Healthcare in the UK, France, and USA - Research Paper Example

of Healthcare in the UK, France, and USA: A Comparative Glance The issue of healthcare, or more precisely its provision to the public, stands as a central political question of the presidency of Barack Obama. The president has placed a great deal of his political clout and reputation toward reforming America’s health care system so that it may function more efficiently, justly, and more democratically (that is so that it covers those who as yet have no health insurance). According to the President himself, his initiative “will provide more security and stability to those who have health insurance. It will provide insurance to those who don’t. And it will lower the cost of health care for our families, our businesses, and our government” (President’s 2009). The debate surrounding the President and the democratically-controlled Congress’ drive to reform the American health care system has been as heated as it has been fraught with acrimony. Throughout the debate, be it in Congress, the media, or just on the street, there has been a constant tendency to compare the American system with those of other countries, so as to appraise it of its overall worthiness, effectiveness, and fairness within the context of socially, economically, and politically similar countries. It is the purpose of this paper to explore the similarities and, more importantly, compare the differences among the health care systems of the United States, the United Kingdom, and France in interests of both contributing to this debate and of better understanding it. The prominence which the health care question has attained both in the US and in other countries derives not just from the attention it has received in the politics and media of the US but also from the increasing interest paid to it by academic institutions and organizations of all shapes and sizes. “The epidemic of health-care reform in the decade or so has been accomplished by a growing interest in cross-national comparisons of health-care systems and their performance. Most of these comparisons have been at a high-level, examining variations in funding and provision…, differences in performance…, and trends in health-care reform. Few, if any, studies have got under the surface of macro-level analyses to explore the reasons for differences between health-care systems. (Ham 2005, p. 192) Our intent here must be to take what we can from these available studies and actually attempt a macro-analysis (albeit a brief one) of three major industrialized countries (US, UK, and France) with the ultimate goal of ascertaining the extent to which the US should or should not borrow from these latter two countries in interests improving its own system. Of all the government-run services available to the public in the United Kingdom, the National Health Service (NHS) is surely the most popular and appreciated. “The National Health Service…has been regarded in the UK for decades as the ‘jewel in the crown of the Welfare State’, pioneering universal access to medical care when introduced in 1948” (Health 1999, p. 120). The NHS provides virtually universal health service for the British public. This level of care has came to be so highly regarded by the public that not even Prime Minister Margaret Thatcher dared to toy with it as she was implementing her various neo-liberal economic policies in the 1980’s. Compared to the US, the UK is system is relatively cheap. “Government controls over spending mean that the UK commits less than 8 per cent of its GDP to health care, compared to almost 15 per cent of GDP in the US” (Ham 2005, p. 193). This funding disparity reflects the fact that the UK system is a single-pay system, that is that the only provider of care is the government (save some limited private insurance for special procedures and services available only to the rich who can afford it). There is no competition among various providers and insurers. As such the UK spends approximately $1,461 per person annually and enjoys the unwavering support and approval of 57% of the UK population (U.S. 2001, p.4). To put this in perspective it is helpful to look at some of the more conspicuous statistics available appertaining to the health and wellness of the population of the UK, which numbers some 61 million people. Of the 192 recognized countries in the United Nations, the UK ranks in the top 30 in comparative health. As of 2007, it maintains an infant-mortality rate of 4 infant deaths per 1,000 births, compared to 9 per 1,000 in 1990. In 2004 there were 4 maternal deaths per 1,000 births. Along with a relatively high literacy rate, the average Briton can expect to live an average of 81 years. As well, the HIV/AIDS rate is approximately 0.4% of the population of adults aged 15-49 (United Kingdom 2004). The British NHS “focus [is] on primary care and the GP [General Practitioners] as the strict entry point for health care”, a feature for which it is praised “in comparison with other EU health care systems” (Health 1999, p.120). Thus the NHS concentrates on providing primary care (access to General Practitioners) as the main means by which patients obtain care and after which they are, if necessary, referred to a specialist or other service. Stressing the importance of primary care has helped to keep costs down because those who see specialists (being small in number and thus availability) only do so when needed and not frivolously. The downside of this system is that the emphasis on primary care often has resulted in under-funding specialists, for whom there are “long waiting lists for in-patient hospital services” (Health 1999, p. 120). Though the NHS is overall popular when compared with other services, according to various surveys there exists a notable amount of public dissatisfaction regarding access to specialized doctors and procedures. The NHS system is highly centralized and is directly regulated and controlled by the British Parliament hierarchically. The Secretary of State for Health is responsible to Parliament for the provision of health services within the NHS. The NHS Management Executive is accountable to the Secretary of State for delivering a set of clearly-defined targets and priorities based on government policy for the NHS. The Management Executive distributes funds according to an annual budget to the 106 District Health Authorities (DHAs), the commissioning authorities within the NHS. The DHAs cover between 250,000 and 1 million people. DHA and GP fundholders hold integrated budgets for the purchase of primary and secondary health care. NHS trusts are self-governing hospital institutions…GP’s and dentists have the status of independent contractors with the NHS. (Health 1999, p. 121) Thus the administration of the NHS very much resembles the administration of a centralized modern government: specific groups (in this case doctors) receive government contracts, there are specific geographical regions of service and authority, funds are allocated based upon perceived need(s), and the hierarchy has most of its personnel at the bottom of the pyramid with the power-brokers at the top. “The NHS is mainly funded from the general tax system (95%)” and its budget “…is set by the Ministry and subject to approval by Parliament” (Health 1999, p. 122). Some controversy sprang up in the UK starting in the 1990’s when the government began introducing measures and policy changes aimed at fostering internal competition between hospitals and providers in the interests of improving service and reducing costs. The idea was to incorporate some of the theory governing the US system (though certainly not all of it). Schemes whereby British doctors travelled to the US to observe services and performance in interests of making comparisons have since the 1990’s become commonplace. “The work in question began with a study of the NHS and California’s Kaiser Permanente” and has since been tried elsewhere (Ham 2005, p. 193). The drive to create “an internal market” in the UK started in 1991. By 1996 the reforms had been fully implemented…In theory, provider markets can be expected to yield greater efficiency savings among providers, although in practice these might be outweighed by higher transaction costs…[T]he public debate, at least in the press, concentrates on the length of ‘waiting lists’ for non-urgent interventions. (Health 1999, p. 124) The system is still a largely public-universal one. The NHS has sought to attempt reforms aimed at bringing about competition similar to real free-market competition, albeit in restricted, “internal” conditions. These efforts reflect the need, of the last decade or so, to reduce costs and hopefully gain some of the benefits of a private system without its alleged drawbacks. The main complaint voiced by the British public centers around the lack of consistent and/or reasonably quick and easy access to specialists. There is constant reference to “waiting lists” and the denial of access to specialized procedures for conditions which are not immediately life-threatening. The government-run trial of “an internal market” makes the UK ideally suitable for comparison with the US where there is presently a push to change its system from one with a regulated market to a more government-run system. The French Health care system is one of the more cited ones in the industrialized world. “France has a complex mix between private and public sector for both service provision and financing health care. The system is based on compulsory public health insurance, which is supplemented to a very large extent by voluntary insurance” (Health 1999, p. 53). In a way then the French system lies somewhere in between the more market-oriented American system and the single-pay system of the UK. The French populace at a glance demonstrates a level of public health and well-being at par with its British counterpart and far better than most other countries of the world. France is a country of some 62 million people, a quarter of whom lives in the capital of Paris. Its ranks in the top 20 countries for the average health of each person. Its infant-mortality rate was some 8 deaths per 1,000 births in 1990 and only 5 infant deaths per 1,000 in 2007. In 2004 it had a rate of 3 maternal deaths per 1,000 births. Its highly educated population could, as of 2007, expect to live until an average of 79 years old. Compared with other rich countries, the HIV/AIDS rate in 2007 was a low one of some 0.2% of the adult population aged 15-49 (France 2004). The health care system in France boasts a near universal coverage of the public. “A wide range and nearly unlimited volume of health services is available in both the hospital sector and in ambulatory care and patients are granted freedom of choice between providers. The system has performed very well in satisfying the expectations of the French population. The French do well in comparison with the rest of the EU in terms of life expectancy at birth and standardized mortality. (Health 1999, p. 53) The one drawback of a publicly administered system like France’s is that costs often get out of control to the extent that France’s system is “amongst the most expensive in Europe.” The French government carefully scrutinizes and regulates the country’s health care system, in which “universal access to health care is guaranteed…” (Health 1999, p. 55). The system of regulation is similar to the UK’s in that it is largely based upon a top-down hierarchy administered by the central government, albeit with some private options. The health care system in France is closely regulated by the government, which has prime responsibility for the protection of all citizens. Central government assumes responsibility for the public’s health in general and secures social protection, controls relations between institutions financing care, exercises regulatory authority over the public hospital system, and organizes training of health professionals. The ministries of social affairs and health are the key institutions for health policy on the national level assisted by subordinate authorities such as the French Drug Authority and the French Blood Agency. The High Commission of Public Health, chaired by the Minister of Health, formulates public health goals…At the local level there are 22 regional bureaux of health and social affairs (DRASS). Their main responsibility is to plan health and social services through annual budget controls, and to monitor the health plans’ which establish the number of hospital beds….and establish rules… (Health 1999, pp. 54-55) The government then sets the rules and regulations for the various plans which are available to the public. This large variety of plans is what contributes to the French system’s higher costs. These plans are the reason the French system is described as public-private. Coverage plans are allocated according to ones profession. The main system covers 80% of the population. The remaining 20% are covered by specific schemes tailored to professions with special status in the country (civil servants, doctors, and students). “The very poor can qualify for medical aid provided by various charitable organizations” (Health 1999, p. 55). The government funds the system through the levying of payroll taxes on both employers and employees with “12.8% of the gross salary from the employer and 6.8% from the employee” (Health 1999, p. 55). So the system is dependent upon both government funding and private-sector cooperation. Though the system is popular with the French public (any past attempts by politicians to dramatically alter it have been met with outrage and protest), it does have some structural problems. “Health care expenditure in France has grown faster than the French economy…There have been a number of short-term political initiatives to contain costs…none…resulted in long-term stability of expenditure” (Health 1999, p. 56). In a system like France’s where funding comes from taxing payrolls, the system can only grow to the extent that the French economy grows. With rising costs in the last 20 years, France has run into budgetary problems because not enough jobs are being created to pay for the system. As well, like many European countries, France has a rapidly aging population and will soon have far more retirees than workers (and thus far more in need of health coverage than are prepared to pay for it). This, mixed with the French insistence of diversity of care, has of late caused many problems (Health 1999, p. 57). The United States has what many have called “a hodgepodge” of private care and options coupled with government regulation of the insurance and medical industries. For several decades now the Federal government has provided health coverage for the elderly and some for the extremely poor (Medicare and Medicaid), but has no active system of guaranteed public health provision. With some “42.6 million people in the U.S. currently without health insurance,” the US has of late been criticized by many countries and international bodies for this lack of care for the poorer sections of its population (U.S. 2001, p. 1). To be fair though, the US reasonably holds its own when compared to other countries’ health statistics. Its infant mortality rate in 1990 was 9 deaths per 1,000 births and in 2007 was some 7 per 1,000. Its maternal death rate was 4 per 1,000 births out of a population of some 300 million. It slightly elevated HIV/AIDS rate of 0.6% of the 2007 population aged 15-49 largely reflects the fact that US was one of the original epicenters of the HIV epidemic and has never been able to rise to the top of that list with other rich nations. And yet its life expectancy stood at 78 years as of 2007, a figure which is not bad compared to the UK and France (United States 2004). It should not be forgotten that much of the health care provision in America is done by the government. Though for the most part the system is a private based one, much of the actual care is not. [H]ealth care in the US incorporates multiple forms of funding and provision in a market-driven non-system. To be sure, the publicly funded programmes for people on low incomes (Medicaid) and those aged 65 and over (Medicare) mean that government contributes almost half of total health spending in the US, but the predominant approach is that of employer-based health insurance and private health-care provision. (Ham 2005, p. 193) The fact that so much of American health care is paid for by the government is something which many people forget or simply ignore when taking part in the country’s current health care debate. Interestingly, the amount of money spent by the US government per patient is higher than any other rich country (most of the latter of course have systems which cover at least 80% of their respective populations). “Government controls over spending mean that the UK commits less than 8 per cent of its GDP to health care, compared to almost 15 per cent of GDP in the US at the last count” (Ham 2005, p. 193). The US spends some $4,178 dollars per person, almost three times what France and the UK spend. These runaway costs are associated with the enormous costs of administration, themselves the result of a great amount of government regulation coupled with a variety of options, nuances, and privately-offered schemes (U.S. 2001, p. 2). The advantages of the US system lie in the wide variety of care, the availability of specialists, and overall high-quality provided (that is for those able to afford the insurance so as to be able to be provided). Quick access (compared to other rich countries) is a feature of the US system worthy of some praise. The fact that the US “has by far the most expensive health care system in the world” but still does not provide for some 40 million people is a point of much contest and criticism (Ham 2005, p.2). Too much money is lost to administrative costs. The fact that health care has become such a “hot” issue since Barack Obama took office can be attributed to his popularity and to the fact that many Americans feel that the system should be reformed, though there is much disagreement over how to do so. Personally, I think that Medicare and Medicaid should be protected but we should not change to a UK style single-pay system. The private sector provides an access and variety of care that would be missing in a completely government-run system. As well, the famous waiting lists of the UK’s NHS are hardly something to strive for. Reducing the cost of administration would be a big step and would free up money for other endeavors. A system more like France’s with mandated purchase of health insurance and a government that helps reduce costs (or at least tries) is something the US should work for. The fact that we spend so much more on people and yet do not get the expected return of such expenditure is a shameful aspect of America’s system. The various bills in Congress right now aim at a variety of different solutions ranging from universal coverage to required purchase of insurance with financial aid for the poor. If the government ultimately just creates more bureaucracy and does not increase the quality or quantity of care, then there is little point in “reforming” anything. The emphasis should be on maintaining access to specialists, emphasizing primary care, reducing bureaucracy, and deregulating those things that the private sector could do better all the while maintaining regulation of those areas which the free-market often ignores. Whether it is Barack Obama, or someone else, something must be done. Works Cited “France.” 26 February 2004. Unicef (official website). 01 December 2009 http://www.unicef.org/infobycountry/france_statistics.html Ham, Chris. “Lost in Translation? Health Systems in the US and the UK.” Social Policy & Administration 39:2 (2005): 192-209. “Health Care Systems in the EU: A Comparative Study.” May 1999. European Parliament Directorate General For Research (Working Paper). 01 December 2009 http://www.europarl.europa.eu/workingpapers/saco/pdf/101_en.pdf “The President’s Plan for Health Reform.” Fall 2009. Organizing for America: A Project of the Democratic National Committee. 01 December 2009 http://my.barackobama.com/page/content/hcsignon/?source=OM_LB_google_HC-search_O-search_tc&gclid=CPKG-8epwp4CFRQhnAod6laUqA “United Kingdom.” 26 February 2004. Unicef (official website). 01 December 2009 http://www.unicef.org/infobycountry/uk_statistics.html “United States.” 26 February 2004. Unicef (official website). 01 December 2009 http://www.unicef.org/infobycountry/usa_statistics.html “The U.S. Health Care System: Best in the World, or Just the Most Expensive.” Summer 2001. From Website of the University of Maine: Bureau of Labor Education. 01 December 2009 http://dll.umaine.edu/ble/U.S.%20HCweb.pdf Read More