Right wing attacks on Obama’s healthcare reform are an echo of previous attacks in the UK during Bevan’s creation of the NHS.
For UK citizens it is hard to imagine a time when the NHS was perceived as a threat. Today the NHS is a sacred object in British politics, and those who wish to be critical of a government (of whatever political shade) merely need to say that they are defending the NHS to obtain public approval. Healthcare practitioners, when feeling threatened, will use the NHS as a shield to protect their interests. So attempts to use private providers to provide NHS healthcare to patients in the UK are presented as attacks or a creeping privatisation of the NHS. This love of the NHS did not always exist.
Back in January 1946 met the British Medical Association, told them his plans, and pledged them to secrecy. The British Medical Journal suggested doctors had been “gagged” and that doctors had been received by Bevan as a Victorian capitalist might deal with a deputation of workers.
There was a gradual ratcheting up of the rhetoric over the next few weeks. Dr Alfred Cox, a respected BMA member, noted that after examining the bill that “it looks uncommonly like the first step, and a big one, towards National Socialism as practised in Germany. The medical service there was early put under the dictatorship of a medical “fuhrer”. This bill will establish the Minister of Health in that capacity.” This was an extraordinary statement, given that the country had only recently finished fighting a war for survival against National Socialism. Right wing newspapers were equally concerned about the bill. The Evening Standard stated “the Bill is the first step towards the full-time employment doctors as State servants.” The BMA became became a battering ram employed by the Tory press and opposition politicians, who had been quick to spot the political opportunities to get Bevan.
By the end of April 1946 Bevan had eloquently talked the bill through a second reading in the House of Commons, winning the argument and the vote by 359 votes to 172. However, the BMA representatives were meeting at the same time. The BMA delegates opposed state ownership of hospitals by 210 votes to 29, control over where GPs practice by 214 to 2, and change to a basic salary and capitation fees by 209 votes to 9. Bevan’s NHS bill was described as “a clearing of the ground for the erection of that glittering ediface of a Socialist dream - a whole-time State salaried service.” A Dr Cockshut suggested doctors would become “West Indian Slaves”, and that the bill could be written in two lines: “I hereby take powers to do what I like about the medical service of the country - (signed) Nye Bevan, Fuhrer.”
Despite further worsening of relations between Bevan and the BMA, and threats of a boycott of the scheme, in the end it started on the 5th of July 1948, with 90 percent of general practitioners joining the scheme, and over 39 million patients signed up - with widespread support within the middle and working class. Opposition parties quietly forgot about their opposition, and the UK’s NHS has survived despite changes in government.
In the US, Obama is attempting to introduce much milder forms of health care reform than Bevan. He is concerned about controlling costs within the US health care sector:
“If we don’t get control over costs, then it is going to be very difficult for us to expand coverage,” Obama said. “These two things have to go hand in hand.”
Healthcare reform “is not a luxury” nor something that must be done because of his campaign pledge, Obama said.
“This is a necessity,” he said. “This is something that has to be done. Soaring health care costs are unsustainable for families, they are unsustainable for businesses, and they are unsustainable for governments … at the federal, state and local levels.”
He said projections indicated a fifth of the U.S. economy was projected to be wrapped up in the healthcare system in 10 years.
One of the ways to control escalating healthcare costs is by the choice of cost-effective treatments, and already right wing organisations are campaigning against the reforms with reference to the UK experience of NICE:
Conservatives for Patients’ Rights (CPR)—which is tied to sections of the US healthcare establishment and has spent millions of dollars on the adverts—has run weeks of the slots, showing doctors and patients ridiculing the UK and Canadian systems over waiting times for operations and the rationing of some treatments and life saving drugs.
CPR says that Obama’s plans to bring down the cost to the state and private insurance companies of the most expensive healthcare system in the world while extending access to about 45 million people without insurance—15% of the population—will result in rationing by the government. This they have likened to the UK National Institute for Health and Clinical Excellence (NICE).
“As our nation goes forward in its own healthcare reform debate, the failures of the British system should have Americans asking some very important questions, such as, ‘Who should make medical decisions—me and my doctor or a government board?’” CPR asks in one of the adverts shown on television stations throughout the US.
Interestingly, SourceWatch tells us that Conservatives for Patients’ Rights (CPR) is a front for a right wing organisation, whose previous form includes attacking John Kerry over his Vietnam war record during the 2004 US Presidential elections. The CPR attck on healthcare reform is extremely well funded, and led by Richard Scott. Maggie Mahar has some interesting background on Scott’s involvement in US healthcare as CEO of Columbia/HCA Healthcare Corp:
In July of 1997, the FBI swooped down on HCA hospitals in five states. Within weeks, three executives were indicted on charges of Medicare fraud, and the board had ousted Scott.
The investigation revealed that the hospital chain had been bilking Medicare while simultaneously handing over kickbacks and perks to physicians who steered patients to its hospitals. One can only wonder how many of those patients really needed to be hospitalized—and how many were harmed.
The company did not fight the charges. In 2000, HCA (which by then had expunged “Columbia” from its name) pleaded guilty to no fewer than 14 felonies. Over the next two years, it would pay a total of $1.7 billion in criminal and civil fines.
This is hardly a good position from which to criticise Obama’s healthcare reforms.
So, the attempt to create a US “NICE” to look at the relative cost effectiveness of medical interventions is seen feared by some, and invokes strong claims form others. Karol Sikora, a UK oncologist, says of this debate that:
There is a good reason NICE has attracted interest from U.S. policymakers: It has proved highly effective at keeping expensive new medicines out of the state formulary. Recent research by Sweden’s Karolinska Institute shows that Britain uses far fewer innovative cancer drugs than its European neighbors. Compared to France, Britain only uses a tenth of the drugs marketed in the last two years.
Partly as a result of these restrictions on new medicines, British patients die earlier. In Sweden, 60.3 percent of men and 61.7 percent of women survive a cancer diagnosis. In Britain the figure ranges between 40.2 to 48.1 percent for men and 48 to 54.1 percent for women. We are stuck with Soviet-quality care, in spite of the government massively increasing health spending since 2000 to bring the United Kingdom into line with other European countries.
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The risks of America’s move toward British-style drug evaluation are clear: In Britain it has harmed patients. This is one British import Americans should refuse.
As a side issue, Karol Sikora, is described at that article as “a practicing oncologist, is professor of cancer medicine at Imperial College School of Medicine, London, and former head of cancer control at the World Health Organization.” The link with Imperial College is subject to dispute.
My colleagues Sarah McDowell and Prof Ferner from the West Midlands Centre for Adverse Drug Reactions have an editorial in the BMJ this week dealing with some of the attacks NICE and neatly describe the importance of cost-effectiveness.
We know this from cost-effectiveness analysis, which establishes whether one treatment is better than another, and if so, by how much—the marginal benefit—and how much has to be paid for the additional benefit—the marginal cost (see figureGo). For the past decade, NICE’s appraisal committees have been considering evidence from industry, doctors, and patients, and using it to provide independent estimates of cost effectiveness for the NHS.10 NICE compares the marginal benefit, measured (perhaps imperfectly) in quality adjusted life years (QALYs), and the marginal cost, in terms of money paid by the NHS and social services.
Treatments can be compared for different conditions. NICE generally accepts those interventions with a cost per QALY less than £20 000 as representing good value for the NHS. While it may also recommend other treatments, the chances of recommendation diminish as the cost per QALY increases. Once NICE has recommended a treatment, the NHS undertakes to fund it. NICE has endorsed full or restricted use for 84% of the treatments it considered, and encouraged research on a further 6% (Rawlins MD, NICE, personal communication).
NICE may decline to recommend costly treatments that bring tiny benefits—such as pemetrexed, which costs over £50 000 per QALY but adds a statistically non-significant 12 days to life expectancy in non-small cell lung cancer. Any unfavourable decision allows critics to deploy poignant tales of personal tragedy,11 often with exaggerated statements of potential health gain, without the counterbalance of tragic stories ensuing from unmet need elsewhere. The US initiative needs to provide data to support moves away from treatments that bring small marginal benefits for huge marginal costs and which fuel rapidly escalating healthcare spending without corresponding improvements in health. Market forces have failed to contain health expenditure in the US or to direct it towards effective treatments.12 This is partly because sensible decisions on medical care, whoever makes them, require information on comparative efficacy and cost effectiveness. The most useful data are unbiased, directly measured, and relevant to the individual. NICE represents the closest current approach to these ideals, and other countries have followed the UK’s lead.
Sir William Beveridge, who in 1942 set out the blueprint for the NHS, wrote: “The first principle is that any proposals for the future, while they should use to the full the experience gathered in the past, should not be restricted by consideration of sectional interests established in the obtaining of that experience.” Sectional interests are trying to defeat long overdue healthcare reform in the US, as they have tried to outflank NICE in the UK.
Like the UK’s health reform in the 1940s the US reforms are being attacked with cries of fascism, totalitarianism, and communism. Hopefully Obama’s reforms will pass, and it is likely that the reforms will be broadly accepted when it is seen that they have a beneficial effect on healthcare provision in the US. The right wing idealogues will be forgotten.