Healthcare is acknowledged as a critical component of social stability in the developed world – and an obvious contributor to the sustainability agenda… and yet, we can’t agree the best way of provisioning it. In the UK, the National Health Service (NHS) is a unique system that provides free healthcare to citizens, publicly owned and operated, funded by taxpayers (Department for Professional Employees, 2016). In contrast, America operates an insurance-based system, in which people either pay for health insurance or cover their own medical bills following treatment. These contrasting systems raise an obvious set of questions: is the price of healthcare a key factor of its sustainability? Or, is whether healthcare is free beside the point – should the real question be how it is paid for?
To answer these questions – and conclude, perhaps, whether a system akin to the UK’s or the US’ is preferable from a sustainability perspective, we can draw comparisons between the two systems, along the lines of their economic, social and environmental sustainability. Let’s start with an overview…
It is estimated that the NHS sees 1 million patients each day, employing over 1.5 million staff (BBC, 2019). Each citizen is entitled to the same access to healthcare, regardless of their socioeconomic status, age, or race. Individuals are treated based on their medical needs, rather than their ability to pay for a service (FUND OUR NHS, 2019): a principled perspective on the system would suggest that it treats healthcare as a basic human right; something granted to every individual, instead of something to be consumed.
In the US, 89% of the population in 2014 were said to have health insurance, be it private or government funded. Of this insured population, 36.5% were covered by plans such as Medicaid, Medicare or a Veterans administration. These insurance plans are privately owned and operated, leading to forms of discrimination inherent in an individual’s ability to pay: in the same year it was recorded that 32.9 million American citizens had no health insurance and therefore limited access to the care they may at some point desperately need (Department for Professional Employees, 2016). These uninsured citizens are disproportionately those with below average incomes, who are unlikely to visit a doctor when sick, seek a recommended medical test, file a prescription, or visit a dentist – because of high healthcare costs (Department of Professional Employees, 2016). Comparatively, it is stated that people in the UK are less likely than other countries to be put off from seeking medical help because of heavy costs, due to the National Health Service (Nuffieldtrust.org.uk, 2019).
Another important point to make is that a number of American citizens receive their health insurance from their employer (Kotecha, 2010). However, this is heavily dependent upon wage level. Those firms with a high proportion of low-wage workers are less able to provide health insurance to their employees. This is also the case for firms with fewer than 200 workers (Department for Professional Employees, 2016). Economic status plays a large role then in a person’s access to healthcare. Yet, despite healthcare being a sector which yields a large sum from its insurance costs, in 2013 the country was said to be spending 16.4% of its GDP on healthcare compared to the UK’s 8.5% (Appleby, 2016), which is almost double the spending per capita when compared to other OECD countries (Department for Professional Employees, 2016). Can this be attributed to the high cost of healthcare in the US? Or is this a sign of the system being economically sustainable?
This point can be argued to be trivial when we look at the efficiency of US healthcare and the vast number of people who are unable to access it. The US system has been described as inefficient “not only because of its high administrative costs and the fragmented care it sometimes provides, but also because of the differences in the quality of treatment for patients, depending on race, income and where they live” (Schroeder, 2013: 74). In fact, it is estimated 40 million workers in the US have no access to paid sick leave, which can have further repercussions for the country’s economy, as worker productivity will ultimately be reduced (Department for Professional Employees, 2016). Minority groups are also disproportionately insured, with 11.8% of black people being uninsured in 2014, compared to only 7.6% of non-Hispanic white people (Department for Professional Employees, 2016). These disparities can also be seen across different states in the US, with Southern states seeing lower family premiums than those in the North East (Department for Professional Employee, 2016).
Socially, there are also great differences between the two systems, especially when we look at survival rates. Using the example of cancer, the NHS looks to be more effective than the US insurance based system, with the survival rate for cancer in the UK being 50% in 2010 (Cancer Research, 2020). While cancer-related deaths in the US are 25% lower than in the UK as a proportion of the overall population (Cancer Research, 2020; American Cancer Society, 2020), according to the 5 year relative survival rate for all cancers in the US, which divides those people alive for 5 years after being diagnosed with cancer by those of the same characteristics (such as age and race) alive without cancer and with a normal life expectancy, there are significant disparities in terms of race:survival rates for white citizens have increased from 39% to 70% since the 1960s, while for black citizens the increase is only from 27% to 64% (American Cancer Society, 2020). While this is clearly an improvement, this calls into question the overall sustainability of the American system.
The NHS seems to be socially sustainable when public perceptions of the system are taken into account. The NHS was founded and established after World War Two and is often cited as one of the top reasons for people being proud to be British; it is a ‘part of the fabric of British life’ (BBC, 2019). It seems to be that there are many negative associations with the NHS- like long waiting lists, cutbacks and deficits. Those with long standing illnesses or disabilities are more negative when asked about the NHS and the service it provides, with 56% of a devised sample disagreeing with government policies (Ipsos MORI, 2015). Yet, the system ensures nobody foots unaffordable medical bills after treatments they need and more than likely cannot avoid, with surveys finding that 67% of the public are satisfied with the running of the NHS today (Ipsos MORI, 2015).
The social sustainability of the American healthcare system is less adequate, with the US having poorer health outcomes than other OECD countries, despite the country having some of the best health care specialists in the world, suggesting these are potentially because of the system employed (Department for Professional Employees, 2016). The US has fewer doctors per capita than any other OECD country (Department for Professional Employees, 2016), as well asa high level of infant mortality in the country, sitting at 5.96 per 1000 live births in 2013, relative to the median for all OECD countries – 3.8 in the same year (Department for Professional Employees, 2016)? Life expectancy in the country also remains lower than in other developed countries around the world (Holder et al., 2017) and the US system falls short of the World Health Organisation threshold, which ‘defines universal health coverage as a system where everyone has access to quality health services and is protected against financial risk incurred while accessing care’ (Kotecha, 2010): many struggle to afford their medical debts, which have increasingly become a common cause of bankruptcy (Kotecha, 2010).
Furthermore, is the question of cost one point among many when discussing sustainable healthcare, which can be put to one side when environmental sustainability of healthcare systems is contemplated? The functioning of these systems requires a massive amount of energy, in order to heat hospitals, cook meals for patients, supply medicines, and transport patients (Schroeder, 2013: 73). The American system emits 10% of the country’s carbon emissions (Cummings, 2019) contributing to 12% of acidification and 10% of smog formation (Kashef, 2016). The NHS is said to account for a quarter of all public sector emissions (Schroeder, 2013: 74) and both systems produce a large amount of unnecessary waste (Kashef, 2016). Thus, should attention be turned to the fact that whilst healthcare systems are in place to manage, treat and cure health problems, they also create them by contributing to climate change? (Schroeder, 2013: 73). Are they therefore breaching one of their main ethical concerns, ‘first do no harm’ (ibid:73) – especially when we consider that the American healthcare system has produced pollution adding to ozone depletion, respiratory diseases and cancer from chemical exposures (Kashef, 2016). Or, should we recognise that with climate conditions getting worse, our healthcare systems and professionals are under increasing pressure and should be praised for what they already do. Perhaps focus should be turned to awarding the extra funding our systems desperately need and making healthcare a right for all, rather than something to be consumed, especially in countries where medical care can be deprived based on a person’s status.
Achieving truly sustainable healthcare systems requires us to consider our values (Schroeder, 2013: 72). Reformed systems should promote things like compassion, kindness, and being mindful, all of which have health benefits and do not incur high carbon costs, implying they are ‘virtually limitless’ (ibid: 72). Sustainability in our healthcare systems will help to reduce carbon footprints, make financial savings and improve quality of care (ibid: 74). The key elements of these revised systems would include a focus on wellbeing, recycling and minimising waste, lower health inequalities, care being closer to home, and hospital admissions being rare (ibid: 75). For this to happen, do we need universal free healthcare for all? Or does achieving this sustainability require a payment to be made? Should it be a government’s responsibility to dedicate funds to a system which is vital to every one of its citizens lives? Or should that responsibility fall tothe taxpayer, or as in America, in the form of medical bills? It is clear that many countries think differently on this matter, but what is evident is that with our climatic conditions everchanging, something needs to be done to deal with the higher number of people in need of medical attention and in sustainable ways, to counterbalance the effect these systems already have on our planet – without losing sight of inequality and social justice.
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