The United Kingdom (UK) instituted universal healthcare in 1948 with the National Health Services (NHS). Meanwhile, the United States (US) utilized a market-based approach with a few exceptions (e.g. Medicare/Medicaid) and expansions [Affordable Care Act (ACA)]. Recent nationalist trends (e.g. “Brexit,” “America First”) spreading throughout Western nations are spilling over into healthcare. While the UK is considering disintegrating the NHS, the US is attempting to dismantle the ACA. Arguably, nationalist healthcare policies are the opposite of nationalism – they prioritize profitability for private companies over public health. With few exceptions, such policies limit healthcare access to those who can afford private coverage or have employer-sponsored insurance. More importantly, such policies exacerbate socio-economic health disparities by failing to prioritize healthy environmental and behavioral determinants of health, including physical activity promotion.
Prevention is key, but is missing in the current system
Evidence suggests preventive measures lessen costs associated with an uninsured and/or unhealthy population.1 For example, investing $10 per person annually in community-based programs aimed at combatting physical inactivity, poor nutrition, and smoking in the US could save more than $16 billion annually within five years, equating to a return of $5.60 for every dollar spent.2 Another recent analysis suggests that if 18% more US elementary school children participated in 25 minutes of physical activity three times per week, savings attributed to medical costs and productivity would amount to $21.9 billion over their lifetime.3 Additionally, simple behavioural changes can have major clinical implications. For example, simply brisk walking for 30 minutes per day (³15 MET-hours per week) has been associated with a 50% reduction in T2DM.4 Unfortunately, prevention is missing from the current US system. This is evident in that the Centers for Disease Control (CDC), the primary agency dedicated to promoting public health, receives only a small fraction of the national budget.5 This leads to missed opportunities for preventative healthcare, including the promotion of healthy lifestyle behaviors such as physical activity.6
Nordic nations provide an example of inclusive healthcare coupled with multi-layered preventive efforts. Scandinavia has utilized a more populist system based on the core idea of universal social rights.7 In this model, all citizens are given the same comprehensive healthcare while social determinants of health are targeted using a broad approach to population health. This includes “mobilizing and coordinating a large number of players in society,” which encourages cooperation among municipal political bodies, voluntary organizations, and educational institutions.7 Non-insurance-related areas that have been targeted on coordinated fronts include obesity, mental health, and physical activity.7
Importantly, the Nordic healthcare model has also translated to superior health in comparison to the US and UK. The Healthcare Access and Quality (HAQ) Index provides an overall score of 0-100 (0 being the worst) for healthcare access and quality across 195 countries and reflects rates of 32 preventable causes of death. Nordic nations had an average HAQ score of 95.4, with four of the five nations achieving scores within the top 10 worldwide.8 In contrast the US and UK had scores of 90 (23rd overall) and 89 (29th overall).8 The populations of the US and UK are far greater and more diverse than Nordic nations, therefore replicating the Nordic model is unrealistic. It can be said, however, that the fundamental values of inclusivity and minimization of health disparities within the Nordic system should be better represented within the systems of the UK, and particularly the US.
Public health and economic ramifications should be at the center of the discussion on the direction of healthcare among Westernized nations. The US is shifting away from the inclusive tenets of the ACA, while the UK is backsliding as nationalist trends surrounding Brexit and disintegration of the NHS are threatening to take hold. “Nationalist”, exclusive healthcare policies will harm the health and economy of the US and UK by straying further from prevention. This is not to suggest that inclusive healthcare will be a panacea, as social determinants of health must also be addressed. Only through universal healthcare and separation from a market based system will there be greater focus on preventive efforts including physical activity promotion.
Conflicts of interest:
Gabriel H. Zieff1 MA; Zachary Y. Kerr1 PhD, MPH; Justin B. Moore2 PhD, MS, FACSM, Lee Stoner1* PhD, MPH, FRSPH
1Department of Exercise and Sport Science, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
2Wake Forest School of Medicine, Winston-Salem, NC 27157 USA
*Corresponding Author E: firstname.lastname@example.org
- Preventing Chronic Diseases: Investing Wisely in Health Preventing Obesity and Chronic Diseases Through Good Nutrition and Physical Activity Percentage of Adults Who Report Being Obese,* by State. http://atfiles.org/files/pdf/CDC-HHS.pdf. Accessed May 14, 2017.
- Levi J, Segal L, Juliano C. Prevention for a Healthier America: Investments in disease prevention yield significant savings, stronger communities. Trust for America’s Health.
- Lee BY, Adam A, Zenkov E, et al. Modeling the economic and health impact of increasing children’s physical activity in the United States. Health Aff. 2017. doi:10.1377/hlthaff.2016.1315
- Hamasaki H. Daily physical activity and type 2 diabetes: A review. World J Diabetes. 2016. doi:10.4239/wjd.v7.i12.243
- Centers for Disease Control. FY 2019 Budget Detail Table.; 2019. https://www.cdc.gov/budget/documents/fy2019/fy-2019-detail-table.pdf. Accessed June 18, 2019.
- Young PL, Leigh AO, Medicine R on E-BMI of. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summar.; 2010. doi:10.17226/12750
- Magnussen J, Vrangbaek K, Saltman RB. Nordic Health Care Systems Recent Reforms and Current Policy Challenges Nordic Health Care Systems. Eur Obs Heal Syst Policies Ser. 2009. doi:10.1353/scd.2012.0002
- Fullman N, Yearwood J, Abay SM, et al. Measuring performance on the Healthcare Access and Quality Index for 195 countries and territories and selected subnational locations: A systematic analysis from the Global Burden of Disease Study 2016. Lancet. 2018. doi:10.1016/S0140-6736(18)30994-2