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We've done the US, Canada, and France. None of them are really socialized healthcare systems. To get at that, we need to go look at a system like that of the UK. More specifically, we're going to talk about England's National Health Service. See what a real "government run" system looks like, how it compares to yours, and what's good (and not so good) about it.

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http://theincidentaleconomist.com/wordpress/?p=55536

John Green -- Executive Producer
Stan Muller -- Director, Producer
Aaron Carroll -- Writer
Mark Olsen -- Graphics

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(Music)
We've done the United States, Canada, and France. None of them are really socialized healthcare systems. To get at that, we need to go look at a system like that of the UK. More specifically, the National Health Service of England is the topic of this week’s Healthcare Triage.

(Opening music)

People like to throw around "government run healthcare" as a phrase. Most of the time it is a little hyperbolic. But, in the case of England it's actually pretty accurate. 

The National Health Service provides care to everyone. All kinds of care. The system covers everyone who is "ordinarily resident" in the country. Basically, that means everyone except visitors and illegal immigrants. But even those groups can receive free care in emergency departments and for certain infectious diseases.

Coverage is pretty broad. Preventive services, inpatient care, outpatient care, physicians, drugs, dental care, mental health care, palliative care, rehabilitation, long term care, even some eye care- it's all covered.

And it's pretty much free to citizens once they pay taxes. Almost everything I mentioned just a few seconds ago has no cost sharing what so ever with the exception of dentistry and outpatient drugs. The latter have a copay of just over seven and a half pounds. Inpatient drugs, on the other hand, are still free.

And there are groups that are exempt, even from outpatient drug co-pays. Kids under sixteen, no co-pays. Kids sixteen to eighteen who are still in school, no co-pays. If you're sixty or over, poor, pregnant, have had a baby in the last year, or have a number of chronic diseases: no co-pays.

It turns out that only six percent of prescriptions actually incur the full copay anyways. So, out of pocket cost are really, really low.

Public expenditures cover more than 80% of all healthcare spending. About 3/4 of that comes from general taxes, most of the rest from a payroll tax. Over-the-counter drugs and other medical products account for another 10% or so of spending. The rest is mostly private hospital care for elective procedures.

A lot of this is covered by voluntary health insurance. Most of it, part of an employer based medical system. Basically, 10 to 11% of the population has private supplemental insurance. two private insurers cover about 2/3 of all of those people. 

People are required to to register with general practitioners, who deliver the vast majority of primary care. Most GPs work under a national contract with the government and are paid through capitated services, a bit of fee for services, and bonuses for good performance. But unlike most other countries, GPs actually work for the government. 

As do specialists. Almost all of them are salaried at hospitals run by the NHS. Patients have more of an ability to choose not only which hospitals they'd like to go to but also which specialists they'd like to see in those hospitals than they had in the past.

About half of specialists treat some private patients in private hospitals as well.

Publicly owned hospitals are run by NHS trusts. They're paid-for-care, nationally negotiated, diagnosis related group rates, or DRG rates. Some carers purchase through the private sector, especially for mental health and elective care.

Finally, the NHS pays for long-term care.  Although, less today than it used to.  Those who make less than 23, 250 pounds are entitled to free state-funded residential care.  Most residential care is paid for by the private sector, though. End-of-life palliative, however, is provided by the NHS in hospices, homes, or even hospitals. 

What's great about the NHS? It’s cheap! In 2011, England spent about 9.4% of GDP on healthcare. Compared to the OECD average of 9.3% and the United States' 17.7%. They spent $3,405 on healthcare per person, which is just above the OECD average, but that $3,405 is only 40% of the more than $8,500 per person spent in the US. 

The number of physicians per 1,000 population at 2.8 is lower than OECD average of 3.2, but above the United States 2.5; which means they have more doctors than we do. They produce higher than average numbers of medical graduates as well.  

Life expectancy at birth is 81.1 years: above the OECD average. Mortality of from cardiovascular disease is similarly better than average. Cancer mortality is below average, though it's worth acknowledging there have been better than average improvements in the last decade. Infant mortality rates are low as are suicide rates.  Diabetes prevalence is low in spite of the English diet. The percentage of adults who report being in good health is well above average. 

And they do this on a shoe-string!  Imagine if we in the United States spent 40% of what we do, right now, on healthcare. We'd have an extra like $1.6 trillion or more to play around with.  We could massive increase spending on tons of other programs and still have a surplus.

There are downsides.  In order to keep spending so low the NHS makes certain decisions other countries might find unpalatable. Some drugs are unavailable.  Technology is nowhere near as prevalent as in other countries. Hospital beds are even scarcer than in the United States. Physicians and nurses work pretty hard.  Hospitals aren't geared towards personal comfort and can be over-crowded, under-staffed, and sometimes even dirty from what I hear. Waiting times can be longer than in other countries, and on many metrics of qualities the UK falls below where they would like to be.  They're working to try and fix some of this. They've tried to increase patient's abilities to make choices. Providers are given more incentives to improve quality. Transparency and accountability are increasing. 

But as with almost all these episodes, it’s important to remember that Britain is a free and democratic nation. They chose the NHS and they do so again and again.  They love their healthcare system.  Even elected officials from the conservative parties support it.  There are trade-offs to healthcare systems as there are with so many things in medicine.  It’s easy to demonize socialized medicine for its short-comings.  We can't ignore its financial benefits, though.  The NHS may not always be the best, but it certainly can lay claim to being efficient.