Here is how to compare U.S. and British health care

Recent headlines highlight problems in delivering appropriate patient care in the United Kingdom as this flu season overwhelms the National Health Service. [1] While this certainly does put a lot of British citizens at risk, the usual trashing of the British health care system by elements of the American press is, as usual, grossly misplaced.

I have lived under the British NHS system and I have served as the treasurer of an American non-profit health center, which puts me at least a couple steps ahead of most of these commentators, so I thought it would be useful to share my method of evaluating any comparison between the British and U.S. systems.

First, don’t compare.

My first reaction is always “Don’t compare the two systems.” From top to bottom, these are two very different health care and health insurance systems, with very different histories. If you are going to make comparisons, then compare with some of the other dozen or so well-run national health care and insurance systems that have elements far closer to conditions in the U.S.

Germany, for instance, has an excellent universal multi-payer system, a mixture of public and private insurance, co-financed by employer and employee contributions, with a lot of patient choice to seek out a mix of public and private providers. You will find varying per-capita cost numbers on the Internet, but they consistently show that Germany spends about 40% less than the U. S. per capita annually for equal or better health outcomes.

The U. S. is not going anywhere near the British model in the foreseeable future, no matter which party is in office. And if you think the Affordable Care Act created a socialized system in the U.S., you have not been seriously researching this. If you span out the successful universal health care systems around the developed world, with the systems with the most governmental control on the left end, and the most market control on the right, the ACA would dangle precariously on the right-most edge, dangling because it is not universal. But there is lots of company on that side of the spectrum, with quite a few countries managing to provide universal health care with significant private market participation, and at much lower costs and better outcomes than in the U.S.

Second, understand how the U. K. rations care.

Using the same data, United Kingdom expenditures on health care per person are usually shown as less than half of U.S. spending, yet also with equal or better outcomes. In the U. S., health care is rationed by price and the widely-varying quality of your insurance. [2] Money in hand or good insurance will get you some choice of providers. This works superbly for many and does not work at all for many more.

Britain has traditionally divided its healthcare-seekers into three groups – preventative medicine, urgent/emergency care, and care that is important but not urgent (for instance a knee replacement). The third category has historically received the most squeeze as the place to ration care, and the first two have typically met the grade in recent years.

The NHS has made many improvements in the less-urgent sector, but it will always remain a challenge because it is the very resource squeeze made here that frees up more services to the other sectors. It is also one of the primary sources of complaint in the system. But in the U.S., this sector has been “where the money is to be made” as specialty providers spin off as separate medical profit centers, and get insurers to pay higher margins for this type of care. And higher U.S. medical costs result.

The U.K. also allows a “relief valve” in the form of optional private health care insurance and facilities, which takes some pressure off public facilities, and thus helps the public system users as well. My British employer paid for a private care policy for me as an add-on benefit, although I never had to use it. This “relief valve” market works more as “true insurance” rather than the “pre-paid care” model underlying much of the traditional health insurance in either the U. S. or the U. K., and is thus relatively inexpensive as a result.

A second “relief valve” has been the availability of excellent care elsewhere in the European Union for the many thousands of U. K. residents who have had (up until now) the freedom of movement within the union.

Finally, the current situation is mostly a political one.

No serious politician in the U. K., even in the ruling Conservative Party, would ever propose a radical change to the way health care operates in Britain. Instead, the parties fight over levels of funding, methods to rein in cost increases, and the system of regional control bodies.

In the article cited in the opening paragraph, the authorities are pleading for an additional 350 million British pounds in funding to cope with this influenza-caused run on facilities. That sounds like a lot of money, but it is really just seven American dollars per U. K. resident, which is less than a typical stop at Starbucks. If the U. K. raised its spending to even 60% or 70% of the level of U.S. per-capita spending, what kind of system do you think they could have?

The reality is that the ruling Conservatives have gotten themselves into a fiscal mess, much of it caused by an ill-advised vote to leave the European Union. Thousands of European nationals working for the NHS have been reported to have left the service in recent months. Something will change as the country tries to wiggle out of its political self-inflicted wound (this type of injury apparently not covered under the NHS).

As I noted in an earlier post recommending an episode of “The Weeds” podcast, the U.S. is spending a lot more money on health care for worse outcomes than in most developed nations, particularly in Europe. This is especially bad when it comes to recent actual declines of life expectancy of adults, and increases to the rate of infant deaths in the U.S.

This is now a national disgrace in comparison with any other place in the developed world. Sadly, I have yet to hear an American politician say, “Let’s compare the best health care systems around the world and see which practices and policies demonstrate improvement realistically achievable by the U. S.” In my observation, most of them think all foreign health systems are all like Britain or Canada, and having never experienced even these two (which are, in reality,  quite good), turn up their noses, and make us foolishly continue to spend far more on health care than we should be spending, given the mediocre outcomes.


  1. Yeginsu, Ceylan. “N.H.S. Overwhelmed in Britain, Leaving Patients to Wait.” The New York Times, 3 Jan. 2018.
  2. One reason for the success of the German model is the much greater standardization of insurance policies, even with retaining good coverage options for the public. This has huge effects in simplifying the processing of claims by providers, and saves billions of Euros in administrative fees annually. Think here: even at Fox News, the insurance for all male employees covers gynecological care, and it makes E.D. drugs available on prescription to female employees. Why? Standardization simply saves money.

2 thoughts on “Here is how to compare U.S. and British health care

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  2. Pingback: Three options between the ACA and Medicare-for-all – When God Plays Dice

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