A while back Trudy Lieberman sat down with Chris Smyth, the health correspondent for The Times of London, who was visiting America to learn more about the US health system, and who has covered the debate over reforms in his nation. What follows is Part two of their conversation about healthcare reform in the US and Great Britain. Part one of the conversation is here.
Rationing care
Trudy Lieberman: I want to discuss rationing a bit more. You told me that doctors will have more authority over treatment under the recent healthcare reforms. In the US, Americans constantly hear from the press that Britain rations care. That people are dying on the streets.
Chris Smyth: In Britain the fact is, care is often rationed, because there isn’t enough money, but it’s done by the managers, and often on flimsy clinical grounds. So the theory under our new reforms is to give power to make decisions on clinical grounds rather than on arbitrary rules.
The positive feature of the current system is the doctor can say ‘my only interest is looking out for my patients, and I will demand they get this treatment.’ When the manager says ‘No,’ the patient doesn’t blame the doctor. When the doctors make the decisions, however, it could affect the relationship with their patients. They might say to patients ‘yes I could give you this care, but I don’t want to pay for it.’
TL: We ration care in America. There’s rationing in every system I’ve looked at. It depends on who is the target of rationing, and how you do it. We do it by price. If you don’t have money to pay for a service, you don’t get care. We have rationing in our insurance system, too. If people have no money, they don’t buy insurance. The Affordable Care Act is designed to ease this a bit. But the question is: Will government subsidies be sufficient, or will they lead to a kind of self-rationing, where people will forego treatment because their insurance doesn’t cover so much.
CS: Do insurance companies deny care?
TL: Yes, that’s done a lot, but now they cannot deny care to someone who has a preexisting condition. They can, however, deny care, if a policy—say one chosen by an employer—does not cover it. Care denial usually provokes outrage, like it did in the late 1990s when they refused to pay for bone marrow transplants to treat breast cancer because it was not cost or clinically effective.
CS: If you have an insurance policy and you say, ‘I want this’ and your doctor says ‘I want this,’ you’ll get it? Or does the insurance company say, ‘We’ll pay some of it and you’ll have to pay some of it yourself?’
TL: It depends on the policy, and, in fairness to insurers, it’s employers who set the terms of the policy. It’s not necessarily the insurer. This has been a very hard concept to get across to consumers. This part of the American system has not been well understood and not talked about. Employers generally control the system here. In the run-up to the Affordable Care Act, you didn’t hear much discussion about what employers were up to.
CS: So it only becomes a nasty shock when they find they need a certain type of treatment and they don’t get it and they blame the insurance companies.
TL: Exactly.
CS: I’ve heard some people on the right say the Act is a cave-in to the insurance companies, and they are going to make huge amounts of money, because they’ll be getting subsidized tax dollars. Others say no, no, they’ll be forced to do things they wouldn’t otherwise do.
TL: The insurance companies, at least the big ones, will do very well. We essentially have four big insurance companies and they are well positioned for the new customers they will get as a result of the Affordable Care Act. They will also figure out a way to deal with risk selection, choosing those least likely to generate claims. The smaller carriers, the so-called niche carriers, may have a harder time.
TL: You really can’t. There’s a willingness on the part of the press to accept what they’re told, without weighing claims and seeing if one claim is more meritorious than another. We have this cult of balance, and it’s a problem.
In the US, you need to remember one thing; what was passed was basically a Republican plan. The ideas had been in the academic literature for years, and they were ideas Republicans would be totally comfortable with. But instead, the Republicans have run against their own plan, so to speak. And when the press fell down on the job of bringing the people along, it made it easy for Republicans to move on this strategy.
Amen to that. The lack of real, probing reporting on the health care act is a serious failure in the MSM. The fact that the enabling legislation effectively prevents the IRS from collecting the tax imposed when someone refuses to buy health insurance is almost totally ignored. There is no attempt to either explain this or to assess the potential impact on the costs of the program. If I were still an editor, I'd be angry if a reporter submitted to me the sort of lazy, "balanced" junk I regularly read in the press about the act.
#1 Posted by Tom Barry, CJR on Wed 10 Oct 2012 at 10:29 AM
Hope to hear more about this surprising info about how NICE advocates for rather than denies good care:
CS: It’s important to note that what NICE has done is make it more likely someone will get treatment, because you will often find a treatment NICE has approved that is in fact not given locally because of these rationing decisions by local health boards. They might say it’s too expensive, we don’t have the money here. But the fact that NICE exists and has said this is a cost-effective treatment means that people can say well, no, hang on a second. I should be getting that because it’s NICE-approved and therefore you should be giving it to me. It has given people the power to demand treatment that NICE has approved.
But NICE is not the same as IPAB (right?). And IPAB is the current focus for "death panel" fear mongering? Does IPAB have potential to evolve like NICE?
It's possible that most Americans know the most about European health care through through British TV & film---we might know the British system better than the others. I have wondered if Doc Martin is good or bad advertising for universal care, particularly because it focuses on a surgeon reluctantly practicing primary care and the doctor's office looks old and run down. But just recently William & Mary and Call the Midwife portray very engaging struggles to deliver care by very passionate, caring, and competent health professionals---who are not MDs. So we get mixed glimpses of British care---but very little about other countries. We probably have no other view of the French system than the death of Diana and in Michael Moore's Sicko. MM covered Canada but elsewhere very little about it. International Mystery on MHZ shows a little bit about some others, mostly Sweden but occasionally Germany, some Italian. So other than TV & film, we have few opportunities to learn (accurately or inaccurately) about other health systems.
Good info presented here. Hope to see/hear more about it.
#2 Posted by MB, CJR on Thu 11 Oct 2012 at 01:09 PM