Monday, March 20, 2017

Decisions, decisions....


Congress (the House of Representatives) should be taking a vote this week on whether they'll be adapting Ryan/TrumpCare or sticking with ObamaCare, which it seems all agree will soon be/is on life support.  The Right is hoping for the former, and the Left (Bernie & friends) would prefer something more like the single-payer (universal) healthcare system they've had in the United Kingdom since 1948.

So what exactly is the UK's system (the NHS) like?  I'd heard the doctors and nurses, the technology, and the facilities are all first rate, but the wait time to be seen by a doctor was very long.  To get to the bottom of it all I corresponded with a British friend* and asked him to give me a quick overview.  I trusted him implicitly and knew he would give me the unvarnished truth to the best of his knowledge.  His response:

First, the NHS is a mandatory insurance scheme paid for by National Insurance contributions, a tax for all intents and purposes.  Almost all prescriptions are included for a flat fee of approx $10US each, with exceptions for the young (<16) and the "more mature" (>60), with a few other special exemptions, too.  One option is a Rx pre-payment plan costing roughly $125 per year which covers all your meds, regardless of how many you might have.

All doctor and hospital treatment is included, as are many optical and dental services.  Doctors, dentists, and "opticians" (optometrists) are all self-employed and may be either working entirely for the NHS under contract, entirely private, or a bit of both.  About 8% of the population also has private insurance over and above their NHS coverage, which generally gets them perks like quicker consultations, private hospital rooms, etc.  (He said it really amounts to not having to rub elbows with the common folk in the waiting rooms.)  Almost all feel there is no difference in the care received, although a few would debate that.  If a doctor has a good reputation and a thriving practice serving the 8%, he can probably make more $$$ by going entirely private than with a NHS contract.

The biggest grumble is indeed the wait time to be seen.  Of course all patients are prioritized, just like here, so emergencies get immediate attention while non-emergencies could be in for a fair wait.  Elective surgeries can take (many months) longer to schedule than here, so you might be hobbling around a lot longer on a bum knee, but at least there will be $0 due when you're finally patched up.  

Another common complaint is that the NHS is in places understaffed.  All this varies depending on where you live, just like service in the US varies depending on if you live in a big city or a smaller town.  On the plus side, paperwork there is nil....just show your eligibility card.  That's it!  *take note Aetna!*

My friend pointed out that, essentially, National Insurance and the NHS is a non-profit system that covers everyone.  The nature of the system means that drug manufacturers have to reach agreement with the NHS about what their prices will be, and as a near-monopoly the NHS can haggle for better prices than private hospitals or doctors can here.  This is largely why treatment costs there are so much lower....the non-profit side combined with the fact the NHS dominates the market.  In the US a very large portion of the money we pay goes to the sort of overhead that any privately-run system has....large salaries for health insurance and pharmaceutical company execs, dividends to shareholders, medical billing and the inevitable write-offs, and so on. 

Now for some numbers** :  The United States spends approx 17.1% of its GDP on healthcare (public and private combined), or about $9,403 per person, which still leaves us with about 12% who have the only option of going to an emergency room for care, which they will likely never be able to pay.  The United Kingdom spends approx 8.8% of its GDP on healthcare (public and private combined), or about $3,377 per person, which includes care for every legal resident.  

On a parallel track, the total tax burden on the average American is 26% of his income, and 32.6% for the average UK resident.  Essentially the top income earners here would come out ahead paying a lower tax rate, while the rest of us would probably do better paying higher taxes but receiving all-inclusive healthcare. 

Just as there is considerable political pressure to cut healthcare costs here, the same applies there.  The Republicans here and the Conservatives (Tories) there are looking to reign in costs (ie: coverage).  Both are having some success, taking some services off the table, although incurring the wrath of many voters in the process.  I will say that every single Brit I have ever heard discuss their system said they were overall "satisfied" or "very satisfied" with it.

It seems to me that if you have coverage here in the US (subsidized) by your employer, if you have ample financial liquidity to pay for all your prescriptions, the ever-increasing co-pays, deductibles, and out-of-pocket expenses, and if you believe your job is rock-solid stable (is there such a thing anymore?), you might want to just leave things alone.  But if your situation is anything other than that, the security of a British-style system might look very enticing.  Also be aware, as I understand it, those here over the age of 47 will be especially hard hit by the proposed Ryan/TrumpCare, so be prepared.

Finally, I ran across this article while doing my research comparing the UK and US systems by someone who has used them both.  It's definitely worth a read....very interesting.

Just something for you to think about.


* Thank you, Sir, for your invaluable insight.  :)

**  Exact numbers are hard to compare.  US, EU, various research groups, etc, differ slightly.  Some numbers, for example, are from 2015, and some from 2016.  Still, the variations are minor.  Tax liability numbers are as close to "apples-to-apples" as I can find.


  1. Like the old saying, "you can please some of the people some of the time, but not all of the people all of the time." No one is ever going to be completely satisfied with any system. However, as pointed out in the Business Insider article single payer works. The U.S. continues to ignore the multitude of other nations that have proven that. The only way this is ever going to happen in the U.S. is to lock out the insurance and drug company lobbyists when a plan is formulated. Also, the attitude here is "I got mine, screw all you others." With that, and our dysfunctional government owned by corporations, single payer isn't going to happen. So long as there is profit and politics in health care, "we the people" just as well bend over and cough.

  2. Terrific post. Kind of boils down to if you have a lot of money you want our system, otherwise you may want the Brits. Is there a way to sort of combine those benefits?

    One concern from reading the included article is the Brits have been doing this for years and have figured it out pretty well, it is a culture, how long would it take for our health resources and patients to adapt? Gigantic health care changes since 1948 that were taken into the Brits system but might not easily fit into an attempt to do the same here. Nothing is easy and clearly nothing is free regardless of the system.

    For sure, before Obamacare too many people skipped health care all together as they could not afford it. Unacceptable. Under Obamacare it seems that covered people are still avoiding healthcare as it is still too expensive with deductibles and such, plus the private companies are dropping out. Unacceptable. We will never have a system that is fair to all, and equally affordable to all, but we should be able to come up with something that is acceptable.

    Keep politics out of it and we have a chance. Is that even possible?
    Nice job Scott!

    1. Joe, as I recall it was you who suggested maybe some sort of hybrid healthcare system....national healthcare could cover catastrophic accident/illness situations, and private insurance could cover everyday healthcare issues. Seems to me this could be a concept worth developing. Surely someone smarter than either you or me are looking into it.

  3. It's nearly enough for me to think about moving to the UK and applying for citizenship....except that I really love the sunshine and warmth of New Mexico (It's not new, and it's not Mexico, ha ha). However, I agree with all of the above. We aren't going to change as long as the insurance and pharmaceutical companies have our health care system by the balls. And, as Bill so aptly put, you can't make everyone happy. Ever.

  4. Weren't you saying competition was the key to lowering prices? But in the UK a monopoly creates lower prices. Hurm...

  5. Another "yep" from me.

    Can we all copy and paste your post into a Word document and send it to our representatives?

    1. Be my guest. Copy and paste it wherever you want. :)

  6. Pat Dilloway beat me to my comment. A fascinating post. Thanks for sharing.

  7. Pat / Stephen....EITHER wide open competition OR complete universal coverage would put the consumer is a better position than they are in now. It's simple economics: Right now the insurance companies occupy the sweet spot. If they control 80% of a market, for example, they can dictate what they will cover, what they won't cover, and what they will charge. If we don't like what they're offering, we can move along. But if there isn't another company in your market, there isn't anywhere else to "move along" to. They win, the consumer loses. But if there were 10 insurance companies in your market, the consumer could shop around, and the companies know this, and some would likely break rank and offer a better deal than the others to entice you so switch to them. Advantage consumer. One insurance company or the other would still make a profit off you, would still be paying a dividend to their stockholders, would still be paying their army of billing clerks, etc, but the consumer would still be better off than they are now.

    In a pure universal system insurance companies wouldn't even exist, so they obviously would have zero say in anything. Again, advantage consumer. Either competition or single payer system would put consumers in a better position than the are in now.