On a recent trip to Great Britain to learn about England’s National Health Service (NHS), we saw the growing overlap between America’s system of primarily private insurance and England’s system of primarily public insurance. While we do not support or expect the United States’ move to a fully public system as favored by some Medicare for All supporters, we can imagine the United States adopting some form of universal coverage based on the Medicare Advantage Infrastructure. . The NHS offers some lessons – both good and bad – around models for expanding coverage.
We’re all in this together. So let’s cover everyone
The United States is an outlier among First World countries because it has no guarantee of universal coverage. The main difference between the British and American systems is that everyone in the United Kingdom receives health care coverage from cradle to grave – and copays at the point of service are rare. We have seen firsthand how universal coverage brings stability to the healthcare system. There is strong support for the NHS across Britain, going back to its creation during the post-World War II recovery and the country’s post-war community spirit – rather it is a spirit of “we’re all in this together” then messaging and pricing that divides Americans between the healthcare haves and the have-nots. The NHS is one of the few nationalized services to survive the Conservative governments of the 1980s and 1990s, which saw the airlines, rail systems and coal mines sold off to the private sector.
Citizens of Great Britain often see healthcare for all as part of their national culture, so much so that the country embedded a celebration of the NHS into the ceremonies that opened the 2012 London Olympics.
Universal coverage eliminates customer churn, leading to significant gains in efficiency
The universal coverage that characterizes the NHS has significant benefits. There is no back and forth between having health insurance and not, or switching types of coverage or insurer to another. This lack of ‘churn’, as health insurers call it, leads to greater efficiency in administration and better control of healthcare costs. Healthcare failures, common in the US, are much rarer in Britain. Furthermore, thanks to universal coverage and the absence of consumer churn, the share of healthcare spending going to administrative overhead in Britain is a quarter of that of healthcare. of US overhead – 1.9% versus 8.9%. That difference of 7 percentage points is significant. With the size of the US healthcare economy at $4.5 trillion per year, this suggests a potential savings of $315 billion per year in avoidable paperwork. That’s more than the entire annual spending of Medicare on prescription drugs.
The NHS also has the ability to negotiate directly with pharmaceutical companies; the lack of turnover and stability in the population it serves allows the agency to make creative pricing arrangements. For example, Janssen Pharmaceuticals entered into a contract with the NHS where the company reimbursed money for every patient who took its drug Velcade (bortezomib) for multiple myeloma and saw a return of the disease after four treatment cycles. These types of creative, value-based contracts are one of the reasons why the NHS’s annual drug spending is among the lowest per capita among Organization for Economic Co-operation and Development countries: $517 USD per capita, compared with $1,432 in the US.
Although switching between insurance companies and uninsurers is unusual in commercial and Medicare coverage, it is practically a defining feature of the Medicaid program. In 2022, Congress passed the Consolidated Appropriations Act, which requires all states to provide eligible children with Medicaid for a full year, regardless of their parents’ income. Some states have gone further to cover eligible children up to age six. Bills have been introduced in the House of Representatives and the Senate that would also require all states to cover all eligible adults for a full year. Reducing Medicaid turnover would reduce administrative costs and enable more innovative use of value-based purchasing arrangements for both health care services and pharmaceutical products.
Addressing the social determinants of health is a universal challenge, even for provinces with universal coverage
Although the NHS eliminated many waiting times in the late 1990s and early 2000s when Labor Party leader Tony Blair was Prime Minister, subsequent underinvestment and labor shortages have led to a recurrence of significant waiting times for diagnostic and non-urgent operations. In both the US and Britain, the intersection between the healthcare system and the social sector is often a point of significant friction, especially where there is insufficient support to help people escape care and live independently in their own homes. People in Britain who cannot safely care for themselves at home while recovering are likely to remain in hospital until there is adequate support at home. This reduces the capacity of the healthcare system and increases waiting times for non-urgent procedures.
Here in the United States, we also struggle with how unmet social needs impact the health care system. People covered by Medicaid face economic insecurity and often lack access to basic services such as affordable housing, healthy food, and safe neighborhoods. Not surprisingly, people with Medicaid coverage tend to have worse health outcomes compared to people who are privately insured.
Community-based Medicaid organizations (MCOs) have been at the forefront of addressing health-related social needs for decades. MCOs are increasingly working with government programs, community organizations, and creative partnerships to meet social needs and improve health outcomes.
While Britain and the US have differences in the underlying structures of insurance coverage, we face common challenges in workforce management, addressing social needs and preparing for changes in the world around us. Both countries have accelerated the use of technology to address quality and racial disparities in access to care and health outcomes. The cross-cultural exchange in studying other systems provides insight into the strengths of our own system and highlights some areas in which we could learn from others.
Margaret Murray, M.P.A., is CEO of the Association of Community Affiliated Plans and a member of the Lead care manager editorial advisory board. Nancy Wise, MPH, MBA, is chairman of Spring Street Exchange.