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For the most part, in the years before the founding of the NHS, the medical system in Britain didn’t work; not in the sense that patients were not treated, but in the sense that the whole structure was financially unsustainable.This had been recognised for decades; as advances in medicine - especially hospital medicine - increased costs, so the historic charitable endowments of the ‘voluntary’ hospitals in each town were unable to support their expenditures. Right up to the end of the 19th century, admission to hospital had been largely confined to poor and working-class patients; anyone with any money would expect to be treated at home for all medical procedures - including major surgery. But advances in antiseptic practice, anaesthetics, radiography and therapeutic techniques (especially in the course of the First World War) meant that, for the first time, hospitals were admitting as inpatients, large numbers of persons from the professional, managerial and landed classes (and their families). Who in turn expected consistently higher levels of service and care delivery - increasing required staffing levels, and so costs. In effect, voluntary hospitals changed from being entirely charitable - applying accumulated historic endowments to treat the poor without charge - into non-profit businesses treating the general population, most of whom were capable of paying fees.These hospitals then established a new profession, the ‘hospital almoner’, whose job was to assess how much each patient might be able to contribute towards their treatment. Voluntary hospitals fitted out a proportion of their accommodation as ‘private beds’ for patients paying a regular fee; and also introduced ‘contributory schemes’ to spread payments. Every voluntary hospital also collected extensively in the streets; and solicited bequests from grateful patients and relatives; but none of this could keep pace with medical cost inflation. And as populations aged; so non-payng ‘charitable’ patient numbers also increased too.Alongside these voluntary hospitals for acute illnesss - each usually called ‘The Royal’; there were in most towns also municipal infirmaries funded from the rates - each commonly called ‘The General’. These had originally been the workhouse hospital departments of the former Poor Law Unions; and so lacked endowments, and had been provided to care for patients with chronic conditions; but under the Local Government Act of 1929 they could be taken over by their host local authority and redesignated to offer general and acute care. Under this legislation, these new general hospitals were required to recover treatment costs where possible, and accordingly changed to become more like the voluntary hospitals; imposing charges on better-off patients assessed through almoners, to supplement their annual budgets from the town hall, and sometimes also creating private wards of their own.But the recovered charges were never enough in total; so there were a whole succession of official reports and commissions on how to fix the system; with governments handing out ‘short-term’ finance to bridge the revenue gap until some sort of permanent solution could be devised. A wide variety of local schemes were implemented in the 1930s, looking to integrate voluntary and municipal hospitals under the overall supervision of of the local Medical Officer of Health, while collecting extra weekly per capita voluntary subscriptions from working-class populations to cover access to hospital; but none were found to be capable of full self-financing for the entire populations of all ages and conditions of employment, in the absence of some form of recurring central grant.Alongside these two hospital systems were General Practice doctors; most of whom maintained a ‘panel’ of patients entitled to access GP medical care under the terms of the National Insurance Act of 1911, which had established a compulsory National Insurance Fund, paid for from employee and employer contributions - although all drug costs were extra. About half of the adult population in 1936 - those with regular employment below the statutory threshold - were on a National Insurance GP panel; but older persons, non-employed wives, and children remained outside the National Insurance system; as did the self-employed and higher-paid, professional employees. General Practitioners therefore established their own supplementary panels, tailored with monthly subscriptions according to assessed ability to pay. Many GPs also worked in hospitals; as did a smaller number of consultant doctors holding medical specialisms. In principle, the doctor’s hospital treatment fee was separate from any assessed hospital payment - so paying patients faced two bills (or three, if continuing drug prescriptions were factored in).But then WWII came; and with it a long-planned wartime doubling of the acute hospital capacity of the country. Heavy civilian casualties were expected from bombing and gassing; and also from psychiatric trauma (which fortunately proved over-pessimistic). But war brought catastrophic injuries; and rapid advances in therapy to deal with them. All general and psychiatric hospitals were effectively nationalised within the wartime Emergency Medical Service. Using standardised designs in pre-fabricated wooden huts; most general hospitals were extended with extra wards. support services, and operating theatres.When the war finished, the old issues of finance would re-emerge; now doubled in scale and triple the cost. Neither the historic charitable endowments of the voluntary hospitals, nor the local rates, had been sufficient to support aggregate day-by-day hospital running costs before the war; now hospital budgets had trebelled, but the endowment income was no different. It was inevitable that the EMS would simply carry forward into peacetime as the NHS. A few hospitals withdrew to become wholly ‘private’ (maternity hospitals in particular); but for the bulk of long-stay, emergency and acute hospital care - including all municipal hospitals- there was no alternative to nationalisation.The tricky issue was General Practice. The British Medical Association fought a long battle to keep GPs from being incorporated into the new NHS; but were outmanouvered by Nye Bevan; who ensured that hospital specialists would receive relatively generous pay packages - plus the freedom to maintain elective private practice ‘on the side’. GP practices remained as private businesses, but their National Insurance panels were replaced by NHS registration (which simply carried forwards into peacetime, the wartime system of national registration that already existed). Even if GPs wanted to practice entirely privately, very few could make a living outside the NHS; as together, hospital-delivered specialist clinical services and General Practice registration by central capitation fees met almost the whole population demand for medical treatment - even for higher paid professional families who had formerly been excluded from state or municipal medical systems.Which is how the system in 1948 became established as ‘free at point of service’ for the whole population, rich and poor; and with no fees charged to anyone - either for treatments or for drugs. Facing a crisis in 1950, the second Attlee government met its financial shortfall by imposing co-payment prescription charges, and charges for dental and optical services (Bevan resigned); but the overall principle was maintained.We can compare this with the history of medical systems in the United States over the same period. Up to the 1890s, the two systems were broadly similar. US municipalites maintained workhouses and county hospitals; while there were a smaller number of large specialist endowed ‘voluntary’ hospitals in the big cities - mostly attached to prestigious medical schools. And just as in Britain, early 20th century advances in medical technology created a demand for greatly expanded access to hospital treatment for populations beyond the very poor. But in the US, there had also always been a considerable number of commercial ‘proprietary’ clinics and hospitals; who had no charitable endowments, but were financed entirely from patient fees paid to the doctors who ran and owned them.In the early decades of the 20th century, proprietary hospitals in the United States expanded rapidly, as outside the big cities, voluntary hospital provision was largely inaccessible. Moreover, as proprietary hospitals were not seeking to cross-subsidise charitable free treatments for the poor from paying patients, they could generally undercut voluntary hospital fees. At the same time, new hospital construction in the United States consisted entirely of ‘private’ wards with individual rooms - whereas in the UK open wards remained the predominant standard, even for newbuild. The United States lacked any system of compulsory public medical insurance, either to pay for doctors or for hospitals; proposals to include health coverage in the Social Security Act of 1935 having been dropped. In 1929 a consortium of Texas hospitals set up Blue Cross, and in 1939 a consortium of California doctors set up Blue Shield. But, without public mandate support, neither Blue Cross nor Blue Shield were able to establish a substantial market share; in 1940 about 9% of the adult population had health insurance.But in the United States - as in Britain - the key factor that wholly transformed the health system was state action and public funding in the second World War, resulting in a centrally driven rapid expansion of hospital provision, and consequently hospital budgets; which continued into peacetime and then needed to be paid for. Following the outbreak of War, the Federal government had introduced strong controls on wage inflation to prevent wartime enterprises bidding against one another for scarce resources of labour. Instead, however, war industries sought to attract workers with heavily cross-subsidised health insurance benefit packages, and from 1943, these were fully tax-deductable for both employers and employees. At the time, this looked like an easy win (wartime workers did not initially use hospitals that much more than before); but it had the long term effect of locking the entire working population into a very costly model of medical care administration and delivery, with spectacular administrative overheads in individual billing and insurance sales; and as these workers got older and their medical needs increased; so too did the consequent costs on the taxpayer. It was indeed already apparent to goverment economists by 1945 that these ad-hoc wartime health arrangements had the potential for unlimited upward cost pressures on public finance, and President Truman proposed to replace them with a standard-benefit national health care package for all citizens, but found himself opposed by the united lobbying of both the medical and insurance industries - as too by trades unions who reckoned to have negotiated more favourable health coverage for their memebers - and the proposal failed. By 1950, 50% of adult Americans were covered by publically-subsidised employer-contracted health insurance; and by 1960 this had increased to 66%. The US system is dressed-up as ‘employer/employee’ insurance funded; but this obscures the actuality that the bulk of this money is underwritten in large degree from the public purse.Lacking a centrally mandated universal health care system, the problems of escalating health spending expectations and demands in the United States fell primarily on employers (who had discretion to determine the scope of insurance policies to be offered to their employees); and on insurers (who had the discretion to negotiate favourable payment arrangements with selected hospitals and clinicians). By the late 20th century, the latter factor had transformed almost all health insurance operations for US populations into arrangements for ‘managed care’. Instead of insurers covering medical bills retrospectively as ‘fee-for-service’, only treatments within a pre-contracted clincical ‘network’ would be covered - generally with a range of coverage exclusions, and co-payments. This did effectively hold down the growth of insured payments - but only by reducing choice and shifting exceptional and excluded payments back onto the patients themselves. At the same time, employers looked for ways to reduce the growth in their health insurance premiums; which led increasingly to policies being offered to younger and healthier employees with lower premium costs, but with high levels of annual ‘deductible’ payments falling on the patient. Whereas co-payments (where the patient makes a standard contribution towards particular treatments) can be shown to hold down some unnecessary health expenditures; deductibles (where the patient is only re-imbursed when annual spend exceeds a standard sum) are notoriously liable to result in over-treatment and investigations of limited value - as the more the total spend, the greater is the proportion of annual cost passed on to the insurer. Anyone developing a medical condition associated with continued health care requirements was likely to lose out both ways; their choice of insurance policy would be constrained by exclusion clauses relating to pre-existing conditions; while annual premiums for policies without high deductibles became much more expensive.Which has now resulted in the paradoxical situtation that the entire publicly funded British National Health System receives lower per capita public funding than does the tax-funded element of the notionally ‘non-socialised’ US health system - once all Medicare, Medicaid, and tax subsidies are taken into account. So, each US resident has to pay eyewatering levels medical support costs through their taxes; and then find ever more exorbitant medical insurance, co-payment and deductible costs on top of that. In fact, far the most common international model of universal health provision is one financed by subsidised individual insurance contracts, with standard terms regulated through a national scheme; and most of these result in health system funding costs per capita not much greater than those of the British National Health system; and often achieving equal or better overall scores on standard health quality indicators. It appears that only the US system manages to combine exceptionally high public funding costs, with exceptionally poor health outcomes from treatment and care for the bulk of their populations with severe health needs. While apparently affording the average US health user far the worst options anywhere in individual treatment choice.So, even the the UK had not adopted a single-payer, tax funded, model of universal health coverage, it is highly unlikely that they would have found themselves facing the combination of runaway payment levels, poor quality outcomes, and grossly constrained individual choices, that now plague the populations of the United States. See U.S. Health Care from a Global Perspective, 2019: Higher Spending, Worse Outcomes?

The history of health care legislation in the United States is a story of special interest influence, which has not only corrupted the political process, but also driven costs to ridiculous levels. Prior to World War II, medical expenses were typically paid by the consumer. However, in the 1930’s Blue Cross began providing guaranteed services for a fixed fee. Also in the 1930’s Roosevelt worked on a plan to create a national health insurance program, but was forced to cancel it due to fierce opposition from the American Medical Association (AMA). During World War II, Roosevelt implemented wage and price controls, which angered the labor unions, so to appease the unions, the War Labor Board exempted employer-paid health benefits from wage controls and income tax. As you can imagine, employer paid group health plans became very popular and eventually replaced individual health insurance plans, which by 2008 were prohibitively expensive to obtain and excluded pre-existing conditions. The system worked pretty well, if you happened to be employed by a firm large and generous enough to provide health insurance as a benefit for its employees.In 1945, President Truman proposed a national health insurance program that would benefit all Americans. The idea was very popular with everyone except the Chamber of Commerce, the American Hospital Association and the American Medical Association. Guess who won?In 1993, President Bill Clinton formed a task force to tackle health care reform. It was to be the centerpiece of his first term. He even appointed his wife Hillary to be its chairperson. Unfortunately, the task force was fraught with controversy from its inception and the plan itself was a complicated mix of public and private mandates, making it an easy target for the pharmaceutical and health insurance industries. It turned out that even though he took office with a majority in congress, Clinton couldn’t even get his own party to completely buy into the plan. By 1994, it was dead. Later that year the democrats lost their majority in the House of Representatives, killing any prospect of a renewed effort.What’s the Problem?We have an incredible health care infrastructure in this country; when you consider the advancements in medical technology, lifesaving drugs, and world class medical facilities. Plus, we have the best educated doctors and nurses. Why then, in 2007, did only 18% of people polled believe that our health system was working well and some 79% believed that the system needed “fundamental change” or “a complete overhaul”.Healthcare as a Percent of GDP— — -— — — 1995 — — — — 2005 — — — — 2014USA — — — — 13.1 — — — — 15.3 — — — — 17.1Switzerland — 09.3 — — — — 11.6 — — — — 11.7France — — — 10.1 — — - — — 11.1 — — — — 11.5Germany — — 09.4 — — — —- 10.7 — — — — 11.3Canada — — — 08.9 — — —- — 09.8 — — — — 10.4Sweden — — — 08.0 — — — —09.1 — — — — 11.9UK — — — — — 06.7 — — — —08.3 — — — — 09.1Japan—— — —06.6 — — — — 08.0 — — — — 10.2Mexico — — — 05.1 — — — — 06.4 — — — —06.3Taiwan — — — 05.2 — — — — 06.2 — — — — 06.5Sources: 2005: Health at a Glance, 2007; Government of Taiwan, (Taken from the book: The Healing of America, by T.R. Reid). 1995, 2014: World Health Organization, Global Health Expenditures Database. 2014 Taiwan: CIA World Factbook.Part of the answer was affordability. By 2008, health insurance premiums in the new millennium had increased by 119%. The insurance companies were frantically attempting to keep up with soaring increases in costs. Health care in the United States was consuming 16% of our GDP, the highest percentage of any OECD nation. And we were also the only nation in the western industrialized world to not have a uniform system, offering universal healthcare for everyone.The basic programs in use around the world are as follows:· A national health service· A single-payer national health insurance system· A multi-payer universal health insurance fundPrior to Obamacare, Japan (which offers universal coverage); had the oldest population in the world, and per capita averaged fourteen visits to the doctor’s office per year. By comparison, we averaged five… yet Japan only spent about $3,000 per person on health care each year, 8% of GDP. We spent $7,000, over twice as much. But, you may ask, what about the quality of care? Surveys showed that Americans who saw a doctor tended to be less satisfied with their treatment than the Japanese. We were also less satisfied than Britons, Italians, Germans and Canadians. At the same time 1 in 6 Americans, about 45 million people were without health coverage and if you looked at the under 65 population (those who were not yet qualified for Medicare coverage), 1 in 3 went without coverage at least part the time during a two-year period.In 2009 we had a new democratic President, filled with the promise of hope and change, and for the next two years a democratic majority in both the house and senate. This seemed like the perfect time to face the daunting task of tackling America’s health care system. But to call it a system is a misnomer. We essentially had four totally different health care systems operating simultaneously, each mimicking one of the four basic models in use around the world.Four Health Care Systems· If, for example: you are under 65 and worked for a company that provides health coverage for its employees, then health insurance is a part of your compensation package. Your employer pays a portion and you pay a portion of the monthly premium. When you go to the doctor or hospital you typically make a co-payment or pay a percentage, but the insurance company picks up most of the bill. There are currently about 160 million Americans or 66% of the population covered by their employers. This system was designed in Germany by Otto Von Bismarck (1815–1898) and is therefore called the Bismarck plan.· If you are in the military or a veteran (14.14 million Americans); or Native-American (2.2 million Americans) you can go to U.S. government owned clinics or hospitals and your doctor or care-giver will be a federal employee. You will never get a bill; your health care is free. This is the British (or Beveridge) model.· If you are over 65 then you qualify for Medicare (50.5 million Americans), which is a National Health Insurance system that pays for basic medical care, hospitalization and prescriptions. Many seniors also purchase supplemental policies for more complete coverage. Medicare is modeled after Canada’s health care system. Medicaid (61.65 million Americans) is similar to Medicare, but only for certain groups, primarily: the elderly, blind, disabled or families with dependent children.· For everyone else (28 million Americans) it’s a pay as you go system, which is the same as your average third world country, except of course we have vastly more facilities. In other words, you have access to care as long as you can pay the doctor or hospital bill. If you can’t pay and you’re sick enough or seriously injured, then you will be given basic treatment in an emergency room, however, you will still be billed and the costs could force you into bankruptcy. Your last option is a charity clinic, if you are lucky enough to find one.