On Healthcare, expat tales of the NHS and the US Medical System

For a while I have missed opportunities to write on health care. I try to blog about a topic when it is in the news and fresh in the public mind. For healthcare, however, I kept avoiding posting on it.  This avoidance comes partially from the highly contentious nature of the topic.  People on both sides of the Pond have strong and often emotional views on the subject.  Furthermore, intellectually is a very involved and difficult topic. If I wrote everything that I wanted to write about healthcare, I could spend weeks, months even, doing the relevant research only to write an essay on the topic. 

I still want to write about though.  People who have lived under both types of medical systems, have a unique, a perspective not tied only to theory.  

Given the scope of the topic, I have broken it down into multiple posts.   I have touched on some of the misleading and misunderstood commonly published statistics (third item), which give the illusion that the US and UK medical schemes have common outcomes.   They don't.  (For more see The Tiger that Isn't, a book about numbers that uses the NHS stats as examples of statistical manipulation.)  This post will address the administrative ease for patients of the NHS.  Next, I will discuss the myth of free health care.  Later, I will discuss some of the inherent weaknesses of the NHS, most notably preventative care.  Then, I will turn to the strengths and weaknesses of the US health system.  Finally, if the law is still around, I’ll turn to Obamacare.   

The Deceptive Ease of Administration

When reading personal accounts of medical experiences in the US and UK, the relative ease of the UK’s NHS jumps out, or more accurately the difficulty of paying health care bills in the US--deductibles, co-pays, collection calls due to hospital bill confusion--shows.  Regardless of if money is tight, the process of paying health care bills in the US is not simple.  

With the NHS, one doesn’t need to even think about paying.  And therein lies the NHS’s greatest strength.   It is easy.

Three elements of the NHS make that perception.  First, NHS services seem free because the bill is never paid the day you visit the clinic.  It is paid though taxes, which are abnormally painless in the UK.  Second, since the NHS is a single payor system, one need not bother with choices about insurance or doctors in system.  With the NHS, you get what you get.  Third, the NHS has a centralized computer system, one that sounds good in theory but has not worked as planned.  I will take each point in turn.  

Healthcare is paid before and after clinic visits by income taxes, payroll taxes, and VAT.  Even though US tax rates are significantly lower, UK taxes are easier to pay.  The VAT is a flat 20% addition to most goods and services that is included in the price tag.  Sales taxes in the US are added at the till.  Few are more than 10%, and those are total rates, state, local, and in some cases reservation.  If you are buying something for 10 bucks in Texas, you will need $10.63 when you get to the till.  That is, even though the American pays little more than a ¼ of what the Brit paid, the American notices the 6% tax; he has to add it on, consciously think of it.  It feels like tipping every time you pay for goods.  

Similarly, the PAYE, Pay As You Earn, withholding system in the UK is more comprehensive and accurate than in the US.  As a result, few besides employers or the wealthy write checks to HM Revenue and Customs.  In short, many people do not feel like they are paying taxes.  Hence, when healthcare is not paid for at point of service, it feels free.  

Next, since the NHS is a single payer system, it is easy for people to use. When going to an NHS facility, you see whomever you see, provided your visit was routine or minor, you do what needs to be done, get whatever meds your doctor prescribed, and walk out--at least this is how it works in theory. Waiting times are a problem.  Prescriptions are a problem.  I found that you can only get a prescription written at the hospital filled at the hospital chemist.  At the eye hospital--I had a piece of metal in my eye--I did not want to wait in line for the hospital chemist.  It was a good hour plus long and I needed to get back to the children.  So I took the scrip to my local chemist.  I suspected I might have to pay more; I did not know that they weren’t supposed to fill it.  It was antibiotic eye creme that they had on hand, so they took pity on me, the newbie American expat, and filled it anyway, mumbling something about NHS kickbacks with meds.  

Getting to the hospital or specialist can be a problem too. If you need the ER, you can go directly, but for any other non-emergency problems, you are supposed to see your General Practitioner first.  Your GP then has to refer you to a specialist or the hospital.    So for instance, with my eye problem, I called the GP first.  He had to refer me.  You can’t think, “Oh, I have something in my eye, I will call an eye doctor.”  Except in an emergency, you need a referral.

So the system is simple if you have basic needs.  When your care gets the slightest bit complicated, so does the NHS.

There is a strange letter of introduction, exchange of test results, doctor letter writing dance that goes on with the GP system.  This is a bit strange because the UK has a reportedly stellar centralized healthcare computer system.  Why all the letter writing and referral dance if they have a database?  

Turns out that the health database sounds great, but it is not nearly as effective as advertised. To start, it is susceptible to privacy and accuracy concerns.  Ironically Brits seem less concerned with health care privacy issues than Americans* so the privacy issues haven’t killed the system.  Worse though, large portions of the database have been lost at least twice since I have been here in London, in 2009, 2007.  Here is a short Times summary of the database debacle including discussion of information uploaded without the doctors consent and a cost explosion from £2 billion to £12 billion.    UPDATE:  They are scrapping the integrated database.  

Then there is how the database plays out in an emergency.  It is and tad unnerving to arrive at the hospital with a child in visible breathing distress only to have the check in to verify your postcode before any triage.  Other than pulling up your centralized data, I am not sure why they ask up front.  It appears from the NHS site that an A&E couldn’t turn you away even if you were not standing in your local hospital.  Everyone is covered under the NHS, tourists and the like. I guess it is because your postcode determines your medical trust area, and every trust does not cover the same treatments or have the same standards of treatment.  Such is the postcode lottery.  The NHS isn’t exactly fair.  (The guy who exposed the lottery atlas recently died of cancer.)  

Next up, the Myth of Free Healthcare.  

*I find the relative lax attitude about healthcare privacy bizarre for a society otherwise fiercely protective of their privacy.  In my own experience, I’ve found that doctors will discuss patient care with someone not the patient, especially if you are paying the tab.  I don’t mean the doctor discussing care of my husband, I mean of other patients, unrelated to me.  In the A&E, I’ve seen consultations and treatments in the waiting room conducted at full volume so that everyone knows what everyone else is there for.  I can’t explain it. I’ve just noticed it.  

Taking the Life in the UK test, the "path to citizenship"

Thursday, I took the Life in the UK test. The LUK test, my acronym not theirs, is their naturalization test. For anyone planning on taking the test, I will discuss the process--the unnecessarily drawn out process--at the end of this post. First, however, a bit about the test itself, because it explains much about the UK's problems assimilating immigrants.

Remember JFK's famous line "Ask not what your country can do for you, but what you can do for your country.". The LUK test study guide reads like a help manual for new immigrants to the UK. 'Here is what life in the UK can do for you.' There is some civics, but the topic is very basic and watered down--Where does the Prime Minister live?--and surprisingly covers the established church in England and Scotland as much as Parliament. The bulk of the test, however, covers PC topics like minority populations and women's suffrage and social welfare topics like how to use the NHS and how to find a job. Granted, some of these are important things to know. Disseminating such information is necessary. But this test is the first step for conferring the privilege of citizenship. Shouldn't the LUK test cover the candidate's knowledge of British culture, of what it means to be British?

Contrast the US test. The US naturalization test is a civics exam. There are 100 questions. The immigration officer asks the candidate 10 of those--no multiple choice. Here are the current questions: http://www.uscis.gov/USCIS/Office%20of%20Citizenship/Citizenship%20Resource%20Center%20Site/Publications/100q.pdf (I will do hyperlinks when I get home. I can't do them easily on mobile Blogger.). Note that none of the questions discuss the Emergency Medical Treatment and Active Labor Act of 1986, which makes it illegal to turn laboring women and the like away from medical care. None of the questions ask under what circumstances a landlord can modify rent or someone can employ children, all of which appeared on my 25 question test. Also on my test--I am not making this up--how to get tickets to watch Parliament.

In short, the US test covers the basic knowledge an immigrant needs to do things for their new country. The UK test covers what British citizenship can do for the immigrant. Under such circumstances, that Brits commonly see immigrants coming in and taking advantage of the social welfare state is frankly to be expected.

Regardless of the merits of the test, however, I had to take it. Yasha has a five year work visa, which expires in a few weeks. Extensions are not an option. At the end of your visa period, you either go home or get started on the Path to Citizenship. The LUK is the first step.

First you call to make the appointment. (again, links later). On the appointed day, take yourself, your passport, £50, and something to read to the test center. When you arrive, you sign in. The sign in sheet won't be easy to find and the other test takers are not always helpful in pointing the sheet out. (Might have been my group, but they watched me flounder in two endless lines at the library desk and silently went into the test center at which point I saw one of the people had been sitting on the sign-in sheet.) Once in the center, somebody gives an overview of the test, tells you to get your ID and money out (cash or card) and come up to the desk when called.

At this point, things get weird. The clerk calls each person individually to present ID, get checked off the appointment list, pay, and receive a computer number. Once everyone is at their computer, about 25-30 people, another clerk calls you to another computer, takes your passport and enters your name, date of birth, and passport number into the computer and asks why, specifically, you seek UK citizenship. He enters that and sends you back to your computer. Once he enters everyone's information, then he explains the test again. At this point a login screen is on your computer, but you don't login yourself. The guy goes around to each computer and logs in everyone. Then you can start the practice test...which you have to take twice. It is only 4 questions each time, but still the computer won't let you proceed until you practice. The UK doesn't have a rep as a nanny state for nothing.

The test itself is 25 multiple choice questions. You have 45 minutes to take the test. As you might guess, it does not take everyone 45 minutes to take the test. If English is not your first language, you might need the time, but otherwise the test is not particularly difficult. Yet, you cannot finish the test, get your results, and go. Even though the test is computerized and the computer knows your results as soon as you confirm you are finished, the test monitors will not give out the results until everyone is finished. You go to the waiting area and read for a half hour plus, until they call you individually to receive your results.

Perhaps there is a good reason for this procedure. I simply don't know. My best guess is the British habit of habit. Brits do lots of things because that is the way they have always done them. So perhaps this time intensive procedure is a vestige from when the test was administered on paper and hand scored.

One last detail about taking the LUK test: the test centers aren't in the nicest parts of town. Mine was in Brixton and I foolishly expected to get back by taxi. On the test day I did not have my Oyster card, and I was short on time anyway. I took a taxi. There are two types of places that don't lend themselves to taxis: remote or low traffic areas and low income areas. Brixton is the latter, and of the rough variety. When we finished, I was waiting at the library doors with 10 other people who hoped to get taxis. I was already later than I expected and poor Vilvy was home with 6 children. (I had forgotten I was taking the test until Tuesday. All in all not my best planned week.)

I could have taken the Tube by cash but thought a single, not from around here gal, confined in the Tube station was more of a mark than walking down a very busy street in broad daylight. So I did the London thing and simply started walking where I needed to go, knowing I'd eventually find a cab. I wouldn't have minded so much if it wasn't the day London got two months of rain in a day. When the inevitable cab showed up about half an hour later, the cabbie laughed at me when I gave him my address. "What were you doing here?" he asked. My advice, arrange for transport ahead of time.

When I told her that I passed, Pip Owens asked me if I felt "frightfully British." Right now I do because I am composing this post in a grey skyed Hampshire with a cup of tea at my side. The test, however, made me feel more American, which I doubt is the intent of British immigration officials.

Michelle Obama v. Sam Cam v. Princess Catherine, Fashion Wars

No big update on the state visit tonight except to second M&M's assessment that no one on the street seems to care that the Obamas are in town.  That was not the case on previous visits to London or Europe.  I have some observations but can't write tonight.  I have to study for the Life in the UK path to citizenship test. I can give a quick link to the fashion wars.

Princess Catherine wins today, with a high street (chain store) dress, while the First Lady and Sam Cam went for designers.  M&M thought the First Lady looked like she was wearing the Queen's curtains.  The Mail though she was dressing like the 85 year old Queen.  Sam Cam's dress is almost great--it is just too busy.  When you are in the spotlight as much as these ladies are, I think simple lines carry the day.  (I personally liked Sam Cam's dress for the wedding, but apparently it was too informal.)  Granted, Princess Catherine is younger, which helps, but both the First Lady and Sam Cam have nice figures.  I think it is actually the dress that wins.  For the Americans who didn't immediately know that was a Reiss dress, of the "high street' shops mentioned in the Mail as favorites of Princess Catherine, LK Bennet is similar to Ann Taylor.  Whistles is kinda Loft meets Anthropologie.  Zara, I think is in the states.  It is wildly popular here.  Warehouse makes me think of an upmarket Urban Outfitter.

The Mail's picture: (Mrs. Obama changed for the PM meet.)

What do the British think of Obama?

UPDATE: Oct. 24, 2012: As the election nears, this post is getting steady traffic, but it is a bit out of date. I have recent posts on Obama's overseas reputation. Click on the title and a few of my recent posts discuss this. Also, I am working on an explainer post for the morning after as a Romney win is the way to bet at this point. I get the impression that this will surprise many overseas.

As mentioned, the British used to love him.  These days, people avoid talking about him most of the time, so it is hard to get a good read.  This Guardian article is the best articulation I've found of British opinion on Obama.  If I were to weave together all the offhand comments, overheard mutterings, mini conversations, I think this is the picture that emerges:

But one of the most curious things about those who support him most is not their disappointments – given their high hopes for him, that's to be expected – but their enduring devotion in the face of those disappointments. It's as though each single disillusionment is consumed as its own discrete letdown. String them together and you have not a narrative of failing to deliver on promises, but a litany of isolated, separate chapters – each with its own caveats, exceptions and explanations....

The article, and remember this is The Guardian, the leftist/progressive paper, goes on to describe the contradiction of the "enduring devotion": 

The strange thing is that much of what Europeans loathed about the Bush era remains intact even as Obama prepares to run for a second term. Guantánamo is still open, rendition continues, there are more troops in Afghanistan and still troops in Iraq.

This could be overstated. Obama's statement on the Middle East last Friday shifts US policy on the region closer to Europe's than it has been for more than a decade. But that wouldn't be the first time he's delivered an impressive speech and then failed to follow through.

Moreover, Europe is implicated in many of the areas where foreign policy has stalled. Part of the problem with Guantánamo is that European governments refused to take many of the prisoners. Some applauded America's intensification of the war in Afghanistan even as they planned to unilaterally draw down their own troops.

"The problem is he's asking for roughly the same things President Bush asked for and President Bush didn't get them, not because he was a boorish diplomat or a cowboy," Peter Feaver, a former adviser to Bush now at Duke University, told the New York Times in 2009. "If that were the case, bringing in the sophisticated, urbane President Obama would have solved the problem. President Bush didn't get them because these countries had good reasons for not giving them."

Either way, Obama's principal defence abroad, as it is at home, is that things were bad when he arrived and would be worse if he went. This is true. But it falls far short of the inspiring rhetoric that accompanied his rise to power. Not so much "Yes we can" as "Could be worse".

European political elites have long been frustrated. "Maybe this is an overstatement, but I see this [European tour] as an opportunity for a reset of the European relationship," Heather Conley, director of the Europe programme at the Centre for Strategic and International Studies, told the Washington Post. "European leaders have really been struggling with where they fit. They had enormous expectations for this president, but they're now wondering, 'Is it that different after all?'"

But this has yet to filter down in any discernible way. So when he has delivered so little, why do Europeans love him so much? Many of the original reasons still stand. He still isn't George Bush, although how long that negative qualification remains meaningful is a moot point....

Smart, charismatic, telegenic and unencumbered by sleaze Obama still, by comparison [to Europe's leaders], represents the possibility of a popular form of electoral politics led by intelligent and public-spirited citizens as opposed to opportunists, egomaniacs and sleazemongers. It's as though his proven ability to articulate the source and scope of problems has enabled some people to look past his inability to provide a solution for them.

But in many ways Europe's Obamaphilia has always been as much a reflection of its weaknesses as his strengths. Like royalists in search of a benevolent monarch in whom they could invest great hopes but over whom they had no democratic control, they have sought not to leverage their own power but instead to trust in somebody else's....

European's attitudes towards Obama tell us more about Europe than they do about the US president. And what they say about both is not particularly impressive.

Michelle Obama v. Sam Cam, The Fashion Showdown

I'll have much to blog about next week, as the Obama's are coming to London for a state visit.  There are many weighty issues on offer, of course, but also fashion blood sport.  Similar to the Royal Wedding being a bigger deal than the Clinton or Bush daughter weddings, Americans do watch what the First Lady wears, but here it is much more of a sport.  Maybe it is just because I am in London.  Regardless, along with Israel, Libya, economics, I'll have plenty to post on fashion next week.  British fashion writers I've seen gush over Michelle's style.

Oh and I'm sure there will be stories about diplomacy, since that went so well last time.

The Sex Scandal About the French Guy

Looks like today is a Sawdust and Planks kind of day.  From VDH on the sex scandal about the French guy:

So far what confuses Americans the most, superficially at least, is that a man of the Left like socialist Strauss-Kahn should seem so comfortable with the elite tastes of the damnable aristocracy — the astronomically priced suits, the $3,000-a-night suite, the Air France privileges, and the medieval Norman baron’s sense of entitlement regarding an immigrant housecleaner — while the supposedly neanderthal, right-wing Americans and their primitive “accusatory” legal system (read the French press on all that) so far are treating the rights of a maid as equal to a Eurocrat’s.

The wonder about the French cultural furor over the incident is not that they consider us parochial and “hung up” on sex, but that the press and its op-ed writers are so blatant in their expressions of class snobbery and national chauvinism. For all the Euro-lectures about Western imperialist colonialism, this story (fairly or unfairly) casts the Americans as the everyman and the French as the haughty technocrat furious that rules of equality under the law apply to him — not to mention modern notions of feminism, about which one would have expected a sophisticated Frenchman to be sensitive.

One might have expected a sophisticated Frenchmen to be sensitive to modern notions of feminism, but that is not the way to bet.  VDH's post is short.  Read the whole thing.

Entertaining Expatria

You'd be amazed at some of the little pitfalls and subtle differences involved in entertaining abroad.  Big differences abound, learning new celebrations or celebrating Thanksgiving overseas.  You expect those.  It is the little differences, however, that trip you up.  Lily and I keep toying with writing a book on entertaining expatria.     There are mine fields of tiny differences in wedding and baby showers, multi-family dinners, invitation etiquette, especially in a place like London where you not only encounter American to British differences, but also American to Danish or Italian or Spanish.  If you want to have real fun, try things like throwing a baby shower when the co-hostesses are American and British and the mother to be is Danish.  The differences aren't drama inspiring--no one gets upset--but they are confusing.

You register for baby showers?  You don't?  Don't you have the shower at one of the host's houses?  No, you have them at a tea room.  You don't you have them at the mom to be's house?  The mom to be provides the food?  Don't you need to leave the presents somewhere else because it is bad luck to open them before the baby comes?

Then there are family dinners.  They aren't really done by the British.  One might have children over for "tea", children's dinner, or one might have the adults over for dinner after the children are in bed.  I must say, that is a very civilized option.  If Americans are hosting, the dinner is likely at home.  If Brits do the inviting the dinner is likely out.  Regardless, adult time after the children are in bed is a delight.  That said, sometimes you want to have the whole family for a big family dinner.  If you are an American household with Italian nannies, you might not know you need to be explicit about "family" or you will find you have a load of leftover food, because the adults will not eat.

I have been there.  A few years ago, I invited Virginia, Lily, M&M, and Foxy over for family dinner.  They came with children.  We fed children. I planned on feeding the adults after the children had full bellies and could go into the other room with Vilvy.  When the kids finished, Virginia had to get back to a newborn who needed a feed so took a load of fajitas home for herself and husband.  M&M and Foxy, however, took their children home.  Lily turned to me and whispered, "You and I are going to eat, right?"

I thought I had learned to be explicit when making dinner plans.  Nope, apparently not.

When planning last week's Serial Expats Supper Club (We cheated and went out to dinner.  That April break was long and none of us had sufficiently recovered for a big cook.) I texted her to say "we needed to get our boys together again."  I was thinking about the boys and TexMex night, when they ate and played while we prepped.  She was thinking about the afternoon after tennis when our husbands were having a good chat that was too often interrupted by their blackberries.  To make a long story short, I showed up with Christopher Robin, not Yasha, at her place Saturday night.  We did not uncross our wires until she came into the kitchen and asked, "Where's Yasha?"  I said he was at home with the girls, obviously.  Her look of shock started my wave of mortification.  I had thought it a little odd that she had suggested 7:30 for kids dinner, and wondered why she had asked me about scallops, but we both have night owls who are great eaters.  None of my wonders were strong enough to cause me to question her plan.  For about a week, we planned a dinner with two different sets of people in mind.

This is what happens when you live overseas for a long time.  You lose your internal social compass.  Today, to compliment my lingering mortification, I have an upset tummy.  I was not about to add insult to injury and not eat heartily last night, which was easy since Suzanne is a fabulous cook.  It worked out in the end, though I've got to make it up to Suzanne for cooking a fab dinner for 4, only to have 3 show and make a dinner on the fly for two boys.  She took the whole thing in stride.  Thank goodness she is American and I don't have to wonder about hidden insults in my mistake.  I can accurately judge my idiocy.

The Slut Walk

Feminists are holding Slut Walks to raise rape awareness. (h/t The Corner)  Empowerment though sexualization, I've been collecting articles with this theme for a while.  Where to start?

• When Feminism Went Nuts  or "Vice work if you can get it" from the Times? (Interesting, but the Times seems to have taken down the Vice Work article.  The server has been busy every time I've tried to get the article from this blog, others, or google.)
• Maria Schneider and The Last Tango in Paris?  and then More Naked Actresses
• Posing Naked
• Welcome to the Harem
• Girl Gone Wild Against Her Will
• I'm done writing about my sex life. 
• Dirty Pictures I Didn't Want Taken 

This was supposed to publish a few days ago.  Must have gotten lost in the Blogger update.  The Slut Walk news went around over the weekend, but the other articles are just interesting reading on this "empowerment" meme.  

Europeans Feeling Smug

Regarding the superiority of manual transmissions.

One of the reasons I like to visit the United States frequently is to gather ammunition against that majority of Europeans for whom it is an article of faith that America’s economic success comes at some intolerable social price. In fact, especially in red states, the level of kindness and consideration puts Britain to shame.

To be frank, with the single exception of health care and gun control, the number of areas where Europeans can feel smug in relation to the United States is vanishingly small (although I suppose it is possible that it is America’s widespread gun possession that makes everyone so polite). So I would now like to tackle one of the last great areas in which Europeans cling to a feeling of smug superiority versus the US — a sense of superiority so deeply ingrained that I may be the first person in any British publication to make this assertion.

You see, I truly believe that automatic transmission in cars is much, much better than manual transmission. And not only better for the owner of the car, but for other road users and pedestrians too. In fact, I think, rather like guns, manual transmission should be outlawed in urban areas.

Here is the whole thing.  Obviously I'd disagree with his exceptions of health care and gun control, but otherwise Mr. Sutherland and I have much common ground.

More Sex

I don't know if the wedding inspired the small uptick in sex related articles on my news circuit, but it is there.  Below I found articles on porn in public libraries and linked to one royal wedding inspired article about living together before marriage. Here are two more from Instapundit:
Hot sex is the key to a happy marriage.  (I don't know if I'd say it is key, but it is essential.) 
Get divorced for hot sex.  The thrust of the article and of the favorable comments is that she just needed to find herself to get back that fire.  I'm with one of Instapundit's other readers: “Should be titled ‘HOW FORGETTING THAT SEX WAS IMPORTANT RUINED MY MARRIAGE’ but that wouldn’t get her published on Salon.”   She spent her post baby days thinking of sex as a chore, and like any good modern woman refuses to have sex unless she is damn well in the mood--maintenance sex is a feminist sin--and then finds herself shocked when she doesn't want her husband anymore.  This story is far too common.