Canada', New England Journal of Medicine, Vol. 349, No. 8, August 2003) The reasons for this vary, but one indicative example is the massive overheads incurred by US insurance companies, most of which are spent on functions (such as underwriting and marketing) that are totally unnecessary in a public system. Extensive legal bureaucracies and the duplication of capacity also suck up resources. And, of course, the fact that someone has to walk away with profit is important - the top ten US health insurers saw their profits rise 428% between 2000 and 2007, from $2.4bn to $12.9bn, mostly paid for by increased premiums. (See this report for figures, [pdf]).
One last thing. How much of this bloated administrative cost goes into denying treatment, and then relentlessly pursuing those who have received treatment to try and get the money back? A congressional probe looked at three companies and found that between 2003 and 2007, 20,000 people had their insurance policies rescinded, so that they could be denied necessary treatment. The saving to the companies would have been hundreds of millions, so undoubtedly this counts as 'efficiency' by their evil standards. Nonetheless, from the point of view of health outcomes, it does seem more than wasteful that there is a bureaucratic apparatus that is designed to kill people, that acts on the perverse incentive to deprive people of mastectomies and chemo that is necessary for their survival. Admittedly, this does call into question the idea that Americans, with their lavish freedom, will never run up against a heartless unfeeling bureaucrat in healthcare. But it does partially explain why no one in the UK, apart from a few cranks on the far right, has any intention whatsoever of emulating America's system.