Health Care at Home and Abroad

By far the best article I’ve read about the British healthcare system, appeared this morning… in the New York Times. It discussed the NHS’s National Institute for Health and Clinical Excellence (NICE), the organization that rations pharmaceuticals in the UK (although you’ll rarely hear the word “ration” used).

When NICE’s decisions are discussed in the UK, it is inevitably in the context of some sad, sick patient denied access to some treatment that could extend his life. But this article took the logical, if unpleasant, stand that, given finite resources, some sort of rationing is inevitable. In the US, this is done by the “free” market — the scare-quotes are to remind us that healthcare spending per patient in the US is several times anywhere else in the world. What that means is that it’s great to be rich in the US — quick access to any drug, any test, any procedure, but only if you (or your insurer) will pay. But in the rest of the civilized world health-care is largely provided directly or indirectly by the government, irrespective of the patient’s wealth or employment. This is fair in an egalitarian sense, of course, but not necessarily in the libertarian sense Americans often prefer: why shouldn’t I be able to spend my money if I have it?

Conversely, this correctly pushes some of the criticism back onto the drug companies. Drug pricing is a particularly contrived manifestation of the invisible hand of the market: true costs are muddied by extensive R&D budgets, and demand is confused by governments and insurance companies willingness — or otherwise — to pay. (Elsewhere in the Times, my Imperial compatriot Olivia Judson touches on the interaction of scientists and drug companies as part of a larger piece on science, politics, Bush and Obama.)

This is not to say that the NHS system is perfect. It suffers from an infamous “postcode lottery”, as different geographical parts of the NHS system make different decisions about the way their resources will be used — that is, rationed. And despite the fact that the NHS is one of the largest single employers in the world, it is still too small for its task: initial doctor’s appointments are usually restricted to about ten minutes, and the waiting times for surgery and complicated tests can be months long. But it truly is egalitarian: I once came across Elvis Costello and Diana Krall in an NHS Hospital ER (A&E, as it’s known in the UK).