International Health Care Systems Public Policy

The birth of the N.H.S.

Why did the British decide to have the government pay for health care?  Are they socialists by nature?  Were they just ahead of their time?  Did some lobbyist win the favor of government?

Actually, it was done out of practicality.  World War II shifted the provision of health care from the private to the public sector.  As Atul Gawande explains in the New Yorker:

” …in the days before war was declared, the British government oversaw an immense evacuation; three and a half million people moved out of the cities and into the countryside. The government had to arrange transport and lodging for those in need, along with supervision, food, and schooling for hundreds of thousands of children whose parents had stayed behind to join in the war effort. It also had to insure that medical services were in place—both in the receiving regions, whose populations had exploded, and in the cities, where up to two million war-injured civilians and returning servicemen were anticipated.

As a matter of wartime necessity, the government began a national Emergency Medical Service to supplement the local services. Within a period of months, sometimes weeks, it built or expanded hundreds of hospitals. It conducted a survey of the existing hospitals and discovered that essential services were either missing or severely inadequate—laboratories, X-ray facilities, ambulances, care for fractures and burns and head injuries. The Ministry of Health was forced to upgrade and, ultimately, to operate these services itself.

Like many “temporary” government programs, this one had sticking power.  

By 1945, when the National Health Service was proposed, it had become evident that a national system of health coverage was not only necessary but also largely already in place—with nationally run hospitals, salaried doctors, and free care for everyone. So, while the ideal of universal coverage was spurred by those horror stories, the particular system that emerged in Britain was not the product of socialist ideology or a deliberate policy process in which all the theoretical options were weighed. It was, instead, an almost conservative creation: a program that built on a tested, practical means of providing adequate health care for everyone, while protecting the existing services that people depended upon every day. No other major country has adopted the British system—not because it didn’t work but because other countries came to universalize health care under entirely different circumstances.

Based on this evidence, Dr. Gawande gives a profound insight.  Any health care reform necessarily will be built out of the existing health infrastructure.  This is true both for individuals who want more or less government involvement.  The U.S. has significant experience with private health insurance and expanding private health insurance would not be difficult.  Expanding public insurance would also be feasible through expansions of the V.A., Medicare, or Medicaid systems.  

Whatever reform path we choose, we must take into account the capabilities and infrastructure already in place when we propose these reforms.  

No country designs their health care system from scratch.


Leave a Reply

Your email address will not be published. Required fields are marked *