In early February, Buckingham Palace announced that King Charles has been diagnosed with cancer. As is often the case for the royals’ personal lives, not a lot is always shared. But the King and his now deceased mother should be congratulated for some of their openness. Like his mother’s announcements when her health was in question, the King’s announcement was meant to encourage everyone to take care and get preventive care performed.
At the same time, the King’s announcement has shined a light on some of the problems in the United Kingdom’s healthcare system. As I have covered a few times in my blogs, the U.K. just celebrated its National Health Services’ 75th anniversary of its founding a few years after World War II ended. The U.K. took the socialized medicine approach, where the government funds, directs, runs, and largely provides healthcare services to its citizens. Some other nations in Europe have this socialized system, but other nations can have two other forms of healthcare access as well: (1) single payer, where the government funds and directs the system but private entities largely provide services (e.g., France); and (2) private affordable universal access, where the government directs and subsidizes some funding but private entities largely run the system and provide services (e.g., Germany). In the case of socialized medicine and single payer, sometimes nations can have aspects of each, although one form usually is more prominent.
The Commonwealth Fund finds that all three systems can be very successful. Its study (see my other blog below for the citation and details) found that all three types of systems were represented among the top five performing systems from an efficiency and quality outcome standpoint. As I often note, America has none of the three system types. It has a patchwork system of employer and government program coverage that leaves tens of millions uninsured. Consequently, it spends the most on healthcare but has the lowest outcomes in the developed world.
Despite recent criticism of the system in the U.K. after the King’s announcement, no one can say the U.K. system does not have quality. Indeed, it was among the top five performers in the Commonwealth study. But the criticisms are real and call attention to the pros and cons of various healthcare systems.
The recent negative news on the U.K. system centers on long wait times for specialists and treatment services (even routine services are impacted and can have waiting lists) . This impacts the timely diagnosis of life-threatening conditions and impacts how quickly one gets treated. We know that early detection of cancer and other conditions is critical. Indeed, in the case of the King, while we do not know his form of cancer, the Prime Minister announced that the cancer was caught early. The King was undergoing a procedure for an enlarged prostate when the cancer was found (but it is not prostate cancer).
But in the case of many Britons, the swift access the King received to the very best treatment may not be what the average commoner receives. In the Associated Press article at the end of this blog, an average citizen is featured. She would have waited three months for treatment of Stage 4 colorectal cancer due to high demand and low capacity of qualified doctors. She had access to private insurance and underwent surgery and chemotherapy treatment. As she implied, the three months could have meant the difference between life and death. The article notes that thousands of people get the same message from the NHS and may not have access to private coverage.
Many view the U.K. system as in crisis due to a lack of adequate funding, advanced technology, and enough qualified personnel. The article notes that U.K. health officials aim for 75% of patients with suspected cancer to receive a diagnosis within 4 weeks of referral and 85% of them to wait less than 2 months for their first treatment. Here in America, most of us would see those wait times as abysmal. But the English portion of the NHS (by far the largest) has not even been able to meet these targets since 2015. One in three in the U.K. wait more than 2 months to start treatment. At least 225,000 people have waited too long since 2020. Less treatment than in other developed nations is also common across cancer types. This means U.K. survival rates are lower than other developed nations.
Now, at least part of this appears unique to the U.K. and issues it is having. Its (once?) cherished system needs a bit of a makeover. But such waiting lists and access issues are not unique to the U.K. We see this in our neighbor to the North (Canada) and in other developed countries. Private insurance options and providers are rising in any number of developed countries with socialized medicine and single payer. Even in those with private systems, buying beyond mandated insurance and accessing services quickly is not uncommon.
So what can we conclude from all of this? Well, foundationally, any universal access system (socialized medicine, single payer, and private affordable universal access) do a few things right:
- They provide coverage to 99% of their citizens. Everyone has access to most health services.
- They emphasize primary care, prevention, and wellness because of the upfront access to healthcare coverage. America tends to have a huge under-investment here.
- Healthcare is not treated as a commodity you earn but as a basic right.
At the same time, the socialized and single-payer systems (and to some degree the private ones too) tend to explicitly ration access in many ways:
- Drug formularies are tighter. Most developed nations have access to about half of the newly introduced treatments. One part of me says we have a terrible drug pricing and innovation system in the United States. High prices can cost lives. At the same time, I want access to every possible treatment.
- Many other developed nations tend to ration higher cost, specialized care in a number of ways:
- Fewer specialists, expert facilities, and technology investments.Limits to treatment access, waiting lists, and excessive wait times.
- The inability to receive certain treatments.
A good use case on this is my daughter’s recent brain surgery. She actually has access to both the U.K. and American healthcare systems. While in the U.K. she saw delays in accessing specialists, MRIs, and drugs for her condition. The U.K. likely would have deprioritized her brain surgery for several years, if she were able to receive it at all. Here in the United States, she received MRIs and had her surgery in a matter of seven weeks. If it were an urgent situation, the time would have been less.
So, in sum, the Commonwealth Fund shows that other systems (regardless of the three types) tend to have better health outcomes overall and the systems cost less. But, as with the U.K., mortality and morbidity can be higher in certain healthcare situations, such as cancer, because of the implicit rationing of these types of services.
But let’s not trash these other systems for their warts just yet. Yes, here in America, the wealthy and those with strong insurance tend to have good outcomes that can rival other developed nations. They also tend to have access to timely and technology-driven care as well as the most up-to-date treatments – simply put, the best healthcare in the world. But the tens of millions of underinsured in America get the worst of both worlds. They don’t get the security blanket of coverage and access to upfront primary care, wellness and prevention found in other developed countries that tend to promote better overall aggregate outcomes. And their mortality and morbidity from cancers, other serious conditions, and uncontrolled disease states (such as diabetes, asthma, and cardiac conditions) tend to be very high. Perhaps setting aside uncontrolled disease states, this mirrors what we see in the U.K. and perhaps other developed countries. These Americans don’t get diagnosed. They can’t afford their meds. They don’t get treated. If they do, it is often too late.
In America, we tend to ration care and access by insurance status and income. These other systems tend to ration across the board by global budgets affecting everyone. The cracks in those systems are leading to wealthier folks to close those gaps by paying for private insurance and private facility access.
I have argued we could fashion a middle ground in America if everyone were committed to do so — one that provides affordable universal access to upfront care as well as the best of an on-demand, high-tech healthcare system. While we might spend more than other developed nations once we transform our system, we could still save against what we spend today as a percentage of gross domestic product.
Additional reading:
https://apnews.com/article/uk-cancer-waiting-times-king-charles-1d519afeb31d840ed084e356f968fdc7
#healthcare #healthcarereform #uk #socializedmedicine #singlepayer #privateaffordableuniversalaccess
— Marc S. Ryan
