Wednesday, 23 May 2012

Health Care Policy: A modern transatlantic comparison.

5th July 1948, the National Health Service (NHS) opens its doors for the first time in hospitals and surgeries around Britain under the supervision of Labour Health Minister Nye Bevan. Following the election of Clement Attlee’s Labour government in 1945 it was agreed that Britain, recovering from its second World War, was in desperate need of social reform, summarised by William Beveridge’s report on welfare. The establishment of the NHS as part of the wider reforms to the Welfare State was initially sponsored by taxation and continues to be so today. Sixty four years later, the NHS is seen as one of the great pillars of British society (Marr, 2007).


The history of modern American healthcare has been somewhat different. Unlike Britain the United States has never and continues not to provide universal healthcare for its population, leaving the market economy to provide health services (Mclintock Roe & Liberman, 2007). However, a recently passed Health Bill has initiated the first phases of compulsory health insurance for all American citizens, a much debated and hotly contested prospect.


Despite these seemingly opposing attitudes to healthcare within the United Kingdom and the United States there is much to compare and contrast as recent, current, and continued policy implementation on both sides of the Atlantic appears to bring the two nations with a “special relationship” closer together.


In July 2010, two months after its election, the UK’s collation government, led by Conservative Prime Minister David Cameron, presented a whitepaper to the House of Commons proposing top-down reorganisation of the NHS. The subsequent Bill, the Health and Social Care Act, was submitted in January 2011 and proposed that the allocation of patient care be removed from NHS Primary Care Trusts and placed in the hands of General Practitioners (GPs). GPs could then choose between a variety of both public and private options on behalf of their patients. The move was described by its supporters as removing the bureaucratic red-tape of healthcare and providing greater options for improved services. The proposal was described by the Daily Telegraph as the “Biggest revolution in the NHS for 60 years”. Andrew Porter, the newspaper’s Political Editor wrote:



“The plan…is designed to place key decisions about how patients are cared for in the hands of doctors who know them… At present, funds are given by the Government to primary care trusts, which pay for patients from their area to be treated in hospital. Under these plans, GPs — who are currently not responsible for paying for hospital referrals — would receive the money instead and pay the hospitals directly.”
          (Porter, 2010)


A second key aspect of the Bill was the revision of the amount of income hospitals are allowed to make from private patients, rising from 2% to 49%. Andrew Lansley, the Conservative Health Secretary described the strategy as positive for NHS patients, he said "If these hospitals earn additional income from private work that means there will be more money available to invest in NHS services” (Briggs, 2011). 


Opposition leaders, including Liberal Democrat members of the coalition cabinet refuted both key aspects of the Bill, describing them as a systematic privatisation of the Health Service, opening the door to American style competition in British health care. Deputy Prime Minister Nick Clegg, leader of the Liberal Democrats, threatened to veto the Bill in the wake of its proposal and vowed there would be no “back-door privatisation of the NHS” (The Telegraph, 2011)  


The Bill was subsequently subject to amendments in both parliamentary Houses, as well as public and professional outcries. One month prior to the Bill’s assent, Dr Richard Nicholl of the Royal College of Physicians (RCP), collected the signatures of 20 RCP members signalling an extraordinary general meeting to stop what he described as a “dangerous” Bill. He said:



"The bill is bad for the country's health and healthcare and will increase inequalities. None of the hundreds of amendments the government has had to table so far deal with the fundamental flaws of the bill"
           (Campbell & Helm, 2012)


As well as criticising the abolition of Primary Care Trusts, Nicholl and other members of the RCP opposed the planned extension of competition within the NHS. Suggesting patients would suffer as a result of coalition plans for hospitals to earn up to 49% of income from private patients. In an interview with the Guardian newspaper Nicholl warned of longer waiting lists for NHS patients as a result of prioritising private patients, Nicholl continues:



“…why the hell are the government forcing this through? Market theory is a disaster in health. People need to stop this bill; it's plain dangerous."
           (Campbell & Helm, 2012)



Following the extraordinary meeting on Monday 27th February 2010, the RCP polled 25,417 fellows and members asking for their opinions on the Health and Social Care Bill, the results proved damning with 6% of respondents declaring their acceptance of the Bill and an overwhelming 69% rejecting it (Royal College of Physicians, 2012). Despite heavy opposition the Bill received Royal Assent in March 2012 and many key aspects of the legislation are expected to be implemented by 2013.


Whilst Britain’s National Health Service appears to be shifting towards increasing privatisation amidst claims of widening inequalities, America is seemingly moving in the opposite direction, all be it from the opposite end of the health care spectrum.


In July 2009, six months after President Obama’s inauguration, Democrat leaders presented a series of proposals on health care reform to the House of Representatives signifying Obama’s intent on change. Significant proposals included the mandatory expansion of health insurance to all American citizens, as well as the establishment of a government insurance plan known as the “public option”. Two federally funded insurance schemes were already in existence; Medicare, supporting the elderly, and Medicaid, supporting the poor. However the “public option” proposed to create a government backed insurance scheme available to all with a view to competing with the private sector. Further proposals included subsidies in the form of tax credits for those most incapable of accessing health insurance and certain reforms of the health industry itself, such as the illegalisation of certain medical insurer activity- such as “dropping” ill patients or denying coverage to those with pre-existing conditions (MacAskil, 2009). The plan also outlined a number of tax increases for both the health industry and wealthy Americans, including a rise from 1.45% to 2.35% of the Federal Insurance Contributions tax for individuals earning $200,000 and couples with incomes over $250,000.


President Obama’s described the proposals as a way of reaching out to the 45 million American’s without health insurance, he said:



"After decades of inaction, we have finally decided to fix what is broken about healthcare in America. We have decided that it's time to give every American quality healthcare at an affordable cost."
           (MacAskil, 2009)


Opposition to reform was led by Republicans throughout Capitol Hill, disapproving of the President’s plans to raise both taxation and public spending in order to alter the American health care model. Senator Jon Kyl of Arizona discussed his party’s opposition with the New York Times stating:



“I think it is safe to say there are a huge number of big issues that people have… There is no way that Republicans are going to support a trillion-dollar-plus bill.”
           (Hulse & Zeleny, 2009)


Professional opposition was also aired by medical experts across the United States. Troy M. Tippett M.D., President of the American Association of Neurological Surgeons stated in December 2009:



"The Senate bill inappropriately expands the role of the federal government in health care decision making, and undermines the doctor-patient relationship that is critical to a health care delivery system that works for patients."
           (Physicians United for Patients, 2010)


Joseph D. Zuckerman, M.D., President of the American Association of Orthopaedic Surgeons reiterated his colleague’s fears:



 "We urge the Senate to take a step back, and make essential changes to this bill before a rush to reform leads to a bad outcome for patients across the country."
          (Physicians United for Patients, 2010)


Despite much opposition and after ten months of hard fought amendment and Democratic compromise in both Congressional Houses, a final piece of legislation was agreed upon and ratified by President Obama in March 2010. The Patient Protection and Affordable Care Act introduced many of the reforms proposed by Democrats almost a year earlier, including obligatory health insurance, medical tax credits for the poorest, increased regulation of the health care industry and higher taxation of the wealthiest to directly support both Medicare and Medicaid.  However, the Bill did not include the “public option” as proposed by President Obama in July 2009, jettisoned by Senate dealmakers to create a passable piece of legislation (Bonnett, 2010) The changes implemented via the Patient Protection and Affordable Care Act 2010 are proposed to extend medical coverage to a further 32 million American citizens. President Obama described the changes as “reforms that generations of Americans have fought and marched for and hungered to see” (Durando, 2010. Sky News’ Foreign Affairs Editor, Tim Marshall summarised the reforms as not being universal, but “the closest America will ever get” (Bonnett, 2010).


Principally, the United States continues along a path of private health care with no universal public insurance policy yet established, whilst the United Kingdom continues to provide healthcare free at the point of access in 2012, as it has done since the dawn of the National Health Service in 1948. However, as we have seen, recent changes in British and American health policy have been both widespread and of great significance, with the United Kingdom entering a phase of partial privatisation whilst the United States has categorically increased access to health care.


As liberal democracies, the political processes of the United States and Britain are open for scrutiny, as are the policies each respective government wishes to legislate. And although both American Congress and British Parliament operate on a bicameral basis, differing challenges were faced by David Cameron and Barack Obama throughout their respective drives for health care reform.


As the first Prime Minister of a coalition government since the Second World War, Conservative David Cameron faced vigorous opposition to his party’s health reform proposals from within his own cabinet. Liberal Democrat ministers, such as Deputy Prime Minister Nick Clegg questioned the degree by which the Bill would privatise the NHS (The Telegraph, 2011). Unlike the United Kingdom, the Executive Branch of American government revolves solely around one man. As such, due to the design of American politics, enshrined in the constitution, President Obama did not face the internal competition his British counterpart did. However, both premierships had to fight to pass legislation once it was opened to the legislature.


Following the general election of May 2010, Conservative MP’s accounted for 305 of the available House of Commons seats, defeating their nearest rivals, and current incumbents, New Labour by 52. The subsequent establishment of a Conservative-Liberal Democrat coalition, with their 57 seats provided a large enough majority to formulate a government capable of passing legislation such as the Health and Social Care Act 2012 (Parliament UK, 2010).  Similarly to the Conservative majority within the House of Commons, President Obama’s Democratic Party also held a majority in the lower-House following his election in 2009. Of the 435 available seats within the House of Representatives, 256 were elected to members of Obama’s party, with 178 in favour of Republican candidates.


Despite similar levels of backing within their respective legislature’s lower chamber, both governments faced different prospects with regards to passing reforms through the upper-House.  Britain’s House of Lords, with a Labour majority, is constrained to rejecting a Bill a maximum of three times in one year (Heywood, 2007). As such its role in the creation of legislation is largely limited to the recommendation of amendments, as was the case throughout the introduction of Cameron’s health reforms. Conversely to the House of Lords, the American Senate is not constrained on its rejection of Bills and as such the importance of its composition is vital to any President hoping to pass legislation. Unlike the unelected House of Lords, where peers are either granted status through birth-right or appointment, the Senate is a fully elected chamber with two senators representing each state (Heywood, 2007). During the period of time immediately preceding the introduction of the Patient Protection and Affordable Care Act in 2010, 57 of the 100 senators represented the Democratic Party as opposed to the Republican’s 41. This slim majority proved to be a key factor affecting the redevelopment of Obama’s original health reform suggestions. Such fundamental changes to the American health system not only split Democrats and Republicans, but also split certain sections of the Democratic Party itself, leaving those responsible with pushing the legislation forward a difficult task. Final key amendments included the abolition of the proposed “public option” and insurances that federal money would not be used to fund abortions.


We can see that the paths of both Prime Minister Cameron’s and President Obama’s health reforms have led through two legislative chambers respectively, however the influences of each nation’s upper and lower Houses have proven to be converse.  Legislation passed within the United States must truly be approved by both the House of Representatives and the Senate, as was the eventual case for the Patient Protection and Affordable Care Act in March 2010.  However, the power divide between Britain’s House of Commons and House of Lords is not so evenly balanced, with the lower elected chamber able to force legislation through due to its neighbour’s inability to consistently reject Bills. 


Furthermore to these two nation’s processional disparities is the composition of the respective Executive branches. As American President, all power of the Executive Branch is vested in Barack Obama, who also acts as Head of State and Commander in Chief of the Armed Forces. All other members of the Executive, including the Vice President, Cabinet and Executive Office are regarded solely as advisory bodies (The Whitehouse, 2012). Unlike the President, Prime Minister David Cameron is not Head of State, and instead, as the leader of the party with the largest majority within the House of Commons following the General Election in May 2010, was asked by the Queen to formulate a government. As Prime Minister he is regarded as primus inter pares or “first among equals” with regards to his role within the Cabinet. He is regarded as the leader of a group of decision makers, rather than acting as the sole decision maker himself (Heywood, 2007). The collective accountability of Cabinet ministers can be difficult enough to galvanise within a single-party government, however Prime Minister Cameron faced a much greater test within the Conservative-Liberal coalition with the debate surrounding health reforms, battling not only to convince Ministers of his own party but Ministers of a party much associated with opposing the privatisation of nationalised services.


Superficially, the American and British political models appear similar as liberal democracies with bicameral legislatures. However, we have discovered many great differences in the operation and mobility of these two nation’s political systems. This trend of partial similarity is something reflected in the comparison of further political concepts within these two countries.


The democratic system of government within United Kingdom and the United States is keenly protected, not only by differing styles of constitution, but also through external participation by both the general public and professional representative bodies, such as Trade Unions, Interest and Pressure Groups.


This interaction, as displayed by both the British Royal College of Physicians and the American Association of Neurological Surgeons alongside the American Association of Orthopaedic Surgeons with regards to their own nation’s recent health reforms exemplifies modern liberal democracy as more than the right to vote. James Laxar writes:



“Essential features of contemporary democracy are the rights to free speech and assembly. Democracy also extends to the rule of law, to the right of those accused of crimes to fair and speedy trials, to freedom from arbitrary detention and the right to legal counsel.”
           (Laxar,p10, 2010)


By upholding the “essential features of contemporary democracy” as described by Laxar, both Britain and the United States allow their own political cultures to flourish.


The protection of democracy is a key similarity when comparing the political culture of these two countries; however there are many great differences also. The great American belief in “rugged individualism”, the notion that citizens thrive with little government interference was summarised by Republican candidate, Herbert Hoover during his Presidential election campaign in 1928, at New York’s Madison Square Garden he said:



“When the war closed… we were challenged with a peace-time choice between the American system of rugged individualism and a European philosophy of diametrically opposed doctrines – doctrines of paternalism and state socialism. The acceptance of these ideas would have meant the destruction of self-government through centralization of government. It would have meant the undermining of the individual initiative and enterprise through which our people have grown to unparalleled greatness.”
           (Cohen, 2008)


Twenty years later following a second World War, actions taken by Britain under the guidance of Clement Attlee and at the recommendation of William Beveridge, establishing the National Health Service, optimised the European-state paternalism discussed by Hoover.  However, although met by some scepticism, one former chairman of the British Medical Association described the move as “the first step, and a big one, to national socialism”, the National Health Service as part of the wider Welfare State in Britain went on to be widely endeared by a nation recovering from the effects of two World Wars (BBC News, 1998).  


The impact of Beveridge’s report on welfare in Britain has gone on to impact the political culture of the United Kingdom throughout the 20th into the 21st century.  Within his article “Attitudes to Welfare”, Peter Taylor-Gooby describes British support for the Welfare State as “strong and enduring in the main” going on to state:



“The NHS, pensions and education command mass support because they meet mass demands.”
(Taylor-Gooby, p77, 1985)  


The defining features of political culture within the United States and Britain have clearly played a key role in the development of health care policy in recent years. Whilst President Obama’s contemporary Democratic Party would widely be regarded as opposed to the hard-line individualism discussed by Hoover, the sentiments displayed by the former Republican President still underline much of the overwhelming American attitude. Similarly, modern British attitudes towards the National Health Service remain widely alike to those surrounding its establishment; supportive of the public model. As such Prime Minister Cameron and President Obama both had to fight to pass legislation largely opposing the views of the popular national political culture.


As such we understand the political cultures of both America and Britain to be of great importance with regards to policy implementation. Summarising Almond and Verba’s study into political culture, Hague and Harrop write:



“Mass attitudes towards government will of course reflect what the government has done in the past but- and here is Almond’s point- these sentiments will in turn affect what the government can achieve in the present and the future. In this way, political culture connects government not just with society but also with its own history.”
           (Hague and Harrop, p105, 2007)


In conclusion, the passing of both the American Patient Protection and Affordable Care Act 2010 and the British Health and Social Care Act 2012 has signified major changes to the health services in the United States and the United Kingdom. Both countries have displayed close similarities within their political systems, models, and cultures, however vast differences have also been apparent between these two liberal democracies from the composition of their legislatures to the wider political attitudes of the electorate.

Bibliography
BBC NEWS (1998). Making Britain better. [online]. Last accessed 5 May 2012 at: http://news.bbc.co.uk/1/hi/events/nhs_at_50/special_report/119803.stm

BBC NEWS (2010). David Cameron and Nick Clegg pledge ‘united’ coalition. Last accessed 5 May 2012 at: http://news.bbc.co.uk/1/hi/8676607.stm

BLOOMBERG (2012) Pow! Wham! Shazam! Health-Care Reform Explained! [online]. Last accessed 5 May 2012 at: http://www.businessweek.com/technology/pow-wham-shazam-healthcare-reform-explained-02232012.html

BLYTHE, Daniel (2010). X Marks the box. London, Icon Books.

BONNETT, Tom (2010). Obama’s Healthcare Reform Bill Explained. [online]. Last accessed 5 May 2012 at: http://news.sky.com/home/world-news/article/15579100

BRIGGS, Helen (2011). ‘Planned 49% limit’ for NHS private patients in England. [online]. Last accessed 5 May 2012 at: http://www.bbc.co.uk/news/health-16337904

CAMPBELL, Denis and Toby, HELM (2012). Nine out of 10 member of Royal College of Physicians oppose NHS bill. [online]. Last accessed 5 May 2012 at: http://www.guardian.co.uk/politics/2012/feb/26/hospital-doctors-oppose-nhs-bill

Cohen, Michael A. (2008). Live from the Campaign Trail- Read the Speeches. [online]. Last accessed 5 May 2012 at: http://livefromthetrail.com/about-the-book/speeches/chapter-5/herbert-hoover

DEPARTMENT OF HEALTH (2012). Health Secretary explains new Health and Social Care Act. [online]. Last accessed 5 May 2012 at: http://www.dh.gov.uk/health/2012/04/health-secretary-explains/

DURANDO, Jessica (2010). Road to health care legislation. [online]. Last accessed 5 May 2012 at: http://www.usatoday.com/news/washington/2010-02-24-timeline-health-care_N.htm

GAY STOLBERG, Sheryl (2009).  Public Option Is Next Big Hurdle in Health DebateI. [online], Last accessed 5 May at: http://www.nytimes.com/2009/10/15/health/policy/15public.html

HAGUE, Rod and Martin HARROP (2007). Comparative Government and Politics. Basingstoke, Palgrave Macmillan

HEYWOOD, Andrew (2000). Key concepts in politics. Basingstoke, Palgrave Macmillan.

HEYWOOD, Andrew (2007). Politics, 3rd Edition. Basingstoke, Palgrave Macmillan.

HEYWOOD, Andrew (2011). Global Politics. Basingstoke, Palgrave Macmillan

HULSE, Carl and Jeff, ZELENY (2009). Democrats Seem Set to Go It Alone on a Health Bill. [online]. Last accessed 5 May 2012 at: http://www.nytimes.com/2009/08/19/health/policy/19repubs.html?_r=2

LAXAR, James (2010). Democracy. London, A&C Black
MaCASKIL, Ewen (2009). Obama outlines plan for universal healthcare system in US. [online]. Last accessed 5 May 2012 at: http://www.guardian.co.uk/world/2009/jun/11/obama-administration-universal-healthcare-reform

MARR, Andrew (2007). A History of Modern Britain. Oxford, Pan Books
McCLINTOCK ROE, Abbie and LIBERMAN, Aaron (2007). A Comparative Analysis of the United Kngdom and the United States Health Care Systems. The Health Care Manager. 26(3) 190-212

PARLIAMENT UK (2010). Current State of the Parties-2010. [online]. Last accessed 5May 2012 at: http://www.parliament.uk/mps-lords-and-offices/mps/state-of-the-parties/

PEAR, Robert and HERSZENHORN, David M. (2010). Obama Hails Vote on Health Care as Answering ‘the Call of History”. [online]. Last accessed 5 May 2012 at: http://www.nytimes.com/2010/03/22/health/policy/22health.html?pagewanted=all

PHYSICIANS UNITED FOR PATIENTS (2010). Physician Groups Oppose Current Senate Health Care Reform Bill. [online]. Last accessed 5 May 2012  at: http://www.prnewswire.com/news-releases/physician-groups-oppose-current-senate-health-care-reform-bill-79456457.html

PORTER, Andrew (2010). Biggest Revolution in the NHS for 60 years. [online]. Last accessed 5 May 2012 at: http://www.telegraph.co.uk/health/healthnews/7880592/Biggest-revolution-in-the-NHS-for-60-years.html

RAMESH, Randeep (2011). Coalition health bill will undermine NHS, says OECD thinktank. [online]. Last accessed 5 May 2012 at: http://www.guardian.co.uk/politics/2011/nov/23/health-bill-nhs-oecd-report

ROYAL COLLEGE OF PHYSICIANS (2012) Results of RCP Health and Social Care Bill Survey. [online]. Last accessed 5 May 2012 at: http://www.rcplondon.ac.uk/press-releases/results-rcp-health-and-social-care-bill-survey

TAYLOR-GOOBY, Peter (1985). Attitudes to Welfare. Journal of Social Policy. 14(1) 73-81

TELEGRAPH, The (2011).  Nick Clegg threatens to veto Coalition health reforms. [online]. Last accessed 5 May at: http://www.telegraph.co.uk/news/politics/nick-clegg/8500907/Nick-Clegg-threatens-to-veto-Coalition-health-reforms.html

THE WHITEHOUSE (2012). The Executive Branch. [online]. Last accessed 5 May 2012 at: http://www.whitehouse.gov/our-government/executive-branch

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