Critical Analysis of the UK health system and USA health system. Author: Dr Christa Maria Joel Module: Global Health Economics Supervisor: Mr Stuart Telfer University of the West of Scotland

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Module Code NURS11124-01
Module Title Global Health Economics & Health Systems
Assessment title Critical analysis of socialised health
system in the United Kingdom and the Free-
market health system in the United
States of America
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2. Critical analysis of socialised health system in the United Kingdom and the Free-
market health system in the United States of America
Introduction
This report will critically compare and analyse the two major healthcare systems in the
world: the United Kingdom (UK) and the United States of America (USA). First, the
background of this report will discuss how both systems were evolved over the years.
Then, the main body of the essay will critically analyse the policy context, resourcing,
funding, performance, and provision within both systems. Finally,
the report will conclude by evaluating the assessments drawn from the analysis.
Background
Health systems are responsible for improving the quality of life of individuals in society
by providing primary healthcare services to restore them to total health. The services
included are prevention and control of infectious and non-communicable diseases and
improving the citizens’ socio-economic and environmental conditions (WHO, 2021).
The founders of the National Health Services (NHS) did not start with a clean slate.
Before the institution of the famous NHS, there were few other systems to provide
medical care to the citizens. One such social assistance system was adopted in the
17th
century, known as the English Poor Law, which laid the foundations for modern
welfare systems. Later it was amended in the 19th
century as The Poor Law Amendment
Act (Guo, 2016). This act segmented the country into smaller administrative units called
unions for providing welfare services. Therefore, the ‘able-bodied’ poor could receive
funds within their union’s workhouse (Durbach, 2013). The development of Poor Laws
in Great Britain (GB) has been a model for relieving the poor and oppressed in western
countries in the modern era (Guo, 2016).
In 1911, Lloyd George’s National Insurance Act was designated as an achievement of
the Liberal administration that held office in GB before World War 1. The act gave birth

3. to the world’s first national compulsory insurance system and provided health
insurance to most families in the country. The National Health Service Act of 1946
would continue this act (Cousins, 2011). However, in 1920, Lord Dawson had
described in “The Civil servant’s forward-looking interim report” about the Future
Provision of medical and Allied services, a structure of the healthcare system that he
had envisioned. According to Dawson, GPs should be accessible, provide domiciliary
services and the necessary treatment, refer cases if it was out of their expertise, and
improve the quality of life of their patients (London Ministry of Health, 1920). In June
1941, when healthcare systems needed a reformation, Sir William Beveridge, a social
worker, wanted to address all the issues in society at once. Thus, the Beveridge report
called the Social Insurance and Allied services came about as a post-war strategy with
a vision to provide universal healthcare in the form of a national tax-based health
system along with full employment, social security, housing and free education (Light,
2003). In addition, he wanted to establish a partnership between the individual and
the state (Ashton, 2018). Therefore, in 1942, the first concept of NHS was proposed in
the Beveridge Report on Social Insurance and Allied Services (Grosios, Gahan,
Burbidge, 2010). On July 5, 1948, the National Health Service (NHS), the legacy of
Aneurin Bevan, was founded after the Second World War. The NHS focuses on
universality, free delivery, equity, and central funding (Delamothe, 2008).
In contrast, in the United States of America, several reforms in healthcare have been
made over the centuries, with only a few successes and more failures. Opposition and
rejection of universal health care by organised medicine were typical for many decades
since 1912 until the implementation of Obamacare in 2010. The earliest healthcare
proposal was the 1854 Bill known as the Benefit of Indigent Insane, but US President
Franklin Pierce vetoed it as he claimed that the government should not commit to social
welfare (Manchikanti et al., 2017). In 1904, the Socialist Party had recommended a
compulsory insurance system. Then Theodore Roosevelt’s Progressive Party in 1912,
included the provision of health coverage in his political campaign (Hoffman, 2003). In
1915, the American Association for Labor Legislation (AALL) proposed a compulsory
health coverage to protect employees against losses of income and treatment costs

4. during ill health, to which the American Medical Association (AMA) initially agreed. This
system was like the existing programs in Germany and England and was implemented
in several states of the nation. Yet the health campaign failed to make its impact by
1920 due to several reasons such as massive opposition from the insurance industry,
World War 1, xenophobia and superpatriotism, and it was termed “Bolshevism”
(Oberlander, 2012). The Committee on the Costs of Medical Care (CCMC) in 1920,
suggested voluntary insurance and group medicine, but this was opposed by the AMA,
which designated this as socialised health system (Hoffman, 2003). In 1933, Franklin D
Roosevelt added publicly funded health insurance to the draft of the provisions to Social
Security Legislation (Manchikanti et al., 2017) which also failed later. However, a
significant change occurred on July 30, 1965, when President Lyndon B Johnson,
following the pioneer of Universal health care, Harry Truman, introduced Medicare and
Medicaid as health coverage for its citizens (Berkowitz, 2008). But the United States
had not seen a significant reduction in the rate of uninsured individuals since the origin
of Medicare and Medicaid despite their successful attempts (Cohen et al., 2009).
Therefore, after almost 45 years of Lyndon Johnson’s initiatives, President Barack
Obama, in 2010, signed The Affordable Care Act or commonly known as Obamacare,
which has been the most critical health care program since Medicare and Medicaid. The
law introduced healthcare reforms that focus on accessibility, quality, and affordability of
healthcare (Obama, 2016).
Main body
Policy context:
The primary purpose of the health systems is to improve the health outcomes in society
(WHO, 2003). Despite both systems being significantly different, the health outcomes in
both systems are not up to the mark (Sarnak et al., 2017). Therefore, both systems are
undergoing rigorous changes over the years to tackle all disparities (Grosios, Gahan,
Burbidge, 2010; Davis, 2008).
The National Health Services (NHS) is known as a “command and control” system. The
health policies and budgets set up by the Department of Health (DoH) and the central

5. government are administered by the NHS (Peckham, 2014). The UK underwent
devolution in 1998, which means that autonomous governments were elected for
Scotland, Northern Ireland, and Wales (Trench, 2015). The devolved four health
systems in the UK are quite similar and symbolise British political unity. The Scottish
NHS and the English NHS was born at the same time in 1948. In 1969, the Welsh NHS
was derived from the NHS in England, whereas the NHS in Northern Ireland was
merged with a system known as Health and Social Care. And all these systems have
their respective advantages and disadvantages (Greer, 2016). But by 2003, all the four
health systems had different stances on health policy (Greer, 2004). English health
policy concentrated on patients’ choice and customer satisfaction (Stevens, 2004)
compared to the Scottish health policy that focused on partnership, mutuality and issues
like mental health (Greer, Wilson, Donnelly, 2016). Welsh health policy emphasised
waiting times and public health, and Northern Ireland’s health policy was similar (Greer,
2016). But all the four health systems shared common characteristics such as
centralised funding, equity, free access and common service conditions (Peckham,
2015). These devolved health systems have shown organisational improvement and
changes in health outcomes, such as reducing average waiting times, decreasing
amenable mortality by half, substantial progress in mortality and life expectancy and
improved staffing levels (Bevan et al., 2014). In England, the Secretary of state
implemented specific roles in the Health and Social Care Act 2012, including
comprehensive health services and reduction in inequalities (Department of Health,
2013). In Scotland, the Public Bodies (Joint Working) Act 2014 integrates health and
social care services to assure quality services to people who need social support and
individuals suffering from multiple chronic disorders (Care Information Scotland, 2020).
With this legislation, the Scottish government is responsible for £8.5 billion for quality
health services (The Scottish Government, 2020). In Wales, the Social Service and
well-being Act (2014) describes that the citizens have control over what services they
require, and local authorities and health systems join forces to integrate and ensure the
provision of the health services, especially mental health services (Welsh Government,
2019). And in Northern Ireland, there is the Health and Social Care Act (2009) which
focuses on integrated health services and primary care partnerships (Thompson, 2016).

6. Nonetheless, the performance of the four health systems was evaluated by the Nuffield
Trust and found out that the Welsh health system is weaker. At the same time, the
English NHS had an impressive efficiency (Connolly, Mays, Bevan, 2010). Another
study showed that Scotland had the cheapest health care system (Himmelstein et
al., 2014). But recent studies and the current COVID 19 pandemic has exposed the
weakness of this health system. It suggested that social care and mental health care
have been forgotten and proper initiatives have not been taken to tackle it. Despite all
the legislations, there has been health inequalities persisting in the system which the
pandemic has exposed widely (Ham, 2020).
In the USA, one of the top three concerns of the citizens is healthcare services. Various
reforms in healthcare have been undertaken, but all of them share a common
characteristic - the importance of reduction of health care costs (Maddox, Bauchner,
Fontanarosa, 2019). The US has a mixed healthcare system comprising public and
private insurance (Zieff et al., 2020). Public insurance like Medicare was implemented in
1966. It was provided for citizens aged 65 years and above, independent of their
economic and health status. Currently, Medicare has grown to provide citizens below 65
years and suffering from disabilities or diagnosed with chronic or terminal conditions like
end-stage renal disease (CMS.gov, 2020). Presently 85% of the people covered under
Medicare are 65 years and above (CMS.gov, 2021). Eligibility criteria for Medicare
include being a resident of the USA for at least five years (Huffman, Upchurch, 2017).
Medicare consists of 4 parts- inpatient services, outpatient services, social care,
prescription of medications (HHS.gov, 2014). But unfortunately, Medicare does not
cover certain medical services such as dental care, ophthalmological care or eyeglass
prescriptions, hearing aids, long term nursing care, and health expenses during foreign
travel (The CWF, 2017). Medicare has helped Americans obtain access to the
necessary medical services after years of financial and racial discrimination (Fee,
2015). Another public health insurance coverage is Medicaid. Medicaid was initially
implemented to help single-parent families and blind, elderly and disabled individuals
with low income. Currently, this insurance allows women and children of low
socioeconomic status to obtain necessary health services such as prenatal and

7. postnatal care and treatment for childhood diseases. Medicaid covers 6% of the costs
related to childbirth (DeLeire, Lopoo, Simon, 2011). In the past decade, there have been
significant health reforms with the introduction of the Patient Protection and Affordable
Care Act (PPACA) on March 23 2010, which was implemented to move closer to
universal health coverage and make healthcare accessible and equitable to all (Obama,
2016). The act has strengthened the existing health insurance by increasing health
coverage to 20 million US citizens who did not have the minimum insurance to obtain
health facilities. The legislation stressed covering citizens with income less than the
federal poverty line of 133% (Rosenbaum, 2011). Due to this, there are improvements
in healthcare access, health outcomes, and mortality decline among adults (Angier et
al., 2020). But like any other health reform, the PPACA is surrounded by opposition.
The Republicans have considered this act a “job killer” and intrusion on people’s
privacy and the healthcare system (Tofield, 2014). However, even after all these
controversies, the number of people covered under Medicaid via this
act has increased, whereas the number of people under employer-sponsored insurance
has declined (Garfield, Orgera, Damico, 2019).
Resourcing and funding:
Universal health care is defined as ensuring that all individuals have accessibility
to adequate good quality health services without suffering from any financial barriers
(WHO, 2021).
The healthcare system in the United Kingdom has been following this definition of
universal healthcare since the initiation of the National Health Services (NHS) in
1948. With the birth of the NHS, the government became the single organization
responsible for providing necessary medical services to its citizens and sufficient
funding (Majeed, 2003). This system was based on the Beveridge model (Liaropoulos,
Goranitis, 2015). According to the Commonwealth report, the UK spends 10% of its
GDP on healthcare (Schneider et al., 2021). According to OECD, the UK has spent
around $5268 per capita on health services (OECD, 2021). The UK has four unique

8. health systems in England, Scotland, Northern Ireland and Wales since the devolution
in 1998. The funding within the devolved countries in the UK is distributed according to
the Barnett formula. According to this formula, devolved governments are given block
grants according to their respective populations (Greer, 2016). But a report by OECD
in 2016 suggested no differences in quality among the four health care systems (OECD,
2016). But in specific areas, improvements were witnessed, such as a reduction in
mortality due to acute myocardial infarction in Scotland due to their quicker ban on
smoking than England (Donnelly, Whittle, 2008).
In contrast, the United States of America has no single health insurance system;
instead, the healthcare services are provided by private insurance companies that are
primarily dependent on the individual’s employment status (Ridic, Gleason, Ridic,
2012). American critics of universal healthcare argue that implementing a single health
system will cause general insufficiency and incur high financial costs (Zieff et al.,
2020). Therefore, the USA has a mixed public-private health insurance system
comprising Medicare, Medicaid, employer dependent private insurance and individual
insurance (Davis, 2007). As a result, the number of uninsured people has gone up to 28
million, according to the American Community Survey data released in 2018 (Berchick,
2018). According to Commonwealth Fund, the USA spends 18% of its GDP on the
healthcare system (Schneider et al., 2021). In 2017, the US spent around $3.5 trillion on
medical services for a population of 325 million. Estimations showed that private health
insurance covered around 197 million citizens, and Medicare covered 57 million
residents (Martin et al., 2019). Medicaid has increased massively with initiation of the
Affordable Care Act, with an increase in the health coverage of citizens from 50 million
to 76 million by 2020 (Goldman, Sommers, 2019). The Affordable Care Act, which had
elements of universal health care introduced under the Barack Obama Administration,
insured around 20 million people. But this system still works poorly for the middle- or
lower-class citizens, according to the Commonwealth Fund President David Blumenthal
(Gulland, 2017). Despite spending such a significant amount on healthcare in the US,
the health outcomes are unsatisfactory compared to other industrialised countries
mainly, the UK (Davies, 2008).

9. Performance and provision:
The United Kingdom healthcare system (UK) is one of the best out of the 11 most
developed nations in the world despite spending a low GDP (10%) on health and was
ranked number four according to the Commonwealth Fund (CWF) 2021. Regarding
access to care, affordability, administrative efficiency, equity, and healthcare outcomes,
the UK ranked fourth while the US ranked 11th (Schneider et al., 2021) Productivity has
increased in the National Health Services more than in any other sector of the economy
of the UK since 2009 (Dixon et al., 2018). The UK health system runs on tax funding
and national insurance contributions (Cylus et al., 2015). The sole priority of the
National Health Services (NHS) is a freely accessible system that provides universal
care for people’s needs which is independent of their employment status (Grosios et
al., 2010). This healthcare system is widely accepted and supported by 90% of the
public in the UK (Wellings, 2017). But like any other healthcare system in the world
that is under pressure, there are certain underwhelming aspects in the UK health
system, such as economic and operational factors (McGuire et al., 2016). Recently due
to global media attention, there have been a lot of issues related to staff inadequacy,
insufficient pay, less patient security, and long waiting lists in the NHS (Dixon et al.,
2013). Due to these limitations, patient satisfaction has reduced over the years and
doctors have complained about issues relating to continuity of patient’s care
(Papanicolas et al., 2019). The waiting list for elective treatment has increased since
2012, and by 2017, 4.1 million people were waiting for treatment (Anandaciva,
Thompson, 2017). But the NHS is determined to tackle and eliminate this issue by
2021-22 by recruiting and training new healthcare workers, increasing the pay,
taking the initiative to improve their careers, avoiding racial discrimination
among staff, and giving a chance to foreign healthcare workers (Beech et
al., 2019). Attendance for preventive medicine services such as cervical cancer
screening is relatively low in the UK. Therefore, various barriers to screening can
be tackled by providing easy accessibility, flexible timings, child support and
psychological counselling (Wilding et al., 2020). Despite all of these disadvantages and
having less control over their treatment and care, the British citizens are still satisfied in

10. paying taxes to allow a universal healthcare system to exist (Bielecki, Nieszporska,
2017).
In contrast, the USA does not have a universal health care policy and is provided by
private insurance companies based on the individual’s employment status. The USA,
an outlier, is at the bottom in ranking for the overall healthcare system performance,
although the country spent the most of its GDP (18%) compared to other OECD
countries. The health system can be rated using the healthcare quality and access
index (HAQ), which measure the mortality due to 32 different diseases. In the US, the
HAQ is 88.7%, while in the UK, it is 90.5, which means that the US has higher
mortality due to the 32 diseases compared to the UK (Kurani, Wager, 2021). The US
outranks better than the UK in only one parameter: the care process. Cost related
access problem is a massive issue in the US and is the highest in the 11 OECD
nations. This means that uninsured citizens do not have a primary care physician
and are often reluctant to seek treatment due to out of pocket costs. Therefore, the US
has higher hospital admissions for chronic diseases like diabetes mellitus and
congestive heart failure and higher caesarean sections than other OECD nations
(Schneider et al., 2021). Citizens in the US also have a higher chance of ending up on
the operating table than residents in the UK. Therefore, there are high rates of post-
operative complications such as pulmonary embolism and deep vein thrombosis
(Kurani, Wager, 2021). Due to bad health outcomes, the utilisation of pharmaceutical
drugs and complementary and alternative medications have also grown over the years
compared to other high-income nations (Rice et al., 2013). Based on the health care
outcomes parameter, nine of the ten measures show that the US has the lowest
performance among the developed nations, which includes having high infant and
maternal mortality rates, low life expectancy at 60 years, and exceedingly high
preventable mortality rate (Schneider et al., 2021). But when it comes to implementing
preventive medicine, the USA ranked higher than the UK. Preventive interventions like
cervical cancer screening were high in the USA. Around 90% of the women population
will undergo screening because the incidence and prevalence were comparatively more
elevated than in the UK (Benard et al., 2014).

11. Conclusion
Both the UK and the US health systems have undergone reforms in the past centuries
to improve access to healthcare and overcome financial obstacles. The UK health
system follows the principles of Universal Health Care and spends less GDP on health.
The devolved health systems have further systematically organised healthcare with
their respective legislations. But the health system has its limitations, such as long
waiting lists and understaffed health systems. However, there are good health
outcomes produced by this integrated health system. Therefore, the health system in
the UK must further concentrate on improving the operational outcomes.
Although the government spends a lot of its GDP on health services, the system in the
USA is not up to the mark. With the implementation of PPACA, there has been a
reduction in the barriers faced by the citizens and more people are getting insured.
However, there has not been much improvement in health outcomes. There is still a
massive inequality faced by its citizens based on race and income. The limitation of the
US health system is that it concentrates more on the monetary benefits than on health
outcomes. Therefore, accessible and affordable healthcare is every human being’s
right, and the US government must strive to make sure that its citizens are getting the
right amount of care as this will improve the public health of the citizens.

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