Over the past year or so I’ve had first-hand experience of the American healthcare system. Having only really known about US healthcare from a UK perspective, my experience caused me to update some of my expectations. This post formed out of some mindless wondering while in a waiting room and is a way to condense and clarify what I learned.
The gist of why I ended up seeing a bunch of American doctors is that my left eye started moving slower than my right eye and, while it could have been caused by a bunch of serious things, it turned out to be an unusually mild case of a super rare auto-immune disease. I’m fine, so we can guilt-free move on to what I learned about the system here. My care started in the UK with the NHS and then shifted into the US, giving me the chance to compare both experiences. Obvious caveat: my experience is mine alone and I have pretty good health insurance, lots of people in the US are not so lucky and will not have this same experience.
Quality of care
Hands down, the US “wins” on quality of care, both in terms of speed and thoroughness.
It took 3 months to get my first US neurologist appointment, with no referral. The wait time to see a neurologist in the UK is currently over a year (although I actually saw a neurologist within 2 hours on the NHS as they thought I might have a brain tumour). After the first US appointment, I saw 5 different types of neurologist within a month: a general neurologist, movement-specialist neurologist, neuro-opthamologist, neuro-oncologist and neuro-geneticist. In all it took just 6 weeks from seeing the first doctor to getting a clear diagnosis, despite being one of just 300 people in the whole USA to have my particular disease. I was impressed.
In addition the the incredible number of specialists I saw (one of whom was Deputy Dean of the Yale School of Medicine), I got a crazy number of tests and scans. I had 2 MRIs, an X-Ray, 2 sets of blood tests, a nerve-conductivity test, an electromyography study and a PET scan. I also eventually had my entire genome sequenced at Yale. In the UK, I had an emergency CAT scan and an MRI, again when they thought I had something serious, but there is no way I can see myself having had anything like these tests on any timeline, and yet they ended up being essential to working out what I had. BTW the nerve-conductivity test involves being literally electrocuted to test the speed of nerve signals in your arms and legs. It sucks.
So yeah, as you’d expect, the US stuff was expensive. It cost just shy of $30,000 to get my diagnosis, with all but $300 of that paid for by my insurance. My treatment, 1.5 pills taken each day, costs a cool $100k per year, also paid for by insurance. I have no idea what my UK care cost, because no patient ever knows that in the NHS, but suffice to say it was way cheaper. The medicine I take here is also available for free on the NHS and costs the UK government roughly £3k/year/patient for the exact same medicine that costs my insurance $100k.
Why did I experience such great healthcare?
The clearest change in my perspective is that I’ve seen what fantastic health care looks like and I wish we provided that in the UK on the NHS. What’s less clear to me is why I had such better care here. For example, why did I see so many specialised doctors so quickly? One obvious reason would be that the US has more doctors than the UK but nope, they actually have slightly fewer doctors per capita than in the UK (2.7 per 1,000 residents vs 2.8). Perhaps US doctors use their time more efficiently and so can each see more patients but in my experience, each doctor had way more time to spend with me than in the UK. Nice for me, but it does not suggest higher efficiency.
Two explanations then come to mind. One is that the US has more specialists, even if they don’t have more doctors in general. A quick Google search backs this up: there are just 5 neurologists per million people in the UK versus 12 in the US. So the UK may have slightly more doctors but way fewer specialists.
The other explanation is that UK doctors experience higher demand than their US counterparts: the UK has about 4.5 doctor visits per capita per year, versus just 2.7 in the US. Possible explanations include the number of uninsured or underinsured people in the US who simply can’t afford to see doctors, and the UK having an older population. Assuming the same pattern applies to neurologists, that means that there are twice as many neurologists per capita in the US, facing about half the demand, resulting in about 4x more neurologists per patient. This very neatly fits my own experience: seeing a neologist in 3 months vs 12 and having appointments of about 1-2 hours versus 0.5 hours.
Why exactly there are so few neurologists in the UK is not immediately obvious. The difference does not seem to be driven by relatively better pay for neurologists in the US. The average UK neurologist earns 89% of the average doctor’s salary, little different to the average US neurologist, who earns 85% of the average US doctor’s salary. My best guess is that a focus on salaries ignores the centrally planned nature of the UK’s NHS: even if doctors face the same economic incentives to be specialists or generalists, the NHS is so dominant that it can actively choose to recruit more generalists without having to incentivise this by increasing their salaries.
As for why I had so many more tests done in the US, and so quickly, the answer seems pretty simple: the US just has way more scanning machines. The UK has 6 MRI machines per million residents vs 38 machines in the US. While the UK has just 54 PET scanners in the whole country, the US has 2,500, or about 10x more per capita. So if you have 5-10x more scanning machines per resident, and those residents are about half as likely to go to hospital in the first place, it’s no surprise you can provide way more scans, faster.
Of course, this is just one level of the explanation: why is the supply of healthcare so much higher in the US in the first place? The obvious explanation is there is so much more money being spent. The spending argument likely applies most strongly to the equipment side of things: an MRI scanner should cost about as much in the US as in the UK, and so more money means more scanners. It seems to apply less on the labor side, since US doctors earn more than twice as much as UK doctors, which might explain why the US has 5x more MRI machines but only 2x more neurologists.
Going much deeper than this will require a pretty detailed knowledge of healthcare systems that I simply don’t have. Perhaps I will dig into it more but for now, it’s been interesting to do this shallow dive. The US has a much higher supply of healthcare to meet a lower demand than the UK does, and so I saw way more neurologists and scanning machines, way faster. I think many people in the UK know how crazy expensive US healthcare is, but few will know just how good it is, for those with insurance. I remain convinced of the NHS’ principle of free care for all, I am certainly not keen to see a private system in the UK. But perhaps we should consider spending way more on the NHS: American-quality care for all would be a something to aspire to.