Health Care Reform Thoughts
A majority of Americans believe everyone should have access to basic health care, even if the person in need cannot afford it. If a nation truly wishes to achieve that, it precludes a solely market-based approach because the market alone would shape health care in a way that maximizes profit. Caring for the poor is never going to be profitable in this context.
So the question is what mix of public and private organization does the best job or providing basic care to all, while researching new treatments and otherwise maintaining or improving public health. It is hard question to answer for a range of reasons. Here are three:
Health care treatments evolve.Public expectations as to what care should be insured evolve with the treatments.
Someone or some mechanism has to draw the line between what care can be covered and what cannot.
Different countries have different answers and accept different trade-offs in addressing these challenges.
Our current mix rations health care on the basis of a combination of wealth (usually augmented by private insurance), access to government insurance, or access to workplace and retirement benefit policies. Emergency room care acts as a stop-gap for many of the people who fall outside of the above, but this is highly expensive and still misses millions.
The result is a wide range in access and quality from among the best in the world to basically non-existent. Within the realm of insurance, decisions on what is or is not affordable are likewise scattered and can often be contradictory.
By way of comparison, the British system makes the rationing decisions consciously for everyone under the National Health Service (NHS). This provides universal care. This is also far from perfect, but it's not the abject failure that some people make it out to be.
My wife got an unexpected tour of the NHS in Scotland last summer by virtue of some poorly-timed gallstones. She ended up at the Royal Infirmary of Edinburgh, (a teaching hospital with a long history). She went in very early Sunday morning ( a sign that Murphy’s Law is in force on both sides of the Atlantic).
The emergency care was first rate, as was the diagnostic unit. Fine care and no questions about insurance. (Foreign visitors get free emergency room care along with everyone else.) Once she made it to a regular ward, you could begin to see where they cut some of their costs. Nearly all patients were in ward units of 4. These were comfortable, with privacy curtains, and well staffed. Sue’s roommates were pleasant, and we could compare notes on treatment. Some of that information is reflected here. Still, that comparative lack of privacy is very different from the semi-private and private rooms that dominate in the States.
More significantly, the tests that Sue needed came more slowly than would have happened in many U.S. hospitals. That’s a clue to another way they cut costs: the trade-offs that they make between advanced diagnostic and treatment facilities and the length of stay is different than in many US hospitals.
She was in five nights and six days, and she might have been in longer if there had not been a cancellation that allowed them to get the stones out on Thursday as opposed to the Friday (they hoped) that had been the original schedule. In fact we felt a bit bad because we suspected that Sue had been moved ahead of some other patients to get that spot precisely because we were visitors. No US hospital would have moved faster on Sunday, but at our regional hospital, it seems likely that she would have been out by Thursday at the latest, and possibly Wednesday.
So, assuming that our experience was at all typical (and that’s a big assumption) here are the trade offs in what was a pretty standard situation--treatment for gall stones—and what seems customary at our regional hospital.
NHS: universal care, usually strong emergency room care, slower in-patient care, slower access to non-emergency procedures for both patients in hospitals, and probably for out-patient care as well.
US: access based on ability to pay (via income or insurance), strong emergency room care, emphasis on moving people quickly through hospitals aided by investment in diagnostic equipment and associated staff. Decision making based in part by the standards of HMOs/insurance companies.
Both: Competent but often overstretched staffs. Also, I think the site of senior doctors trailed by junior physicians and nurses rather like acolytes is universal at teaching hospitals.
Moral: As I said above, no approach is perfect. How important is universal coverage to Americans? How good should it be? What are they willing to trade—or invest—to get it? These questions mingle resource considerations and moral choices in the most unsettling ways. We should not make light of them by either demonizing or idealizing any particular approach, but look at them all with open eyes.
PS: For those who are curious, the meter starts running on foreign tourists after they clear the diagnostic unit (called “Combined Assessment” there) and are formally admitted to the hospital. The cost looked much like the costs at a US hospital—though I have made no attempt to do a procedure by procedure comparison.
We, that is Sue’s employer-based insurance, did cover it. I did have to purchase a Scottish cell phone in order to call the states and the Infirmary’s overseas representative repeatedly to make sure that they played well together. In the end, they did, though there was at least a day in which everything was stalled because the folks at Blue Cross Blue Shield Worldwide did not understand the Scottish reps accent when she gave them our policy number.
PPS: I do hope that phone access is easier in Scotland. I think it took a full day before I could figure out which number on the back of Sue’s card actually reached the people I needed to talk to.
PPPS: Sue’s gallstone removal went well. Within two days she felt better than she had in months. We even managed to salvage a portion of our trip and tramp around the Royal Troon golf course watching the British Senior Open. The weather was even sunny!