The high cost of health care in the United States drove Erica Rex to move to England following her breast cancer diagnosis.
The high cost of health care in the United States drove Erica Rex to move to England following her breast cancer diagnosis. iStockphoto
I moved to England in September at the age of 53, three days after my student health coverage at Columbia University ran out. Diagnosed with breast cancer last April, I knew I would not be able to buy a plan on the open market, even if I could have afforded it.
I had been struggling to find a full-time job in New York since 2003, following the breakup of my first marriage. It had been grim. Between the economy and the state of my profession – I'd been working as a journalist for many years – I hadn't been able to land full-time work. After yet another promising job melted into "we've had our requisition pulled so now we can't hire you," it occurred to me that a journalism degree might help. So in the fall of 2008, I returned to school for a mid-career masters degree at Columbia Journalism School.
Six weeks from finishing school, already deeply in debt from years of underemployment and student loans, I learned I had breast cancer—a rather large tumor of 1.6 centimeters that had luckily, not spread. A lumpectomy followed, then two months of radiation therapy.
At the time I was diagnosed, I had been seeing my English partner for less than a year. We had decided we would marry at some point; yet I had hesitated to set a date. I was career-obsessed. The cancer forced my hand. Our only choice – if I intended to continue treatment without going into even more debt – was for me to move to England, and for us to marry as quickly as possible so I could get on the National Health Service.
Lindenhall Surgery ("surgery" is the English term for a general practice, every NHS patient's first port of call) occupies a rambling house on a quiet, leafy street in Newport, Shropshire, where my husband works, a town about 90 miles northwest of London. I met Dr. Christopher Lisk, the principal general practitioner, after arriving in September and then returned later for his first examination of me. That exam was needed to get a in referral to a breast cancer center for a follow-up appointment with a specialist.
His waiting room windows overlooked a garden. Pamphlets lay on every available surface, offering guidance on topics from child safety to confidential chlamydia testing.
Then there were poetry pamphlets. I picked one up.
"To wake the soul by tender strokes of art,
To raise the genius and to mend the heart..."
- Alexander Pope
Poetry in the Waiting Room (PitWR) was the brainchild of a poet who discovered many of his friends were spending lots of time in NHS waiting rooms. It's funded by the British Arts Council and the NHS and aims, according to a brochure, "to comfort those waiting to see the doctor through poetry." An informational footnote declared that the pamphlets were described "in a House of Lords debate as the most widely read national poetry publication."
I tried to picture Orrin Hatch, Richard Lugar and Robert Byrd debating poetry on the floor of the Senate. I drew a blank.
Dr. Lisk called me to his consulting room over an intercom. He's a tall, sixtyish man with thinning blond hair, clad in a smart three-piece navy pinstripe suit. Scores of millefiori paperweights decorated his desk. A folding wood partition separated the examining space from his consulting office. Dr. Lisk's practice has a full-time staff of six general practitioners, a clutch of nurse practitioners and a harried office staff who cater to the medical needs of a substantial catchment area in Shropshire.
Dr. Lisk asked me how I'm doing on Tamoxifen, a breast cancer drug he prescribed in September. I explained to him that I was worried about my six-month mammogram, which I had not yet undergone. The chances that I'll make it to 12 months or two years improve if I haven't suffered a recurrence by six months. Breast cancer is a numbers game.
"First things first," said Dr. Lisk. "Take off everything but your panties and have a seat on the bed." I undressed behind the partition. There were no gowns. I sat on the examining table in my underpants, hugging my arms over my chest. The room was freezing.
He came in, washed his hands, and reached for a sphygmomanometer, to take my blood pressure. It was like those I remember from childhood: a rubber bulb squeezed to inflate the cuff, a vertical column of mercury encased in glass. He held the cold disk against my skin, and listened as the air hisses out of the valve.
Then he palpated my breasts, then my armpits. "How many lymph nodes did they remove?"
"Six," I replied. He listened to my chest. Then, vertebra by vertebra, he examined my back.
As his fingers probed, he was looking into space, his head cocked to one side, as though he was listening for some furtive whispered message. He was like a talented pianist, meticulously pressing the piano keys, discovering nuances of the music even as he plays. He probed more – my neck, then my groin, searching for the elusive lymph node that would divulge a tale of metastasis.
"Aches? Pains? Other complaints?"
Besides weight gain, night sweats and attacks of gas which he apologetically attributed to the Tamoxifen, I couldn't think of any.
"Get dressed then," he said, "and come sit down."
Putting on my clothes, I concluded it's impossible to characterize the difference between health care in Britain and the United States in a few sentences.
Every feature of U.S. health care, from insurance company to doctor's office to drug company, exists as a separate for-profit enterprise. Here, health care is part of the social fabric. Prevention isn't just a matter of common sense, it's public policy. Cigarette packages have the words "Smoking Kills" emblazoned on them in huge black letters. Tobacco is taxed at a figure approaching 100 percent.
Erica Rex is a journalist currently living in the United Kingdom.
For me, though, what's critical is knowing that if I have to have more surgery, I won't find out, after the fact, that I owe hospital copayment charges of $4,000 — and this, after my surgeon forgives $6,000 of his $12,000 fee. (It turned out he wasn't in my insurer's preferred provider network.) My prescription drugs, now that I'm on the NHS, are free.
Shortly before I left New York, I had drinks with a South African friend. He asked me how I felt about the move.
"I wonder whether I'll ever get past the feeling that the bottom could fall out any minute, even once I'm on the National Health Service," I said.
We agreed survival anxiety probably accounts for a lot in the American character. Our edginess, perhaps. Unless, of course, you're Bill Gates. In the U.S., money really is everything.
Sometimes my husband Roger gripes about what he calls the British "nanny state." So much is done for the English, he maintains, they can't think for themselves anymore. Showers, for instance, are statutorily equipped with automatic shut-off valves on the thermostats. In case the water gets too hot. I remind him that the opposite of the nanny state is me in the U.S. with breast cancer and no steady job and insurance.
I had some wonderful doctors in New York, caring and helpful. But I also had to fight with my hospital there to get the tests I needed, and several of the specialists were so difficult to deal with I chose medical protocols to avoid them—no matter what the best option for treatment was. What I really notice about the health care providers in England is that they seem to have more than half a second for me – and they actually listen.
At his desk, Dr. Lisk scribbled notes on a pad. He said that he was referring me to a breast center at Rowley Hall Hospital in Stafford. The building, he told me with some amusement, used to house a reformatory for wayward girls, until the NHS bought it.
"They'll send you a letter with an appointment," he explained.
"When?" I asked.
"Within a fortnight, I should think. Ring me if you haven't heard from them by the end of next week."
I stood to go. I thanked him. He walked over from behind the desk and clasped my right hand in both of his.
"Try not to worry. They'll take good care of you at the breast center. It's a very good one." His face had the same slightly abstracted look it did while he examined me. Then he changed tense; he changed pronouns. "I'll see to it myself you're taken care of. I personally will take responsibility for your care."
This story was produced through collaboration between NPR and Kaiser Health News (KHN), an editorially independent program of the Henry J. Kaiser Family Foundation, a nonpartisan health-care policy research organization. The Kaiser Family Foundation is not affiliated with Kaiser Permanente.