Socialized Medicine

The weekend we eloped, we didn’t do much. I was nauseous and Robert was exhausted. We went for a couple of walks in the nearby arboretum, did marriage, finished a prenup. But one thing we did immediately once the paperwork was in was add me to his employer-sponsored private health insurance. I was pregnant and uninsured except in Washington State or in case of accident abroad.

It was less helpful than we’d hoped. As an American, I expected even the most basic private plan to cover two things: pregnancy and checkups. In the UK, private plans apparently cover everything except that, by default.

You can see a doctor, but only if you have symptoms. And if you get pregnant, you’re meant to buy a “pregnancy package,” somewhere in the realm of £9k-£25k depending on whether you might want an epidural or multiple ultrasounds.

In the context of the National Health Service (NHS), this kind of makes sense. No NHS hospital will turn away a pregnant patient — no questions asked. Everybody has a general practitioner (GP) who takes care of all referrals. If you’re a citizen, all of this is free (or, covered by taxes). If you apply for a visa, you pay up front to be included, at about £1k per visa year.

That’s not for insurance, to be clear. That’s a flat rate for a year of full healthcare, at about the cost of a single month of decent insurance for a healthy American 64-year-old. It includes most of the body, though I think dental care is separate.

But although I could have gone to an NHS hospital for my early prenatal care, I didn’t want to jeopardize my anticipated visa application by acting like I lived there. A good instinct, it turns out: I later had to prove that my medical expenses had been privately paid as part of the application paperwork. So instead, Robert and I paid out of pocket for two ultrasounds, doctor visits, antenatal bloodwork.

Though I’ve never intended medical tourism, I’ve gone for medical care in Panama, Costa Rica, France, China and Kenya (surf-abraded earwax, ringworm, suspected typhoid, dysentery, and potential tapeworm, respectively). Across the board, I’ve found emergency care to be faster and much cheaper than in my home country.

In California, I once waited six hours to be seen for poison oak rash. Another time, I was informed that bookings for check ups were not available for the foreseeable future because the calendar didn’t go that far forward. Worried about a bleeding mole, the dermatologist (I called around until I found one I could see sooner than a month out) told me I could get a biopsy to find out if it was cancer, or just wait and see.

“Why would we not do a biopsy right away?” I asked.

Basically, she explained, it’s expensive. Not everybody goes for it.

Back in Washington, I’m on the state plan: no income means free health insurance, and it’s pretty good. My 20-week ultrasound (self-referred) was free. Back in 2018 when I was seeing a therapist, it was covered until I got part-time employment — at which point it became prohibitively expensive and I stopped going.

The United States has a very weird scheme for healthcare. It’s unevenly applied across the states (my California no-income healthcare was much harder to use) and full of perverse incentives. Like many Americans, I’ve been trained out of seeing a doctor unless absolutely necessary, because it’s always expensive and usually in mysterious ways.

Now that I have my spousal visa to officially live in the UK, I’m very interested to try out what a country with socialized medicine offers its residents.

I’m on the NHS, as of this week. I filled out a few online forms, identified one of the three clinics within a half mile of our apartment, and was assigned a primary care provider (GP, here) and NHS number. It was roughly as straightforward as applying for a library card. I’ve been asked in for an initial appointment: as yet unscheduled, but I’ve put in a request. We’ll see.

In the meanwhile, I’m also still exploring the private insurance available through Robert’s work. It’s interesting: quick to respond, but heavy on the pre-approval. I’ve been pre-authorized to see a dermatologist about a different mole I’d like checked out, but it took four or five phone calls to ensure I was authorized to see a specific practitioner with availability before mid-August.

“And make sure you call,” the man on the phone cautioned me, “if they want to do a biopsy or anything.”

“But isn’t that exactly what they will do?” I asked.

“We need to authorize the specific procedure code,” he clarifies. “So have the doctor tell you what it is and then call while you’re at the appointment. Don’t worry, they are used to waiting a few minutes.”

Very efficient.

He also warned that they might offer to do it “as aesthetically as possible” for an additional £500, which would not be covered, as it is cosmetic.

In the meanwhile, I’m over halfway pregnant and I still have no idea about care teams, locations, or available facilities for the birth.

Robert bought an expecting-parent book bundle. In that small stack is one by a UK midwife, which tells me to get the N8 form from my GP for free pregnancy prescriptions. The author describes a range of care options, implying that the NHS supports the same range of birth options (home birth in a blow-up labor pool all the way through full hospitalization) I would expect back in the states.

I’m interested to see what my GP has to say, how much guidance they will provide.

A fellow American expat on similar insurance tells me that she and all her friends who have given birth here would “of course” buy a private pregnancy package. But I suspect this is a tax bracket logic more than a well-reasoned choice.

I haven’t been impressed by the private system so far. At my first prenatal appointment, the doctor asked me more questions about the diamond on my finger than about my pregnancy symptoms. The second took three rounds of emails to give me a dosage for the iron supplements she recommended.

Both doctors looked to me to direct the proceedings, rather than offering guidance. And online, comparison guides suggest that the pregnancy package might buy you a better room for labor, but if you need specialized care, they offload you to NHS anyway.

Though my experiences have not been heartening, they have been interesting — and not worse than I’m used to. Price clarity is legally required up front, so consultant fees are listed at the time of booking. When I got my blood test done, the doctor’s order for the lab tech looked like a dim sum menu: check the box next to the selected test types. There was a price listing for each one.

Although pregnancy is a highly medicalized process, that’s a pretty modern conception of it. I’ve enjoyed my ultrasounds; it’s comforting to be assured that there really is a baby, that everything is proceeding on-plan. But nothing happened at the three doctor visits I’ve now done that will meaningfully change either process or outcome.

It’s my hope that it stays that way: this is a project of my body. The fetus takes the nutrients it needs; I eat and sleep, stretch and waddle around according to its changes. Even at birth time, I’m hoping me and the baby largely figure it out.

But it’s nice to take a bit of price uncertainty out. I’m on the national healthcare system now. No matter what happens, I’ll have the American-novel experience of giving birth without counting the cost.

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