Hours-long waits in the emergency department, patients treated in hallways in the midst of an intense flu season, and canceled elective surgeries are only a few of the problems the National Health Service (NHS) England, which provides health care to all Britons, is facing this winter.
At first glance, the struggles of NHS England appear to embody conservative arguments against the kind of single-payer health care system that many progressives in the U.S. have rallied behind as a way to expand health insurance to all Americans. In this view, the troubles of NHS England clinch the case that universal health insurance is a fool’s errand.
Not so fast.
Let’s begin with what is actually happening at NHS England, where the primary problem this winter has been that demand for care — compounded by a severe flu season — is surging past the system’s ability to supply care. Despite the shocked reporting about this in both the U.K. and the U.S., the crisis was widely predicted months ago, and was potentially preventable.
In the U.K., the Conservative-led government is continuing an austerity regimen for NHS England. Its funding is projected to increase a meager 1 percent per year from 2010 to 2020, compared with an historic average of 3.8 percent per year since the NHS was founded in 1948. This transpired against a background of relative parsimony in overall health spending in the U.K. Britain allocates 9.9 percent of its gross domestic product to health care — about average for industrialized countries — compared to more than 18 percent in the U.S.
Adding to the pressure on NHS England was a simultaneous 7 percent real reduction over the last decade in spending on social services, such as care at home or in residential or nursing homes. This cut has increased the demand for health services, especially among frail elders with no place else to turn. To make matters worse, worries about Brexit are sparking an exodus of essential European Union doctors and nurses who were staffing an already under-resourced NHS England.
The unique structure of this system also leaves it more vulnerable to political whims. Unlike most other industrialized countries that provide universal health coverage, the U.K. government owns a large proportion of the hospitals and employs many of the health professionals who provide daily care to its citizens. This control can easily turn into continuous meddling in the health system’s organization and financing. Every change in government — and even a new Secretary of State for Health — seems to unleash another major reorganization that risks distracting and confusing health care providers.
Despite these significant stressors, the U.K. has built a much stronger primary care sector than the U.S., and its health care system is typically ranked one of the best among wealthy nations. In addition, the NHS remains extremely popular. Satisfaction with the system hovers around 60 percent, with low levels of dissatisfaction. And even though 92 percent of residents of England, Scotland, and Wales believe that the system is facing a funding problem, survey data show no appetite for major changes in the structure of the NHS. This suggests that, from the public’s point of view, the system is still doing its job.
So, what does all of this say about the how the U.S. health system should expand health insurance, if it chooses to do so?
In answering that question, it is essential to keep in mind that every country’s health care system is a unique reflection of its history, politics, and culture. Wholesale importing of one nation’s approach to another is both unlikely and unwise. But that doesn’t mean the U.S. can’t learn from other nations’ successes and failures.
First, regardless of how a nation’s health care system works, it must be appropriately funded. Health systems need sufficient resources to meet the predictable needs of their patients, especially when facing an epidemic.
Second, underfunding social services risks inflicting pain and suffering on sick and needy citizens and can be self-defeating when it causes health care costs to rise. The U.S. currently invests little in social services compared to what it spends on health care. It should reevaluate this imbalance and its effects.
Third, providing universal coverage does not require government ownership and control of the health care delivery system. As the NHS England example suggests, that approach presents enormous political and technical challenges. Given the strong affinity in the U.S. for non-governmental solutions, building on its largely private delivery system is the direction it will almost certainly take.
Whether you favor or oppose expanding health insurance coverage in the U.S., don’t conclude from the U.K. experience that universal coverage can’t work. Health insurance coverage is essential to the health and well-being of millions of Americans, and to the success of its health care system. There are many ways to structure a system that provides Americans with the coverage they need and deserve.
The U.S. can learn from the National Health Service — and other health systems — about paths forward and paths to avoid as it designs a uniquely American approach to its immense health care problems.
David Blumenthal, M.D., is president of the Commonwealth Fund. Jennifer Dixon, M.D., is chief executive of The Health Foundation in the United Kingdom.