Examining Alternatives: What can ‘managed care’ say to the NHS?
First, a declaration: I love the NHS as perhaps only a (once-) foreigner can. I grew up largely uninsured in an under-insured family in the United States. As a child, all my medical and dental care was delivered by earnest students and harried junior doctors in America’s over-stretched urban teaching hospitals. Offering me up as ‘teaching material’ was the only way my student parents could afford such treatment. Most of that care was excellent, delivered with kindness and a clear sense of vocation. But it was not preventive. Indeed, it was not health care, but the emergency picking-up of shattered pieces: a tuberculosis infection spotted only by a vestigial school detection programme that was shuttered only a year later; perpetual chest and throat infections amplified by cold housing and extreme weather; malaria brought home from my parents’ tropical research travel. And my timely access to such care was only really guaranteed by my parents’ high levels of education and determined advocacy – their pointy middle class elbows still worked, despite our poverty-level family income.
By comparison to this precarious, contingent and unequal ‘system’ of medical care, the NHS looks and feels like a health paradise, and one that I certainly don’t take for granted. From the moment I arrived in the UK, I knew that I didn’t have to keep an insurance card visible in my wallet (‘just in case I get hit by a bus’); didn’t have to wait until I needed emergency care to address a lingering illness; didn’t have to worry about friends and colleagues facing medical emergencies. This last was a particularly sharp and delightful change from my experience at one US institution, where we held bake sales to support a colleague with poor insurance and a chronic condition.
So when I talk about examining alternatives to the current NHS model, it is by no means because I seek to change the current NHS ‘offer’: universal care from cradle to grave, free at the point of need. I have seen what a ‘competitive’ free market in health care offers to the poor, the socially disadvantaged, and even the ‘strivers’: insured individuals and families in work and well above the poverty line, who find themselves facing sky-rocketing medical costs that their insurers won’t pay. In this free market, if you are hit by cancer, or any catastrophic medical emergency, or even a long term chronic condition like diabetes, you must prepare to lose your house, your car, your access to credit, because there is no way you can afford the care you’ll need even on a middle class income – unless you are one of the lucky few with really good medical coverage.
And this is one face of any comparative analysis of alternatives to the NHS: in this period of austerity and NHS brinksmanship, comparing a nationalised (or even a regionalised, as in Manchester) health system to a medical free market shows us what we, as patients, stand to lose if ideology replaces evidence in our healthcare debates.
But there is another face as well. In the US, the alternative medical system that I know best both as a consumer and a researcher, there are systems analogous to the NHS, but embedded in the neoliberal marketplace. What can such systems tell us about both barriers and pathways to healthcare excellence? And what can they say about the ‘meanings’ of the NHS, both to our health and to our culture?
Kaiser Permanente, one of the largest managed care groups in the USA, is one such system – and it has some striking historical parallels to the NHS. Established in 1938 to serve the employees of industrialist Henry J. Kaiser’s steelworks, shipyards, and Grand Coulee Dam project and opened to other consumers in 1945, this managed care plan runs hospitals, clinics, general practices, and health education programmes, and hosts both publicly and privately funded healthcare research — just like the NHS. Since it is of roughly the same vintage, it can – and now does – boast of ‘Kaiser babies’, just like we talk about being ‘born in the NHS’. And like the NHS, it is a system rooted in a vision of better health (and thus lower costs) as the natural outcome of promoting preventive care and ‘positive health’ for its users. Of course, unlike the NHS, Kaiser is neither free nor universal, but it does offer health services on the basis of capitation (that is, to individuals based on paid memberships), rather than on a fee-for-service basis.
In April 2016, I spent time as a Visiting Professor at Kaiser Permanente’s Northern California Division of Research, hosted by the Division’s Health Care Delivery and Policy Section (thanks to Drs. Alyce Adams and Julie Schmittdiel for the invitation!). Like me, this team is especially interested in disparities in health and access to care, and social determinants of health behaviour and health outcomes. Thus we had a shared focus on a topic where history is highly relevant, despite the very different systems in and on which we work. Here in the UK, recent research has made one thing very clear. In terms of generating equal health outcomes for all populations, free is not enough. Even with the NHS operating on the basic principle that healthcare should be accessible to all regardless of ability to pay, there are still marked differences in both self-reported and clinically observed measures of health and wellbeing between population groups. Almost identical patterns of health disparities emerge in data from the Kaiser system, even when researchers design interventions specifically intended to lower financial and structural barriers to good health for system members. Over the next few years, members of the Kaiser DoR and of this NHS team will be working together to ask ‘what do these similarities – as well as the obvious differences – mean for each healthcare system and its members’? What can we learn from comparing ‘cultures of health’? We’ll keep you posted!