The Great Health Care Debate

United States health care is comprised of a mixture of managed care and other employee insurance plans. This system arose as a proposed solution for high rates of medical inflation. Managed care consists of various types of plans, such as PPO, POS, and, most prominently, HMOs. In plans such as HMOs, an organization provides the subscriber with a primary care physician who oversees all parts of the subscriber’s health care, including referrals to specialists. Subscribers (who pay an annual fee) are limited in their choice of health care by pre-approved lists of hospitals and physicians.

If an individual receives treatment outside of this list, then insurance will many times not cover the treatment. PPOs (Preferred Provider Organizations) offer more flexibility in allowing a subscriber to choose physicians, but such plans also offer incentives for participation in a ‘network’ of pre-approved facilities and physicians. However, unlike HMO plans, providers of PPO plans can be sued for malpractice. Managed care organizations place great emphasis on monitoring every aspect of care, and remain highly focused on preventive education.

Cost effective measures are of primary importance. In contrast, the operation of alternative employee insurance plans directs individuals to subscribe to an insurance plan, in which a portion of medical expenses are paid for in exchange for monthly payments (premiums) to an insurance company. Most modern insurance plans arise as part of a tax-free employee benefit package for workers (Gratzer, 2005). However, many unemployed and otherwise impoverished individuals and families cannot afford insurance plans.

For these individuals, federal and state governments have offered two programs, Medicaid and Medicare. The former consists of medical assistance for the poor, and eligibility requirements for Medicaid have varied widely from state to state. Medicare, on the other hand, is a program designed to assist senior citizens aged 65 or older and to assist the disabled. The latter program receives much of its funding from Social Security taxes. Despite all of these options, millions of Americans (an estimated one in seven) nevertheless go uninsured every year (United States Embassy, 2006).

Recognizing this problem, mid-nineties legislation aimed to expand insurance coverage for individuals suffering recent job loss and for individuals with pre-existing medical conditions. The legislation also sought to provide states with more control over their respective health care plans (Findlay, 1993). Regardless of the gains, health care remains a contentious political and social issue on the American landscape. UK Health Care Halfway around the world, the National Health Service represents the face of health care in the United Kingdom. Utilizing quite a different philosophy than America, the UK is a model of universal public health care.

Four organizations provide health care to the region’s citizens, at no cost to the citizens themselves. The NHS is funded completely by tax dollars, boasting an estimated budget of 96 billion pounds. NHS organizations in England are headed by the nation’s Department of Health, and management is the responsibility of specially appointed general managers. In addition, the NHS employs all doctors and nurses who provide NHS services (European, 2003). Comparative analyses with other health care systems have shown the NHS strong in issues of equitable treatment, quality primary care, continuity of care, and patient satisfaction (Ham et al, 2006).

However, some still desire a more market-based approach to care. Reform in the 1990s brought about the National Health Service & Community Care Act, which introduced the aspect of market competition into health care by allowing certain physicians to assume “fund holder” status and purchase specified care in primary care trusts (success stories such as the waiting-time reducing, cost-saving Tetbury practice seemingly validate this approach). (Lewsey & Smith, 1996) Outsourcing services has now become encouraged.

While most services are free for patients, prescriptions do require expenditure from patients, with the exception of elderly or exceptionally ill individuals. Other reforms, including facility closures, corporate governance, budgeting, service standards, directives against smoking and obesity, and health career incentives have arisen in response to increasing financial burdens placed upon the NHS. Perhaps the most ambitious reform project has resulted from plans for a National Program for IT, which would computerize all patient records (McDougall, 2005). This endeavor, along with the NHS as a whole, has fallen under harsh criticism.

Rising debt (estimated at 366 million pounds cumulatively) (Sylvester, 2005), foreclosure of community hospitals, forced limitation of hours for employees, and staffing shortages have led many to question the desirability of a universal health care model which many Americans view with envy (Lawlor, 2001). The Better Bargain? Which system of health care—US or UK—sets the better standard? It would be simple to pick one, simultaneously praising the chosen system and admonishing the “weaker” system. However, just as with most issues in life, the answer is not a simple matter of black and white.

Rather, we must consider the less desirable, but more realistic gray. Truthfully, both systems have their strengths and their weaknesses. An ideal system would likely comprise aspects of both systems. British health care heralds many positive achievements. Small family practices still thrive in a way that is perhaps missing from American health care, strengthening the primary care relationship that has proven so vital to quality care in numerous studies (Ham et al, 2006). Further, the physicians of the NHS do not face to temptation of “overcharging” or “undercharging” for services. In American fee-for-service plans, a physician’s earnings are

directly correlated to the amount of work required. Sometimes, such an arrangement can lead to the ordering of unnecessary tests and procedures which will increase profit for the physician (Lewsey & Smith, 1996). (Such a concern is one of the primary reasons why private contracting of health care services is forbidden in welfare programs). (Matthews, 2001) The ever-rising monthly fees of insurance companies (producing over 70 million dollars profit in some instances) are evidence of this problem (Desperate measures, 2006). HMOs, on the other hand, operate on a less-is-more philosophy.

Possessing a fixed budget, HMO providers want as few tests and procedures ordered as possible—an outlook which may be detrimental to the patient. American health care is a for-profit business, whilst UK health care (with its fixed salaries) is a social service that provides for everyone, rich or poor (Lewsey & Smith, 1996). Another advantage of the UK system is its size. US health care is a relative behemoth of bureaucracy and red tape, the proverbial eight (or eighty-thousand) headed monster. Smaller, streamlined organizations are a proven commodity in the corporate world, providing more effective decision-making and swifter policy reforms.

The UK system is unified, reducing local and regional squabbling concerning policies (Doran, 2006). In contrast, the American health care system is a smorgasbord of wildly differing state statutes and practices (Findlay, 1993). Case in point: the healthcare program of Tennessee (TennCare) recently removed 150,000 people from its coverage, prompting protest (Smith, 2005). Conversely, one of the programs which does somewhat mirror UK health care (the Department of Veterans Health) received high marks on various testing procedures in comparison to commercial care groups (Associated Press, 2004).

Even on a local level, fundholding groups provide a potential model for effective management in the United States. If implemented, physician health trusts (of four or more physicians per regional designation) in America could offer fixed premiums for patients and incentives for physicians (who could only become a part of the trust if they had a certain number of patients). (Lewsey & Smith, 1993) Most crucial, the trusts which serve as a cornerstone of UK policy quite appropriately build a “trust” with patients. One of the reasons why managed care has waned in the United States is precisely because of the bureaucratic distrust and cold

impersonality which serves as the unfortunate face of corporate medical policy. The status of health-provider/patient relations is perhaps most evident in the voices of citizens themselves. Reputed polls have compared British and American patients on both satisfaction and overall health. The results of these surveys are illuminating; British patients were more satisfied (American patients ranked HMO providers second to last on an ethics survey) (Gratzer, 2005)…. and they were healthier. For example, both cancer rates (Fauber, 2006) and diabetes rates in England were nearly half the percentage of rates in the United States (even after

adjustments were considered for outside factors). (Baker et al, 2006) American health care is not without its own benefits. Several factors are present in the United States system which are lacking in the UK. The United States Institute of Medicine is an envy of many British, including renowned chief medical officer Sir George Godber. Boasting over 1500 members, the issues famed reports place a reputable spotlight on many critical healthcare issues, such as medical error and childhood obesity. Members are selected from a diverse pool of fields and sciences, and they are free of any government and professional

pressures as a collective, peer-reviewed independent organization. Further, American health care can claim more complex specialty procedure centers (for actions such as transplants) and multibillion dollar modern learning programs which keep the medical learning curve high (Smith & Quam, 2005). Such benefits are evident in comparative studies such as that undertaken between the NHS and a California-based health system known as Kaiser Permanente, a study which rated the latter system as superior in comprehensive treatment, specialist services, and hospital admission rates (Feachem et al, 2005)(1.

112 million UK citizens await hospitalization). (Lawlor, 2001) The multidisciplinary learning characteristic of American health care has already found a tentative footing in the UK, with the onset of physician personal development plans and better defined professional examinations. The UK, as already mentioned, is also actively pursuing another hallmark of American health care: the computerization of records (Smith & Quam, 2005). Ironically enough, the very market-based atmosphere which American health care is often criticized for may be one of its cornerstone benefits. A study by Dixon et. al (2004)

surveyed five managed care organizations for quality measures. Their surprising assessment found that market-induced pressure actually increased the incentive to insure quality, effective care for patients. Failure for patients meant failure for the organization. Competitions between managed care organizations kept quality concern at the forefront, although not for entirely altruistic reasons. Financial incentives for physicians and institutions also raised the quality of clinical treatment. In the UK system, little incentive exists for physicians and institutions to set a high bar for performance, because pay and job security remain static.

One survey suggests even British physicians share this concern; nearly half use private medical plans rather than the NHS (Doctors, 2006). The introduction of fund-sharing and pay-for-performance programs has created a potential opening for more market competition within the UK system (Adams et al, 2004). Neither health care model is ideal. A comprehensive research survey (covering twenty- one areas of care) conducted in 2004 found no significant differences in overall quality among the world’s major health care systems (McDougall, 2005). However, a “real,” most applicable model would apply the best of all policies.

Can one find a system that concurrently emphasizes unity, patient choice, competition/progress, and social equity? The demand may seem impossible, but innovative strategies such as MSAs (Medical Savings Accounts) (A comeback, 2003) are a signal of the world’s willingness to compromise with forward creative thinking.


Adams, J. , Asch, S. M. , DeCristofaro, A. , Hicks, J. , Keesey, J. , Kerr, E. A. , & McGlynn, E. A. (2003). The quality of health care delivered to adults in the United States. The New England Journal of Medicine 348(26), 2635-2645. Associated Press. (2004). Study: VA provides best care for diabetics.

August 16. Baker, R. , Diaz, V. A. , Everett, C. J. , Koopman, R. J. , Mainous III, A. G. , Majeed, A. , & Saxena, S. (2006). Diabetes management in the USA and England: comparative analysis of national surveys. Journal of the Royal Society of Medicine 99: 463-469. A comeback for MSAs. (2003). Wall Street Journal (June 30), 57-59. Desperate measures: America’s health care crisis. (2006). The Economist (Jan. 26), 14-21. Dixon, J. , Finlayson, B. , Gray, D. , Lewis, R. , & Rosen, R. (2004). Can the NHS learn from US managed care organizations? British Medical Journal 328, 223-225. Doctors opt to have private operations. (2006).

New York Times (March 26). Doran, T. , Fullwood, C. , Gravelle, H. , Hiroeh, U. , Kontopantelis, E. , Reeves, D. , & Roland, M. (2006). Pay-for-performance programs in family practices in the United Kingdom. New England Journal of Medicine 355(4), 375-384. European hospital financing reform-developments and business implications. (2003). M2 Presswire (July). Fauber, J. (2006). Want to be healthier? Move to Britain. The Milwaukee Journal Sentinel (May 3), 12. Feachem, R. G. A. , Sekhri, N. K. , & White, K. L. (2002). Getting more for their dollar: A comparison of the NHS with California’s Kaiser Permanente. British Medical Journal

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