Are you on drugs?

My Foray into Socialized Medicine

My first experience with socialized medicine was as a child. I was a military brat and if you were in the military, you'd sometimes be called upon to protect us from communism and socialism while enjoying the finest socialized medicine our taxes can buy. We never paid for medical treatment. We never paid for medications. If we needed medical attention, we received it, plain and simple. It wasn't always great, but then, as an adult who sometimes not had insurance and sometimes had virtually worthless insurance, I'd happily take the government's socialized medicine over none at all. When you can't get a prescription for antibiotics, much less afford to pay for them, you're pretty damned miserable.

However, despite my experiences, I was nervous about the National Health Service (NHS) in the UK. After all, since the news reports the planes which crash and not the planes which land, you only hear the horror stories. I was expecting a long wait for an appointment. I read in the paper today about a woman who waited 13 years for a hip replacement surgery. Just today, there was an article on BBC about a hospital which lost £2.5 million pounds of funding for not making patients wait a minimum of four months for treatment. You also read stories about women getting voluntary mastectomies rather than wait over two years for breast cancer screening results. Or you can read about the NHS IT budget cost overruns in their new National Programme that would link hospitals, patients and doctors. The project was initially said to cost £2.3 billion before the NHS admitted it would actually cost £6.2 billion. The article claims that current projections are that it will £12.4 billion but I was reading in the paper today that they're expecting the final project will cost between £20 to £30 billion. In US dollars, that's an initial estimate (at today's exchange rate) of $4.3 billion up to a possible £56 billion dollar. Fortunately, that's only one sixth of current estimated the cost of the Iraq war, so killing people is still less efficient than saving them, eh?

So I'm expecting a long, painful process. Not only is this a system bogged down in cost overruns and red tape, I'm a foreigner. So I called them and explained the situation. "That's fine", I'm told, "can I come in now?" What? No, I'm at work. Can I get something for this afternoon? Yes, yes I can.

I get to the office in Sneinton, an area of town which I've been warned to avoid. Sure enough, I am walking by people obviously strung out on drugs, people who stink so bad I can't bear to be near them and shady guys drinking beer on the street in the middle of the day. However, the Steinton office is the one assigned to my area, not the Stoney street clinic which is closer, but not overly so. I walk into the clinic and I can't believe what I see. It's not really dirty, but it's obviously run down. The paint is awful, the signs are old and the carpet has plenty of stains. This is not a welcoming place.

I got there half an hour before my appointment because I know how this works. Reams of paperwork need to be filled out. In addition to medical history and payment details, I'm used to filling out promises not to sue, insurance information, if available, and promises to pay up front if it's not. However, this didn't happen. I had a short sheet to fill out stating who I was, when I entered the country, what my address was and a few medical questions. It took about five minutes.

After a bit of a wait, I saw my doctor who examined me, asked me a few more questions (she obviously had not read the information I filled out), and then prescribed antibiotics for my ear infection and made me promise to come back if it didn't clear it up. It was quick, painless, and efficient. Despite the appearance, it was easier than seeing a US doctor (and I've seen many of them).

Interestingly, they never asked for ID and I understand this is common. If you're there, you get basic medical treatment. Anything out of the ordinary, though, can be quite difficult. Fortunately, after I've been on the job for three months, I get supplementary insurance to cover the "out of the ordinary" medical situations.

Medicine, however, is not free, but the prices are capped. For my antibiotics, I only paid £6.65. However, if I couldn't afford that, there are various situations in which I would get the medication for free:

  • Under 18 years old

  • 18 but in full-time education

  • Pregnant or have given birth within the last 12 months

  • Receiving Income Support, Jobseeker's Allowance or 'Guarantee Credit' on your Pension Credit - or your partner is receiving one of these

So despite basic care being readily available, the rest of the system is in chaos. How did Britain get into such a terrible situation? Despite what many people believe, economics and politics are not the same thing. However, they are closely intertwined. In chatting with British people about the NHS, I always get the response that basic medical care should be free of charge to anyone who needs it. Even the so-called "Libertarians" I have spoken with over here agree that the government should provide basic medical services. The Brits are quite adamant about this point. When it gets into specialized needs, opinions start to diverge. Following the well-known Pareto rule that 80% of the results stem from 20% of the effort, we can clearly see that most folks over here support that 20% of the effort. Obtaining the last 20% of the results is where things get difficult and expensive. In fact, since the "80%" of results is what most British people see, there's probably far too much political pressure to let up on this, so the common needs are handled quickly and efficiently.

Even though most people need to see doctors for routine issues, few people get hip transplants. Thus, there's far less pressure to handle the unusual issues, but this has led to complacency on the part of the government and the NHS to get things done and by ignoring the situation long enough, the British government appears to have allowed a problem to grow into a crisis.

Contrasting this with the US shows a curious problem. Naturally, there's no socialized medicine. If you can't afford a doctor, you're out of luck. However, the US Congress, faced with the embarrassment of people dying outside of hospitals passed a law requiring that emergency rooms provide the minimum necessary services to "stabilize" a person, then they can kick them to the curb.

This causes a huge problem. If you're familiar with the situation at all, you know that emergency rooms are the most expensive form of routine medical treatment you can get. If you really have to go to an emergency room, you probably need far more medical attention than if you had gone to see a doctor when you first noticed that your headache wasn't going away or that cut on your leg wasn't healing. Worse, you need that attention now, not when the doctors can fit you in the schedule.

This is part of the reason why the US has the most expensive per capita health care costs in the world. This is a major reason why we have the highest infant mortality rate of any major industrialized nation (no pre-natal care for poor women -- kick 'em to the curb!). Congress, in trying to shore up a glaring weakness in the US health care system actually drove up costs to a ridiculous point. There's no reason a homeless person should die because they have the flu.

I think the problem with the British health care system stems from a systemic problem with bureaucracies: they have no incentive to be efficient. Now a Republican or Libertarian would say "that's because they don't have competition!" Perhaps, but that still doesn't explain why the US health care system is still the most expensive in the world but we have lower life expectancies (Andorra kicks our ass here. Andorra!) and higher infant mortality rates than many industrialized nations. Of course, if you want to dig in, you'll find many more problems with the US system and these can often be found to be the result of a lack of basic medical care.

I'm not sure how to fix the British system because it deals with a fundamental problem that all bureaucracies face. How do you give government bodies incentive to be efficient while still providing the services they're supposed to provide? Swimming pools kill far more children in the US than handguns, but politicians are more willing to mandate locks for handguns then to mandate fences around swimming pools that children have access to. Huge pharmaceutical companies spend millions lobbying the government while the everyday worker has no voice. But should the everyday worker have a voice in complex decisions which they have no knowledge of and others spend decades studying? Do you really think you're competent to decide what percentage of the government dollar should be spent on mesothelioma research?

But we can't just leave all of this up to politicians. Central planning is a failure and it has no way of immediately responding to rapidly fluctuating market conditions. Just turning the problems over to individual government units means that they will be sure to spend all of the money they receive lest their budget get smaller. Politicians are subject to political pressures from ill-informed constituencies and lend a willing ear to those who can finance their political campaigns. Yet despite these problems, I'm unwilling to give up on democracy. Democracy is a miserable way to run a country but everything else seems to be far, far worse.

We need a new system. We need a system whereby private goods will be left to the market and public goods will be administered in the public's interest. But how to do we achieve the latter? The only thought I've come up with is offering public servants a percentage of the money they save so long as they are still doing what they're supposed to do. But who would judge if they've accomplished their goals? The public is often ill-equipped to do so but I don't trust the politicians since we've seen what they're incapable of.

I'm at a loss. Ideas welcome.

Update: I forgot to point out that the idea of offering government employees financial incentives for cutting costs is difficult for other reasons. If the incentives are too low, they may not be motivating. If they're too high, corruption will result.
  • Current Mood: thoughtful thoughtful
Having lived under socialized medicine for five years I will agree with you that it's better (here in Canada) than in the US, at least for the routine stuff.

And it's the little things, like reassurance that the person behind the lunch-counter has access to proper medicine... And the egalitarian aspect of holding the entire country up to some minimum standards...

As for ideas, I'm at a loss. I know the answer isn't more complicated bureaucracy.

Maybe semi-meritocracy is the right approach? Allow user-choice in service provider, all licensed and funded by the government, funding based partly on numbers served and partly on user satisfaction ratings. Plus, aggressively removing the licenses for providers who suck rocks.

The biggest problem in Canada is lack of qualified and licensed doctors to serve in all areas. Docs aren't paid enough to prevent them from leaving to practice in the US... And there are qualified doctors who were trained outside Candada, but there are huge waiting-lines for the licensing process. Which seems a solvable problem, but it hasn't been, yet.

When my wife was pregnant with our first child we lived in Berkeley. We took a birthing class which helps you to know what's going to happen before it's happening. The class was at the Hospital at the Berkeley/Oakland border, with maybe 20 people in the class.

None of them were black, even though probably 30% of the population around there is. Being used to the Berkeley environment, the absence was very notable to me.

Now, of course the African-American population is disproportionately represented among the lower income groups, who in turn have less insurance and health coverage. But this was Berkeley. While there is less healthcare coverage among African-Americans it is by no means nonexistent. And African-American professionals are quite common there. My guess was that African-Americans, for reasons unknown to me, were not taking advantage of prenatal services. Considering the rates of gestational diabetes, that's a really bad choice. I later learned from my sister-in-law, who works in social services, that this is a known problem among the African American community.

I wonder what other groups within the US exhibit the same odd behavior. You gotta figure any group which ignores available prenatal care is going to have a much higher level of infant mortality. Here in California, the state provides prenatal care for anyone who cannot afford it.

So while I agree that prenatal care should be pretty much a Right -- since the baby doesn't pick its parents and should be taken care of by the state if the parents are unable to provide -- I think the problem is more about changing the attitudes among communities who ignore the problem.
To add to your point about prescription charges, if you pay for medication and need more than 5 prescription items in 4 months or 14 items in 12 months it's cheaper to buy a pre-payment certificate; a 4-month PPC will cost you £34.65 and a 12-month PPC £95.30. Additionally, contraception is free.

My personal experience of the UK healthcare system is that it is fantastic for emergency, life threatening situations and basic care wherever you live. For everything between those two extremes, however, the provision is patchy at best.

I like your idea for a new system, although this may be because I am a public servant. ;) Seriously, I wouldn't want a penny from the service area's budget (I provide financial assistance for schoolchildren from low-income families); all I want is to be listened to by the officials who make the decisions I enforce.

We should meet up for coffee sometime and throw ideas around for a bit. I'd love to hear more about Britain's political/economic systems from your perspective.
I probably won't be getting to London too soon (and in any event, it's big enough I'd probably get lost trying to navigate it). I suspect you don't have much call to visit Notts, either. However, meeting up coffee sounds great. We've known each other for years but we've never met. We should rectify that.
Lovely post, and I wish I could add something useful to it. Instead I'll just note an oddity: I've noticed more physically disabled people walking about here, and more advertisements for post-masectomy bras. I never considered that the reason might be poor medical care. I considered the lingering evolutionary effects of a major war (where being inelegible for military service is a survival trait), and people being more open about it, but never that there are simply more people who don't get proper nonemergency medical care.
Am I simply overly anglophilic?
You know, I've also noticed more people on crutches here. I thought that was a bit odd, but I figured that I'm seeing a new country so I simply notice things that I didn't notice before. Curious we would both see this.
Two medical systems that intrigue me are India's and Thailand's (specifically, Bumrungrad). How is it that India is actually *ahead* of the rest of the world in hip replacement technology? The medical care at Bumrungrad is world class and, best of all, inexpensive.

Mind you, I realize that part of the lower cost is the lower cost of living in general, and it may not be sustainable, but I think it would be worth a look to see how they run things.
I make 20,000 a year am at poverty level for us and I can't even get reduced care anymore thanks to Dubya as of jan. 1. Sucks to be me.
Socalized Medicine?
(Anonymous)
In several posts I have seen you refer to the U.S. Military medical care program as socialized medicine. I strongly disagree with your characterization. As a Soldier in the U.S. Army I PAY for that health-care by the job that I do. I have to maintain a level of physical fitness that puts me in the top 1% of the nation, I have to abide by the CONTRACT that I signed and be willing to go into harms way at the behest of my government AND I have to put up with boneheaded officers. If the U.S. Military health-care system is socialized medicine then ALL employer provided health-care is socialized medicine.
At this point in time I do not in any way support any kind of socialized health-care. However, if there were a socialized right to a lawyer that came with a socialized health-care package I would most definitely support that! Everyone should have the right to a FREE lawyer who was REQUIRED to present every case to the courts. Instead of what we have now where the lawyers choose their cases based upon the likelihood of profit and not based on any kind of justice.