• 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.


    • I think we too often confuse efficiency and “value.” Simply paying a doctor “too much” for medical care is only, by itself, a problem of distribution, not efficiency. The inefficiency only comes into play when overpayment causes us to train too many doctors (seems unlikely to be the case in the US) or to under-utilize their services (hence, “rationing” care isn’t the right answer).

      Now I don’t doubt that the US healthcare consumer gets a lower “value” for his healthcare dollar than Europeans–we pay way more but only perform similarly on most health outcomes measures. But I’m less convinced that the higher health spending in the US is all just inefficiency and waste–there are very real reasons why provision of healthcare would cost more in the US, including less healthy diets (for example, while in London recently, I discovered to my dismay that Europeans don’t have soda fountains), less exercise, more environmental contaminates like pesticides, lower population densities, longer commutes and higher freight costs, more research expenses, higher wages, etc.

      • Matthew, I believe your last point – that the US has other reasons for high levels of health care spending – is the issue that Seddon and Lee addressed. The current US system has fewer incentives than a universal health care system to promote social changes that encourage healthy lifestyles and environments; changes that would prevent the onset of diseases.

      • Matthew – soda fountains? ha ha What is this 1955? 😉

        Anyway, I think an issue between the UK & the USA that would be worth considering is time spent in cars yes – the commuting and car culture in the U.S., I think, is not particularly health promoting. Communities are much more walkable in the UK, and public transport is a lot more usable, from what I’ve heard from pals who live in the UK, and from what I’ve read.

        I think of this because I did not get a car until I was 28 years old. Before that I walked, took buses, and rode a mountain bike as my transportation. I went to the grocery store with a large back-pack – on the bike if the weather was nice, and on the bus if it wasn’t.
        And I had to carry my bike up & down steps to a 3rd floor apt.
        When I got a car immediately I put on weight – it was pretty dramatic, and it took me awhile before I actually got my exercise & diet more in line with being a motorist. Before that, I never ever had to exercise on purpose, and I never worried about eating too much that’s for sure.

        In addition to not walking, and not being on public transport… commuting in a car affords more opportunities for unhealthy activities than just being sedentary. People commuting in their own cars can eat junk food, drink coffee or soda, smoke, and whatever other unhealthy or risky activities people might do in a car while driving, that people are not allowed to do, or would refrain from doing, if they were walking or on public transport.

        Sorry for the tangent. But though I might envy universal health coverage of the UK… I am also very envious when my pal in Scotland has said he was posting to a forum and surfing the web on the bus during his commute. I spend 40+ minutes (1-way) commuting in my car.

    • Structurally, our health care system has little incentive to do anything long-term. The average American changes jobs every 5 years, companies change insurance. Individuals on the private market churn, too. People churn in and out of Medicaid.

      The savings of investing in better control of chronic disease have to outweigh the costs within a year or two to be anything but a losing proposition.

      • Contrast this with the UK’s NHS or single-payer systems where governments have “skin in the game”. Healthier citizens leads to lower government outlays. Health is of concern to governments from pre-natal care through death and with universal coverage, government seeks to improve citizens’ health regardless of wealth/poverty or class.

        In the U.S., which health-care stakeholder is vitally concerned about improving the health of the citizenry? There are medical researchers and health-care heroes but overall, the U.S. system generates more profits for almost everyone involved from the BAD health of its citizens (Medicare may be one exception although the opportunities for the U.S. government to improve health for 70 year olds is limited, e.g. flu shots, exercise, etc..). Excessive medical costs and poor health outcomes are a feature, not a bug – the authors are too polite to put it that baldly.

    • 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).

      If one decides that that is true one would then ask themselves why.

      Also the same claim can be made about USA schools. The USA Governments at all levels combined spend more and the results seem at a shallow level to be worse.

      • The US is one of the few countries without a national curriculum. I don’t think any other country with a good school system finds any value in local control, either. Most would find the idea that each state can set its own standards, allowing 50 definitions of “proficient” to be looney tunes.