Tuesday, 14 December 2010

UK and USa Healthcare Reforms - spot the difference

As the UK and USA each attempt to solve the unsolvable – how to provide affordable healthcare - one must have sympathy for both nations. The leaders are on a hiding to nothing as our expectations for better and longer lives are fuelled by ever increasing technology and expertise.

As an observer on both sides of the Atlantic, I cannot help but notice the similarity of the challenge (at least in terms of complexity) and the difference in emphasis.

Scale: We are talking about a budget of £100 billion in the UK. In the US, the estimates vary between $1 and 2 TRILLION. In the UK, for instance, there are 2.8 million diabetics compared to 23.6 million in the USA.

Access: Not an issue for the UK as free healthcare is available within the NHS to all 61 million residents and many other visitors besides. Access is key for the US as over 32 million people have no health insurance or guaranteed access to medical care which is the main thrust of the Patient Protection and Affordable Care Act. (PPCA)

Health insurance: In the UK, there are currently 4 million policies probably covering around 5 million people. This insured population, of course, also has access to free healthcare with the NHS. A standard insurance policy does NOT cover for primary care, outpatient drugs, maternity or chronic conditions such as diabetes, asthma and epilepsy but does cover acute flare ups of the conditions. In the US, policies routinely cover primary care, drugs, pregnancy and chronic conditions and is therefore much more costly.

Cost: In the UK, the NHS is free, paid for by a ‘single payer’ (via national insurance contributions - i.e. taxed at source). Medical insurance is seen as a perk for the privileged few, guaranteeing fast track access to medical care, less rationing of expensive treatments and a more comfortable hospital environment with ‘hotel style’ facilities.  An individual insurance policy for a 50 year old with no medical restrictions is between £1,500 - £2,000 ($2250 – $3000) per year with no regional variation. In the US – there are 50 different definitions of Health Insurance (by State). The ‘equivalent’ policy in the US (which will, unlike the UK, cover for all the conditions listed above) – can vary greatly according to State and benefit package, will cost between $2,470 (Phoenix) –and $10,000 (NY)

Insurance cover for children: It is generally accepted that access for care to children through the NHS is pretty good in the UK and health insurance for ‘dependent’ children tends to be attached to adult schemes up to the age of 18 or 21 if in full time education. The new PPCA regulations in the US state that ‘adult children up to 26 years old’ should be covered.

Quality: Cost effective, high quality care is a priority for the NHS reforms. This will involve the measurement of outcomes instead of targets and mortality rates will become a key performance measure. The main emphasis for cost reduction is the many managers and administrators currently working in the NHS. Obama’s bill seems to concentrate more on access and availability and the assumption is that the medical providers will take care of quality. It would appear that the performance measures in place for this are down to the individual provider.

Promises: One common area for both reforms is that the governments both promise great improvements.
The PPCA claims to address access to care, cost containment, and quality of care.
The UK health reform initiatives aim to address quality, outcomes and cost effectiveness.

Obama claims that there will be no net increase in healthcare costs (medical inflation is currently running in both countries at around 10%) while Lansley (UK Secretary of state for health) aims to save £20 billion

Will the reforms actually take place? In the US, Republicans have drawn the ‘first blood’ as a federal judge has decreed that it is ‘unconstitutional’ to force people to buy health insurance. There are several other lawsuits pending in various US states, questioning the legality of the mandatory elements of this Act. If these other suits follow this ruling, the reforms may need to be enforced via the Supreme Court and Obama’s political victory of 8 months ago pails into insignificance as he struggles to bring the PPCA into being.

In the UK, the reforms will initially have their main impact within the NHS, as restructuring and rationalisation takes place, and I am not aware of any legal or political challenges currently threatening reforms. As the consultation process draws to a close, the government will be announcing the ‘roadmap’ for efficiency savings shortly. The inside word is that the aims of the White paper are unlikely to change, but whether there are enough GPs with the appetite to form new consortia remains to be seen.


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