Politics of healthcare in England and the USA

International comparisons

“The result will be that at the end of this Parliament we will once again be back into a debate that I thought we had buried – whether tax based health care free at the point of need is the right basis for health provision. That is the last debate we should be having, but it will be product of this Bill. I believe the Secretary of State when he says he supports the NHS. But by the end of this Parliament, when the structural flaws are clear, he is not going to be around to defend it.”
David Miliband

The future debate

Some on the US right argue that the NHS is a dangerous socialised medicine which contains long waiting lists, little patient choice, and fully rationed care. Some on the UK left have also been responsible to the opposite effect in relation to US healthcare, with claims that people will be required to show their credit card before being allowed to step foot in an Emergency Room. Neither is the case.

The notion that it can depend upon one’s employer as to the healthcare that one is entitled is a fundamental difference between the US and UK healthcare. It is this that makes the debate around healthcare reform important and necessary. The Health and Social Care Act will not bring about an overnight change into the UK healthcare system that will leave people without healthcare if they do not have insurance from their employer, or if they are unemployed, or no longer in work. Nor will the PPACA bring about change that is so radical that it will bring the US healthcare system into one that offers full health coverage to all within the US regardless of their economic standing.

As has been discussed, the HSCA does however have the potential to bring UK healthcare closer to the US system with regard to the role of market mechanisms; but does not appear to challenge the notion of free at the point of use healthcare. Likewise, the Patient Protection and Affordable Care Act 2010 does have the potential to bring healthcare to more people at a more affordable rate; but it does not mean that people requiring healthcare in the US will be able to access such care and not receive a bill after treatment.

The principle that will remain throughout is that UK consumers will not have an explicit financial commitment to the healthcare treatment that they receive, nor might the cost of treatment be a primary consideration.

The reliance upon the US Constitution and individual liberty is a barrier to a US-style NHS. Whilst the nation was founded upon the principle of “we the people”, some people worry that any form of government spending amounts to “socialism”– which, given the nation’s historical role in opposition to such ideology, carries a negative connotation.  Given that the Veterans Administration spends $33billion annually on military healthcare, however, it is not unheard of to have universal healthcare coverage.

The political paradox of priority setting in the NHS

The NHS, a system which employs 1.7 million people, is always going to be a significant political issue, not least because of the potential to impact people’s lives. As has been discussed however, the reforms contained within the HSCA do not have the potential to have such action in a positive manner.

Such reforms, assuming that the NHS maintains the status quo of implicit priority setting of care; combined with the HSCA reforms of an increased integration with market mechanisms and competition through greater use of private sector services; and the already existing financial pressure that the NHS is under, will lead to greater rationing of care within the NHS.

This will create a political paradox of priority setting for whichever party/parties are governing after the 2015 general election. One positive aspect about the HSCA reforms however, is that there has been some debate – albeit minimal in understanding due to the HSCA’s complexity – within the public about the NHS. Further implications following greater rationing within the NHS will hopefully lead to a wider public debate about the value of health and healthcare, as was seen in the OHP. Such debate will, perhaps, lead to a greater utilisation of explicit priority setting, for long-term gains within the NHS.

Given the political sensitivity of the NHS, it is common for politicians and policymakers to avoid reference to rationing. Perhaps now is a real opportunity for the adoption of priority setting processes, and an opportunity to take valuable lessons from the OHP, and to increase the effectiveness of the NHS.

Such an opportunity – to ensure a comprehensive, free at the point of need, solidarity-based, truly National, Health Service – will be adopted by those who have the faith to fight for it.

Ian has been working with us for the last year and this is part of his undergraduate dissertation submitted to the University of Sheffield.