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Stones & Bones: health care / volume 10 number 12, December 2008 DOSE OF REALITY Next to Canada’s, the United Kingdom’s universal health care system is the favorite target of conservative Americans who talk against the idea of installing a system of universal health care in this country. They like to trot out anecdotes about waiting times or other problems intended to illustrate how bad the British universal health care system is, while at the same time refusing to face the fact that overall this system is far cheaper and far more effective than ours. Perhaps one reason for their refusal is that the United Kingdom’s health care system is almost purely socialistic, and Americans are deeply imbued with the idea that private enterprise unfettered by government regulation is the end answer to everything. “Oh no, we can’t have socialism here; it’s un-American!” is the standard knee-jerk reaction, typically expressed with a horrified look on the face indicating that further discussion on that topic is likely to be unproductive. However, if such a person is open-minded enough to be at all receptive to factual information, one place to find some is in a report by Dr. Martin Roland published this month in the New England Journal of Medicine.* Titled “Lessons from the U.K.,” this report describes how the United Kingdom is moving ahead with its health care system to make it better than it already is. The main thrust is to improve primary care, the reason being that the British recognize that primary care is the crucial element in an effective health care system. The best health outcomes result from people’s receiving timely early care coupled with a continuity of care made possible by comprehensive record-keeping and continuing cooperation between primary caregivers and specialists. Toward this end, it is comparatively easy to establish standards and methodologies in a single-payer health care system, and almost impossible in a fragmented multi-payer system such as exists in the United States where too much of the decision-making is by for-profit insurance companies. They revere the bottom line—the financial bottom line for themselves, not the general public’s bottom-line need for adequate and affordable health care. The new emphasis on primary care in the United Kingdom follows two paths. One tactic is to use modern technology to maintain each patient’s lifelong health record; it details each visit to a primary doctor or specialist, lab results, and any treatment and medication received. That allows both the primary doctors and the specialists to easily download the information when needed, and thereby serve the patients better. The second approach is to make more use of interdisciplinary teams for taking care of patients in ways that maximize care and best utilize medical talents. One consequence is that nurses are taking on an increasing proportion of the work. They may be the first to see patients with minor illnesses, and they are assuming more responsibility for routine management of chronic diseases. Another is that the role of the primary doctor is being emphasized to the extent that primary care doctors are making more money. Paid by a combination of risk-adjusted capitation and a 25 percent additional amount for performance, primary care doctors in the United Kingdom now have average annual earnings of $220,000. The average annual income of a primary care doctor in the United States is far less, about $150,000. What this tells us is that it is possible to hone a workable universal health care system to make it better in ways that are very difficult or impossible to achieve in a multi-payer system such as we mostly have in the United States. However, in single-payer components of the United States’ system, improvements similar to those being enacted in the United Kingdom are taking place. The outstanding example is the Veterans Administration health system, which is making changes similar to those underway in the United Kingdom’s system. That is possible at the VA because the organizational structure is similar to that of the British system; both use government-owned facilities manned by government employees, thereby both avoiding the wasteful funneling of health care money through for-profit private insurance companies. Herein is, of course, a strong hint at the overall direction we must move if we want to reduce health care costs and improve health care delivery in the United States. Instead of trying to force more people to buy private health insurance, we need to establish a single-payer health care system. With our current unhappy financial situation, now is the time to proceed. By instituting a proper single-payer system we should be able to cut overall health care costs by one-third. That is an annual saving of $700 billion, give or take $100 billion. It’s enough to pay for the bail-out we seem to be intent upon performing to “save” our financial institutions and our floundering domestic auto industry. If my statement about how much we could save sounds wild, consider how much the United Kingdom’s health care system costs compared to ours. The cost of health care in the United Kingdom in 2006 was $2,760 per person, less than half the per-capita cost of $6,714 in the United States. Not only that, the British system gets better results, as is attested to by the facts that the child mortality rate is lower in the United Kingdom, and the citizens there live longer than we do. Overall, the system is rated on several counts as being better than ours, and British primary care doctors make more money, as well. It’s simply a matter of putting the money where it should go, and that is not into the for-profit private insurance industry. * Available on line at http://content.nejm.org/cgi/content/full/359/20/2087-b.
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