• Crag

Healthcare: Private versus Public

While the Coronavirus pandemic of 2020 has gone some way in motivating me to publish this, I started this analysis in 2017. I intend to write about healthcare provision in general and not the pandemic. Hopefully, this will provide some food for thought around one of society’s most important endeavours in a way that escapes the current news cycle. As a Briton, I will mostly be writing in reference to my home country, Europe, and the USA.

Healthcare is the eye of a political storm. Here we have the provision of a service which could be met through private arrangements but is instead in the UK paid for via taxation and provided by the state. This situation is apparently the envy of many, particularly the American left. As in the case of education, the idea of healthcare being a “right” and that therefore the state must provide it, holds true. In the case of healthcare, some people go so far as to call it a “human right”. It does not follow that commodities necessary to sustain life ought to be provided by government. Where the absence of healthcare for a sick person could spell the end of their life, so would the absence of food and water for any person – yet no reasonable person suggests that the government should dispense food and water. World history and our lives as they are today are proof beyond a doubt that the market provides food and water at levels of abundance, quality, variety, and affordability that no government could ever dream of achieving. Indeed, government control of food and agriculture has caused the deaths of tens of millions in living memory¹,². World food poverty has been all but eradicated³ by free market principles and private charity. It is clear, therefore, that government provision of healthcare is something that must be taken on its merits and demerits, and not a policy accepted as preferable based on feelings, ideology, or faulty axioms.

The UK’s National Health Service (NHS), instituted in 1948, is a government owned and run healthcare system which is funded out of general taxation. This state-enforced monopoly has a huge amount of support from the population generally - so much so that openly making an argument in favour of privatisation is political suicide. Those MPs, mainly in the Conservative Party, who have made noises about privatisation or have written about it, have had to retract their statements in public or deny they were ever made when pressured. Otherwise, they talk in euphemistic terms about “having a mature debate about the funding of healthcare in the country”, as Ann Widdecombe did on the BBC’s Question Time⁴. This was simultaneously sensible sounding and cryptic enough that it garnered applause from the audience. The implied solution could be interpreted to be dramatically more NHS funding, with or without hefty cuts elsewhere, or to be a private system funded by individuals – all biases appeared to be satisfied. However, the mere implication that there may be options for funding the NHS other than by the state continually spending more is sufficiently risky that a politician can only say it if they are retired. As Ms Widdecombe quite sensibly pointed out, three premises on which the NHS was founded - that demand would decline as we get healthier, that demographics would stay roughly the same, and that the stamp tax (national insurance today) would cover much of the cost - have all been proven wrong. Demand is higher than ever, our population is more aged than ever, and our expenditure on healthcare from general taxation has forever risen.

The British public are by-and-large staunch supporters of the NHS, and many assume the alternative situation to having the NHS is a country without healthcare where people just die. It is a bizarre assumption, for sure, but a pervading one on social media⁵. To broach the subject of private healthcare as the alternative with most Millennials is to find that their perception of it is solely based on pitting the USA against “Europe”, as though Europe has the same healthcare system everywhere and must have better outcomes than the USA. Many young people especially deem the USA’s system to be the worst in the world and vastly inferior to the great NHS. Given the anti-American sentiment regarding government policy harboured by British people in general, it is an uphill battle to have a fair discussion in good faith around this issue. To briefly dispatch of the ideas, let us firstly point out that the USA is not the only country which has a private healthcare system. Most countries, including the vast majority of first-world countries, have private healthcare systems. The UK finds its system most similar not to other European social democracies’, but to Cuba’s. Secondly, the USA is the world leader in healthcare. We will come to the detail of healthcare outcomes, but consider: the USA is responsible for more medical research and development than any other country by a long way. This point is widely agreed upon, but those who are doubtful can observe some hard evidence in the international rankings for medical research documents production and citations⁶. This is not to say that the USA is some kind of healthcare utopia – it has its problems, like any country. One of its problems today is the Affordable Care Act, also known as “Obamacare".

The Affordable Care Act is essentially the provision of taxpayer money for subsidising eligible insurance coverage plans and the payment of a fee to government if you are not insured (in essence, a fine which if unpaid will be held back by the Inland Revenue Service at any given opportunity - the fine has been discontinued as of 2019 under President Trump, but we shall proceed with the critique of Obamacare in its full original form). In the conversations I have with people, it seems most have the idea that Obamacare has been at minimum a necessary policy change and at best a great success. It is alleged to have saved many lives and is a step towards the nirvana that is state-run healthcare. On the contrary, the Affordable Care Act has seen mortality rates increase⁷, the aggregate number of people insured has not increased (new enrolees are offset by losses in private coverage), and it did not make healthcare more affordable – it has made it more expensive. While it would be difficult to prove that Obamacare has itself caused an increase in mortality rates, we can say at the very least that it has done nothing to reduce them or stop an increase. We can say with more certainty that Obamacare has directly affected costs. Average state individual market premiums were to increase by 41% between 2013 and 2014, according to the Manhattan Institute⁸. A study in the Brookings Papers on Economic Activity used actual pre-ACA individual market premium data and found that “across all states, from before the reform to the first half of 2014, enrolment-weighted premiums in the individual health insurance market increased by 24.4% beyond what they would have had they simply followed state-level seasonally adjusted trends.”⁹ Economists at the University of Pennsylvania, also using actual pre-ACA individual market data, estimated that the total expected price of individual market coverage (premiums plus out-of-pocket payments) increased by 14% to 28% as a result of the ACA¹⁰. However, if you trust the strong and stable state more than those scelestic statisticians, you will be pleased to know that it’s not just economists who come to the conclusion that Obamacare has cost Americans more money. According to the Department of Health and Human Services (HHS) under the Obama administration, premiums were expected to rise by 25%¹¹ (HHS also claimed that this didn’t matter too much because the taxpayer funded subsidies should offset some of that increase, and I have a feeling they didn’t say this ironically). We should not forget that so long as the policy remains in place, government subsidies for healthcare will rise to prop it up. Arizona’s premiums were to increase by a whopping 116% after the bill was enacted. All this extra expense for the privilege of having less choice as insurers pull out of providing plans through the ACA programme. The severity of the limiting of choice has been enunciated by a county by county analysis of current projected insurer participation in health insurance exchanges, carried out by the Centers for Medicare and Medicaid Services (the federal agency responsible for overseeing Obamacare)¹². I do not think the agency responsible for overseeing the project can be accused of overegging the pudding of failure, and they say that almost 40% of all counties nationwide are anticipated to have only one insurer left. 47 counties are expected to have no insurers engaging in the exchanges – none. Ironically enough, it is usually advocates of nationalisation of all kinds who complain most about monopoly, and they blame free markets for their existing. Having one option to choose from sounds pretty close to a monopoly to me, and having no options under the scheme sounds remarkably like access has reduced – especially when coupled with increased premiums. The reality is that a free market, free from government intervention and free of punitive or preferential treatment for businesses, is the best tool to minimise monopoly and ensure it is as short lived as possible. The direction and intention of Obamacare may not have been to protect one insurer from competition, or to push insurers out of markets, but its results have had the same effects and worse. In the case of Obamacare, not only has government intervention meant that thousands of counties will have only one insurer to choose from, but it has also managed to remove all options under the scheme in the states where no insurers remain. Only government, by wielding legislation, could pull off the feat of making a market which is desired and required by the vast majority a nation’s population so unattractive that no-one wants to participate in it on the terms set. As Milton Friedman once quipped, “If you put the federal government in charge of the Sahara Desert, in five years there’d be a shortage of sand.”

When challenged on the failure of Obamacare, proponents now usually do not quarrel with the facts, but blame them on “the wrong implementation”, or that “it wasn’t embraced”. So, naturally, the next step in politics to fix a broken idea is to reincarnate it in a more extreme way. “If only this failed experiment had more money thrown at it, then it would surely work”. Enter the Sanders proposal: the ‘single payer healthcare’ plan. This policy was one of the reasons he was such a hugely popular candidate among young Americans (and young Brits, for that matter). The Tax Policy Center estimates that Sanders’ proposals would increase the national debt by $18 trillion over a decade¹³, which is almost as much as the total US federal government debt was at the time (2016)¹⁴. That is to say: one popular policy change would have doubled the national debt in a mere ten years. Compounded with all other manners of overspending the US government is currently engaging in plus interest, the prospective figure would be astronomical. Even the Urban Institute, a left-leaning think-tank, part of whose statement is to “reduce hardship among the most vulnerable, and strengthen the effectiveness of the public sector”, accept that the amount of money raised by Sanders’ tax and revenue proposals would fall $16.6 trillion short of funding his single payer healthcare plan¹⁵. To clarify: that is only the healthcare plan, not including any of the funding required for non-health spending in Sanders’ manifesto. If this fact is not a blunt enough an indictment of Sanders’ plan, then I do not know what is.

Scary-looking hospital bills are shared on the internet purported to be from American hospitals. One example, tweeted by Gary Barker (referenced by Metro as the original tweet seems to have disappeared)¹⁶, shows a photographed receipt from a hospital with his tweet reading: “For those who just shrug at the thought of NHS privatisation - this a bill for just six nights in a US hospital.” There is only a list of services with prices adjacent – there is no currency or hospital name in sight, nor any reference to verify the validity of the photograph. The Metro then ran this tweet as a news article, of course checking all the non-existent references first for accuracy’s sake. Around $55,000 is close to the average for a six-night stay in a US hospital, and my quibble is not with that figure per se. The first thing to point out is that this average is just that: an average, not what you can expect to pay for every condition. Naturally, conditions which demand more complex care are more expensive, while minor ailments and simpler care are cheaper. Secondly, the cost would be mostly met by your insurer. For example, they would pay 60% to 90% of the expenses, and the remaining 10% to 40% would be paid as coinsurance or copayments. The out-of-pocket maximum means when out-of-pocket payments meet a threshold, the insurance plan pays for itself for the rest of the year¹⁷. Insurers must compete with one another for your custom in a marketplace, so their plans must be attractive. The main problem with a reference of this kind being used lies with how these bills are presented as an argument against private healthcare, because it is implied that these costs are somehow exclusive to the private market and do not exist when the state provides healthcare. It is as though the proponent seriously believes the hospital will just give away its services if the government is the face of the customer or if the government owns the hospital. This style of “criticism” is just another way to reinforce the old myth that provision by the state is “free”. It is not – healthcare costs money. This debate comes down to how the cost should be met, not whether it should be met.

The Commonwealth Fund’s “Mirror, Mirror on the Wall” report¹⁸ is often cited to me as the definitive case-in-point source by those arguing in favour of state-run healthcare and against privately run healthcare. In writing, in conversation, and on social media, it rears its head, for it presents conclusions attractive to many. It places the USA dead last out of the eleven countries included in the report. The eleven countries chosen for comparison appear to have been chosen because they are all first-world wealthy nations (and not because of their membership or not of the British Commonwealth – to avoid any confusion, The Commonwealth Fund is a US think-tank). Curiously, countries like Hong Kong, Singapore, and South Korea (which, you may recall from another piece of mine, had some of the best education establishments in the world) are not included in the report. Why this is I do not know, and the selection criteria for countries included are not provided. Stranger still is that the UK scores top on nearly everything. The Americans who put together the report must not have seen headlines in the UK which perpetually describe the NHS as being “in crisis”. Brits often to go to Europe and America on their holidays, and whenever a friend or relative of mine has had to visit a hospital abroad they tell tales of how superior they are to our own. I can profess the same experience. One often has to pay for it, but it is better. It is common knowledge that foreigners have access to better healthcare facilities than we do, but this is of course purely anecdotal. Foreign excursions aside, it is alleged that the NHS was supposed to be on the verge of collapsing because of “Tory cuts”. (The Conservative party have decreased the amount by which the NHS budget raises each year, but the NHS budget has still increased every year since its inception in 1948). The data is from 2011-2014, so it was collected amidst George Osborne’s infamous austerity budget¹⁹. The leftist cannot have their cake and eat it: the NHS cannot simultaneously be collapsing under Conservative rule and be the best healthcare service in the world under Conservative rule. If the Conservatives are running the NHS into the ground, surely privatisation would be a preferable policy as it means some persons other than the worst government in the world would be running the show. Putting aside the strange juxtapositions of the political rhetoric and the report’s findings, let us turn to some specifics.

The report scores each country on “Quality Care”, under which are the subheadings: effective care, safe care, coordinated care, patient-centred care; “Access”, under which are cost-related problems and timeliness of care; “Efficiency”; “Equity”; “Healthy Lives”; “Health Expenditures/Capita”. These all sound like perfectly reasonable metrics by which to assess a country’s healthcare, but closer examination is required to find it why the NHS ranked 1st on 9 out of 12 scores (including the overall ranking). “Efficiency” is the most surprising and humorous measure on which the NHS came 1st. Even if I discount the anecdotes of idleness and inefficiency I have heard from NHS and ex-NHS employees, and the complaints of a disproportionately large number of managers (‘too many chiefs, not enough Indians’), I still cannot square the results of an internal audit, the leader of which said that before the NHS deserves any more funding it needs to “put its house in order” and “make changes to improve the quality of care”²⁰, with a number 1 spot on both efficiency and quality of care. When the national director for clinical quality and efficiency, Professor Tim Briggs, says the service currently wastes too much money on “poor care”, I am more inclined to pay attention to him than to the people at the Commonwealth Fund. When the chief inspector of hospitals, Professor Ted Baker, says the NHS is “not fit for the 21st century”²¹, I am inclined to question the methodology used in compiling the “Mirror, Mirror on the Wall” report. Why is it that they do not see what auditors at the NHS see, then? This is where we must look at precisely what measurements were taken and fashioned into the generic headings listed above.

If we take the first aspect listed, which Professor Briggs says is somewhat lacking - quality care - we find that the score is arrived at by measuring things such as: “Physicians reporting it is easy to print out a list of patients who are due or overdue for tests or preventive care”; “Doctor or other clinical staff talked with patient about a healthy diet and healthy eating”; “Physicians reporting it is easy to print out a list of all medications taken by individual patients, including those prescribed by other doctors”; “Hospitalised patients reporting infection in hospital or shortly after”; “Patient believed a medical mistake was made in treatment or care in past 2 years”; “Doctor receives alert or prompt to provide patients with test results”; “Primary care physician always or often receives notification that patient is being discharged from hospital”; “Patient given wrong medication or wrong dose at a pharmacy or while hospitalised in past 2 years”. Some of these criteria seem reasonable, but those are few and far between. The majority are either trivial or misleading. How much does the ease of list-printing contribute to the quality of one’s medical care? A physician’s opinion about the ease of their process in printing out lists seems even less important. What if one nation’s doctors are more inclined to complain about trivial tasks than others? What if another nation’s doctors don’t do much of their own admin at all? Onto another measure: is what patients believe about how many medical mistakes are made a good measure of quality of care, or would the actual number of medical mistakes made be more useful? Pharmacies in the UK are privately owned and must apply for inclusion on the NHS pharmaceutical list - if private pharmacies perform well does the NHS take the credit for this, in this report? And, on the flip-side, does the NHS effectively take the blame for an individual pharmacy’s failure? Since this report and others like it are regularly used in debate regarding how we should go about providing for healthcare, these distinctions are important.

“Health Expenditures/Capita” is another interesting measure to pick for assessing “access”, and one that is easily spun. Simply quote the raw data for national spending per person, as this report does, and those countries that spend a lot on healthcare appear to be less affordable places to obtain healthcare. That is not necessarily the case logically, and indeed is not the case factually. The “Mirror, Mirror on the Wall” report makes no distinction between types of spending, which is crucial – it measures total expenditures on health as a percentage of GDP and ranks people by this figure alone. This is deeply flawed. According to OECD data, voluntary spending is far higher in Switzerland, Australia, and the US, than the UK, for example²². These three high-spending countries are among the lowest scoring for “affordability” in both the 2014 and 2017 “Mirror, Mirror on the Wall” reports, and that is severely misleading. What on earth does high voluntary spending have to do with whether goods and services are affordable or not? It could be the case that laser eye surgery is 10% cheaper on average in country A than country B, and people are 40% more likely to get the surgery in country A precisely because it is more affordable, making the overall expenditure much higher than in country B. Take a real comparison: a prostate-specific antigen test (PSA) is a common screening for prostate cancer. In Australia, the typical cost is $30 to $50 (AUD, or £16.66 to £27.72). The same test in the UK is not easy to obtain, firstly because the NHS rations tests by its own criteria which make far fewer people eligible for screening than in other countries. I know men in my own family who contracted the disease before being eligible for an NHS test and went on to develop stage 4 cancer, and other men aged 50 who were turned away when requesting a test. If a British man would like to purchase a screening from a private provider, this is not easy either. There are few private providers to choose from, especially ones with physical premises, and the ones there are do not provide a price without a consultation. The entry cost for a consultation is typically £100, so it would be safe to take that as a baseline cost. Prostate Health UK charges £160²³, but it appears if you are not a corporate customer there are additional hoops to jump through. This leaves a couple of online laboratories which we are fortunate enough to have had pop up in the last few years, one of the most well-reviewed being an American firm called “”. Additionally, how can a category assessing access to healthcare characterise high voluntary spending on healthcare as a “cost related problem”? Those people who choose to spend more on healthcare, and naturally experience better outcomes for it, would surely consider it a problem if they lost the freedom or ability to do so. If a health-conscious American, Swiss, or Australian were plucked out of their respective country and dropped in the UK, where there is no strong culture of voluntary spending on healthcare and the services are dramatically restricted and priced more highly compared to where they came from, I cannot imagine they would be best pleased. It is also reasonable to assume that citizens in richer countries – which is the same as saying, richer world citizens – will spend more on all manner of things, including healthcare, if given the opportunity to do so.

You will notice, reading through all the individual criteria for what constitutes “Quality Care”, that there are probably none that you would have guessed or chosen yourself. For example, in my opinion the most important goal in any healthcare system is to prevent deaths from illness. Not dying seems, to me, a fundamental part of receiving healthcare, but it is not considered in the “Mirror, Mirror on the Wall” report. An obvious place to go to might be cancer survival rates. Cancer kills many millions every year and will be contracted by one in every two people at some point in their lives²⁴. We have already seen that the UK is the poster child for quality healthcare in the Commonwealth Fund’s report, with “effective care” being only one of many measures on which the UK is number one. The UK has among the worst cancer survival rates in Europe²⁵²⁶ and Europe in general lags way behind the US. How can it be the case that a country, in which if you contract cancer you are more likely to die than if you were in virtually any other first world country, can be scored number one on effective healthcare? The USA, on the other hand, is a world leader in cancer treatment. Even Cancer Research UK accepts that 5-year survival rates for men with prostate cancer are 51.1% in the UK against 91.9% in the USA²⁷. They would struggle not to accept it, seen as they funded the study²⁸ - CONCORD, performed by the Lancet - which is a remarkable piece of research. However, they do contest it on the basis that the USA is detecting prostate cancer too often. If only the Americans had a detection rate about as bad as ours, then our survival rate statistics might be closer. A peculiar objection, for sure, but let us hear them out. Cancer Research UK’s contention is that the testing used in the USA sometimes detects cancer that is not life threatening, and so a cancer is recorded as being survived which might not have killed the patient anyway. It seems a strange criticism to make, as the medical profession normally says that early detection and catching a cancer at a low-risk time when it is more easily treatable is better. The decision as to whether to treat or not can be taken after that. The fact that their detection measures are better is a genuine contributory factor to better survival rates as people are less likely to go undiagnosed. Some diagnoses might be unnecessary, and some would have been missed otherwise, so the original contention seems to be without merit. Indeed, Prostate Cancer UK does recommend screening at a rate far higher than the NHS has capacity for²⁹. Cancer Research UK then goes on to say, “the NHS is doing a pretty good job of managing it when it’s detected early”. Detecting it as early as possible is only a laudable feat when the UK does it, it seems. PSA testing is clearly a topic of debate in the medical field at the current time. In either case, neither positives nor negatives of early detection can account for a 40% differential in survival rates. Breast cancer is another of the most treatable forms of the disease, with some of the highest survival rates in general. The 5-year survival rate for breast cancer in women is 83.9% in the US, 82.5% in Canada, 81.6% in Japan, 80.2% in Finland, 75.5% in Germany, and 69.7% in England. On the 5-year survival rate for colon cancer, the UK falls behind Republic of Ireland, Northern Ireland, Spain, Finland, Austria, France, Portugal, Sweden, Norway, Germany, Iceland, Italy, Denmark, Netherlands, Australia, USA, Canada, and Japan, and perhaps others for which we do not have data. Obviously, there are factors aside from healthcare received which vary from country to country and could affect survival rates: genetics, diet, smoking, alcohol, drug use etc. Nonetheless, healthcare is a hugely significant factor, more similar countries can be compared to reduce other disparities if necessary, and the statistical results referenced are striking.

Waiting times are also a top concern for many people, and it has been considered in the report in question. The Commonwealth Fund’s report finds that, in the UK, 21% of doctors report patients often experience long wait times to receive treatment after diagnosis. For the USA, that percentage is 8%. I do not find this very surprising, but I do find some of the other countries’ numbers a bit suspect: 59% for Germany? Perhaps it really is awful over there, or maybe the Germans just complain more because, again, this is a measure based on perception and opinion rather than hard data. The most eyebrow-raising part of this section is not any one particular statistic, but the glaring absence of one for the UK under “waiting time of 4 months or more for elective/non-emergency surgery”. Apparently, the sample size of our 65 million strong population all accessing the same healthcare service is “too small”. At this point, it is becoming clear that some of the most damning statistics are simply left out of the report (purposefully or not, we can only speculate). There is a well-known problem in the UK surrounding waiting times, especially for elective surgery, and a wait of a 6 months to a year or more is commonplace. It is sufficiently bad that a standard was put in a place – a lax benchmark, but a benchmark nonetheless – intended to improve the situation. England’s 2010 “NHS Constitution” declared that no patient should wait beyond 18 weeks for treatment after GP referral. The principle is one thing, but the actual target was that this should be true for 90% of patients. By August 2019, less than 49% of hospital services achieved that target and the average wait time in England was 23 weeks. In September 2018, the proportion of people waiting more than the six-week target for diagnostic tests was at its highest since records began³⁰. The BBC subsequently discovered, and published in 2012³¹, that many patients initially assessed as needing surgery were later “re-categorised” by the hospital trust and removed from waiting lists. In short, they were kicked off the waiting list to make it look better. The Royal College of Surgeons President Norman Williams called this “outrageous... very, very worrying”, and charged that hospitals are cutting their waiting lists by simply raising thresholds for surgery. Health Secretary Andrew Lansley said that treatment should not be “rationed”. Out of hours care is notoriously difficult to obtain, and the only place I or anyone I know has ever accessed it is the Accident & Emergency room with a regular wait time of 4 hours or more. There is an out of hours service available which is contracted out to a company called Vocare, but it is only available until 8pm and the providing company has a poor reputation. Naturally, due to the public system, the tender process for this contract is hardly as free as a private one, and whoever wins it is the sole provider - there is no other one can choose if the service is bad. Despite all this, the Commonwealth Fund claims that “The U.K. has short waiting times for basic medical care and non-emergency access to services after hours. The U.K. also has improved waiting times to see a specialist and now rates fourth on this dimension with the U.S. ranking third.” To arrive at precisely the reverse conclusion to the reality is quite bewildering.

I often hear conservative US commentators warn their fellow citizens that healthcare will be rationed under a single-payer system, and their warnings are laughed off by their adversaries. Those warnings are not unfounded, friends – that is how it works. Even the Commonwealth Fund, which seems to observe socialised systems while wearing rose-tinted spectacles, reported in 2007 that the UK and Canada had the highest numbers of persons who had to wait four weeks or more, at 60% and 57% respectively, to see a specialist physician. If they will not point it out directly this is at least indicative of rationing. In the USA, only 23% reported a wait of four weeks or more. Long waiting times clearly represent a reduction in “access” to healthcare, which is probably the word most often used in defence of socialised healthcare. Another important consideration regarding access is the phenomenon of the “postcode lottery” (zip code, for our American friends). When services arise from the market, unfettered by government meddling, the supply – the types of service and the amount/capacity available – match the requirements of the geographical area they serve. A central planner could never hope to gauge this properly because the problem is far too complex, therefore the areas in which people live are often mismatched with the services made available to them. This is described colloquially as the postcode lottery – a situation where people in one geographical area are luckier than people in another geographical area in the abundance and quality of government distributed services made available, in this case healthcare. This disproportionately affects the poor, because low income people often do not have the means to move to areas with better services. Reports like the one under review here seem to skip over facts like these.

At this point, it is worth pointing out the obvious political orientation of the authors of the “Mirror, Mirror on the Wall report”, The Commonwealth Fund. It is self-described as “a private foundation that promotes a high-performance health care system providing better access, improved quality, and greater efficiency. The Fund’s work focuses particularly on society’s most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.” They hope to “stimulate innovative policies and practices in the United States and other industrialised countries.” You can almost guarantee that any organisation which defines itself as working on behalf of the down-trodden, the marginalised, the poor, minorities, will be left-leaning. Whether their policy prescriptions will benefit those groups is an entirely separate issue. You often find, as we do here, that the results are actually the reverse of their stated aims. The outcomes of public healthcare we have reviewed hardly represent an advancement in the lot of the poor. My suspicions of this strong Statist bias were confirmed when the report went on to speak in praise of then President Obama’s Affordable Care Act in completely unquestioning terms, without any evidence to back up their assertions about the real effects of the Act. So, as it happens, the above distortions are not at all a surprise to find. I have no problem with bias, per se, because everyone has it. I am biased toward enhancing and preserving the freedom of individuals because I believe it is grounded in good principles and has preferable outcomes. So long as people are honest about their biases, we can navigate discourse properly. Sadly, this report is presented as a factual analysis, and is not forthcoming about its agenda.

My aim, in briefly deconstructing this particular report, is to plant a seed of doubt in the minds of those who take reports at face value, and those who take for granted that healthcare is “good” if it is “given” to you and “bad” if you have to pay for it as an individual, and to challenge the peculiar status of the NHS as the UK’s golden calf (remember the 2012 London Olympics opening ceremony – a truly religious experience). Like any product, healthcare comes in varying qualities at different prices, and the government does not give you anything – it pays for things with your money, and you, your children, and their children will pay it back.

Before moving away from The Commonwealth Fund, I regret to inform the reader that my subject matter outpaced me at the time of analysis. The Mirror, Mirror 2017 report³² was released at the same time, and I felt it necessary to address it. Fortunately for me, and perhaps the reader who has had quite enough of report breakdowns, they didn’t do enough differently to warrant dwelling for long. The benefit of this, though, is that at least we know the last report was not just a bad egg. Unsurprisingly, the UK scores first and the USA last, again. However, if I didn’t know full well that my criticisms have been seen by no-one yet, and that it would be inconsequential even if they had, I might have been fooled into thinking that the Commonwealth Fund had acted on something I pointed out. They have included cancer survival rates in their new report – a measure bizarrely left out in the last report. It is worth pointing out that they have only included two types of cancer: colon and breast cancer, which, coincidentally or not, are not as disparate in their survival rates across countries as other types. Results that make the UK look too bad and the USA too good do not suit the Commonwealth Fund’s agenda, but we still have plenty to go at. On both of the included statistics, the UK is last – lower than the other countries combined by on average 6.5% and 8.6%, respectively. As a result, this latest report bears on reality a little more accurately than the last one in one regard: the UK is 10th/11 on “healthcare outcomes” i.e. survival and mortality rates. However, true reflections of reality stop there, as the UK somehow still ranks no. 1 overall. Furthermore, the USA is placed 11th/11 on healthcare outcomes, despite being consistently among the top performers on numerous measures in the same report. How did the overall scoring in one category manage to drag the USA down to last place, then, if their scores were high? The sceptic in me points to selected, strange criteria, such as the percentage of “Adults age 18 to 64 with at least two of five common chronic conditions”, the chronic conditions being: joint pain or arthritis; asthma or chronic lung disease; diabetes; heart disease; and hypertension. A country’s healthcare surely must be rated on the care that it provides for someone with a chronic condition – it should not be rated on how many of its patients walk through the door with chronic conditions asking for treatment. A person can have a weak or strong genetic disposition to any and all of these conditions, and gene pools vary from country to country, from ethnicity to ethnicity. Components like diet and exercise, which also affect these conditions, are the personal choices of the individuals. Trends of behaviour vary between countries, genders, ages, ethnicities etc. too. There are too many variables outside of the control of the healthcare system of a given country to make this measure reliable. Why should a healthcare system be blamed for a population’s personal choices or weaker constitution? Take the USA: black American adults age 20 or over are 77.5% more likely to have diabetes than white Americans, Hispanic Americans 66% more likely, and Native Americans 364% more likely³³. Asian Americans have significantly lower death rates for cardiovascular disease³⁴. There are many disparities along these lines, and it is accepted different races have predispositions to particular illnesses. With these facts in mind, consider that the USA has 21% of patients with at least two of the five common chronic conditions while the rest of the countries in the Mirror Mirror report have an average of 10.6%. Is it the fault of private enterprise, American medical staff, or American lawmakers, that the USA has over 104 million people in the three ethnic categories carrying the highest risk of diabetes, while the whole of Europe is home to approximately 10 million people of the same ethnicities combined³⁵,³⁶,³⁷? The apparent incidence of higher rates of chronic illness could also be a simple reflection of the USA’s superior testing and diagnosis capacity, or Americans’ greater voluntary spending on preventative care, both of which we already know contributes to their favourable survival rates for disease. The inclusion of this measure and the respective statistics significantly knocks the USA’s score on “healthcare outcomes” without reflecting whatsoever on the efficacy of the American healthcare system. Imagine if, rather than ‘the 10-year rate of survival for skin cancer’, the ‘number of people diagnosed with skin cancer’ was taken as a measure: sunny countries with majority white populations would be significantly over-represented and branded failures – specifically, Australia, New Zealand, and Denmark (with an average of 8 hours sunshine per day from May to August, interestingly³⁸) would be the victims of such shoddy statistical shenanigans³⁹. As for the UK’s favoured performance, especially with a ranking of one in “care process”, I can only imagine the researchers didn’t think questions like ‘number of patients left in corridors of hospitals’ were of interest⁴⁰. One measure: “primary care physician reports electronic clinical decision support in practice” - I have no idea what this actually means, and nor do the doctor or dentist I asked, but it sounds like an administrative process. If the Commonwealth Fund thinks that form filling and red tape is equivalent to safe care, then we Brits shall never fall from our lofty position. With the political motivations discussed earlier, it is apparent that the Commonwealth Fund’s report is constructed for the UK to win and the USA to lose, for that means their conclusions point to their end goal: greater government spending and state involvement in healthcare. The Commonwealth Fund’s bias toward the UK healthcare system may be part of a wider US bias in the same direction. I have visited the USA numerous times, and every time I have found Americans singing the praises of the NHS without ever having accessed it. The idea of socialised healthcare was positively utopian in the view of the Californians and Arizonians I spoke with. My advice to Americans would be: don’t do it.

A great example of private healthcare provision in action, in recent history, is laser-eye surgery. In the USA, it has never been covered by Medicare, Medicaid or most private insurance policies. It therefore has a position in the marketplace unlike other healthcare products: it is more of a commodity, less regulated, available for purchase from many more providers, and subject to fierce competition. Such surgery can be life changing for people, and yet it is still viewed as optional rather than essential by most people, which is the very reason its position in the marketplace is so potent. That it is not ‘essential’ has saved it from the clutches of regulation and public provision. Even the New York Times, which has a habit of bashing the free market (as it does in the article which this is extracted from), says: “The competition for patients led to price cutting. The price for laser eye surgery, including operations offered by companies and hospital centers that still charge $2,750 for each eye, dropped to $1,650, on average, recently from as high as $3,000. There has been a similar drop for cataract surgery; the costs, typically covered by health insurance, can be $1,400 to $2,000 for each eye, down from $3,000 when the procedure was new.”⁴¹ These price reductions, created by individuals competing with other individuals in providing better products at lower costs to garner business and profit, are against a backdrop of otherwise increasing healthcare costs mostly regulated and subsidised by government. Sadly, this example is an anomaly in a market with increasing limitations on economic freedoms. LASIK MD, a Canadian firm and major competitor in laser eye surgery, may never have begun operating in the US at all were it not for laser eye surgery being excluded from government-subsidised healthcare provision. Canada has restrictions on much privately funded healthcare, and the crowding out of private enterprise by heavier public expenditure precludes entry to industry.

It should be no surprise that the privilege of better healthcare costs money. The best healthcare in the world, based on measures which I deem important such as survival rates from disease and waiting times for surgery, are those with private systems operating within freer economies. The citizens living under free, highly productive economies are also richer, so the healthcare costs are more affordable in relation to their incomes than for people from other parts of the world. I do not think Britons would have a problem in paying more for their healthcare, and polling shows that Britons do support greater taxation specifically for the NHS. There is no guarantee that raising tax rates would increase revenues, but that is a conversation for another day. If there is a willingness to pay more for healthcare via taxation, it stands to reason that the same people would be willing to pay more in their individual capacity in a market system. This seems especially likely when one considers that Britons have on average more disposable income than almost all other European countries⁴². Indeed, as far back as 1961, D. S. Lees identified that “far from being extravagant, expenditure on the NHS has been less than consumers would probably have chosen to spend in a free market. The record of hospital building in particular has been deplorable”⁴³. The Netherlands is often cited as having among the more successful of healthcare systems, and it is among the highest spenders on healthcare in Europe. It also has “universal access”, or in other words a legal requirement for you to have insurance. Essentially, the government provides funding for a basic level of insurance, and anything beyond that is arranged by the individual citizen. Switzerland, another much admired country with enviable healthcare outcomes, has no state provision for healthcare at all – only a legal requirement that everyone procure their own private healthcare insurance. It may be of surprise to an American or Brit that European systems are run privately, through profit and non-profit private insurers and hospitals. In fact, it is the rule and not the exception that European and Scandinavian countries have private health and insurance providers, and do not rely primarily on publicly owned ones. These systems offer the individual more choice and foster a level of competition between healthcare and insurance providers.

Canada is often presumed to be similar to the UK in its healthcare set-up, and while Canada does mostly provide for healthcare funding via the public purse, hospitals are not government owned. The Canadian system is socialised to a significant degree, but it is not a socialist system. That is to say, much of the funding for the sector is from the public purse, which affects the system, but it is not centrally owned or run. The UK system is socialist in nature - the government owns and manages the health service - but is trending toward privatisation in order that it may continue to function. In Canada, the restrictions on private funding in healthcare and the government allocation of public funding to healthcare providers have caused supply problems, just like the UK (as opposed to levels of supply responding dynamically to demand in a free market). Expectedly, but still somewhat ironically given the intentions of the policy, a tendency toward socialisation and “universal access” has resulted in fewer people having access to healthcare. Health tourism to the US from Canada is a well-known phenomenon, and one that is increasing in frequency. People vote with their feet, and the signs are telling: between the Spring of 2006 and the start of 2008, over 150 critically ill Canadians were rushed to the US because intensive care beds and specialised services were not available in Canada. In 2017, 217,500 Canadians left the country for healthcare. That amounts to Canadians spending $690 million on healthcare abroad in one year. Time takes its toll on any socialised system as its flaws are given the chance to produce results. What is a relatively young healthcare system in Canada is beginning to experience aged organisations with insufficient competitive pressure falling in standards, and an ageing population causing expenditure in healthcare to run away, and therefore for government expenditure in general to far outstrip its revenues. Now, there are increasing calls in Canada for increased privatisation to alleviate some of these problems⁴⁴.

One of the most striking datasets in the Lancet report referenced earlier on cancer survival rates is that which relates to Cuba: the only other country with a socialist, government-owned healthcare system like the UK’s (that’s right, not even China, or Vietnam) – and yet, somehow, despite its similarities with an under-performing UK healthcare system, this island in the Caribbean with a GDP per capita (per person) about one fifth that of the UK has healthcare outcomes which surpass the whole world! If you are not suspicious yet, you should be. The crucial difference between the UK and Cuba here – and there are many – is that the Cuban’s socialist healthcare system exists within a centrally planned, socialist economy, while the UK’s socialist-in-nature but decreasingly socialised NHS exists inside a relatively free market economy. A great boon of the Lancet study is that it takes large datasets from centralised analysis sources, with central quality-control procedures, and standard analytic methods in countries across the world – but this is a double edged sword when including countries which manipulate their statistics. Cuba is a repressed, communist country, without political freedom⁴⁵ or economic freedom⁴⁶, which saw a mass exodus of citizens after the revolution, and further refugees in “Freedom Flights” from 1965, followed by more refugees on the “Mariel boatlift” in 1980 and the “Balseros” in 1994. Because of this history, and the persistent desire of Cubans to emigrate to the USA, from 1995 onward the “wet feet, dry feet policy” allowed Cubans who arrived on US soil preferential treatment in the US, with a fast-track to residency. This policy was ended with immediate effect by Barack Obama in 2017 (which sounds counter intuitive but was part of a wider relaxation of stricter policies against Cuba). Cubans have been among the top ten immigrant groups in the US since 1970, with over 1.3 million Cubans now living the US. With a total population of 11 million, one has to wonder why more than 11% of Cuba’s population would flee paradise for the nightmare that is the USA? Likely the same reason that the country manipulates its healthcare statistics: it is Cuba more closely resembling a nightmare. Do not take my word for it, listen to contemporary dissidents in the Castro regime like Rosa María Payá⁴⁷, who tells of the lies coming out of the country, the corruption and criminality at the top of this totalitarian regime, and of the state sponsored assassination of her father. Listen to the doctors willing to speak out about the reality of Cuban healthcare and its “internationalist missions”⁴⁸. Listen to the academics who warn us that repression, dishonesty, misallocation of resources, and not quality of care, are responsible for Cuba’s glowing standards of infant mortality and life expectancy⁴⁹. The reality of life in this nation is quite different to what tourists and international observers are allowed to see. Like Seth Rogan’s Kim Jong Un keeps the socialist dream alive by putting fake fruit in shop windows in “The Interview”⁵⁰, so does the Cuban government keep its socialist dream alive by making a disproportionate number of Cuba’s citizens doctors – paying them $15 a month for their services and confiscating up to 90% of any earnings made abroad. It is a charade, a regime keeping up appearances as having the greatest health service in the world. Would Cuban authorities require a strict rule book to prevent citizens defecting to their foreign host countries if their healthcare system back home were so idyllic? Another effect of the Cuban government sinking so much of the little resources it has into healthcare is that most other parts of life in the communist regime are impoverished.

Creator: TIM CHAPMAN | Credit: AP

Copyright: 2000 AP

Information extracted from IPTC Photo Metadata.

The UK’s failures are sometimes covered up, certainly – the Alder Hey organs scandal, the Bristol heart scandal, the Stafford Hospital scandal, the contaminated blood scandal etc. – all of these dreadful episodes took many years to come to light, but they did come to light. We ought to be appreciative and protective of the relative freedom and transparency our society generally upholds, which allows us to learn of failures and abuses of power - even if in the cases of government failure there are no real consequences. I add that caveat of consequences with the contaminated blood scandal in mind: while this was a worldwide issue in the 1970s and 1980s, victims of the scandal in most other countries and especially the US received substantial compensation inside and outside of court from the private healthcare providers liable. UK victims received nothing because it was the NHS that was liable. The government owns the NHS, and the government does not hold itself to account. It is not likely to prosecute itself or to pay significant compensation. These are unfortunate examples, but at least we in the UK become aware of them and able to debate them in the public sphere. We will never learn of many a Cuban healthcare atrocity. This is no fault of the Lancet in compiling their report, their job here is to assess medical statistics, not the reliability of the contributing governmental sources. The Lancet must include the data it receives from the authorities for its academic integrity, but we have every reason to disregard Cuban data.

Interestingly, all the sources referenced in this piece, and all discussions I have had thus far on this subject, play themselves out as though Asia does not exist. We should not forget that some sources do pay mind to some of the most highly performing countries on the edges of our consciousness, like Singapore: a country proud of having a social trampoline rather than a social safety net⁵¹, and another example of a highly efficient privately run healthcare system⁵². In 2019 in the UK, £500,000 was raised by crowdfunding (an online charitable process which is free to set up) for a five-year-old boy called Oscar who had leukaemia⁵³. This was raised in order that his parents could take him to Singapore for life-saving treatment. The reason it was necessary for them to do this is because 1. The NHS rations stem cell transplants, and Oscar had used up his permitted amount of treatment for 12 months, and 2. The NHS does not offer treatment for the form of cancer Oscar had. Conditions like these being the inhibiting factors to receiving treatment are unconscionable to people from countries with more regular privately run healthcare organisations. To the date of publishing, this fundraiser has raised £670,484.14 ($857,649.79), plus gift aid (a euphemistic name for a scheme in which the government graciously gives a proportion of the money confiscated in tax on earnings back to the charitable cause - 25% on the amount donated) it totals £713,674.05 ($912,896.16)⁵⁴. This example is an important illustration that hard cases exist in all systems and that there is unique opportunity for them to exist in socialised systems. The cost of correcting a hard case in a socialised system is far greater because the costs initially sunk into the socialised system, which cannot be opted out of despite it failing the patient in the first place, are compounded with the travel costs and out-of-pocket medical costs incurred by obtaining treatment in a country with a well-funded private healthcare system. Britons do not tend to buy medical insurance of any kind, not least international insurance, because of the cost and culture created by the compulsory National Insurance tax, and therefore all private medical costs must be paid directly by the patient. The practically fictitious horror bills posited in countries thoroughly backed by health insurance are a reality for most people obtaining private healthcare in the UK. Such costs would come as a shock to a Briton who has the expectation that their national “universal healthcare system” should provide “universal” care. Only in a socialised system is it conceivable that a person could be forced to pay for a service they never receive, and then be forced to pay again to obtain it privately if they want to obtain it at all.

There are many variations on how a country might legislate around healthcare, with varying levels of taxpayer money raised and spent on it⁵⁵, and they all demonstrate the fact that healthcare providers are better at providing healthcare than the government and insurers are better at providing insurance than the government. It is obvious from the evidence that the provision of healthcare and health insurance is better achieved in a free market system. The source of funding is a different issue, but it does inform provision to some extent too. In a free market system where people spend their own money on their own healthcare, the market can most accurately and dynamically respond to the wants of its participants. Generally, I think the principles of freedom, personal responsibility, and economic efficiency extend to the idea of having health insurance and therefore also to who is responsible for obtaining it. That is: individuals, and not government officials, should purchase coverage. In my view, people should not be coerced into buying a good or service by forcing a coverage plan, or a voucher, or a fine for abstaining from market participation, upon someone. People act more responsibly when they are given responsibility, therefore it seems not just undesirable to curtail a citizen’s freedoms by legislating what they must buy, but unwise to. Furthermore, the government is an expensive middleman to perform a procurement exercise which we can perform better as individuals with greater relevance to our own lives. The quite literally extortionate cost of government represents an introduction of significant inefficiency into a transaction which does not require it. There is no reason private or public funding assistance could not be available for those who struggled to arrange their own affairs due to disability or other complication, and for other hard cases. At the very least, citizens ought to be able to opt out of any government-issued insurance schemes (including National Insurance tax in the UK).

None of us would disagree on our aims in this discussion: to obtain the best healthcare, at the lowest prices, maximising access, availability and choice in healthcare goods and services for as many people as possible. The results matter and must be separated from the stated intentions of a proposed policy. The person who insists that government must distribute healthcare to all citizens on the grounds that “healthcare is a human right”, despite it having worse outcomes, has at best not given the issue enough thought and at worst has admitted their willingness to see thousands of people die for the sake of indulging in their preferred ideology.

[1] WEMHEUER, FELIX. Famine Politics in Maoist China and the Soviet Union. Yale University Press, 2014. JSTOR, Accessed 26 July 2020.

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