Universal coverage, value, and health system envy

In NEJM, Nick Seddon and Thomas Lee make a claim worth considering and discussing.

Only when societies commit to covering all their citizens with their limited resources do they take on the difficult work of improving the value of care. […]

Universal coverage creates challenges — notably, the rationing that results from competition for scarce funds. But without commitment to universal coverage, it’s too easy to “solve” financial problems by not insuring or underinsuring people. Universal coverage forces discipline. It also shapes social solidarity, community responsibility, and even audacious aspirations. In U.S. institutions, for example, “stroke teams” think about giving great care to people who’ve had strokes. In the English National Health Service (NHS, which is administered separately in England, Northern Ireland, Scotland, and Wales) stroke teams do the same but also think about how to reduce strokes in a given population.

It is remarkable to me how much squabbling we’ve endured over the coverage question (a century and no signs of letting up) relative to the value question. Though it’s true that the nature of the coverage regime imposes some constraints on and distortions to value, I don’t think they’re as large as often suggested. Meanwhile, it is hard for me to reject the hypothesis that the haphazardly accreted U.S. status quo delivers less value per dollar, on average, than just about any of the designed systems of countries to which it is often compared (from Singapore to Switzerland to the U.K. to Canada).

The authors go on to describe aspects of U.S. and U.K. health systems that should make each country the envy of the other. I was surprised to read that the U.S. offers great outcomes and service, two areas I find lacking, especially given the price. We have not committed to universal coverage. Hence, by the logic above, we haven’t fully taken on “the difficult work of improving the value of care.” Amid all the bickering and obstruction (which goes “both” ways), it’s hard to imagine we soon will.

The paper is ungated.


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