Socialized Medicine's Aches and Pains

▪ 2001

by Bryan Christie

      After a detailed examination by the World Health Organization (WHO) to assess the standards, responsiveness, and effectiveness of health systems in 191 countries, France was judged to have the best health care service in the world. The first-ever analysis of the world's health systems, published in the The World Health Report 2000, produced some surprising findings and revealed wide variations in performance. The United States, which spent more than any other nation on health care, was ranked 37th and trailed countries such as Colombia and Morocco, which had much lower levels of health spending. Italy, Spain, Oman, Austria, and Japan all captured spots in the top 10, whereas many African countries—dragged down by the high death rates caused by the AIDS epidemic—were among the poorest performers. The publication of the report came at a time when health systems around the world faced ever-increasing pressures. The triple effect of an aging population, which placed additional demands on health services; of medical advances, which produced new and usually more expensive drugs and treatments; and of a public with high expectations of what medicine could achieve—all combined to push up costs, particularly in the developed world.

      The strains produced by these pressures were seen most clearly in “socialized medicine,” nationally funded health systems such as Great Britain's National Health Service (NHS). Many countries voiced concern over long waiting lists for treatment and deteriorating standards of care, but state-controlled budgets proved incapable of providing the level of care people expected. As a result, serious doubts were being raised about the ability of socialized medicine to provide what was seen by many as the civilized answer to health care provision in the 21st century.

      In Norway protests were staged in June outside the Storting (parliament) following a decision to raise charges for patients who saw their family doctor. Such charges had risen 40% in three years. In The Netherlands the government appointed a task force to report on the future of the Dutch health system as concern mounted about lengthening waiting lists, shortages in health staff, and budget restrictions. Following the deaths of several patients awaiting surgery, the Spanish government ordered that additional operating sessions be scheduled to reduce hospital waiting lists. In an attempt to control the ever-escalating budget for medication, the government in Spain also proposed an end to free prescription drugs for old-age pensioners. Doctors working in public hospitals in Israel imposed a series of sanctions over 18 weeks in an effort to gain a pay increase. The dispute led to the cancellation of 30,000 nonemergency operations and ended when the doctors accepted a 13% salary increase. The physicians also were given guarantees that a national review would be conducted of public medicine, including the possibility of allowing private medical services in public hospitals. Though France was judged to have the best health system in the world, that ranking did not make the country immune from these problems. Hospital staff staged demonstrations in February to protest staff shortages and budget restrictions.

      Meanwhile, Canadians were increasingly dissatisfied with their publicly funded health system—which was also plagued with long waiting lists—especially when Canadians could see that just across the border Americans were being treated much more quickly. A report published by the Canadian Institute for Health Information—Health Care in Canada 2000: A First Annual Report—revealed that more and more Canadians were dissatisfied, and it noted that between 1987 and 1997 the proportion of those who felt that the system could work properly after only minor changes were made fell from 56% to 20%. Problems included delays in treating seriously ill patients, extreme overcrowding of hospital emergency services, and shortages of staff and vital equipment. Canadian Prime Minister Jean Chrétien responded to concerns that the country's health system was failing by announcing a 35% increase in spending over the next five years. The Can$23.4 billion (about U.S. $15.6 billion) increase was welcomed, although there were warnings that even more money would be needed in the future.

      A similar solution had been fashioned in the U.K., where the NHS received the biggest funding increase in its history following widespread concern about the system's viability. The U.K. had some of the poorest cancer-survival rates, employed fewer medical specialists, and had a lower use of new drugs and medical technologies than most of its European neighbours. The NHS, which the British once believed was the envy of the world for establishing free access to high-quality health care for all, had been exhibiting all the signs of terminal decline. Owing to hospitals' inability to cope with demand during winter peaks, operations were canceled and waiting lists became lengthier. Expensive drugs were denied to those who needed them, and deteriorating standards of care were recorded across the country. These criticisms persuaded the British government to fund an extra £20 billion (about U.S. $30 billion) over the next five years to bring spending more into line with the European average.

      “The essence of a satisfactory health system is that the rich and the poor are treated alike, that poverty is not a disability and wealth is not an advantage.” This was the view of Aneurin Bevan, the British politician who helped create the NHS in 1948. His vision also led to the expansion of socialized medicine, which raised money through taxes or social security contributions to pay for health care for all. It was never imagined, however, that equity would mean that everyone would suffer from the same deteriorating level of service and that reality would force a call for change. Though additional funding seemed likely to solve the existing problems in the U.K. and Canada in the short term, an escalation in costs could obliterate a long-term solution. For that reason, the British Medical Association embarked on a wide-ranging review of future funding options for the NHS.

      Socialized medicine was not the only system with problems. The U.S. was considered the Jekyll and Hyde of modern health care. It offered the best level of health care provision in the world, but in a system in which millions of uninsured people feared the consequences of falling ill. The WHO report found that the U.S. had the most responsive health service in the world and provided the most prompt attention, but when the fairness of the financing of health care was considered, it ranked 55th of the 191 countries.

      The United States, which spent almost twice as much as most European countries on health care, also found a need to try to reduce costs. The U.S. left cost containment to the marketplace, which over the past 20 years had led to the development of health maintenance organizations (HMOs). Although HMOs were privately run for-profit organizations, they worked in a similar fashion to socialized medicine, the state-run systems. HMOs provided medical care to large populations within tightly controlled budgets and often employed the doctors and nurses that supplied care. The persistent difficulty of meeting financial targets as demand for services constantly grew was demonstrated when Harvard Pilgrim Health Care, the largest HMO in New England, went into receivership earlier in the year. It was only one of a number of failures among HMOs in recent years.

      Americans also became increasingly angry at restrictions placed on their access to health care and accused some HMOs of denying them the care they needed. The problem was highlighted in June when the U.S. Supreme Court ruled against a woman who sued her HMO for failing to provide the best possible care. Cynthia Herdrich suffered a ruptured appendix days after she went to her HMO doctor complaining of abdominal pain. Herdrich had to wait eight days for the test at an HMO-affiliated hospital more than 80 km (50 mi) away. Her appendix ruptured prior to the test, and she won a $35,000 malpractice suit against the doctor and sued the HMO in a federal court. She claimed the arrangement that allowed doctors to keep a share of the HMO's profits gave them an incentive to act in their own interests rather than those of patients. The Supreme Court threw out the claim, however, and cited that “no HMO could survive without some incentive connecting physician reward with treatment rationing.”

      In The World Health Report 2000, WHO explained the complexity of adopting a single health care model. “The world is currently experimenting with many variants and there is no clear way to proceed.” WHO did, however, consider systems that funded health services through prepayment schemes such as taxes, insurance, or social security preferable to those that relied on patients' paying the costs of treatment when illness struck. The report stated that governments worldwide should embrace the “new universalism”—the establishment of essential services that would be available to all citizens—but cautioned, “Clearly limits exist on what governments can finance and on what services they can deliver. . . . If services are to be provided for all, then not all services can be provided.”

Bryan Christie is a freelance medical writer working in Edinburgh; he is a regular contributor to the British Medical Journal and to other medical publications in the U.K.

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