WHO are doing a free Webinar on Refugee and Migrant Mental Health on the 16th October. Click here for details.
What’s the big deal?
During the summer, the effort to repeal Obamacare was all over the news. I called my friend Lucy for an interview to better understand why this was such a big deal. Admittedly, Lucy is a paediatrician rather than a GP, but she knows more about healthcare in the U.S than anyone I know. She’s married to an American, has a Masters in Public Health from Harvard and is a faculty at the Institute for Healthcare Improvement (IHI) based in Cambridge, Massachusetts. I met Lucy during my elective and we have been friends ever since. Who better to ask? Just to brace you, Lucy uses the words ‘complex’, ‘complexities’ or ‘complicated’ 16 times in our 40-minute interview. This may give you an indication of what this conversation was like.
U.S healthcare is an insurance-based system, unlike the NHS, which is a single-payer healthcare system. “US healthcare is paid for by insurance and you have to opt in and, up until the Affordable Care Act [A.K.A Obamacare] in 2010, there were large parts of the population who were totally uninsured. Your employer purchased your health insurance or you were responsible for privately insuring yourself. There were a few exceptions to this, government funded insurance programs: Medicaid is for people with low income, Medicare is for older people, there’s also the Children’s Insurance Program (CHIP) and the Veterans’ Health Administration”
“Healthcare in the US is complex. It has multiple stakeholders, multiple funding sources, both government [Medicaid, Medicare, CHIP and VHA] and private insurance, and these have different features. The ACA had the intention of making healthcare more affordable within this framework and is an attempt to make healthcare more accessible by increasing coverage and thus allowing more people to receive care. There are also other pieces within the ACA that try to shift the focus to prevention and towards higher-value care.”
“Insurance companies can be for profit or not-for-profit. Further complexity exists where these insurance-providing organsiations may have links to particular health systems and may have more of a socially conscious mission and may be involved in physician groups as well having a leaner view of healthcare.” I think what Lucy’s saying here is that there is even a huge variety when it comes to insurance companies, including those that are not for making huge profits.
“Traditionally, those who are uninsured are undocumented individuals and those who cannot afford private insurance – so those who don’t qualify for Medicaid assistance based on income level but can’t, from disposable income, afford private healthcare.” This is reminding me of a conversation I had with an international student from the U.S at my medical school that has obviously stuck with me over the years. One of her friends, who had studied music as an undergraduate, was a self-employed music teacher after graduation. She had not ‘opted in’ because she couldn’t afford the monthly premiums once she had paid her monthly bills and her university repayment. So, if she became unwell, she was not covered. “And if you are an individual trying to navigate this system it is incredibly complex. Even senior health leaders struggle to do the paperwork for these governmental applications and you can imagine that applying for governmental assistance is a significant road block, especially if you have any difficulties with literacy.”
“The NHS has its benefits and its failings. One great benefit of the NHS is that it is a single system, which means that we can ensure that a basic standard of healthcare is provided regardless of who you are and where you live. Whilst there is still variation within the UK, the variation is less broad [than the US] but one of the downsides of a single-payer system in the UK is that innovation and flourishing of excellence is sometimes quashed by the fact that we exist in one financial system. The upper echelons of US health care can offer technologically advanced and experimental care but the problem still lies in access and individual cost of accessing healthcare.”
What’s your feeling on the NHS? Is it better than the US system? “I’m enormously pro NHS but it’s not a utopia and we have different barriers. It is free-at-the-point-of-access so coverage and access are not problems that we have here. We have resource issues. We have a different kind of rationing, We’re just not rationing at the point of access to healthcare. We have resource constraints because the funding is finite. Within the NHS, even though we governmentally fund all of our healthcare, the money is finite and the restrictions have to be played out in a different way.”
And how does the US spend 17.8% of its GDP on healthcare in 2015 when the UK is spending 9.9% (2014)? “Broadly it’s more utilisation and higher costs of healthcare but even that is complex and mysterious. It may be because the price of units of healthcare is different. It may be that we utilise less healthcare in the UK for a given episode of illness, it may be that people access more healthcare in the US, but it remains an interesting question”.
“If you plot life expectancy against healthcare spending in different countries, there are certain outlier countries who disproportionately spend despite the life expectancy achieved. It is not possible to directly correlate the two because life expectancy and the need for healthcare is dependent on so many other population features such as income, education, and inequality within a society.”
So who was in favour of and who was against the ACA? “Those who favoured expanding healthcare coverage were broadly pro. Those who felt that it would be damaging to the economy or could create unneeded healthcare usage were against. The tension can be partly explained by party politics [Democrats vs Republicans], most simply. A classically heard viewpoint in opposition to the ACA was that if you expand coverage, people would just use healthcare because it is there. This remains a very well-travelled argument about healthcare access that is not without basis, but misses the larger picture of the value of preventative healthcare and the advantage of treating conditions earlier in their course.” Perhaps Jeremy Hunt needs to take notes here.
“Basically it’s very difficult to know at this juncture whether it [the ACA] has increased life expectancy. But the implications of the repeal of the ACA are clear. The body of evidence indicates that coverage expansion increases peoples’ access to care, expands access to preventative and primary care, and seems to bring significant improvements to health. We can’t know that for sure but that’s what we know this far in. If you repeal it that stuff will go away.”
“I think the simplest and compelling argument for increasing coverage is, to misquote President Obama, ‘you should not be sick because you are poor and nor should you be poor because you are sick’.”
“One of the implied pieces of the ACA is that we should be thinking more about preventative healthcare rather than treatment healthcare. At a countrywide level we should not be defunding public health. We should be thinking very cautiously about where to spend our money on upstream healthcare. If I were in charge in any country, more money would go into public health and education because education is the biggest determinant of life expectancy and healthcare outcomes aside from income. Every government needs to think further and further upstream within the social determinants of health. We only need to look at countries where life expectancy is at its greatest to learn more about the role of exercise, obesity prevention, healthy eating, walkability of cities, quality of education, empowerment of women, and availability of contraception as powerful determinants of public health.” I totally agree with this. We can talk about healthcare until the cows come home but at the end of the day it is such a drop in the ocean when considering the impact of infrastructure, education, and societal values on health. There’s an excellent free course on Futurelearn run by the BMJ about social determinants if you’re interested in learning about this further.
So from this conversation, I’m feeling more confused than ever. It’s clear that despite being a similar system to Japan (insurance-based, direct access), it is mind-blowingly different. “I think there are few people in the US who would profess to fully understand US healthcare. It’s state-dependent and it depends on your coverage. It is a complex system for sure. I think it would be an unequivocally bad thing to repeal the ACA. I would caution any British doctor from perceiving the US system as universally better than the UK system. Having seen it from the inside, the effect of a single-payer system, such as we have in the UK, is a good thing. I think we can do better in the NHS at fostering innovation, considering care quality outcomes, and reducing low-value care , but if you asked many who treat patients within the US healthcare system, they might wish that they had what we have.”
So I’d like to finish with a funny story from last year when I visited Lucy in Boston whilst she was working at IHI. One of my striking memories from this trip was a conversation with a random American in the queue for a lobster restaurant (I was meeting my lobster needs solo as Lucy was at work). We got chatting on why I was in Boston and where I was from. He was also quizzing me about the NHS. The bit that really got me was, when we were discussing how healthcare should not be for profit, he looked around furtively and whispered to me “I’m a communist too…”