Above Photo: Headquarters of NHS England. (Lad, CC BY-SA 4.0, Wikimedia Commons)
It is safe to say that, far from being overstated, the Americanization of the NHS is very nearly complete, write Stewart Player and Bob Gill.
One of the recent roles of the Parliamentary Healthcare Committee has been to reassure the British public that any claims regarding the ‘Americanization’ of the National Health Service (NHS) were wildly overstated, “creating a climate that risks blocking the joining up of services in the interests of patients.”
In fact, the penetration of the healthcare system by the giant U.S. insurer UnitedHealth reveals the opposite to be true, with the full extent of its influence capable of surprising even seasoned NHS watchers.
The Health and Care Bill making its way through official channels simply reinforces this, with the bill’s centerpiece, the 42 regional-scale Integrated Care Systems (ICSs), aimed at bringing together GPs, hospitals, mental healthcare and council services. It is being effectively designed and fast-tracked by the private UnitedHealth.
The U.S. healthcare system is of course a thing of nightmares. Insurance payments extract almost half the income of an average family, in return for which the nation consistently ranks last for access, equity, and outcomes of care in periodic studies by the Commonwealth Fund.
Not content with employer — or individual-based customers — giant insurers now see as much as 50 percent of their revenues coming from federally-funded services, with studies from Texas revealing the greatest profits within the privatized Medicaid system resulting from denying care to medically fragile children and the severely disabled.
Fraud, scandal, bloated executive salaries and minimal care constitute the norm, yet, owing to the state-capital symbiosis that defines the U.S., the cyclical clamor for reform only sees the industry emerge stronger every time.
This was nowhere more evident than the Affordable Care Act (ACA) of 2010 – also known as Obamacare. Less one thinks this is a digression, it is arguable that one can’t understand the position of the British NHS without also understanding the ACA.
According to BusinessWeek, the leading role in ensuring that ‘reform’ doesn’t happened and that ACA proved a bonanza for health insurers was played by the largest of them, UnitedHealth.
While superficially progressive, those newly insured under Obamacare were all channelled either to subsidized marketplaces or to privatized Medicaid to the extent that within a few years these programs had become the main artery of corporate profits.
The Role of Simon Stevens
Serving as point man in the process was the Briton Simon Stevens. Newly promoted as UnitedHealth’s vice-president, he was also charged with leading the company’s “strategic positioning for national health reform.” The company was nothing if not forward thinking when it also appointed him head of UnitedHealth’s Global Health Division.
With capital’s position secure in the heartland, United began to think of further expansion. In his new role, Stevens first helped set up in September 2011 the Alliance for Healthcare Competitiveness, a high-level lobby group with the aim of deregulating trade laws and forcing other nations to open up their health systems to U.S. for-profit insurers, hospitals, pharmaceutical firms, IT companies and other investor-owned firms.
However, it makes little sense to open up national systems unless these conform to standardized templates, and within the year, Stevens was acting as project steward within the World Economic Forum’s (WEF) project on sustainable health systems.
Advocating new care models – though in effect rebranded U.S. Health Maintenance Organizations (HMOs) – the WEF envisaged a climate where “health schemes and insurance markets boom as people seek to cover their health costs,” while governments “focus on regulating large integrated health providers in a complex expanding global marketplace.”
It only remained for Stevens to return to Britain – “my heart is in the NHS and in U.K. public services,” he said – and in October 2013 he was duly appointed as chief executive of NHS England. Since then he has pursued to the letter the aims of the World Economic Forum and U.S. capital’s.
A Mixed Economy of Care
In the process, UnitedHealth’s influence has extended across the board. Take commissioning of NHS patient care, for example. Under the terms of the 2012 Health Act, this was to be led by general practitioners but few family doctors had a clue (why should they?) and those that were involved were in it for the extra income and to rubber-stamp decisions made by the commissioning ‘support’ market. (The health care act removed responsibility since 1948 for running the NHS from the health secretary to clinical commissioning groups (CCG), providing an entry for private insurers.)
Serving as chair of the Commissioning Support Industry Group from May 2013, and also providing its secretariat, was UnitedHealth. The group also involved U.S. consultancies, KPMG, McKinsey, EY and PWC. UnitedHealth paid for an annual trip for “senior-level executives from across the U.K. health system” to find out how the company operates in the U.S. and to “explore their applicability in the U.K.”
Since then, this has meant amassing major contracts not only in commissioning support, but also in clinical governance, communications, human resources and workforce development, medicines management, and in implementing Personal Health Budgets.
Groomed By US Capital
As well as bankrolling the largest primary care network, Modality, it has also meant a near-monopoly in data analytics for United, particularly those relating to population health management and the risk stratification of patient cohorts – all exercises in assessing insurance risks and their subsequent costing as the system moves to a mixed economy of care.
But most importantly it has meant United playing the lead role in both defining and fast-tracking ICSs as they await formal legal status. Launched by NHS England in January 2018, the Optum Alliance – consisting of United and PwC – delivered a “major capabilities building programme” to “facilitate the move to whole system working” for the most advanced ICSs.
This included those in Birmingham, Warwickshire, Northumbria, West Yorkshire, Devon, Dorset, and Cumbria, and involved developing capabilities in care redesign – including “radical transformation of outpatient services” and developing primary care networks – financial management, effective leadership, integrated contracting, governance and delivery, as well as building sustainable, value-based, strategies.
For the program, UnitedHealth fielded its most senior partners and directors, all of whom were “experienced leaders in complex business systems.” Under the lead of ICS and clinical commissioning groups, hospital CEOs, finance officers, and local authority chief executives, worked alongside the Optum Alliance and NHS England. But as the director of commissioning for the West Midlands, Alison Tonge, pointed out, it was “UnitedHealth and PwC, who led the sessions.”
As such, despite the talk in policy circles of emerging leaders being brave, innovative, and capable of “high learning agility within new healthcare ecosystems,” it would instead appear they are dutifully being groomed by U.S. capital. Indeed, it is safe to say that, far from being overstated, the Americanization of the NHS is very nearly complete.
The Harm Caused
The Health and Care Bill will essentially provide legislative lock-in for the changes already embedded throughout the NHS. Patients will be denied care to generate profits for the ICS, over which their family physician or hospital specialist will have no influence, while the growing unmet patient need will have to be serviced either through out-of-pocket payments, top-up private insurance, or not at all.
The inevitable harm and suffering endured by patients without the money to pay for treatment will affect their families, carers, clinicians and society as a whole. Healthcare professionals working in this two-tier system will themselves be exploited, made to work beyond the competence, offered perverse incentives to act against the interests of patients to generate profits and in doing so fundamentally betraying the healing relationship.
The NHS will, in the immediate future, resemble ‘Medicare Advantage’ or ‘Medicaid Managed Care’, a basic, publicly funded, privately controlled and delivered corporate cash cow repurposed to make profit, though in time the full range of the organizational options found in the U.S. will follow.
All this will increase the total cost of healthcare, deliver less, harm thousands, enrich foreign corporations and destroy what was once Britain’s national pride.