• 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.


    • Hi Don – read your post with interest. As a UK citizen working inside the NHS, would make the following observations – i] the private bit of health provision in the UK relies completely on the public part of it for a lot more than primary care; it requires public provision of medical training, the majority of medical practitioners’ income, emergency services and a great deal of infrastructure; ii] when waiting times for the public health service in the UK were reduced below an 18 week threshold, something achieved after significant and continued investment, demand for private treatment dropped significantly and private providers began to look to provide services into the public sector. There is no practical reason why the huge benefits of scale a national public health service brings would not work in the US. There may be insurmountable political reasons. Always enjoy your blog, bw Dan

      • @Dan
        thanks for the comments. These are good points you make, thanks for making them. Political and cultural barriers are the main obstacles to any change of any sort in the U.S. health system, especially one that directly takes on the joint reality that everyone eventually dies, and if this is true eventually things designed to forestall death stop working. My book linked on the side bar talks about these issues as barriers quite a bit.