Rarely do stories occurring on opposite sides of an ocean so perfectly compliment one another.  Yet last week Santa Barbara Congresswoman Lois Capps described the new health care reform legislation as “a big gamble”, one whose effects could not be known with any degree of certainty.  This from a strong proponent!  Well, this week I read of some interesting developments in England where similar language was used.  Both are likely true, and it is fascinating to see the evolution of government administered care 60 years hence.  Gambles indeed, let’s take a look.

One can view the British NHS as the quintessential example of a centrally administered health care system.  Layer upon layer of bureaucracy determine which services will be covered and for whom, what every professional in the chain of delivery will be paid, who may deliver services and even what people may contract for with their own funds.  It is in fact, the largest employer in the Europe, with over 1.3 million employees.  But that is about to change.  Articles in the BBC and the WSJ describe an NHS in crisis.  A 60 page government document details the overhaul planned for the NHS over the next four years.  Among the changes will be elimination of an entire layer of financial managers (bureaucrats) with the goal of saving 45% in management costs and reallocation of these funds to support “front-line services”.  Gone will be the 10 “Strategic Health Authorities” and the 152 management bodies known as “Primary Care Trusts”.  They will be replaced with one “Independent Board” overseeing up to 500 consortiums of GPs tasked with setting standards, and controlling costs.  Oh, and this board is to be free of political influence or pressure as such bodies usually are.  To me this is sounding somewhat eerily like the HMO model, but as the reports state, only time will tell.  The fact is, to quote the British government report,  the changes “will cause significant disruption and loss of jobs … but it has rapidly become clear to us that the NHS simply cannot continue to afford to support the costs of the existing bureaucracy; and the government has a moral obligation to release as much money as possible into supporting front line care.”

Other reform features include lifting restrictions on how much money GP consortiums may earn from private care, encouraging private hospitals to compete with NHS facilities for patient services while also allowing the NHS hospitals to see private payer patients, and even allowing physicians who have opted out of the NHS system to once again provide contracted services.  Of course, just as here, such transformational change is seen through wary eyes.  Shadow Health Secretary Andy Burnham described the moves as “a huge gamble”.  NHS staff are split with some predicting “chaos” and others lauding the reform.

So why is this relevant here?  Simply because with large change come unplanned effects and unforeseen secondary consequences.  We know this well, having detailed many possible collateral effects of Obamacare on the pages of this blog.  Still, folks here in Santa Barbara were astounded last week to hear admission of this uncertainty by our Congresswoman Lois Capps.  Ms. Capps had arranged for a private meeting with the Primary Care community to describe for them the wonderful changes they could expect under HCR.  Unfortunately, most were not buying.  One local Internist asked where they expected to find all the physicians to care for the 33,000,000 new patients to be added to the system, a point we have raised in the past.  Her answer belied awareness of the 7 years  required to mint a new family MD, versus a demand which begins in three.  One Anesthesiologist (your humble narrator) asked Ms. Capps how she could assure us the bill would not lead to an explosion in medical costs, since the original cost projections for Medicare proved off by a factor of 9x, might this pattern be repeated destroying both the health care system and the overall economy?  Channeling Ms. Pelosi her answer was far from reassuring: “I don’t have a lot of answers to your questions because we have to see if it works”.  Amazingly she described the entire endeavor as “a big gamble” a statement that  drew ire from both those in attendance and many citizens who wrote letters to the editor dismayed at the thought. Had we not been told they had this all figured out, all under control?  How could a Congresswoman, a former nurse who claims expertise in medical issues, be so without answer for the simplest of inquiries?

Well we can hazard a few guesses as to why.  First, it is unlikely many of the Congressmen/women read this legislation before passage, and even more clear they had not read the conference committee bill which was drafted in secret by majority leaders Pelosi and Reid.  Second, they have essentially zero insight into the nuts and bolts of medical practice.  They perceive unlimited office budgets to purchase electronic medical records systems, to comply with the 50,000 pages (to date) of Medicare regulations or to absorb ever decreasing reimbursement.  They have no idea how long it takes to train a physician, the different skill sets involved in primary care versus various specialties or even the customization of medical decision making based on personal patient criteria.  What they believe, instinctively and with almost religious fervor, is the capacity of expert panels to set best practices from a think tank in D.C.

One may consider it an odd juxtaposition that the British NHS, after 62 years experience, is moving in the polar opposite direction from our policies in America.  Slashing layers of bureaucracy, in an acknowledgment of the ponderous beast it has become, NHS seeks to devolve power to the periphery even as the U.S. administration seeks to concentrate it in Washington.  We hear word from our English progenitors that it is morally unconscionable to waste such vast resources on planners, to the detriment of care.  Just as Greece can provide us with a painful example of sovereign debt gone awry, a path we are also seeking to emulate rather than avoid, the NHS provides us with a clear picture of the dysfunction inherent in vast bureaucracies and the poor service they tend to deliver.  Like the refusal of the G7 to provide additional stimulus, our socialist allies are once again schooling a putatively free market economy on the excesses of government overreach.

So yes, I suppose both the British Health Secretary and our own Congresswoman are both correct; this is all an enormous gamble.  There is no way to predict the second and third order consequences of such decisions, a fact both have reluctantly acknowledged.  I wonder, will either stop to consider whether they serve the will of the people they theoretically represent or their own ideological needs?  Likely they will not.  But it is equally likely they will amble on, delivering a gamble no one asked for with potential consequences none can predict.