Die in Britain, Survive In The
Which is better — American or British medical care? If a defender of the
National Health Service wants to win the argument against a free market
alternative, he declares, ‘You wouldn’t want healthcare like they have in
America, would you?’
That is the knock-out blow. Everyone knows the American system is horrible.
You arrive in hospital, desperately ill, and they ask to see your credit card.
If you haven’t got one, they boot you out. It is, surely, a heartless, callous,
unthinkable system. American healthcare is unbridled capitalism, red in the
blood of the untreated poor.
For goodness’ sake, the American system is so bad that even Americans —
plenty of them anyway, if not all — want to give it up. They want something more
like the Canadian system or our own National Health Service. That is what
Hillary Clinton wanted and there are still plenty of people like her around.
Tony Judt, in a recent edition of the New York Review of Books, was damning
about American medical care and glowing about European healthcare. Think of all
the money that is wasted in America invoicing patients and administering lots of
separate, independent hospitals.
At the same time, we can’t help being aware that back here in Britain the NHS
is not exactly perfect. The waiting lists have come down, according to the
government. They have probably come down somewhat in reality, too. But they
still exist and, come to that, there is the worryingly high incidence of
hospital infections. So is British healthcare better than American? Or the other
way round? And how do you judge?
Let’s try the simple way first. Suppose you come down with one of the big
killer illnesses like cancer. Where do you want to be — London or New York? In
Lincoln, Nebraska or Lincoln, Lincolnshire? Forget the money — we will come back
to that — where do you have the best chance of staying alive?
Britain has one of the worst survival rates in
the advanced world and America has the best.
The answer is clear. If you are a woman with breast cancer in Britain, you
have (or at least a few years ago you had, since all medical statistics are a
few years old) a 46 per cent chance of dying from it. In America, your chances
of dying are far lower — only 25 per cent. Britain has one of the worst survival
rates in the advanced world and America has the best.
If you are a man and you are diagnosed as having cancer of the prostate in
Britain, you are more likely to die of it than not. You have a 57 per cent
chance of departing this life. But in America you are likely to live. Your
chances of dying from the disease are only 19 per cent. Once again, Britain is
at the bottom of the class and America at the top.
How about colon cancer? In Britain, 40 per cent survive for five years after
diagnosis. In America, 60 per cent do. With cancer of the oesophagus, survival
rates are low all round the world. In Britain, a mere 7 per cent of patients
live for five years after diagnosis. In America, the survival rate is still low,
but much better at 12 per cent.
if you have a medical problem your chances are
dramatically better in America than in Britain.
The more one looks at the figures for survival, the more obvious it is that
if you have a medical problem your chances are dramatically better in America
than in Britain. That is why those who are rich enough often go to America,
leaving behind even private British healthcare. One reason is wonderfully
simple. In America, you are more likely to be treated. And going back a stage
further, you are more likely to get the diagnostic tests which lead to
Fewer than one third of British patients who have had a heart attack are
given beta-blocker drugs, whereas in America 75 per cent of patients are given
them. In America, you are far more likely to have your heart condition diagnosed
with an angiogram — a somewhat invasive but definitive test. You are far more
likely to have your artery widened with life-saving angioplasty. In Britain not
very long ago, a mere 1 per cent of heart attack victims had angioplasty. In
America you are much more likely to have heart by-pass surgery. In 1996 British
surgeons performed 412 heart by-passes for every million people in the
population, less than a fifth of the 2,255 by-passes per million performed in
the United States. America has many more lithotripsy units for treating kidney
stones — 1.5 per million of population compared with 0.2 in Britain.
It is true that in America they overdo the diagnostic tests. In one hospital
they did a CT head scan on absolutely everybody who came in complaining of a
headache. Even some of the doctors began to think this might be over the top
when they realised that only in 2 per cent of cases was anything found. But in
Britain the problem is the other way round. Having any diagnostic test beyond an
X-ray tends to be regarded as a rare, extravagant event, only to be done in
cases of obvious, if not desperate, need.
Peggy, an American radiologist, came to Britain to meet her English
boyfriend’s family. A pall fell over the visit when the boyfriend’s father found
blood in his urine. He went to the local NHS hospital. Peggy knew that blood in
the urine could mean something worryingly serious or could be utterly minor. A
few tests could make things clear: a CT scan or cystoscopy for example. That
would be routine in the US. But no such tests were done by the NHS hospital in
Welwyn Garden City where the father was a patient.
Tests are underperformed in Britain: first, because there is
a shortage of equipment and second, because the equipment is underused.
Tests are underperformed in Britain: first, because there is a shortage of
equipment and second, because the equipment is underused. Britain has half the
CT scanners per million of population that America has (6.5 compared with 13.6).
It also has half the MRI scanners (3.9 per million of population versus 8.1). In
Britain these machines are generally used during business hours only, regardless
of the fact that some are extremely expensive. At the Mayo Clinic in America, by
contrast, an MRI scanner is in use around the clock.
And if you do get your X-ray scan in Britain, it may well be done with an old
machine. Dr Colin Connolly carried out an audit on behalf of the World Health
Organisation and found that over half of British X-ray machines were past their
recommended safe time limit. Come to that, he found plenty of other machinery
out of date, too. More than half of the anaesthetists’ machines needed
replacing. Even the majority of operating tables were over 20 years old — double
their safe life span.
Look at any proper measure of the capacity or success of a medical service
and one finds, again and again, that America comes out better. In Britain 36 per
cent of patients have to wait more than four months for non-emergency surgery.
In the US a mere 5 per cent do. While in Britain the government celebrates if
the waiting times get a bit lower, in America they don’t do waiting.
There are more American doctors per patient so, not surprisingly, patients
have more time with their doctors. American patients also get to see specialists
as a matter of routine whereas in Britain 40 per cent of cancer patients, for
example, don’t see a cancer consultant. There are shortages of specialists in
many areas of medicine in Britain.
The father of Peggy’s boyfriend had asthma that was getting worse. In America
he would have been seen by an asthma specialist while in hospital. They would
have thought it convenient to do any necessary tests while he was readily
available. Not in Britain. The father lay in his hospital bed with breathing
difficulties but still did not see a specialist. He was told the wait would be
‘in America we’d go nuts if we were told we would
have to wait six weeks to see a specialist.
Peggy was surprised at how ‘accepting’ her boyfriend’s family was. She didn’t
say too much because she did not want to come across as a pushy, arrogant
American but she was thinking that ‘in America we’d go nuts if we were told we
would have to wait six weeks to see a specialist. Expectations are so much
higher.’ Shortly afterwards, her boyfriend’s father was discharged from
hospital. Back home, before his appointment with a consultant came up, he died
of an asthma attack.
‘Ah yes,’ comes the knowing response, ‘but what about the poor? The rich
might get great care in America, but the good thing about the NHS is that
everyone gets treated equally. The care is, in the hallowed phrase, “free at the
point of delivery”.’
Before going into any detail, let us remember one thing: all those figures at
the start about death rates from various forms of cancer were not just for the
rich. They were for the whole population, poor included. That said, yes, it is
true that American healthcare is expensive. It is true, too, that the financial
burden on people is awesomely unequal; but not in the way you might expect. The
seriously poor do not get the worst of it. They get treated for free.
They get Medicaid, the national subsidy for healthcare for the poor. Their
treatment is paid for by the state and subsidised by the hospital, or rather its
other patients and — if it is a for-profit hospital — the shareholders. The poor
might not get showered with as many diagnostic tests as those with full
insurance, but they get treated and without the delays that are normal in
No, the people who get the worst of the cost of the American healthcare
system are not the poor. They are not the rich either, of course. Come to that,
they are not the old, who are covered by Medicare, another government programme.
And they are not the majority of people who are in jobs and have company health
The ones who face major problems are somewhere between middle-income and
poor. They are the ones who are not earning enough to take out an insurance
policy, or not one with a high limit on medical expenditure. So if they come
down with an illness which requires a long — and therefore ruinously expensive —
stay in hospital, their insurance may run out and they may have to sell their
homes or even go bankrupt. Those who are temporarily unemployed, between jobs,
are similarly vulnerable.
Half the bankruptcies in America are people who had
previously been ill. In Britain the system might kill you. In America the
system will keep you alive but might bankrupt you.
The numbers are not large in relation to the whole population. We are talking
about a minority of the American population — figures of 35–45 million are
mentioned — which is not insured and which is not covered by Medicare or
Medicaid. Of that minority only a small proportion will need fairly long-term
hospital treatment. But financial disaster can happen and sometimes does. People
lose their homes, their savings, everything. Half the bankruptcies in America
are people who had previously been ill. In Britain the system might kill you. In
America the system will keep you alive but might bankrupt you.
So there is no doubt that the American system is lousy in certain ways.
Actually it is lousy in lots of ways. The insurance policies that cover most
people are extremely expensive. They can cost as much as $8,000 a year. Part of
the problem is that each state dictates what must be in such policies, thus
raising the cost and reducing the competition among providers. A young man can
be obliged to pay for a policy which insures him against getting pregnant. State
interference means that people cannot easily get the kind of insurance they
would really like and which could lead to the most economical healthcare. That
could be insurance with a large ‘excess’ — offering coverage against real
disasters but not against regular bills for ordinary visits to a doctor.
The tax rules in America are also highly favourable to insurance provided
through a company, but offer little of the same advantages to anyone taking out
insurance personally. That gives rise to the ‘between jobs’ period of risk of
There is much that is wrong with American healthcare. The inflated cost is
boosted by restricted entry into the medical profession. It has been pushed up
by the courts which have given crippling damages for medical negligence. The
doctors have to insure themselves against such damages and so the insurance
premiums they pay are huge. Doctors can only pay these by charging high fees.
The risk of being sued is also an important reason why American doctors would
rather give you too many tests than too few.
Let’s face it, the American system is rotten. It is not even a system. It is
a hotch-potch. Most hospital provision is by not-for-profit, private hospitals.
But the biggest buyer of medical care is the US government. Through Medicaid
(for the poor) and Medicare (for the old) and other schemes, the government pays
for 45 per cent of all healthcare. (The British assumption that American
healthcare consists of an unfettered free market could not be more wrong.)
Most British people do not realise that the non-private
hospitals in America are not run by the federal government.
Most British people do not realise that the non-private hospitals in America
are not run by the federal government. They are local government hospitals. The
San Francisco General is run by the City of San Francisco. And another
unexpected thing for Brits is that even in such local government hospitals
treatment is not free to those who can afford it. (Incidentally, all sorts of
American hospitals — especially the not-for-profit ones — receive large sums of
cash from charitable benefactors.) And if you think all the above is confusing,
that is hardly even the beginning of the bewildering diversity and
contradictions of American healthcare. It is a muddle.
The British system was a muddle, too, until Aneurin Bevan came along in 1945.
As minister of health, he set about unmuddling it. We, too, used to have local
government (‘municipal’) hospitals until he took them over. He took over the
charitable hospitals too, like St Mary’s and Moorfields and many other famous
ones. He made it not confusing at all. What could be simpler than the central
government being in charge of everything? Over time, the government put itself
in charge of all the doctors, too. So all was made simple and clear.
the new, improved, simple state system of Britain
does not work as well as the American muddle.
But the curious thing is that the new, improved, simple state system of
Britain does not work as well as the American muddle. You have a better chance
of living to see another day in the American mishmash non-system with its sweet
pills of charity, its dose of municipal care and large injection of rampant
capitalist supply (even despite the blanket of over-regulation) than in the
British system where the state does everything. It is not that America is good
at running healthcare. It is just that British state-run healthcare is so
amazingly, achingly, miserably and mortally incompetent.
James Bartholomew’s book, The Welfare State We’re In is published by