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"Two Essential Truths"

"There are, I think, two essential truths in international health policy," writes Alex Massie. "No-one sees fit to copy the [U.K.'s] National Health Service and no-one sees fit to copy the American system." That sounds about right to me. The NHS and the American system are both outliers. The American system biases doctors toward overtreatment by paying them for everything intervention they try. The British system does the opposite by paying them a lump sum for each patient, and every treatment comes out of that total. The effects are predictable: The American system is extremely expensive. But the British system is extremely cheap. Uncommonly cheap. Weirdly cheap. About 41 cents for every dollar we spend per capita cheap.

That makes the British system, to the mind of most people, too cheap. The American system, of course, is far too expensive. The British system might be a better deal than our system is, but there's no reason we have to buy the thing on sale. Which is why other countries refuse to imitate either our model or the British model and generally go for a more hybrid system.

Anyway, Massie actually lives amid the NHS and goes on to explain some of the differences:

The relevance of the NHS to American health care plans seems pretty limited anyway since, as best I can tell (though I try not to pay too much attention to these things) Obama doesn't actually plan on copying the NHS.

Fundamentally, however, the difference between the systems is psychological. In Britain you worry what will happen when you fall ill; many Americans worry about what will happen if you fall ill. Will your insurance cover you? Often (but not always), yes it will and the best American care probably is better than the best British care, but there's a greater psychological security to the British system. That's probably worth something too. In other words, many Americans find themselves fretting about healthcare even when they're perfectly healthy. That's a psychological burden people in this country (and many others), don't have to worry about.

For more on the differences between the world's many health-care systems, go here.

By Ezra Klein  |  August 11, 2009; 12:11 PM ET
Categories:  Health of Nations  
Save & Share:  Send E-mail   Facebook   Twitter   Digg   Yahoo Buzz   StumbleUpon   Technorati   Google Buzz   Previous: It Is Democracy, Not Health-Care Reform, That Is Sick
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Yeah, I remember reading, a year or so ago, about how Britons were resulting to pulling their own teeth because the care was so good.

Posted by: whoisjohngaltcom | August 11, 2009 12:38 PM | Report abuse

"the best American care probably is better than the best British care, but there's a greater psychological security to the British system."

Psychological. So, in other words, our system here would get better immediately if all the socialists in the media would just stop talking it down. Thanks, Ezra. You're a great American.

Posted by: whoisjohngaltcom | August 11, 2009 12:41 PM | Report abuse

I live amid the NHS system too, and I think there's something else going on. It's not just the systems that are different, it's the very culture.

Americans (including me) tend to assume that because we speak the same language we think the same. We don't. Americans have different values and standards than Brits do. We'd never put up with, for instance, a doctor who doesn't wash his hands before treating us. We expect dentists to have full MDs, not just an extra year of schooling. We are especially attentive to cleanliness, whereas Brits are not. We like to complain, Brits have stiff upper lips when it comes to health care and terrorist bombs. They don't mind shabby waiting rooms or shabby airports. (Have you been to Heathrow's Terminal 1 lately?)

I've lived here five years, and every day I notice some new subtle difference. I'm not saying Americans and American attitudes and values are superior; clearly we're not. We're just different, and those differences are expressed in how we deal with health care.

Posted by: KathyF | August 11, 2009 12:57 PM | Report abuse

I remember reading the Galtroid lying and exaggerating and BSing. But that doesn't take a long memory.

But heh, thanks for diminishing the impact that living in fear of medical debt, or living with medical debt, can have on families. Whadda bastard.

Posted by: pseudonymousinnc | August 11, 2009 3:18 PM | Report abuse

As an American who lived for four years in Britain and had two children there, I get a bit emotional when I think of the care I received in British hospitals. Sure, the waiting rooms were shabby, but I was actually offered more treatments than I asked for and received very thorough care.

I did not realize how passive I had become until a GP in Scotland noticed a skin condition I had long neglected because my HMO in the U.S. didn't cover the treatment. "You don't have to live with that," he said, and he sent me to a specialist who cleared up the problem.

Doctors and nurses in the UK care about practicing medicine and treating patients, not about making more money. The system is not perfect, but it works amazingly well given its budget constraints.

Posted by: miriamhils | August 11, 2009 5:11 PM | Report abuse

In discussing the US health care system compared with Britain’s, for the moment let’s put aside the 50 million uninsured and the additional 35 million or more underinsured. Let’s put aside the people whose insurance refuses to pay, kicks them out, and so on. Everyone knows those people would do better in Britain, so we’ll forget them.

The problem is that the poorest 20% of people in Britain get better health care results than the richest 20% in the US. What’s that about?

It turns out that there is a problem with US health care that goes like this: if you need a high tech, expensive, elaborate intervention you have come to the right place. If you have decent insurance, either public or private, you will get that intervention. However, if you don’t need a high tech, expensive, elaborate intervention, there is an excellent chance you will get it anyway. And in the process, you will risk complications of the procedure, be exposed to the risk of being in ICU’s, OR’s, and hospitals, risk mismanagement and mistakes, and so on.

The problem is even if you are rich, can afford the best care, have excellent insurance, and so on, in the US our approach to medical care exposes you to extra risks of death or injury. Just ask Andy Warhol.

Unfortunately, despite the “failure to wash hands,” the crowded waiting rooms, the general shabbiness of facilities, Britain gets better results (including, apropos the hand washing, lower rates of infection in hospitals.) The reason appears to be British adherence to the Hippocratic Oath’s injunction to “first, do no harm.”

In the US, you will get fancier lobbies, nicer rooms, better lunches, newer and shinier equipment, and the latest medical technologies -- if you can pay. But in Britain you will get better health care results.

Posted by: PatS2 | August 11, 2009 7:49 PM | Report abuse

"The British system does the opposite by paying them a lump sum for each patient, and every treatment comes out of that total."


What you're referring to is the "capitation fee" which is paid for General Practitioners for each patient on their list. Back of my mind says it's about £20 per patient but that could be woefully out of date. It's more of a payment to get people onto the lists than it is anything else.

However, this is not the only amount payable to GP's. Not sure what proportion it is now but in the mid 80s it was something like 45% of income.

Capitation fees have absolutely nothing at all to do with hospital treatment though. There is no rationing by budget in that sense at all. (ie, there's no budget for the treatment of an indiviudal, nor an overall one for all patients on a GP's list).

Rationing is done from the other end: NICE says that this treatment will get funded for all, that one won't get funded for anyone (would you believe they turned down Aricept for Alzheimer's because the $4 a day was too expensive?).

Then there's the total system budget and if that's going to be breached then people simply have to wait for treatment until hte next budget period.

Posted by: timworstall | August 12, 2009 5:55 AM | Report abuse

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