The most notable way the U.S. differs from other industrialized countries is the absence of universal health insurance coverage – Mirror, Mirror on the Wall, 2014 Update: How the U.S. Health Care System Compares Internationally, the Commonwealth Fund, executive summary


This summer I took my 11-year-old twins to England to visit family and we ended up in the emergency room on the first day. I was worried about the ER visit, not because of the cost but because in the United States we are constantly bombarded by politicians striking fear into our hearts about the National Health Service (NHS), so I imagined hours and hours of waiting and terrible care. (Keep in mind in the U.S. we needed the Supreme Court to rule that the government requiring health care coverage was constitutional, so it’s a little wonky here)

Our experience with the NHS was great. I spoke to family who live in England, many who have unfortunately had lots interactions with the health system courtesy of tuberculosis, diabetes, lupus. lung cancer and spinal stenosis. Listening to their stories it seemed to me that they also had really good care. There was a shortage of hospice beds and a primary care doctor that brushed off symptoms that a year later were eventually diagnosed by a private doctor as lupus, but by and large everyone had great care.

So I wrote about it. Lots of people liked it and the post went crazy. It was picked up by BuzzFeed in the UK, the Huffington Post in the US, UK, and Canada, and a print version appeared in The Independent. What amazed me more than the number of people who read it and shared it were the comments. At last check there were 799! The stories are amazing and quite personal (thank you to everyone who shared) and the majority were in staunch support of the NHS/universal health care. Yes, people realized there are issues (no system is truly perfect), but it seemed to many that the alternative was unacceptable.

If you don’t have universal health care you have what we have in the United States, a patch work system of private and government-funded health care. Government programs include Medicaid (for those who qualify financially or medically),  Medicare (for those over 65), the Veteran’s Administration (VA), and the Indian Health Services. However in 2013 that still left 13.4% of the country, a staggering 42 million people, without health insurance. There is a big regional variation – in several states 19-20% of people have no health insurance.

Percentage without health insurance by state
Percentage without health insurance by state


Employer sponsored health insurance is over $16,000/year and a typical employee pays over $4,500 of that cost. In addition, there are co-payments and many people end up paying for care that isn’t covered (for example, some plans limit the number of physical therapy visits a year or don’t cover durable medical equipment). When my children were born they were on oxygen for a year at home and my coverage for home oxygen was maxed out after 4 months. But your children who are on oxygen, well, they need that you know? And when you have two of them you go through quite a bit.

But even when the government funds the health care in the US there are lots of out-of-pocket costs. The complex system of copayments and cost of medications means many can’t afford tests or physical therapy or medications. As the reimbursement with Medicaid is often so poor it can be hard to find a doctor who accepts that insurance. And a recent study tells us that 19% of people on Medicare struggle to pay for their health care needs (versus 5% of similarly aged people on the United Kingdom).

Then there are all the indirect savings. When more people have access to health care the population is generally healthier so there are fewer sick days. When all pregnant women get high quality, accessible health care the rate of prematurity drops dramatically. Given premature delivery is the number one cause of infant death and morbidity more term babies means fewer children with long-term health problems. And of course the healthier the population the less health care that is needed, further reducing costs (there really is something to that whole preventative medicine thing).

If there were any doubt about who is actually getting what they are paying for you only need to look at data gathered by The Commonwealth Fund. The United States pays more for health care than other industrialized countries and is outperformed by the NHS, a universal health care program, on every single measure.


I can’t imagine how a universal health care system would work in the United States. We over test and over treat for a variety of complex reasons I can’t fully grasp. Sometimes doctors push it, sometimes hospitals and labs encourage it, and sometimes patients demand it. We have a system that is ripe for abuse. There are hospitals that waste money on surgical robots to do surgeries at a much higher cost with no benefit (and possibly more risk). I’ve seen physical therapists not give home exercises to patients with excellent insurance so they keep coming back for more visits. I’ve seen doctors jumping to procedures that reimburse the best, glossing over the poorly reimbursed non-surgical therapy that might work as well or even better. There are patients who insist on unnecessary imaging. People get physical therapy denied by their health insurance carrier, but have no problems getting back surgery that is unlikely to help. SOmetimes t just hurst to think about the waste.

For universal health care to really work everyone has to feel like they are a custodian of the system. Everyone. I’m not sure how that could ever work in a society that at times to someone not born here seems a bit like a cult of the individual.

uhc-day-badgeYesterday was Universal Health Care Coverage Day. I didn’t see much news coverage. Maybe it’s disease-of-the-month fatigue or it just seems so foreign to the US that it went by barely noticed, which is a shame.

Universal Health Care doesn’t mean the insurance is free, but with the NHS it means that 100% of the population gets covered for less than half the cost of covering 87% in the Unites States. The NHS isn’t perfect, but compared with other industrialized countries it’s number one in almost every metric and certainly it seems like the UK taxpayers are getting a better return on their health care investment than most.



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  1. This is a great article, but I think you missed one thing. Epidemics. They usually start with the poorest people. If your first patient with cholora/typhoid/ebola can’t get treatment quickly, you’ll soon have a whole load more patients who are only sick because you didn’t treat the first one.

  2. We have Medicare in Australia and it’s sending our economy broke. The saddest thing is that because it is free, people take it for granted and some abuses it. I have more grateful patients in private and more medicolegal complaints in public patients. A large percentage of people who actually use it are non tax payers and the system is straining under stress.

  3. Recently I asked husband (who runs a region of behavioral health places) if the two dozen-or-so reimbursing agencies (who regulate, review, and who each have multitudes of exacting requirements) in ANY way had EVER had the positive effect of keeping standards high and organizations on their toes. You can well guess his response.

  4. USA as a country prioritizes individual wealth over shared wellness. Looking at the outcomes, it seems that you get what you want. It seems to me, though, that the existing system socialises the costs much more effectively that the risks.

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