TL: The American press hasn’t really covered NICE and it’s decisions much. A case in point: When cost-effectiveness and clinical effectiveness for new treatments was being discussed during the health reform debate, I did an interview with Andrew Dillon, who heads NICE, hoping to encourage reporters here to look at NICE. There was no interest. Yet at the time there was considerable talk in Congress about how we could not have any government body doing cost-benefit analysis on drugs and other therapies. Congress set up an apparatus to consider clinical effectiveness but not cost, under the Affordable Care Act, that’s just getting started. NICE is very different. The very thought of a government body questioning medical treatments sparked our “death panel” debate. People still believe they exist.

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.

Reorganizing how care is delivered

TL: We’ve had a lot of talk about how care is delivered, and the Affordable Care Act has made money available for organizations that improve the way care is delivered.

CS: The thing policy people in the NHS talk about the most is the need to reorganize the system. They want to reorganize the system away from the strict primary and secondary care division that was set up years ago in the old industrial-accident world, where people would get sick, come in and get better, and go away. They want a system and a way to manage people with longterm conditions. Those people account for two-thirds of the NHS spending. Their care is often done inefficiently, particularly for elderly people.

Theoretically it should be easy to improve healthcare at home in the community in a sort of top-down system. But in fact, it’s proven extremely difficult, because people are resistant to any sort of change in the way health systems are set up. The infrastructure for community care is not as good as it should be. Lots of efforts are being made to change that, so far, with limited success, really. Presumably those pressures exist in the US, and I’m wondering how dominant they are.

TL: In the US, if you ask people where they want to be cared for, it’s in the community. And yet our financial payment structure is not set up to support that. People go to nursing homes because federal and state dollars are directed toward nursing homes rather than toward home and community care.

This is going to be a big issue going forward—especially since states can now decide if they want to expand their Medicaid programs. States are really balking at spending much more on Medicaid.

CS: Who does pay for residential and nursing home care?

TL: Medicaid pays for about half of all nursing home stays. Private long-term care insurance pays for a small portion, and families pay the rest.

There hasn’t been much attention to long-term care in the press here. I tried to urge the press to cover it during the debate, but few reporters did. It’s like it’s not that interesting— and yet it’s going to be very interesting as time goes on, as America gets older and the costs of care outstrips what families can afford to pay.

Trudy Lieberman is a fellow at the Center for Advancing Health and a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR’s healthcare desk, which is part of our United States Project on the coverage of politics and policy. Follow her on Twitter @Trudy_Lieberman.