Some Bri­tish lessons on ‘sin­gle payer’ per­for­mance

Cri­sis is the sober truth about na­tional gov­ern­ment-con­trolled health care

The Washington Times Weekly - - Commentary - By Robert E. Mof­fit

Con­gres­sional spon­sors of Medi­care for All sin­gle­payer leg­is­la­tion — bills abol­ish­ing vir­tu­ally all ex­ist­ing public and pri­vate health in­sur­ance — rou­tinely prom­ise that all Amer­i­cans will get equal ac­cess to higher qual­ity care and en­joy su­pe­rior med­i­cal out­comes. Per­for­mance, how­ever, is the acid test of sound pol­icy. While the U.S. “sin­gle payer” ex­pe­ri­ence is lim­ited to the Veter­ans Ad­min­is­tra­tion pro­gram, re­cently plagued by head­line­grab­bing care de­lays, work­ing mod­els of na­tional health in­sur­ance can teach Amer­i­cans sober lessons in gov­ern­ment­con­trolled health care.

Look at the Bri­tish cri­sis. Con­sider Bri­tain’s Na­tional Health Ser­vice (NHS), es­tab­lished in 1948. In 2017, the

Bri­tish House of Lords is­sued a stun­ning re­port on the state of the NHS. They con­cluded, “Our NHS, our ‘na­tional re­li­gion’, is in cri­sis and the adult so­cial care sys­tem is on the brink of col­lapse. No one who lis­tened to the ev­i­dence pre­sented by a vast ar­ray of ex­pert wit­nesses who ap­peared be­fore us can be in any doubt about this.”

That ev­i­dence has been build­ing for decades, and re­cent high-pro­file cases show that the Bri­tish cri­sis is chronic. In the Oc­to­ber 2019 is­sue of the An­nals of Surgery, one can check out a com­par­a­tive study of English and Amer­i­can in-hospi­tal mor­tal­ity be­tween 2006 and 2012.

Re­searchers found that Amer­i­cans’ sur­gi­cal treat­ment for ab­dom­i­nal emer­gen­cies (like ap­pen­dici­tis or a rup­tured aneurysm) was roughly twice the rate for com­pa­ra­ble English pa­tients, and that the English death rate was also sig­nif­i­cantly higher. Thus, they con­cluded, “Eng­land and US Hos­pi­tals dif­fer in the thresh­old for sur­gi­cal in­ter­ven­tion, which may be as­so­ci­ated with in­creases in mor­tal­ity in Eng­land for th­ese 7 gen­eral sur­gi­cal emer­gen­cies.”

In­ter­est­ingly, this 2019 study re­in­forced ear­lier find­ings in the April 2018 edi­tion of the An­nals of Surgery, where an­other team of re­searchers found greater pa­tient mor­tal­ity af­ter emer­gency la­paro­tomies — sur­gi­cal ab­dom­i­nal in­ci­sions to treat emer­gency med­i­cal con­di­tions — in Bri­tain com­pared with the United States.

Re­gard­ing Bri­tish per­for­mance, med­i­cal out­comes for the world’s top killers, can­cer and heart dis­ease, is an­other big story. While Amer­i­can pa­tients’ sur­vival rates for can­cer, such as breast, colon and prostate can­cer, are among the high­est in the world, the Bri­tish per­for­mance is com­par­a­tively poor.

The rea­son: Bri­tish can­cer pa­tients do not ben­e­fit from the kind of ro­bust in­vest­ment in com­bat­ting can­cer that char­ac­ter­izes Amer­i­can health care. That in­vest­ment in­cludes not only the re­cruit­ment and de­ploy­ment of more highly-trained med­i­cal staff to serve the pa­tient pop­u­la­tion, but also a greater re­liance on ad­vanced med­i­cal tech­nolo­gies and cut­ting-edge phar­ma­ceu­ti­cal ther­a­pies.

The Bri­tish, op­er­at­ing un­der a gov­ern­ment “global bud­get” for health spend­ing, do not even come close to the Amer­i­can ef­fort. For Bri­tain, there are ap­prox­i­mately seven ra­di­ol­o­gists per 100,000 peo­ple. Even in the Euro­pean Union, there are an av­er­age of 12 ra­di­ol­o­gists per 100,000 pop­u­la­tion. De­lays in can­cer care thus con­trib­ute to Bri­tain’s rel­a­tively poor can­cer sur­vival sta­tis­tics. “Our di­ag­nos­tic ca­pac­ity is woe­fully poor,” says Sir Michael Richards, Bri­tain’s pre-em­i­nent can­cer ex­pert.

As noted, Bri­tish health care op­er­ates un­der a global bud­get, a fixed al­lot­ment of funds for the health ser­vices. This is roughly the same fi­nanc­ing ar­range­ment em­bod­ied in the House Democrats’ leg­is­la­tion (H.R. 1384) to re­place and rad­i­cally re­make Amer­i­can health care. There is no log­i­cal rea­son why Amer­ica’s fu­ture ex­pe­ri­ence with such a sys­tem would be rad­i­cally dif­fer­ent.

The clash of high pa­tient de­mand for “free care” at the point of ser­vice with lim­ited health care sup­ply is man­i­fest in the no­to­ri­ous Bri­tish wait­ing lists. Ac­cord­ing to The Guardian, a prom­i­nent left-lean­ing Bri­tish news­pa­per, last year a to­tal of 4.3 mil­lion Bri­tish cit­i­zens were await­ing hos­pi­tal­iza­tion, the high­est level in 10 years.

As for short­ages, the costs to pa­tients are man­i­fest in many other ways, es­pe­cially in doc­tor and nurs­ing short­ages. Ac­cord­ing to a re­cent edi­tion of The Guardian, the Bri­tish sys­tem is fac­ing a se­ri­ous physi­cian short­age, par­tic­u­larly spe­cial­ists, and es­pe­cially in ru­ral ar­eas. Worse, 43 per­cent of ad­ver­tised med­i­cal po­si­tions ad­ver­tised went un­filled last year, ex­ac­er­bat­ing the short­age in Eng­land.

Pa­tients, of course, bear the brunt of this dearth. Not­with­stand­ing po­lit­i­cal prom­ises of equal ac­cess to care, gov­ern­ment bud­get­ing guar­an­tees no such thing. Bri­tish men­tal health pa­tients, as just one ex­am­ple, are be­ing short­changed.

Ac­cord­ing to an­other re­cent edi­tion of The Guardian, men­tal health pa­tients be­ing treated in “de­crepit,” un­der­funded and un­der­staffed men­tal in­sti­tu­tions are at in­creased risk for sui­cide. Ac­cord­ing to NHS Providers, “Con­tin­ued un­der-pri­or­i­ti­za­tion of the men­tal health es­tate is hav­ing a real im­pact on pa­tients.”

To im­prove the de­liv­ery of health care, Amer­i­cans need not con­vert to any­thing even re­motely re­sem­bling Bri­tain’s sec­u­lar “na­tional re­li­gion.” Rather than de­stroy what’s work­ing in Amer­i­can health care, Wash­ing­ton pol­i­cy­mak­ers should take de­ci­sive steps to lower health costs through in­tense com­pe­ti­tion and em­power in­di­vid­u­als and fam­i­lies with greater per­sonal choice of cov­er­age and care.

The clash of high pa­tient de­mand for “free care” at the point of ser­vice with lim­ited health care sup­ply is man­i­fest in the no­to­ri­ous Bri­tish wait­ing lists.

Robert E. Mof­fit is a se­nior fel­low at The Her­itage Foun­da­tion (her­itage.org).

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