Q. Why the passion over healthcare reform in the US?
A. In Europe, the arguments over universal healthcare were over decades ago: all that remains is a polite discussion over the best way to fund them. But in the US, the idea that Government should have any place in the relationship between doctor and patient remains controversial to many, and a red rag to a few.
Town hall meetings to discuss healthcare reform have been turned into fights, one Congressman has had a death threat, posters denouncing reform are proliferating. Bill Clinton's attempt to reform US healthcare failed; President Obama's is in trouble. Doubts about the cost of the project at a time when many think the Obama administration has been profligate in its economic stimulus have combined with old antipathies to "socialised medicine" and overwheening government to create a potent cocktail.
Q. Is US healthcare really in such a mess that it needs wholesale reform?
A. Less than 20 per cent of Americans believe their healthcare system is in crisis – a proportion that has not changed in 15 years. Based on health insurance, supplemented by Medicare for the over-65s, and Medicaid for the poor, the system at its best provides good care. But premiums are rising fast, and deductibles (the equivalent of an "excess" on a UK insurance policy) are also rising. For almost 20 per cent of those insured, deductibles exceed $1,000.
A large number of people, 47 million out of a population of 300 million, have no insurance. That means they must pay for healthcare out-of-pocket. Medical costs accounted for 60 per cent of US bankruptcies in 2007 – and this includes many people who were insured. Since insurance is often part of an employment contract, it can disappear if illness causes unemployment.
Q. That sounds bad. Why don't Americans welcome a reform that would provide universal coverage?
A. Most question whether it would benefit them personally – 84 per cent are insured and say they are satisfied with their care. They fear government involvement would make things worse, not better. While nearly 80 per cent think healthcare costs too much, almost half think a reformed system would cost more.
Q. But aren't they right to argue that medical standards in the US are higher than ours?
A. This is a tricky comparison. At its best, US medicine is outstanding. But as a system judged on quality, access, efficiency, equity and healthy lives, US medicine lags behind the UK, Australia, Canada, Germany and New Zealand, according to the Commonwealth Fund. It scores well on rapid access to elective treatment (second only to Germany) and on preventive care, where it is the best of all – largely as a result of managed care plans trying to save costs by keeping people out of hospital. The UK and the US rank last in death rates from conditions amenable to healthcare.
Q. If that's so, why are so many Americans opposed to reform?
A. Because they don't put the criteria of equity, access and efficiency as high on their list of priorities as does the Commonwealth Fund (a private foundation rather like the King's Fund in the UK). They would argue that a comparison of this sort is designed to make their system look bad. And they are unaware that their expensive system doesn't deliver good results.
Q. What is President Obama's plan?
A. He doesn't really have one, but is leaving Congress to bring forward proposals that meet three objectives: reducing costs, guaranteeing that every American has the freedom to choose their own health plan (including a public plan to compete with private insurers) and ensuring that all Americans have quality and affordable healthcare. Insurance would still be the basis of the plan, not tax as in the UK. But that need not be an obstacle, as countries such as France and Germany have universal insurance-based systems that in general work well.
Q. How does he propose to control costs?
A. That's a bit vague. In 2007 the US spent $2.2trn (£1.34trn at then prevailing exchange rates) on healthcare, against the UK's £118bn. The UK's spend was 8.4 per cent of GDP, the US's 16.2 per cent. Since wages and salaries represent 60 per cent of costs, big cuts are hard to find. Obama has talked about cutting out ineffective treatments but is unlikely to find huge savings that way. Hard as it is to stop costs rising, it is much easier than cutting them once they are high.
Q. What's the major obstacle to reforms working in the US?
A. The lack of a consensus around the idea that universal healthcare is an ideal worth striving for. European countries made it part of their "new start" after the Second World War: they cannot imagine a world without it. The US saw no reason to abandon individualism, and now it is much harder to do so. While the protests have been orchestrated, they would not have occurred at all unless they chimed with deep and strongly-felt sentiments.
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