This is one of a number of blogs that will appear on my daughter. I call her Kitty. She is a wonderfully talented, bright, and empathetic individual in her late ‘20s. She and I agreed I would write this series to impart how important health coverage is. Not only is her decision to have surgery courageous, but so is her decision to share her journey through me.
The principal reason to share the journey is because we both want to explain what many average Americans go through financially when they have major operations and do not have the best insurance or no insurance at all. My daughter is privileged to come from a well-off family and to have consistent and robust insurance. This will mean that she will pay a tiny amount for a surgery with a sticker price in the hundreds of thousands of dollars. But for uninsured and underinsured Americans, the costs of such a surgery could literally bankrupt them. In the alternative, they would forego important medications and the surgery altogether. My daughter has not had to do that, but millions of Americans do each year.
Throughout this series, we will give you updates on Kitty’s surgery and progress as well as share her health insurance journey, the bills she receives, the amount she pays, and calculate what someone who is uninsured and underinsured might pay. As well, since she has a connection to the United Kingdom, we will compare and contrast the U.K. and American healthcare systems.
For an overview of my daughter’s condition, go to Part 1: https://www.healthcarelabyrinth.com/part-1-my-courageous-daughter-is-having-brain-surgery/
Kitty’s connection to the U.K.
As we told you in Part 1, my daughter, Kitty, has a special connection to the United Kingdom (U.K.), more exactly Scotland. She attended the University of Edinburgh in Scotland for four years, getting an undergraduate Master’s degree in Arabic and Persian. The Brexit vote occurred in mid-2016. Job sponsorships for foreigners were scarce and my daughter could not stay post her graduation in 2018. She returned to the United States and of course COVID hit in 2020. She remained here working for a British corporate intelligence firm and as a coffee shop manager. She returned to the U.K. in 2023 to obtain a Master’s degree in Russian, East European, and Eurasian Studies from the University of Glasgow.
When attending school or working full-time in the U.K., foreigners are covered by the National Health Service (NHS). There are really several health services, with devolved areas having the ability to run their own systems. In this case, she was covered by the Scottish National Health Service by paying a very affordable fee with her visa. My daughter is now on a graduate visa with the same health benefit for two years (she paid about 800 British Pounds per year) and hopes to remain in the U.K. indefinitely once she finds employment.
The healthcare systems compared
You know what the American health system looks like, but let’s discuss the U.K.’s. The U.K. has what is called a state-run or socialized system of the healthcare. Do not be afraid of the word “socialized” – it simply means that the state is providing care via public funds. The U.K.’s National Health Service (NHS) just celebrated its 75th anniversary, having been founded in 1948. There are really four systems in the U.K. – the English, Scottish, Welsh, and Northern Irish National Health Services.) In the U.K. system, everyone that is a citizen of the U.K. and some foreigners are entitled to healthcare. While some areas may have small fees for prescription drugs, overall people access the system for free and care is supplied from the taxes on citizens and businesses in the U.K.
Generally speaking, healthcare is delivered by public institutions at the local and regional levels. Specialists on up largely are employees in NHS institutions, but primary care services largely are furnished by private providers (the government enters into contracts with doctors and other providers). The NHS is even experimenting with value-based care arrangements with PCPs. A majority of payments to them are via capitation to enhance holistic care of individuals and care management.
It is also true that because of gaps in the system (uncovered services or long waits for certain services), private insurance and truly private practices and facilities are emerging in the U.K., forming a bit of a hybrid system. But overall, the U.K. has a public, socialized system, while the U.S. has a private healthcare system that is primarily employer based with Medicare, Medicaid, children’s health, and the Exchanges filling the gaps. While the uninsured rate is about 1% in most developed nations, ours is 8% to 10%.
Is one healthcare system better than another? That is a tough question. In the blog I did back in late November, ( https://www.healthcarelabyrinth.com/american-healthcare-is-a-huge-outlier-in-terms-of-costs-and-outcomes/ ), I noted the Commonwealth Fund found that all three system types (socialized, single payer, and private universal access) performed in the top five of 11 countries surveyed. The UK ranked fourth, with the U.S. dead last at eleventh. In fact, the U.S. was a negative outlier even against the lowest performing developed nations studied. So in general, people in the U.K. and other developed countries have better outcomes in the aggregate and have a much more cost-effective system.
But it is not that easy. Implicitly, every healthcare system rations care. In the U.S., we use utilization management and prior authorization to decide what is medically necessary or not. We, too, have a high rate of uninsured, which itself is a form of rationing. In other developed countries (across the socialized and single-payer systems), many use global budgeting to ration care. Each year, a budget is set for healthcare. The systems must live within that allocation. That means rationing care through a few means. Primary care physicians act as gatekeepers to higher levels of care. It often takes time to see specialists in these systems. Waiting lists may be established for elective surgeries. In general, if you have good insurance, the American system allows earlier access to these types of services than in other developed countries. As well, there is some concern that stingy budgets have meant the U.K. and other nations’ healthcare systems have fallen behind in terms of access to the latest technology, drugs, etc. And given budget woes, these nations seem to be seeing a personnel crunch, although doctor and nurse shortages are hitting our system, too.
So how does this then lead to better outcomes in the U.K. and other developed countries? Everyone is guaranteed access so everyone can get care. In addition, other developed nations spend more time on ensuring control of chronic diseases and conditions, which also contributes to wellness. While these developed nations tend to limit some drugs, it is also true that citizens get access to drugs that cost them nothing or are very affordable. This boost adherence and keeps diseases in check. But there is growing concern that in these nations long wait times and shortages do impact life expectancy for some. For example, if testing to identify cancer takes time and then more time occurs waiting for the start of critical radiation or chemotherapy, will mortality rates for those with cancer increase?
How has Kitty faired in the U.K. system and would she have been approved for her operation there?
Because of some of the constraints noted above, my daughter has largely kept her connection to the U.S. healthcare system and receives most of her care in the U.S. It is a choice we make and we continue to carry a $800 per month policy for her here. A few examples as to why:
- She was able to get some free medications from the U.K. In other cases, her expensive medications were not on the national formulary. But they were on her U.S. policy because we sought out high-cost insurance that covered them. So we stockpiled meds and she picked them up on visits back home. In our view, these medications for her conditions are very necessary, but she did or would have seen huge delays in accessing them (or outright denial). A good example is a migraine medication. It took my daughter over one year finally to get approval for the medication. The biggest delay was more than a year to get to a specialist to approve it.
- When she did have an episode with her brain during her undergraduate years in the U.K., she waited four-plus months for an MRI. The episode was not deemed life-threatening, when she would have likely been seen by a specialist and receive her MRI in the U.S. within say a week or two.
My daughter is having surgery in the U.S. largely because she will be near family for the weeks or months of recuperation. But would Kitty have been approved for her operation in the U.K.? The answer is “likely no” or if she were to be it would likely take years to have the operation.
Her symptoms would likely not have been deemed life-threatening and she would have waited to see multiple specialists (neurologists, neurosurgeons, and perhaps more) to assess her and the need for the operation. She might also have been required to change medications (perhaps multiple times) to determine if her symptoms could be better controlled before any surgery was undertaken. If she were eventually approved, then she may have been placed on a waiting list for what would have been deemed an elective procedure.
In the United States, the power of relative wealth meant she had instant access to specialists, surgeons, and more when she decided to have the surgery. The power of her $800 a month insurance also carried great weight. It is well known that providers are attracted to serving patients with strong commercial policies – they get paid more and claims usually go through with much fewer hassles. The prior authorization was easy given her symptoms. It was not even a question as it might have been in other situations or countries. Despite the cost, an insurer would not want the risk of something happening later in our case.
And there you see a bit of the difference between the two systems. The U.S. healthcare system is on-demand, technology-driven, and gives people access to the very best (personnel and technology). By and large, U.S. healthcare is a commodity which can be accessed quickly and easily by those with wealth and strong insurance. The U.K. system is based on the concept of social good, where everyone is served as well as the budget allows. Hence, the wealthiest 10% in the U.K. buy private insurance and go to a budding private healthcare system of facilities and providers.
What system do I prefer? Well, for me and my family, the choice is easy. We have the means to afford and access the best system in the world. But for the 85 million or more Americans who are uninsured or underinsured – and for perhaps tens of millions more – a case can be made that their health would be better overall in the socialized medicine, single-payer, or the private, affordable-access models of other developed nations. They would receive consistent coverage, access to life-saving maintenance drugs, and more. They would enjoy high levels of protection against medical debt and also have minimal out-of-pocket payments. They don’t get that here, even with the U.S. spending 50% to 100% more in terms of gross domestic product (GDP) on healthcare. In other countries, their coverage would be based on an over-arching clinical need rather than their ability to pay.
Conclusion
All this is not to condemn the U.K. or other developed world systems, but to say there is a better way in the United States. Through carefully crafted medical and drug price reform, true affordable universal access, and a pivot to managing people’s chronic condition, we could be the envy of the world for crafting a system that recognizes social good as well as on-demand, technology-driven healthcare. We might even decide to spend a little more than others to have that cutting-edge system.
Yet, there appears to be no appetite for compromise on Capitol Hill to create such a model. The progressives in the Democratic Party caucus seem fixated on a Medicare for All model that would further drain America’s coffers and likely not mean better quality (if the Medicare fee-for-service (FFS) system is any indication). Right-wing Republicans are happy with the current system and view healthcare as some “Wild West, pull-yourself-up-by-your-own-bootstraps” commodity, the poor and disabled be damned. The reasonable middle of each party appears to have no power.
Next
So my daughter is here in the U.S. having brain surgery. Her operation is Thursday. On that day, I will be at the hospital most of the day. But that same day I will publish a blog that goes into the estimated billed costs for her surgery. The prices will shock you.
#healthcare #healthcarereform #coverage #aca #exchanges #medicaid
— Marc S. Ryan
