Private insurance and the NHS

Bob Watcher has a great post on the relationship between the NHS and private health insurance that jives with my understanding of how the two work together based on my post-doc at the University of Manchester in the mid-1990s, and my interest in that system ever since (h/t Brad Flansbaum, on twitter @BradleyFlansbau). Go read the post for a description of the many subtle details. A few big picture thoughts on the NHS and what it means for the U.S.:

  • All citizens have a stake in the NHS running as well as possible since they all use the NHS for primary care (everyone using the NHS is the best quality control program possible).
  • They explicitly acknowledge a tiered system and embrace the idea that those with private insurance or enough money can choose to go outside the NHS for specialty care to avoid waits, etc. This is often understood as helping to relieve pressure on the public system.
  • Access to the cheaper part of the system is easy, but much harder to the more expensive part.
  • They invented the system for themselves; it wasn’t imposed on them.

When Americans peer in and imagine “copying” that system, we rightly say “that won’t work here!” Of course it won’t, it is their system constructed by them for them; we have to come up with our own way of acknowledging limits and running the system. It is a matter of how we will ration, not if, but we do not seem to be able to acknowledge this and have a forthright conversation about how we will deal with this reality. It is interesting and even useful to look at how other systems work, especially to understand how incentives function in practice, but in the end, but we cannot and should not copy another nation’s health care system. We have to figure out how to make our system work for us.


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