Written by Zara Jacob
Economics is often framed as the study of choice. When it comes to healthcare, making better choices can mean significantly improving, if not outright saving, lives. Three years out of the start of the pandemic, health care systems around the world are still grappling with the structural flaws the pandemic brought to light (The Economist, 2023). Though developing countries certainly suffered the brunt of this public health crisis, it was the breakdown of health systems in developed countries that was particularly jarring (OECD iLibrary, 2019). For the first time in 20 years of polling by Gallup, less than half of Americans considered the quality of healthcare in the US to be excellent/good in 2021. As for the UK in 2021, the King’s Fund measured the largest decline in the overall satisfaction rate with the National Health Service (the nationwide healthcare system in the UK) since the 90s. Given bed shortages, staff shortages, overwhelmed ER departments, and a general lack of adequate infrastructure afflicted both the US and the UK, an analysis of these healthcare systems during the pandemic would demonstrate what many headlines have already pointed out: neither country was as prepared as it should have been (The Economist, 2023).
However, what may be worth analyzing is how these systems compared prior to COVID and what their respective strengths and weaknesses can foreshadow about their recovery in the next few years.
Background
The NHS is a healthcare system funded by direct income tax deductions where the government employs the majority of healthcare staff and runs operations for most hospitals. The selling point of the NHS is that treatment is free at the point of use and available to any citizen. Additionally, since the government is the only buyer (single-buyer system) and you have multiple private sellers, the costs for things like drug treatments are lower. (World Economic Forum, 2020)
In the United States, there is a mixed system of public insurance for select groups and private insurance (World Economic Forum, 2020). The most widely used public insurance programs are Medicare and Medicaid, while the majority of those privately insured are covered by employer sponsored insurance (Bureau, 2021). Medicare offers coverage for those above the age of 65, or those who are younger with specific health conditions and Medicaid offers coverage for low-income families and individuals. In 2014, the Affordable Care Act (ACA) was implemented and outlawed discriminatory practices in private insurance markets, expanded Medicaid (though the extent of the expansion varies by state), and created government-regulated healthcare exchanges (World Economic Forum, 2020).
Before COVID
Satisfaction Rates
In 2019, the King’s Fund annual survey found a 60% overall satisfaction rate with the NHS. 68% of the respondents cited the quality of care as one of the top reasons for their satisfaction with the NHS. Waiting times and getting appointments were some of the key reasons for dissatisfaction with the NHS system. However, King’s Fund economists John Appleby and Dan Wellings note the potential influence of an announcement of additional funding for the NHS made in 2019 on the satisfaction rates.
Acccording to a Gallup poll on American’s views of US healthcare quality, 52% rated it as excellent/good in 2019. Yet, when the question was slightly changed to asking about an individual’s own satisfaction with their own healthcare, 79% rated it as excellent/good. One important factor that may play into the lower 52% satisfaction rate is Republican opposition to the ACA which passed in 2010. In 2010, 62% of American’s rated US healthcare quality as excellent/good. That number has been in decline since suggesting a correlation with the political implications of the ACA. (Gallup, 2023)
Healthcare System Performance
The Commonwealth Fund conducts an analysis of the healthcare systems of 11 developed countries every few years. According to their latest report published in 2021 analyzing data primarily up to 2019, the US had an overall ranking of 11 out of 11 and the UK ranked 4 out of 11.
The only category which the US does not rank last in is Care Process, which entails preventive care, safe care, coordinated care, and engagement and patient preferences. Not only did the US not rank last, but it was the 2nd best country by these measures. The UK ranks 5th in this category.
The UK and the US both seem to have poor health care outcomes ranking 9th and 11th respectively in that category.
The other categories, Access to Care, Administrative Efficiency, and Equity play to the strengths of a nationwide healthcare system which guarantees the same quality of healthcare to every citizen, regardless of income, and is standardized across all hospitals. The efficiency of spending will be lower in a mixed, multi-payer system by design. For example, one would expect more time and labor to be spent navigating paperwork and finances when you are treating patients of varied insurance coverage.
Evidently, there are tradeoffs to both systems. The NHS is funded by taxes paid by citizens, but guarantees quality, satisfactory healthcare to every single citizen. In the US healthcare system, both the government and the private sector take on funding responsibilities, and though a majority of citizens have access to insurance and quality healthcare, there is a proportion that does not.
A particularly striking statistic included in the report by the Commonwealth Fund was the rates of preventable mortality, which is defined as deaths that could have been prevented by timely and effective care and/or better public health measures. So, while the debate of prioritizing an individual’s freedom to choose their insurance or an individual’s right to affordable healthcare continues to divide US politicians, the UK has consistently had lower rates of preventable mortality according to data obtained from the OECD.
Prediction about Recovery
Multiple experts have expressed particular concern for the NHS in the past few months citing facts like the 7.2 million citizens on waitlists for treatment or the estimated 500 “excess deaths” each week due to overwhelmed ER departments (New York Times, 2023). While there has been increased day-to-day funding and growth in doctors and nurses (despite recent strikes and higher rates of burnout), the underlying problems of bed shortages, outdated software, and extended stays by patients persist and will continue to get in the way of waiting times (Financial Times, 2022). Since 2010, Conservatives have been in power in the UK and have cut NHS spending significantly in favor of a “lean” nationwide system (New York Times, 2023). However, Prime Minister Rishi Sunak has announced that waiting lists are his top priority (BBC, 2023). In fact, £500m was announced in September 2022 to be put towards those specific underlying problems, and another £250m announced in January 2023 (BBC, 2023). Given that the UK ranked 4th in Administrative Efficiency, targeted funding towards expanding capital like beds and hospital software systems can be expected to go a long way in terms of addressing the problems outlined above. Additionally, despite a 36% satisfaction rate with the NHS, there is general consensus (over 90%) in regards to maintaining basic principles of the NHS including free at point of use, funded by taxes, and available to everyone. Given that popularity of a nationwide system has not fallen and politicians across the spectrum are prioritizing the NHS, it seems safe to remain optimistic about the future of the NHS in the next few years.
The pandemic revealed health disparities across the world, including the UK and the US. However, unlike the UK, if you lose your job in the US, you are at risk for uninsurance.
Keeping in mind that unemployment was higher among low-income communities in 2020, the disparities observed are not just simply a reflection of the larger global inequality issue, but are actually embedded in the design of a mixed system as demonstrated in the low rankings in Access to Care and Equity before COVID (U.S Bureau of Labor Statistics, 2023). In reflecting on what needs to happen to the US healthcare system post-COVID, MIT Economist Johnathan Gruber underscores “the importance of universal, non-discriminatory health insurance coverage in the United States.” However, the term “universal coverage” does not exactly inspire consensus in the US, in fact there still continues to be disagreements on the fundamentals of our healthcare system at every primary and presidential debate. As for the bed shortages and the updated systems, there have not been any announcements of additional funding by the government and the data for 2022 is still yet to be published. It would be worth it to further delve into how Administrative Efficiency was measured and whether the flexibility for hospitals to raise the funds through the private sector could actually result in more beds and better software (perhaps, a safe guess would be there would be differences among the hospitals serving different communities). However, that would take another 1,500 words to analyze, so for now, taking into account that the Commonwealth Fund has ranked the US last and the political polarization, the future of the US healthcare system and its ability to address its shortcomings remains unclear.
References:
Avoidable mortality (preventable and treatable) | Health at a Glance 2019: OECD Indicators | OECD iLibrary. (n.d.). Retrieved May 8, 2023, from https://www-oecd-ilibrary-org.proxy.lib.umich.edu/sites/3b4fdbf2-en/index.html?itemId=/content/component/3b4fdbf2-en
Bureau, U. C. (n.d.). Health Insurance Coverage in the United States: 2021. Census.Gov. Retrieved May 8, 2023, from http://www.census.gov/library/publications/2022/demo/p60-278.html
Burn-Murdoch, J. (2022, December 16). The real reason for the NHS crisis. Financial Times. https://www.ft.com/content/2ee16591-a973-4f9f-93e3-3ec6db66cf48
How does the quality of the U.S. health system compare to other countries? (n.d.). Peterson-KFF Health System Tracker. Retrieved May 8, 2023, from https://www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries/
https://www.kingsfund.org.uk//node/6800. (2020, April 3). Public satisfaction with the NHS and social care in 2019. The King’s Fund. https://www.kingsfund.org.uk/publications/public-satisfaction-nhs-social-care-2019
Inc, G. (2023, January 19). Americans Sour on U.S. Healthcare Quality. Gallup.Com. https://news.gallup.com/poll/468176/americans-sour-healthcare-quality.aspx
Mirror, Mirror 2021: Reflecting Poorly | Commonwealth Fund. (n.d.). Retrieved May 8, 2023, from https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly
N, H., Lisa. (n.d.). Employment barriers within low- and moderate-income communities: Monthly Labor Review: U.S. Bureau of Labor Statistics. Retrieved May 8, 2023, from http://www.bls.gov/opub/mlr/2020/beyond-bls/employment-barriers-within-low-and-moderate-income-communities.htm
NHS to buy care beds to make space in hospitals. (2023, January 9). BBC News. https://www.bbc.com/news/health-64204367
Pollock, A., & Roderick, P. (2023, March 17). Opinion | You Don’t Have to Be a Doctor to Know How Much Trouble the N.H.S. Is In. The New York Times. https://www.nytimes.com/2023/03/17/opinion/nhs-britain-privatization.html
Roberts, L. (2023, January 1). Up to 500 people dying each week from emergency care delays, doctor says. The Telegraph. https://www.telegraph.co.uk/news/2023/01/01/500-people-dying-week-emergency-care-delays/
Schellekens, I. G. and P. (2021, May 27). COVID-19 is a developing country pandemic. Brookings. https://www.brookings.edu/blog/future-development/2021/05/27/covid-19-is-a-developing-country-pandemic/
TEDMED – Talk Details—What’s next for healthcare reform. (n.d.). Retrieved May 8, 2023, from https://www.tedmed.com/talks/show?id=770754
The world has 4 key types of health service – this is how they work. (2020, October 9). World Economic Forum. https://www.weforum.org/agenda/2020/10/covid-19-healthcare-health-service-vaccine-health-insurance-pandemic/
United States. (2020, June 5). https://www.commonwealthfund.org/international-health-policy-center/countries/united-states
What has the pandemic revealed about the US health care system—And what needs to change? (2021, April 5). MIT News | Massachusetts Institute of Technology. https://news.mit.edu/2021/what-has-pandemic-revealed-about-us-health-care-what-needs-change-0405
Why Aren’t More People Working in Low- and Moderate-Income Areas? (2020, January 1). https://www.kansascityfed.org/research/economic-review/4q19-edmiston-why-more-people-low-moderate-income-areas/
Why health-care services are in chaos everywhere. (n.d.). The Economist. Retrieved May 8, 2023, from https://www.economist.com/finance-and-economics/2023/01/15/why-health-care-services-are-in-chaos-everywhere
