From the Editor
Opposing free healthcare
Health economics are not a common feature of the festive scene but there may still be something to celebrate. As the rosy years of financial expansion in the NHS draw to a close, we must turn our attention not to an introspective review of the institution but to the healthcare reforms proposed for the USA by Barack Obama and the Democratic Party.
In the heady days on the presidential campaign trail, health reform was a key feature of the party's agenda. Its importance was easily encapsulated in sound bites across the country: ‘a system of healthcare that would guarantee to all Americans the basic medical treatment taken for granted in other advanced democracies’. Strong support might have been expected for such a reasonable assertion but the violence and opposition to the plans, particularly at local meetings held with the intention of promoting the proposed reforms, has highlighted the American health dilemma.
Of the Americans who vote, 94% have private health insurance and of them three quarters think that their medical insurance is either good or excellent. In other words the majority of the voters are happy with the status quo. Most agree that everyone has a right to high quality affordable healthcare, but no one is keen to relinquish much of what they already have to solve the problem. The proposed resolution is not a cheap option. The Health Bill that promises affordable healthcare for all Americans is a $1 trillion (£600 billion) idea that is a burden too far for many of those to shoulder who already have the luxury of personal health insurance cover.1
Even before these proposed additional costs can be incorporated, US health spending has already reached staggering proportions currently around $8,100 per head annually on healthcare, which is 17.6% of their gross national product (GDP) and rising. This is almost half as much again as the 11% of GDP spent in France and Germany and nearly double the 9% spent in Britain. Despite this huge outlay, some 17% (47 million) of the 300 million American citizens still have no health insurance cover.2
For some of the uninsured group help is forthcoming from the publicly funded Medicare programme financed by a payroll tax. There is defined and limited support for those aged 65 years and over and those with disability or those, for example, needing permanent renal dialysis. However, as the number of elderly in the population rises and the number contributing to the payroll tax in the present recession falls, spending now greatly exceeds the available income. The other major source of support is the Medicaid budget which is a limited means-tested programme for children, pregnant women and those with defined disabilities financed by combined federal and state funding. This budget is also under increasing financial pressure. Indeed there is looming insolvency for both these programmes of the publicly funded part of the US healthcare system which covers some aspects of care for around 30% of Americans.
In July 2009, Theodore Dalrymple (a pen name for Anthony Daniels, a British doctor) discussed in The Wall Street Journal whether we have a right to healthcare and suggested that the question is not one of rights but in practice how best to organise that care.3 However, he castigated many aspects of the NHS with sweeping statements unsupported by evidence, for example ‘the UK is by far the most unpleasant country in which to be ill in the western world’, but compared with the uninsured population in the USA, we might create some festive cheer by toasting our own NHS where everyone regardless of income can still obtain medical care – a remarkable achievement for any healthcare system.
- © 2009 Royal College of Physicians
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