Background
The
original meaning was confined to systems in which the government
operates health care facilities and employs health care professionals. This narrower usage would apply to the British National Health Service
hospital trusts and health systems that operate in other countries as
diverse as Finland, Spain, Israel, and Cuba. The United States Veterans Health Administration and the medical departments of the U.S. Army, Navy, and Air Force, would also fall under this narrow definition. When used in that way, the narrow definition permits a clear distinction from single payer health insurance systems, in which the government finances health care but is not involved in care delivery.
More recently, American conservative critics of health care reform have attempted to broaden the term by applying it to any publicly funded system. Canada's Medicare system and most of the UK's NHS general practitioner and dental
services, which are systems where health care is delivered by private
business with partial or total government funding, fit the broader
definition, as do the health care systems of most of Western Europe. In
the United States, Medicare, Medicaid, and the US military's TRICARE
fall under that definition. In specific regard to military benefits of a
(currently) volunteer military, such care is an owed benefit to a
specific group as part of an economic exchange, which muddies the
definition yet further.
Most industrialized countries and many developing countries
operate some form of publicly funded health care with universal coverage
as the goal. According to the Institute of Medicine and others, the United States is the only wealthy, industrialized nation that does not provide universal health care.
Jonathan Oberlander, a professor of health policy at the University of North Carolina,
maintains that the term is merely a political pejorative that has been
defined to mean different levels of government involvement in health
care, depending on what the speaker was arguing against at the time.
The term is often used by conservatives in the U.S. to imply that
the privately run health care system would become controlled by the
government, thereby associating it with socialism, which has negative connotations to some people in American political culture. As such, its usage is controversial, and at odds with the views of conservatives in other countries prepared to defend socialized medicine such as Margaret Thatcher.
History of term
When
the term "socialized medicine" first appeared in the United States in
the early 20th century, it bore no negative connotations. Otto P. Geier,
chairman of the Preventive Medicine Section of the American Medical Association, was quoted in The New York Times
in 1917 as praising socialized medicine as a way to "discover disease
in its incipiency," help end "venereal diseases, alcoholism,
tuberculosis," and "make a fundamental contribution to social welfare." However, by the 1930s, the term socialized medicine was routinely used negatively by conservative opponents of publicly funded health care who wished to imply it represented socialism, and by extension, communism. Universal health care and national health insurance were first proposed by U.S. President Theodore Roosevelt. President Franklin D. Roosevelt later championed it, as did Harry S. Truman as part of his Fair Deal and many others. Truman announced before describing his proposal that: "This is not socialized medicine".
Government involvement in health care was ardently opposed by the AMA,
which distributed posters to doctors with slogans such as "Socialized
medicine ... will undermine the democratic form of government." According to T.R. Reid (The Healing of America, 2009):
The term ["socialized medicine"] was popularized by the public relations firm Whitaker and Baxter working for the American Medical Association in 1947 to disparage President Truman's proposal for a national health care system. It was a label, at the dawn of the cold war, meant to suggest that anybody advocating universal access to health care must be a communist. And the phrase has retained its political power for six decades.
The AMA conducted a nationwide campaign called Operation Coffee Cup during the late 1950s and early 1960s in opposition to the Democrats' plans to extend Social Security to include health insurance for the elderly, later known as Medicare.
As part of the plan, doctors' wives would organize coffee meetings in
an attempt to convince acquaintances to write letters to Congress
opposing the program. In 1961, Ronald Reagan recorded a disc entitled Ronald Reagan Speaks Out Against Socialized Medicine
warning its audience the "dangers" that socialized medicine could
bring. The recording was widely played at Operation Coffee Cup meetings.
Other pressure groups began to extend the definition from state managed
health care to any form of state finance in health care. President Dwight Eisenhower opposed plans to expand government role in healthcare during his time in office.
In more recent times, the term was brought up again by Republicans in the 2008 U.S. presidential election. In July 2007, one month after the release of Michael Moore's film Sicko, Rudy Giuliani, the front-runner for the 2008 Republican presidential nomination, attacked the health care plans of Democratic presidential candidates as socialized medicine that was European and socialist, Giuliani claimed that he had a better chance of surviving prostate cancer in the US than he would have had in England and went on to repeat the claim in campaign speeches for three months before making them in a radio advertisement. After the radio ad began running, the use of the statistic was widely criticized by FactCheck.org, PolitiFact.com, by The Washington Post,
and others who consulted leading cancer experts and found that
Giuliani's cancer survival statistics to be false, misleading or "flat
wrong," the numbers having been reported to have been obtained from an
opinion article by Giuliani health care advisor David Gratzer, a Canadian psychiatrist in the Manhattan Institute's City Journal where Gratzer was a senior fellow. The Times reported that the British Health Secretary
pleaded with Giuliani to stop using the NHS as a political football in
American presidential politics. The article reported that not only the
figures were five years out of date and wrong but also that US health
experts disputed both the accuracy of Giuliani's figures and questioned
whether it was fair to make a direct comparison. The St. Petersburg Times
said that Giuliani's tactic of "injecting a little fear" exploited
cancer, which was "apparently not beneath a survivor with presidential
aspirations."
Giuliani's repetition of the error even after it had been pointed out
to him earned him more criticism and was awarded four "Pinnochios" by
the Washington Post for recidivism.
Health care professionals have tended to avoid the term because
of its pejorative nature, but if they use it, they do not include
publicly funded private medical schemes such as Medicaid. Opponents of state involvement in health care tend to use the looser definition.
The term is widely used by the American media and pressure
groups. Some have even stretched use of the term to cover any regulation
of health care, publicly financed or not.
The term is often used to criticize publicly provided health care
outside the US, but rarely to describe similar health care programs
there, such as the Veterans Administration clinics and hospitals, military health care, or the single payer programs such as Medicaid and Medicare.
Many conservatives use the term to evoke negative sentiment toward
health care reform that would involve increasing government involvement
in the US health care system.
Medical staff, academics and most professionals in the field and international bodies such as the World Health Organization tend to avoid use of the term. Outside the US, the terms most commonly used are universal health care or public health care. According to health economist Uwe Reinhardt,
"strictly speaking, the term 'socialized medicine' should be reserved
for health systems in which the government operates the production of
health care and provides its financing." Still others say the term has no meaning at all.
In more recent times, the term has gained a more positive reappraisal. Documentary movie maker Michael Moore in his documentary Sicko
pointed out that Americans do not talk about public libraries or the
police or the fire department as being "socialized" and do not have
negative opinions of these. Media personalities such as Oprah Winfrey have also weighed in behind the concept of public involvement in healthcare. A 2008 poll indicates that Americans are sharply divided when asked about their views of the expression socialized medicine,
with a large percentage of Democrats holding favorable views, while a
large percentage of Republicans holding unfavorable views. Independents
tend to somewhat favor it.
History in United States
The Veterans Health Administration, the Military Health System, and the Indian Health Service
are examples of socialized medicine in the stricter sense of government
administered care, but they are for limited populations.
Medicare and Medicaid are forms of publicly funded health care, which fits the looser definition of socialized medicine.
Part B coverage (Medical) requires a monthly premium of $96.40 (and
possibly higher) and the first $135 of costs per year also fall to the
senior, not the government.
A poll released in February 2008, conducted by the Harvard School of Public Health and Harris Interactive,
indicated that Americans are currently divided in their opinions of
socialized medicine, and this split correlates strongly with their
political party affiliation.
Two thirds of those polled said they understood the term "socialized medicine" very well or somewhat well.
When offered descriptions of what such a system could mean, strong
majorities believed that it means "the government makes sure everyone
has health insurance" (79%) and "the government pays most of the cost of
health care" (73%). One third (32%) felt that socialized medicine is a
system in which "the government tells doctors what to do."
The poll showed "striking differences" by party affiliation. Among
Republicans polled, 70% said that socialized medicine would be worse
than the current system. The same percentage of Democrats (70%) said
that a socialized medical system would be better than the current
system. Independents were more evenly split, with 43% saying socialized
medicine would be better and 38% worse.
According to Robert J. Blendon, professor of health policy and
political analysis at the Harvard School of Public Health, "The phrase
'socialized medicine' really resonates as a pejorative with Republicans.
However, that so many Democrats believe that socialized medicine would
be an improvement is an indication of their dissatisfaction with our
current system." Physicians' opinions have become more favorable toward
"socialized medicine."
A 2008 survey of doctors, published in Annals of Internal Medicine, shows that physicians support universal health care and national health insurance by almost 2 to 1.
Political controversies in the United States
Although the marginal scope of free or subsidized medicine provided
is much discussed within the political body in most countries with
socialized health care systems, there is little or no evidence of strong
public pressure for the removal of subsidies or the privatization of
health care in those countries. The political distaste for government
involvement in health care in the U.S. is a unique counter to the trend
found in other developed countries.
In the United States, neither of the main parties favors a
socialized system that puts the government in charge of hospitals or
doctors, but they do have different approaches to financing and access.
Democrats tend to be favorably inclined towards reform that involves
more government control over health care financing and citizens' right
of access to health care. Republicans are broadly in favor of the status
quo, or a reform of the financing system that gives more power to the
citizen, often through tax credits.
Supporters of government involvement in health care argue that government involvement ensures access, quality, and addresses market failures
specific to the health care markets. When the government covers the
cost of health care, there is no need for individuals or their employers
to pay for private insurance.
Opponents also claim that the absence of a market mechanism may slow innovation in treatment and research.
Both sides have also looked to more philosophical arguments, debating whether people have a fundamental right to have health care provided to them by their government.
Cost of care
Socialized
medicine amongst industrialized countries tends to be more affordable
than in systems where there is little government involvement. A 2003
study examined costs and outputs in the U.S. and other industrialized
countries and broadly concluded that the U.S. spends so much because its
health care system is more costly. It noted that "the United States
spent considerably more on health care than any other country ... [yet]
most measures of aggregate utilization such as physician visits per
capita and hospital days per capita were below the OECD median. Since
spending is a product of both the goods and services used and their
prices, this implies that much higher prices are paid in the United
States than in other countries.
The researchers examined possible reasons and concluded that input
costs were high (salaries, cost of pharmaceutical), and that the complex
payment system in the U.S. added higher administrative costs.
Comparison countries in Canada and Europe were much more willing to
exert monopsony
power to drive down prices, whilst the highly fragmented buy side of
the U.S. health system was one factor that could explain the relatively
high prices in the United States of America. The current fee-for-service
payment system also stimulates expensive care by promoting procedures
over visits through financially rewarding the former ($1,500 – for doing
a 10-minute procedure) vs. the latter ($50 – for a 30–45 minute visit). This causes the proliferation of specialists (more expensive care) and creating, what Don Berwick refers to as, "the world's best healthcare system for rescue care".
Other studies have found no consistent and systematic
relationship between the type of financing of health care and cost
containment; the efficiency of operation of the health care system
itself appears to depend much more on how providers are paid and how the
delivery of care is organized than on the method used to raise these
funds.
Some supporters argue that government involvement in health care
would reduce costs not just because of the exercise of monopsony power,
e.g. in drug purchasing,
but also because it eliminates profit margins and administrative
overhead associated with private insurance, and because it can make use
of economies of scale
in administration. In certain circumstances, a volume purchaser may be
able to guarantee sufficient volume to reduce overall prices while
providing greater profitability to the seller, such as in so-called "purchase commitment" programs. Economist Arnold Kling attributes the present cost crisis mainly to the practice of what he calls premium medicine, which overuses expensive forms of technology that is of marginal or no proven benefit.
Milton Friedman
has argued that government has weak incentives to reduce costs because
"nobody spends somebody else’s money as wisely or as frugally as he
spends his own".
Others contend that health care consumption is not like other consumer
consumption. Firstly there is a negative utility of consumption
(consuming more health care does not make one better off) and secondly
there is an information asymmetry between consumer and supplier.
Paul Krugman and Robin Wells
argue that all of the evidence indicates that public insurance of the
kind available in several European countries achieves equal or better
results at much lower cost, a conclusion that also applies within the
United States. In terms of actual administrative costs, Medicare spent
less than 2% of its resources on administration, while private insurance
companies spent more than 13%. The Cato Institute
argues that the 2% Medicare cost figure ignores all costs shifted to
doctors and hospitals, and alleges that Medicare is not very efficient
at all when those costs are incorporated.
Some studies have found that the U.S. wastes more on bureaucracy
(compared to the Canadian level), and that this excess administrative
cost would be sufficient to provide health care to the uninsured
population in the U.S.
Notwithstanding the arguments about Medicare, there is overall
less bureaucracy in socialized systems than in the present mixed U.S.
system. Spending on administration in Finland is 2.1% of all health care
costs, and in the UK the figure is 3.3% whereas the U.S. spends 7.3% of
all expenditures on administration.
Quality of care
Some
in the U.S. claim that socialized medicine would reduce health care
quality. The quantitative evidence for this claim is not clear. The WHO
has used Disability Adjusted Life Expectancy (the number of years an
average person can expect to live in good health) as a measure of a
nation's health achievement, and has ranked its member nations by this
measure.
The U.S. ranking was 24th, worse than similar industrial countries
with high public funding of health such as Canada (ranked 5th), the UK
(12th), Sweden (4th), France (3rd) and Japan (1st). But the U.S. ranking
was better than some other European countries such as Ireland, Denmark
and Portugal, which came 27th, 28th and 29th respectively. Finland, with
its relatively high death rate from guns and renowned high suicide rate
came above the U.S. in 20th place. The British have a Care Quality Commission
that commissions independent surveys of the quality of care given in
its health institutions and these are publicly accessible over the
internet.
These determine whether health organizations are meeting public
standards for quality set by government and allows regional comparisons.
Whether these results indicate a better or worse situation to that in
other countries such as the U.S. is hard to tell because these countries
tend to lack a similar set of standards.
Taxation
Opponents
claim that socialized medicine would require higher taxes but
international comparisons do not support this; the ratio of public to
private spending on health is lower in the U.S. than that of Canada,
Australia, New Zealand, Japan, or any EU country, yet the per capita tax
funding of health in those countries is already lower than that of the
United States.
Taxation is not necessarily an unpopular form of funding for health care. In England, a survey for the British Medical Association
of the general public showed overwhelming support for the tax funding
of health care. Nine out of ten people agreed or strongly agreed with a
statement that the NHS should be funded from taxation with care being
free at the point of use.
An opinion piece in The Wall Street Journal
by two conservative Republicans argues that government sponsored health
care will legitimatize support for government services generally, and
make an activist government acceptable. "Once a large number of citizens
get their health care from the state, it dramatically alters their
attachment to government. Every time a tax cut is proposed, the
guardians of the new medical-welfare state will argue that tax cuts
would come at the expense of health care -- an argument that would
resonate with middle-class families entirely dependent on the government
for access to doctors and hospitals."
Innovation
Some
in the U.S. argue that if government were to use its size to bargain
down health care prices, this would undermine American leadership in
medical innovation.
It is argued that the high level of spending in the U.S. health care
system and its tolerance of waste is actually beneficial because it
underpins American leadership in medical innovation, which is crucial
not just for Americans, but for the entire world.
Others point out that the American health care system spends more
on state-of-the-art treatment for people who have good insurance, and
spending is reduced on those lacking it
and question the costs and benefits of some medical innovations,
noting, for example, that "rising spending on new medical technologies
designed to address heart disease has not meant that more patients have
survived."
Access
One of
the goals of socialized medicine systems is ensuring universal access to
health care. Opponents of socialized medicine say that access for
low-income individuals can be achieved by means other than socialized
medicine, for example, income-related subsidies can function without
public provision of either insurance or medical services. Economist Milton Friedman said the role of the government in health care should be restricted to financing hard cases.
Universal coverage can also be achieved by making purchase of insurance
compulsory. For example, European countries with socialized medicine in
the broader sense, such as Germany and The Netherlands,
operate in this way. A legal obligation to purchase health insurance is
akin to a mandated health tax, and the use of public subsidies is a
form of directed income redistribution via the tax system.
Such systems give the consumer a free choice amongst competing insurers
whilst achieving universality to a government directed minimum
standard.
Compulsory health insurance or savings are not limited to
so-called socialized medicine, however. Singapore's health care system,
which is often referred to as a free-market or mixed system, makes use of a combination of compulsory participation and state price controls to achieve the same goals.
Rationing (access, coverage, price, and time)
Part of the current debate about health care in the United States revolves around whether the Affordable Care Act as part of health care reform
will result in a more systematic and logical allocation of health care.
Opponents tend to believe that the law will eventually result in a
government takeover of health care and ultimately to socialized medicine
and rationing based not on being able to afford the care you want but
on whether a third party other than the patient and the doctor decides
whether the procedure or the cost is justifiable. Supporters of reform
point out that health care rationing already exists in the United States
through insurance companies issuing denial for reimbursement on the
grounds that the insurance company believes the procedure is experimental or will not assist even though the doctor has recommended it.
A public insurance plan was not included in the Affordable Care Act but
some argue that it would have added to health care access choices, and others argue that the central issue is whether health care is rationed sensibly.
Opponents of reform invoke the term socialized medicine because
they say it will lead to health care rationing by denial of coverage,
denial of access, and use of waiting lists, but often do so without
acknowledging coverage denial, lack of access and waiting lists exist in
the U.S. health care system currently or that waiting lists in the U.S. are sometimes longer than the waiting lists in countries with socialized medicine.
Proponents of the reform proposal point out a public insurer is not
akin to a socialized medicine system because it will have to negotiate
rates with the medical industry just as other insurers do and cover its
cost with premiums charged to policyholders just as other insurers do
without any form of subsidy.
There is a frequent misunderstanding to think that waiting
happens in places like the United Kingdom and Canada but does not happen
in the United States. For instance it is not uncommon even for
emergency cases in some U.S. hospitals to be boarded on beds in hallways
for 48 hours or more due to lack of inpatient beds
and people in the U.S. rationed out by being unable to afford their
care are simply never counted and may never receive the care they need, a
factor that is often overlooked. Statistics about waiting times in
national systems are an honest approach to the issue of those waiting
for access to care. Everyone waiting for care is reflected in the data,
which, in the UK for example, are used to inform debate, decision-making
and research within the government and the wider community. Some people in the U.S. are rationed out of care by unaffordable care or denial of access by HMOs and insurers or simply because they cannot afford co-pays or deductibles even if they have insurance.
These people wait an indefinitely long period and may never get care
they need, but actual numbers are simply unknown because they are not
recorded in official statistics.
Opponents of the current reform care proposals fear that U.S.
comparative effective research (a plan introduced in the stimulus bill)
will be used to curtail spending and ration treatments, which is one
function of the National Institute for Health and Care Excellence
(NICE), arguing that rationing by market pricing rather by government
is the best way for care to be rationed. However, when defining any
group scheme, the same rules must apply to everyone in the scheme so
some coverage rules had to be established. Britain has a national budget
for public funded health care, and recognizes there has to be a logical
trade off between spending on expensive treatments for some against,
for example, caring for sick children.
NICE is therefore applying the same market pricing principles to make
the hard job of deciding between funding some treatments and not funding
others on behalf of everyone in the insured pool. This rationing does
not preclude choice of obtaining insurance coverage for excluded
treatment as insured persons do having the choice to take out
supplemental health insurance for drugs and treatments that the NHS does
not cover (at least one private insurer offers such a plan) or from
meeting treatment costs out-of-pocket.
The debate in the U.S. over rationing has enraged some in the UK and statements made by politicians such as Sarah Palin and Chuck Grassley
resulted in a mass Internet protest on websites such as Twitter and
Facebook under the banner title "welovetheNHS" with positive stories of
NHS experiences to counter the negative ones being expressed by these
politicians and others and by certain media outlets such as Investor's Business Daily and Fox News.
In the UK, it is private health insurers that ration care (in the sense
of not covering the most common services such as access to a primary
care physician or excluding pre-existing conditions) rather than the
NHS. Free access to a general practitioner is a core right in the NHS,
but private insurers in the UK will not pay for payments to a private
primary care physician.
Private insurers exclude many of the most common services as well as
many of the most expensive treatments, whereas the vast majority of
these are not excluded from the NHS but are obtainable at no cost to the
patient. According to the Association of British Insurers (ABI), a typical policy will exclude the following: going to a general practitioner; going to accident and emergency;
drug abuse; HIV/AIDS; normal pregnancy; gender reassignment; mobility
aids, such as wheelchairs; organ transplant; injuries arising from
dangerous hobbies (often called hazardous pursuits); pre-existing
conditions; dental services; outpatient drugs and dressings;
deliberately self-inflicted injuries; infertility; cosmetic treatment;
experimental or unproven treatment or drugs; and war risks. Chronic
illnesses, such as diabetes and end stage renal disease requiring dialysis are also excluded from coverage.
Insurers do not cover these because they feel they do not need to since
the NHS already provides coverage and to provide the choice of a
private provider would make the insurance prohibitively expensive. Thus in the UK there is cost shifting from the private sector to the public sector, which again is the opposite of the allegation of cost shifting in the U.S. from public providers such as Medicare and Medicaid to the private sector.
Palin had alleged that America will create rationing "death panels"
to decide whether old people could live or die, again widely taken to
be a reference to NICE. U.S. Senator Chuck Grassley alleged that he was
told that Senator Edward Kennedy
would have been refused the brain tumor treatment he was receiving in
the United States had he instead lived a country with government run
health care. This, he alleged, would have been due to rationing because
of Kennedy's age (77 years) and the high cost of treatment.
The UK Department of Health said that Grassley’s claims were "just
wrong" and reiterated health service in Britain provides health care on
the basis of clinical need regardless of age or ability to pay. The
chairman of the British Medical Association, Hamish Meldrum, said he was
dismayed by the "jaw-droppingly untruthful attacks" made by American
critics. The chief executive of the National Institute for Health and
Clinical Excellence (NICE), told The Guardian newspaper that "it
is neither true, nor is it anything you could extrapolate from anything
we've ever recommended" that Kennedy would be denied treatment by the
NHS. The business journal Investor's Business Daily claimed mathematician and astrophysicist Stephen Hawking,
who had ALS and spoke with the aid of an American-accented voice
synthesizer, would not have survived if he had been treated in the
British National Health Service. Hawking was British and was treated
throughout his life (67 years) by the NHS and issued a statement to the
effect he owed his life to the quality of care he has received from the
NHS.
Some argue that countries with national health care may use
waiting lists as a form of rationing compared to countries that ration
by price, such as the United States, according to several commentators
and healthcare experts. The Washington Post columnist Ezra Klein compared 27% of Canadians reportedly waiting four months or more for elective surgery with 26% of Americans reporting that they did not fulfill a prescription due to cost (compared to only 6% of Canadians). Britain's former age-based policy that once prevented the use of kidney dialysis
as treatment for older patients with renal problems, even to those who
can privately afford the costs, has been cited as another example. A 1999 study in the Journal of Public Economics
analyzed the British National Health Service and found that its waiting
times function as an effective market disincentive, with a low elasticity of demand with respect to time.
Supporters of private price rationing over waiting time rationing, such as The Atlantic columnist Megan McArdle, argue time rationing leaves patients worse off since their time (measured as an opportunity cost) is worth much more than the price they would pay.
Opponents also state categorizing patients based on factors such as
social value to the community or age will not work in a heterogeneous
society without a common ethical consensus such as the U.S. Doug Bandow of the CATO Institute
wrote that government decision making would "override the differences
in preferences and circumstances" for individuals and that it is a
matter of personal liberty to be able to buy as much or as little care
as one wants.
Neither argument recognizes the fact that in most countries with
socialized medicine, a parallel system of private health care allows
people to pay extra to reduce their waiting time. The exception is that
some provinces in Canada disallow the right to bypass queuing unless the
matter is one in which the rights of the person under the constitution.
A 1999 article in the British Medical Journal,
stated "there is much merit in using waiting lists as a rationing
mechanism for elective health care if the waiting lists are managed
efficiently and fairly." Dr. Arthur Kellermann, associate dean for health policy at Emory University,
stated rationing by ability to pay rather than by anticipated medical
benefits in the U.S. makes its system more unproductive, with poor
people avoiding preventive care and eventually using expensive emergency
treatment. Ethicist Daniel Callahan has written that U.S. culture overly emphasizes individual autonomy rather than communitarian morals and that stops beneficial rationing by social value, which benefits everyone.
Some argue that waiting lists result in great pain and suffering,
but again evidence for this is unclear. In a recent survey of patients
admitted to hospital in the UK from a waiting list or by planned
appointment, only 10% reported they felt they should have been admitted
sooner than they were. 72% reported the admission was as timely as they
felt necessary.
Medical facilities in the U.S. do not report waiting times in national
statistics as is done in other countries and it is a myth to believe
there is no waiting for care in the U.S. Some argue that wait times in
the U.S. could actually be as long as or longer than in other countries
with universal health care.
There is considerable argument about whether any of the health bills currently before congress will introduce rationing. Howard Dean for example contested in an interview that they do not. However, Politico
has pointed out that all health systems contain elements of rationing
(such as coverage rules) and the public health care plan will therefore
implicitly involve some element of rationing.
Political interference and targeting
In
the UK, where government employees or government-employed
sub-contractors deliver most health care, political interference is
quite hard to discern. Most supply-side decisions are in practice under
the control of medical practitioners and of boards comprising the
medical profession. There is some antipathy towards the target-setting
by politicians in the UK. Even the NICE criteria for public funding of
medical treatments were never set by politicians. Nevertheless,
politicians have set targets, for instance to reduce waiting times and
to improve choice. Academics have pointed out that the claims of
success of the targeting are statistically flawed.
The veracity and significance of the claims of targeting
interfering with clinical priorities are often hard to judge. For
example, some UK ambulance crews have complained that hospitals would
deliberately leave patients with ambulance crews to prevent an accident
and emergency department (A&E, or emergency room) target-time for
treatment from starting to run. The Department of Health vehemently
denied the claim, because the A&E time begins when the ambulance
arrives at the hospital and not after the handover. It defended the
A&E target by pointing out that the percentage of people waiting
four hours or more in A&E had dropped from just under 25% in 2004 to
less than 2% in 2008. The original Observer
article reported that in London, 14,700 ambulance turnarounds were
longer than an hour and 332 were more than two hours when the target
turnaround time is 15 minutes. However, in the context of the total number of emergency ambulance attendances by the London Ambulance Service each year (approximately 865,000),
these represent just 1.6% and 0.03% of all ambulance calls. The
proportion of these attributable to patients left with ambulance crews
is not recorded. At least one junior doctor has complained that the
four-hour A&E target is too high and leads to unwarranted actions
that are not in the best interests of patients.
Political targeting of waiting-times in Britain has had dramatic effects. The National Health Service
reports that the median admission wait-time for elective inpatient
treatment (non-urgent hospital treatment) in England at the end of
August 2007, was just under 6 weeks, and 87.5% of patients were admitted
within 13 weeks. Reported waiting times in England also overstate the
true waiting-time. This is because the clock starts ticking when the
patient has been referred to a specialist by the GP and it only stops
when the medical procedure is completed. The 18-week maximum waiting
period target thus includes all the time taken for the patient to attend
the first appointment with the specialist, time for any tests called
for by the specialist to determine precisely the root of the patient's
problem and the best way to treat it. It excludes time for any
intervening steps deemed necessary prior to treatment, such as recovery
from some other illness or the losing of excessive weight.
