Not long ago I sat down with Chris Smyth, a health journalist for The Times of London, who was traveling in the US to research American healthcare. Meanwhile, I have made several trips to the UK to report on the British system. So we had plenty to discuss.

When Smyth and I started talking, we realized that, regarding healthcare, there were points of difference between the two countries, but many similarities, too. Both struggle with increasing costs of care; both have embarked on programs to make care better; both have instituted reforms that keep within the boundaries of their systems—a national health service in Britain, in which everyone is covered as a matter of right, and a private healthcare market in the US, with reforms and subsidies meant to insure more Americans, though millions will still be without insurance. The following is part one of an edited version of our conversation (part two will run tomorrow).

The view from across the pond

Trudy Lieberman: Americans have a very bad image of British health care. They believe it’s rationed; people can’t get want they need or want. The British view of the American system, meanwhile, is like the American view of the English system, for very different reasons. Last year a woman in Blackpool told me, ‘We would never want to go to the American system, where you ration care and nobody gets what they need.’

Chris Smyth: That’s the thing that’s struck me when comparing the reform debates in the two different countries. In Britain, the only thing anyone can agree on is, ‘We don’t want to become like the American system—That’s awful.’ And in America, people agree, ‘We don’t want to be anything like the British system because that’s awful.’ Perhaps each side really doesn’t know much about the system they’re so scared of.

TL: People in America do not understand social insurance and what it is and does. They don’t understand that social insurance can mean a single payer or multiple payers, but that everyone pays into the system and everyone receives care. They like Social Security and Medicare—those programs are very popular—but it’s popularity without the real understanding that these are social insurance systems.

Is that the case in England, where the National Health Service (NHS) is popular, but people don’t understand it?

CS: Yes, but less so. The NHS is very popular, and at the moment the satisfaction levels are probably at the highest they’ve ever been. Although they don’t have a deep policy understanding, I do think people understand the basics of how it works, where the money goes, and what structure does what in the system, and how they fit into it. They also understand what they can expect from it and what they can’t.

Perhaps that is changing a bit. People’s expectations are rising and there are more treatments and drugs available, and less certainty about how they’re going to be paid for. People are not quite aware of that coming crunch.

TL: People’s expectations for healthcare are very high in the US. In fact, people want everything done—every treatment imaginable, even if it doesn’t work or is not cost effective. If the treatment is denied, it’s called rationing, and it’s something most people think we don’t do in this country. But we do. Americans don’t understand that medical care is already rationed—to poor people and others who don’t have insurance, or when doctors in some areas refuse to accept their insurance. Increasingly, we are seeing rationing in our Medicare program, where doctors say the reimbursements are too low—Medicare patients have complicated problems—and they claim they don’t get enough money to treat them. That’s not the case in the UK, is it?

CS: No.

TL: Why do people in Britain like the NHS so much?

CS: It’s something people interact with all the time, both in their daily and medical lives and when they think about politics. It is something people pay a lot of attention to. They do care about the NHS, not only because they rely on it for needs and such, but also—people are proud of it, and of Britain—as a sort of sign of social solidarity. Attempts to tinker with it, or change it, only work if people agree that there is a problem that needed solving.

TL: Americans love to say we have the best healthcare system in the world, but when you probe further, you find Americans deeply troubled by the system. It’s organized around private insurance companies and most Americans don’t like them. On the other hand, doctors work in private offices, or for private companies like HMOs, and people generally love their doctors.
