Many of the problems with the NHS derive from the UK government's attempts to privatise it. If you're short on time but want to understand more, look at the mess with PFI used to fund the building of new hospitals.
EDIT: If you've got more time/interest I'd recommend the documentary Sell-Off:
Exactly. The Conservatives literally run on a platform of "Government-run things are shit", so they need to ensure that they don't run anything that works. From the East Coast rail franchise (which went downhill immediately after selling to Stagecoach/Virgin) to the NHS and more.
Quite right. Whilst there are probably some pragmatic Conservatives, the general ideology of the Conservatives is that publicly-run services are poorly run and should be privatised, even when it's clear that they're effectively run.
To give another example, look at what has been happening with the Land Registry recently, there has been talk of privatising the functions that the Land Registry performs, even though the Land Registry is a profitable institution that makes money for the government.
You seem to be interested in this subject. As an outsider, I've been wondering why there hasn't been more of a ruckus after the Royal Mail privatisation.
As I understood it, the shares turned out to be underpriced by about 80% and were primarily sold to a secret list of short time investors that made bank.
Have I misunderstood what went down? If not, how is this possible in the UK without any political repercussions?
I'm not overly familiar with what happened with the Royal Mail privatisation, but thank you for suggesting it as a subject, it sounds like something worth investigating further.
I'm also not overly familiar with mainstream news media in other countries, but if you had to point the finger at any one group in terms of why there hasn't been more resistance in the UK to the dismantling of public institutions, a large portion of the blame lies with our crap mainstream news media. The public aren't kept informed about matters of substance, they're distracted by misinformation and personality politics. It may be a problem we share with other countries (from the outside, the US mainstream news media seems similar/worse), but it doesn't have to be this way. We could have mainstream news outlets that gave people a chance to get better informed about the issues being faced in their country/community. It's an essential part of society that is sadly missing, I don't think you can have an effective democracy (effective in the sense of standing up for public interest) without a well-informed public.
If I recall the story correctly, the government sold at a price that had been suggested to them by many highly paid financial services consultants. The fact that the pricing was wrong may or may not have been avoidable, but one of the basic arguments for privatisation is that it's hard to get and keep competent civil servants, so the fact that the final act of privatisation itself is often screwed up is not supposed to be very surprising. Just think how often pricing decisions were screwed up before!
> You seem to be interested in this subject. As an outsider, I've been wondering why there hasn't been more of a ruckus after the Royal Mail privatisation.
I think people just care a lot less about the postal service since we stopped writing personal letters with the advent of email and social media. It's just not the lifeline it once was. Postal services are now in the business of delivering junk mail.
> Maybe teach kids in school how to use the health care system (hey, why not NHS ed alongside drivers ed or sex ed?).
We should probably break the news to her that there is no "drivers ed" in the UK.
But she is right. The NHS can be great, but the way the government is fucking with it at the moment will prove disastrous. It is education, not privatisation, those are the answers to the problems of the NHS.
I suspect that some of the meddling with the NHS is intended to be disastrous so that public opinion is more likely to accept profit-generating private schemes.
NB Some schools (at least here in Scotland) do offer classes on the theory part of the driving test as "interest" courses.
Edit: I eventually found the quote that sums up the approach that is being taken with the NHS:
"Only a crisis - actual or perceived - produces real change. When that crisis occurs, the actions that are taken depend on the ideas that are lying around. That, I believe, is our basic function: to develop alternatives to existing policies, to keep them alive and available until the politically impossible becomes the politically inevitable.”
Milton Friedman
Of course, the crisis that created the NHS was WW2 - I remember my father (who served in the RAF in WW2) being pretty clear that returning to the pre-war status-quo was not an option that anyone was interested in, which is why there was such a resounding defeat of Churchill at the polls when the war ended.
I think the NHS is a massive government department that uses a huge amount of money (legitimately) and absolutely no government is capable of being in power and not "meddling" with it.
Which is idiotic. e.g. if you get tests done in one country and move to another they cannot access your scans/x-rays and end up just doing them again. Waste of money but more importantly the case history is getting distorted as you're repeating it and likely missing notes the original doctors had made.
On the other hand... for a lot of things, NHS Scotland handles long-term healthcare better than NHS England. NHS England essentially got forced into creating a watered-down version of the Gender Reassignment Protocol a few years after Scotland implemented theirs, and from my understanding it's incredibly difficult to get anyone to follow it. I wouldn't give up NHS Scotland for the English system - and I think many Scots would agree. (And I voted No to independence!)
As an outsider my understanding is that one of the first things Scotland did after getting the ability to do so, was to roll back may of the recent changes to the NHS. This to the point that Norwegian politicians, the nation going through something akin to the Thatcher-Blair process, went visiting.
Scotland can do this partly because it is heavily subsidised by the English. If the subsidies vanished I think NHS Scotland's performance would be significantly worse.
I didn't really put my point across properly. Separation is important so citizens in each country can tailor services to their specific needs but data sharing should still be possible and automatic.
UK for all intents and purposes, is four nations sharing a crown. Not unheard of in European history, just look at the likes of Denmark-Norway, but perhaps the only one that has lasted to the present day.
And I imagine the long-term goal would be to share the records among EU countries (well, not the UK anymore) since healthcare is valid across the union, but language barriers make that pretty difficult
Health data, including imaging and genomics, should be held by third party custodians and delivered as needed to registered providers. The data can be handled by the provider's viewing system. The cost can be covered by charging the system providing the care a fee: part transmission, part long-term storage.
This is already starting to happen, but is still regionalized and very fragmented.
"I suspect that some of the meddling with the NHS is intended to be disastrous so that public opinion is more likely to accept profit-generating private schemes."
This is exactly how the Tories do things: they get agents on the inside to sabotage a system, run it down, give it a bad reputation until it can be killed-off with the public's blessing. The BBC is also being sabotaged.
The Conservatives are so brazen about it they'll even spell it out in writing. This is the Google Books synopsis for the book Privatising the World by Conservative MP Oliver Letwin:
"Identifies the reasons why governments in a number of different countries have chosen to privatise their nationalised industries. The opposition to privatisation and the techniques used to overcome this opposition are also analysed."
You realise the UK has a large deficit, right? And taxes are comparable to other western countries.
The NHS will never not be broke. Your position is typical of the British left but is entirely meaningless: the government could go into Greek style debt to double the budget of the NHS tomorrow and 10 years later it'd be once again constantly broke.
Depends on your definition of "broke". If you think of something that requires tax money to function as perpetually broke then you're only seeing half of the story. Do you agree that, per person, the British spend less per head on healthcare than people living in the US? If so, why do you think this is?
As I said in a different comment, many of the problems in the NHS have come from privatisation. If you want the NHS to cost less, take a look at what's happening with PFI. Just by stopping PFI funding of hospitals and going back to the old funding model of government loans at low interest rates could save huge sums of money.
I do agree that the UK spends less per head than the US does and gets more for it. But the USA has one of the world's most dysfunctional health systems. Constantly comparing the NHS to it, or worse, implying that people face a binary choice between the US system or the UK system, is a fallacy that ignores the highly capable and often very efficient healthcare systems in other countries. Which don't seem to suffer the same ills of the NHS.
It's also not the case that the UK vs US comparison is one of government vs capitalism. All healthcare systems have heavy government involvement and distortion of the healthcare market, and this is fine, because developed societies always choose these problems over the much larger problem of poor people being unable to afford healthcare.
PFI schemes have not been good value for money and were essentially a trick to hide the ballooning costs of the NHS from a population that can't treat the topic rationally. Unfortunately, too many people in the UK look at this sort of thing and instead of saying "wow our government is really bad at public procurement, we should give them less power" conclude something along the lines of "oh noes, they should have guessed that trying to buy things from companies would lead to disaster - the solution is a fully state run economy!"
All kinds of organisations manage to procure services and investment from the private sector, all over the world, every day ... without problems. PFI boiled down to a complicated kind of loan that let Labour do what it always seems to try and do: massively increase spending on the public sector without raising taxes. No surprise that they paid a very high interest rate for such a thing.
> "Constantly comparing the NHS to it, or worse, implying that people face a binary choice between the US system or the UK system, is a fallacy that ignores the highly capable and often very efficient healthcare systems in other countries. Which don't seem to suffer the same ills of the NHS."
I'm glad you could admit that the NHS wasn't the worst system out there. As for better systems, I'm not saying the NHS is perfect, what I am saying is that it can be improved by stopping the drive towards privatisation, as this drive is making the NHS less efficient at spending money on healthcare, not more efficient. Furthermore, even with these inefficiencies, the NHS continues to offer a cost-effective service, and I don't even need to use the US healthcare system to compare it to. The UK spends less per person on healthcare than France and Germany, for example:
The NHS isn't a money pit, it's a bargain. If you made it more efficient by getting rid of the privatisation efforts, it could be even more of a bargain.
> "PFI boiled down to a complicated kind of loan that let Labour do what it always seems to try and do: massively increase spending on the public sector without raising taxes. No surprise that they paid a very high interest rate for such a thing."
This is where your partisan bias is blinding you. PFI wasn't just popular with New Labour, it's been popular with the Conservatives that replaced them in power. If the Conservatives are supposedly more fiscally responsible, why do they continue to use expensive PFI schemes to fund government spending?
PFI reached its peak in 2007. Current number of deals being added are at the level they were at in 1995.
It's worth asking why any new deals are being signed at all, but when we're down to the level of 8 per year (vs 65 at the peak of New Labour) it's fair to say that they're much less popular than they once were.
To anyone who intuitively understands why the maintenance of human health and well-being might suffer for being corrupted by vested interests who are more interested in said vesting than human health and well-being (ie, "opposition to privatisation"), the disturbing aspect is precisely how non-nefarious and academic the synopsis seems.
"Starve the beast" and other traditional conservative anti-public-service techniques are functionally sabotage, yes. I'm not sure what other concept might succinctly describe "cut as much funding as you can, then highlight the resultant disaster as proof that the private sector can do better". The cultural acceptance of the practice doesn't change what the practice is.
I'd think the UK population are a bit gunshy about privatization after privatisation of British Rail. I'd also think that the US would have learned their lesson by looking an Enron... but since when have facts gotten in the way of a good story?
That quite can be applied to the whole neoliberal process that has been ongoing since the 80s.
First laden the public services with excessive regulations and budgetary constraints to make it crack, loudly publicizes the resulting failures, claim TINA on privatization/deregulation of the market, laugh all the way to the (offshore) bank.
This is indeed a classic tactic, but I'm surprised you refer to it as "neoliberal". Deregulation, privatization, and "Starve the beast" have been conservative platforms since Reagan.
"Neoliberal" is a particular economic approach within the broad umbrella of political conservatism. (In the US this is somewhat confused because lots of the Democratic Party is neoliberal, but the Democratic Party is basically a coalition of moderate left to center-right, leaning more to latter.)
Services like the NHS are money pits: no matter how much money they are given they will always be broke, and given the total lack of accountability inherent in the system there will always be regulations trying to improve their efficiency. Thus ANY public healthcare service, at ANY time, will be perceived by some large part of the population as "laden with excessive regulations and budgetary constraints".
This is not some neoliberal conspiracy, it is the natural consequence of any system which allocates money without sufficient accountability.
You buy a copy of the highway code and you learn it. You then do a theory test, which has a relatively high pass mark - covers rules of the road, hazard perception, etc. Then you do your practical test. Most folks seem to fail at least once. I failed twice.
I've both UK and US licenses - did drivers ed in illinois in the 90's, aged 15. Watching gruesome films didn't make me a better driver, and I remember being stunned when I was told I'd passed - we didn't even go on a public road!
I can tell you this is pretty vastly different now. I also grew up in Illinois, and after passing the theory test you are only granted a learner's permit. To obtain a license you need 50 hours of supervised practice behind the wheel, at least 10 of those hours being at night. You're then given a practical test at the DMV where you take public roads with a designated instructor.
At least, that's the process to get a license before you're 18, I think after 18 you just need to pass the practical test. And since usually the person filling out the 50 hours sheet is one of your parents it's definitely possible to just lie about it.
In Ohio, it consists of about 10-15 minutes of driving around public roads following the instructions followed by a parallel parking test using cones. Most other states are pretty similar.
For comparison, in Sweden the practical test is 45 minutes of driving on public roads (including a highway) where things such as eco driving and safe driving (not slowing down past a parked bus is an automatic fail) are also judged. The standard is doing it in a manual transmission car and a minority choose the exception of doing it in an automatic. Sweden's a Nordic country so we also have a mandatory snow driving (skid pad) experience before you can take the test.
Would you consider it difficult to pass? Are there any numbers what the failure rate is?
Just for comparison, here in Germany, you have to take a 14 hours of theory lessons and then do a theoretical test (which has a 25%+ failure rate). Once you passed that, you have to take 20 hours of mandatory driver training with a certified instructor. The instructor will decide if you need additional training hours (up to another 8 hours). The practical test then consists of 25-30 minutes of driving and parking (in a real parking spot, not cones). This practical test also has a 25%+ failure rate. Also, all that happens in a car with manual transmission.
Technically doesn't have to be a manual, if you're fine with not being allowed to drive a manual afterwards. So basically only done by people with medical conditions that can't drive a manual anyways.
No. It's literally driving around a few streets, stopping at a stop sign / stop light, and (maybe) parallel parking. I had to do it with real cars, which in retrospect were junkers that the DMV had for the purpose.
> Are there any numbers what the failure rate is?
Massachusetts provides a list of drivers ed schools with their pass rates - it seems to vary from 50% to 90%. Cutting that in half and adding a little bit, (the highest pass rates come from large, successful schools) the pass rate seems to be around 75% or so.
However, this is for teenagers who went through driver's ed - adults have a much, much easier time with the test because they're more mature.
Also, it greatly depends on the state. When I was in the Marines, I had the wonderful task of teaching boots how to drive so that they could get an Arizona driver's license. Their test was literally just driving around the block, no parallel parking involved.
I took the test in a manual because that's what my dad had, but most take it in an automatic. In all seriousness, though, a manual really isn't that hard once you spend a few hours stalling at every stop sign in a suburban neighborhood.
There's no assumption that all students will need or want to learn how to drive, so it's not a part of any standard curriculum; you pass the exam and get a driving licence when and if you're ready for that.
Many do it soon after they can, many do it later as adults, and many never do. In UK only ~35% of adults aged 17-20 and ~65% of 20-29 have a driving licence; I assume that this is a bit different in USA.
It's not, I have no idea what the person you replied to is talking about.
It's a private school. Most kids learn by their parents teaching them. If the parent can not do it for whatever reason, then they register with a drivers ed school, and the teacher teaches them.
In some states if you take the theory classes [not the road practice] you get a discount on your insurance - that sometimes is part of highschool.
Every state is different though, some require a logbook with road hours, some don't, some have more theory classes, some less. It varies a lot.
It varies state-to-state. I grew up in Florida, where I started learning to drive at age 14. I was taught entirely by my mother, and I earned my learner's permit at 15, then was fully licensed at 16 after passing the tests.
About five months after I was issued my driver's license by the state of Florida, we moved to North Carolina, where driver's education is compulsory for people under 18. They would not issue me a North Carolina driver's license unless I completed driver's ed., even though I was already licensed in the state of Florida.
As a result, I enrolled in driver's ed. via my high school. Classes took place in the afternoon after all my regular classes were finished. Then, while my classmates were waiting for their rides, I got in my car and drove myself home. For the on-road portion of the coursework, I drove myself to and from the school on Saturday mornings and hopped in the "Student Driver" car. My instructor, knowing I already knew how to drive pretty well, just had me drive him on his errands -- grab a coffee at McDonald's, return some tapes to Blockbuster, deposit his paycheck at the bank, etc.
It was bullshit, but I had to do it to obtain an NC driver's license.
Of course, after college I moved to northern Virginia for work, and getting my VA license was as easy as filling out a form and showing them my NC license. Done! The VA DMV puts the NC DMV to shame in many ways, including efficiency. (In NC, we also have separate DMV offices for licenses and tags. Pain in the ass!)
There are many places where it's not a private school. In the places I'm familiar with, it's an elective. I had both theory and road practice as one of my (standard, school-hours) classes sophomore year. The instructors were basically all sports coaches.
There is, but not in the same way. In the UK driving lessons are not typically taught in schools. At age 17 you can apply for a provisional driving licence, which allows you to drive on most roads with 'L plates' attached and a fully-licenced driver in the passenger seat. Many people pay for lessons, but it's possible to pass your test after only informal practice. There's a theory test that must be passed before taking your practical test; your practical test will be on real roads and not an area designed for that purpose.
Offering it in schools makes sense... it's education. If "compulsory" wasn't being implied, then it's an obvious non-issue, and I'm not sure why anyone brought it up.
Because they were commenting on the fact that it isn't offered in the UK in schools at all, which the author didn't appear to realise. I don't see anyone calling it an "issue" at all.
The NHS is great at emergency care. I came down with a severe infection a few months ago and landed in Glan Clwyd. I was practically grabbed as I staggered through the door, and spent a few days in a private room (!!!) white they figured out whether what I had was infectious. Then a few days on a general ward, then discharged, well enough to finish sorting myself out at home. The staff were lovely, friendly, genuinely caring people - although I worry for their futures, given that most were EU nationals, and the only UK natives were agency staff. In my less delirious moments we chatted about the impending brexit vote - very worried faces.
When it comes to long term or weird and wonderful stuff - not so great. I've been bouncing around referrals for five years, and the lack of digital records means that they have to mail 30lbs of paper to each other before I show up. If the records didn't arrive, I have to dictate my case. Again, and again, and again. Still undiagnosed. One particularly spectacular SNAFU ended up with me having unnecessary surgery, because someone read the wrong notes.
Their core infrastructure is in dire need of modernisation. The government seem to think the answer is creeping privatisation. If they hadn't wasted £14bn on lining their chums pockets, the NHS would probably be pretty unassailably brilliant by now. https://en.m.wikipedia.org/wiki/NHS_Connecting_for_Health
It isn't like that doesn't happen here in the US. That sounds like part bureaucratic problem and part difficulty of diagnosis. I know plenty of people who ended up in similar situations or got the wrong diagnosis for years despite having pretty good medical insurance. You'd still have to get your medical records transferred around.
You talk about "they" as if government is a single group of people.
The fact that the NHS is still fundamentally paper based, in 2016, is exactly the kind of problem that leads politicians to want more use of the private sector. In many private industries, even highly regulated ones like finance, the people who first successfully transitioned the industries to computer based systems are now dying of old age. The NHS hasn't even started. In fact it's fair to say that the NHS has shown no ability to fundamentally improve itself. It deploys new medical techniques and drugs (developed in the private sector) but when it comes to changing the organisation or adapting to new business ideas, like computerisation, it has utterly failed.
This is very frustrating for the politicians who are ultimately held accountable for the performance of the NHS. They sit right at the very top and can hardly influence anything - all they can do is set general directions like "use computers for medical records", and then watch helplessly as the incompetent staff below them screw it up, over and over again. Meanwhile they watch as Google or Facebook go on to build self driving cars and global communication networks.
Worse, as students of politics, they know full well what the reason is: the NHS is a classic, communist style top down command-and-control system. Deep institutional rot is exactly what to expect from such an arrangement. Yet they can't change it because the British have an irrational knee jerk reaction to anything that implies people in the private sector can be equally or more competent than people in the public sector.
> In many private industries, even highly regulated ones like finance, the people who first successfully transitioned the industries to computer based systems are now dying of old age. The NHS hasn't even started.
I wish Canada's system was that good. I've been to the ER twice. 6-8 hour wait for things that weren't life threatening but definitely required an ER visit. Ever waited in an ER for 8 hours while sick as a dog? It's awful.
But then I think about how often I intend on being at the hospital and will gladly pay 8 hours every time if it means nobody has to find a co-pay to learn if their cancer is back.
I can't speak for other provinces, but in Quebec this whole story would have ended very differently. I guess we have a lot to learn from the UK in that department. From what I understand we have a shortage of Doctors AND an ageing population, which makes things even more difficult.
Quebec has a shortage of doctors because the College des Medecins is prejudiced against foreigners and makes it harder for immigrant doctors to practice there (compared to other provinces), meanwhile the doctors that do get a degree there are probably not interested in the low salaries and also go elsewhere
I waited 6 hours in an US emergency room. Compared to EU ER rooms an horrible experience. All kinds of people with unfixed long term problems that apparently only the ER is obliged to handle.
Btw the reason was even more frustrating:
A us doctor (turned out nurse/practitioner) told my GF that all the obvious reasons are not the cause of her short breathness. So it might be a deadly one - we needed an xray to make sure - we had an xray with us but she wasnt comfortable looking at it because of missing education. She offered us an ambulance to the ER. We had no issues whatsoever - she just tried to cover her ass in case of.
I waited 6 hours in an US emergency room. Compared to EU ER rooms an horrible experience. All kinds of people with unfixed long term problems that apparently only the ER is obliged to handle.
If it makes you feel better many doctors are themselves disillusioned with the system: http://jakeseliger.com/2012/10/20/why-you-should-become-a-nu... and I have heard many ER docs complain about how they don't have enough time to adequately see, understand, and diagnose each patient. And the rants against EMRs are epic. One friend said that he chose a hospital because they still use T-sheets.
But the NHS keeps telling us to not go to the doctor!
"See a nurse rather than a doctor! See a pharmacist rather than a doctor! Phone a helpline rather than see a doctor! Go to your high street chemist rather than see a doctor! Self-treat rather than see a doctor!".
I had subpar experiences in the UK with the NHS but not horrible.
Telling people not to go to a doctor is dangerous but i can understand the intend.
Eg:
(Can only judge with Austria/Germany experience)
Pharmacists are extremely highly trained there. They are implicitly used as a simple doctor. We do the same. You feel bit weird you go to the pharmacy just to gauge what it could be and how serious they take it. If serious enough you go to a doctor asap.
> You feel bit weird you go to the pharmacy just to gauge what it could be and how serious they take it. If serious enough you go to a doctor asap.
They must be very confident pharmacists. If anyone ever asked me 'do you think I should see a doctor' I would say 'yes' every time.
What happens if you get it wrong? Doctors are protected by major institutions, insurance, legal precedents. What about someone working in Boots (UK high street pharmacy chain) who tells you not to bother seeing a doctor and then you die?
We have a bunch of different health advice, from NICE and Public Health England and etc. So if a pharmacist is getting close to that advice they're going to be protected.
Admittedly their advice would be "You probably don't need to see a GP for this, but if you're at all worried you should make an appointment".
You're missing the wood for the trees. The 'doctor' part of the statement wasn't the important part, it's that early diagnosis is encouraged. For example, the NHS has the NHS 111 helpline for times when you want medical advice but it isn't something that requires visiting a doctor (they can refer you to a doctor if it is something that requires further investigation).
If you do any of those things and it turns out to be something they can't handle, they send you to a doctor. I've phoned 111 a couple of times, once had an appointment made for me with an emergency dentist, and once been told to wait my illness out (severe stomach pain) as it was unlikely the doctor could do anything for me aside from prescribe painkillers. If I'd seen a doctor the second time, it would've been a waste of the doctor's time.
Yes, but look at how many people go to see a doctor with a cold or at the first signs of a sore throat. That, along with missed appointments, are what makes the process so inefficient.
The reason the EU model works is that doctors (and other medical professionals) get paid less. A quick google search suggests a US ER doctor or radiologist gets paid more than 3x what a British one does, a family practitioner 2x.
"You have a concern - you go to the doctor" is a waste of money. We've done randomized controlled trials to study this question and the result is more money spent with no increase in health.
>> "The reason the EU model works is that doctors (and other medical professionals) get paid less. A quick google search suggests a US ER doctor or radiologist gets paid more than 3x what a British one does, a family practitioner 2x."
I'm not sure if you were posing this as a problem or not but as long as doctors want to work for the NHS it isn't one.
I'm not posing it as a problem. I'm simply pointing out the real reason things work in the UK is that people pay less for the same thing.
Tangentially, if anyone proposes UK-style solutions to health care problems in the US without proposing 50-66% wage cuts for doctors/nurses, they are lying to you.
I have no problem, in theory, with socialized medicine that we drastically underfund. It's probably a great way to waste fewer resources on medicine.
In practice that's just not politically feasible in the US. An illustrative example: a few years ago, a major study found that mammograms before age 50 are financially wasteful and medically harmful. Congress passed a law requiring insurance companies to pay for them anyway.
> Medicare, Medicaid and the must stabilize mandate for ERs are underfunded. It's one of the reasons that out of pocket costs are so high.
Exactly. This is the hidden secret about US healthcare that very few people are aware of. Even providers usually don't see this anymore, because they're so removed from the billing process (especially now that most providers are salaried and not running their own practices).
Medicare and Medicaid are the reasons that sticker prices for treatment in the US are absurdly high. Incidentally - and most people don't know this - if you're uninsured and self-paying, you almost never have to pay the sticker price. Hospitals really don't care, and if you just tell them that you're self-paying and can only afford (say) 10% of what they billed you for, they'll almost always immediately agree to a 90% discount. The only reason they're showing you that bill is that they need to present high bills to private insurers (to make up for the loss on Medicare/Medicaid reimbursements) and they're not legally allowed to present differently-priced initial bills to patients based on their insurance status.
For us to underfund it to UK levels, we'd have to expand medicare or medicaid to every single person while simultaneously cutting the total government budget for health care by 2.5%.
The UK system isn't competing with private US consumers for a limited pool of services. The comparison perhaps illustrates the poor value/dollar achieved in the US, it isn't instructive as to whether US government funded healthcare meets the costs of providing the services it mandates (a perfectly reasonable definition of underfunded).
To clarify, when I said I'd favor socialized medicine that we drastically underfund, the goal was to stop wasting resources on medicine. I.e., we should bring our health care utilization/spending down to UK levels, since evidently that doesn't significantly harm health.
Using a definition like "meets the costs of providing the services it mandates" inherently contradicts this philosophy since in the US, all sorts of crazy services will be mandated. E.g., mammograms for women under 50.
So I have read through the US Preventative Service Task Force Recommendation about 10 times in conjunction with Obamacare and preventative services, as well as been involved in some of the politics behind the data sets.
The US government actually tracks mammograms in the US through the Breast Cancer Surveillance Consortium. http://www.bcsc-research.org/
Their research basically has it come down to a massive case of Simpson's Paradox among many important subgroups needing early screening (black women, ashkenazi women, previous radiation to the chest) that suddenly disappears when they are added together en masses.
The US Preventative Service Task Force, however, is not in the business of explaining stats: it is basically a guidebook of what insurance will or will not cover, and they went with the rating they did as a compromise over the simpson paradox over the fear that these subgroups would lose coverage in high deductable plans
In exchange, they actually did cause problems by not doing comprehensive DNA testing and ONLY covering BRCA testing - which is bad science.
Except that the per-capita spend on health in the US is approximately three times what it is in the UK, which seems to corresponds quite nicely to what you're saying is the difference in salaries.
So, actually, yeah, you probably could move to a UK style solution, with the same per-capita spend as in the US while still preserving the seemingly very high wages for doctors and nurses.
It's always possible to get someone to be a doctor. Since there are many other jobs paying competitive salaries for smart folks, paying doctors less necessarily means they will be lower quality all other things equal.
They don't. Doctors in the NHS work longer hours than their U.S counterparts, and those who go through the system tend to move to either private practice, Australia, or the U.S after their residencies. For now, the system is still working, but it's clear that medicine is a much less lucrative/desirable job in the U.K than, for example the U.S. (And maybe that's a good thing – I don't know).
It's possible the problem is that we don't have enough qualified staff. Any source showing is that's the issue or it's that a huge number of people are going abroad?
I agree. I have several friends who have went abroad because they get paid more, work is less stressful and the weather is nice. I'd like to see a proper breakdown. From what I can see the problem is more of an increase in total jobs that was not met by the number of people qualifying which could just be poor planning.
1) I cant believe that it's only the doctor costs.
I see people with all kinds of health problems in the US that should be treated early. Classic example is people with foot problems not treating them asap -> soon stumbling, crutch, amputee.
2) Comparing salaries in the US to the UK/EU are super hard. We have by usually lower costs of livings in europe (health, education, housing).
Personal anecdote: i could earn half my money i earn in california and would still be top paid in germany/austria. i would be able to save more money though.
3) I am unsure how much doctors should earn. They earn very good money in Europe. But maybe that's just my "it's a mandatory service not a privilege" pre-trained mindset speaking.
1) It's also nurse costs, etc. The bulk of health care costs is labor.
Again, I linked to RCTs showing that improving access to health care doesn't improve health and does increase costs/utilization. Do you have any evidence to the contrary?
2) The UK is 6% more expensive than the US. I don't know where to find the exact PPP factors, but you can back them out of GDP statistics by dividing GDP(PPP) per capita / GDP(nominal) per capita.
Also, the per-capita healthcare spend in the US is nearly 3 times that in the UK, for outcomes that are very similar. One might even suggest that the insurance companies, private hospitals and doctors in the US aren't very good value for money...
That depends on your socio economic status. If you're rich, the service is unbelievably good, if not, it's not. You can't treat figures about the US the same way while ignoring the massive inequalities.
Define "rich". Most people go to the same hospitals as everyone else and get similar treatment to everyone else. Contrary to popular belief, the US doesn't have signs reading "NO POORS" posted everywhere. I live in an affluent suburb and the people here go to one of the four hospitals in the area just like everyone else.
Yes, it's true at the far extremes there are people that can both afford and choose to pay personal doctors, but it's very rare, even among "the rich". Most people don't consider that a good use of funds.
It's illegal for American hospitals to deny necessary medical care due to inability to pay. I've gone to American hospitals both when I was indigent and when I was well off, and I feel the service quality was identical. In fact, hospitals usually have a designated administrative employee who handles the billing; the actual health professionals involved in treatment will often have no idea what your financial situation is and/or whether you even have insurance.
It is now illegal for Americans to fail to carry some form of health insurance. If someone absolutely can't afford it, there's Medicaid, the government-sponsored insurance program, which is actually really good. For people in-between, there's the government-subsidized health exchanges.
Healthcare in the US is a complete mess, but it's not as simple as "rich v. poor". Practically, most of the poor continue to get medical care, and if they don't manage their insurance or care properly, they just take big hits to their credit. Which, don't get me wrong, is not good either, but it's definitely recoverable and survivable.
To add to this, certain professions in healthcare receive free education because there's such a large demand. My cousin is a radiologist and paid nothing for her degree (or rather the NHS paid for it).
> "You have a concern - you go to the doctor" is a waste of money.
Wrong, depending on the angle. Prevention is the key, it's the same with computer bugs
Correct, don't send them to a doctor for anything that shows up, that's why the initiatives are to have Nurses evaluating the problem and escalating if it's a bigger/more urgent issue
theoretically people should go to the ER only when it's urgent or life-threatening
> a US ER doctor or radiologist gets paid more than 3x what a British one does, a family practitioner 2x
In US you need to get paid more, so you can afford health insurance for you and your family, pay for daycare and school and college for your kids. In Europe you get these mostly free, so you can get the same quality of life with a lower salary.
The numbers I've listed are salary. Most doctors have health insurance paid for by their employer, so their total compensation (including health benefits) is likely higher.
I linked to numbers elsewhere in this thread showing that cost of living is higher in the UK.
How many US employers provide the kind of health insurance that you don't end up anyway paying over $1000 a year (for a family) in all kinds of fees and deductibles and whatever?
Let me do the math and illustrate that you are arguing about irrelevancies. Let me assume all doctors spend $10,000/year in fees/etc, or 10x the number you suggest.
US ER doc: $209,161 - $5,000 = $199,161.
UK ER doc: $60,504 - $0 = 60,504. ($57,709 after adjusting for purchasing power, which is lower in the UK.)
This really doesn't change my conclusion at all. (PPP factors, salaries are taken from links I've posted in other comments.)
$1000? At my last job the premiums for this year for a couple with children is $12,000 plus deductibles and coinsurance. The only cheaper option is an HSA+ catastrophic plan which is kind of a joke but they were encouraging us to take it because employee premium was $0.
HN will be full of Googlers and startups with funny money who can throw around gold plated plans to their people but in the real world this is how it is, and premiums are getting worse every year.
If you have evidence that providing more preventative care will either save money or make people healthier, present it. All the evidence I've seen (see my links in other posts on this thread) suggests the US provides too much of it.
Strangely, not a single person telling me I'm wrong has cited a single source or done a single back of the envelope calculation.
Because your sources aren't proving what you think they do.
The Oregon trial was only two years long and it actually did report some health improvements, diabetes and depression in particular. It also found improvements across a lot of other medical issues, they were just considered statistically insignificant (given it was only two years, not really a surprise).
The RAND experiment found that money does reduce unnecessary medical treatment (and therefore reduces costs). But it also found that it reduced necessary treatment too.
I agree that the exact numbers and costs are controversial, but basically everyone aggress that it improves the quality of life for everyone. And even if preventing disease is costlier, isn't better that fewer people get a serious disease in the end?!
The Oregon trial had no effect on diabetes. It caused people to consume more diabetes medication which the authors speculate might make them healthier.
You are correct that having insurance made people feel better. So what?
It also found improvements across a lot of other medical issues, they were just considered statistically insignificant...
And you've just demonstrated that you have goals here other than finding truth, or perhaps you just don't understand hypothesis testing.
Your medscape article is just a press release parroted by some innumerate reporter. Further, the article is focused on stuff like "stop smoking" and "stop drinking" support, not medical interventions. The full study isn't even linked.
>>> The Oregon trial had no effect on diabetes. It caused people to consume more diabetes medication which the authors speculate might make them healthier.
It increased the rate of diagnosis of diabetes. And what do you mean speculate? What's the point of giving medication if it doesn't help?
>>> You are correct that having insurance made people feel better. So what?
Treating depression is part of healthcare.
>>> And you've just demonstrated that you have goals here other than finding truth
I don't think so. I just thought it's an interesting observation. Combined with the fact that it was a short term experiment it makes one think. But you're right, it's not significant.
>>> "stop smoking" and "stop drinking" support, not medical interventions
Stopping smoking and drinking is part of healthcare. At least in the UK. Perhaps you don't think preventive care works because you don't think improving ones wellness is part of it? Why are insurance companies including preventative care in their packages if it actually costs them money?
Here's a study that found a list of preventative measures that do save money: vaccinating children and adults, smoking cessation, daily use of aspirin, and screening for issues with alcoholism, obesity, and vision failure.
But you're right. In part. Other preventative measures do not save money. Like preventing heart attacks by treating hypertension early on with drugs did not save money in the long run. It's more cost effective to let people have heart attacks. But at least the insurance company saves a few bucks (rolls eyes).
And what do you mean speculate? What's the point of giving medication if it doesn't help?
By "speculate" I mean it didn't demonstrably improve health, but the authors speculate that maybe it will later.
Stopping smoking and drinking is part of healthcare. At least in the UK.
Try to follow the discussion. We were originally discussing the statement "You have a concern - you go to the doctor". andreasklinger proposed that this is why EU medical systems are cheaper.
Your own source - a political op-ed published in a medical journal, disagrees with this claim:
Our findings suggest that the broad generalizations made by many presidential candidates can be misleading. These statements convey the message that substantial resources can be saved through prevention. Although some preventive measures do save money, the vast majority reviewed in the health economics literature do not.
The fact that obesity reduction might improve health is great, but totally unrelated to the topic at hand. Telling people to stop smoking and being obese != "you have a concern - you go to the doctor".
No one disputes that your health will go up if you eat right, exercise and stop smoking. You are arguing against a straw man.
Also, your own source does not address the marginal question that I asked. I asked for evidence that "providing more preventative care will either save money or make people healthier".
Your article says: In addition to determining which preventive measures and treatments are most efficient, it will be necessary to identify those that are not yet fully deployed and those that could serve a large population and bring about substantial aggregate improvements in health at an acceptable cost. Findings that some cost-saving or highly efficient measures are underused would indicate that current practice is inconsistent with the efficient delivery of health care. Other services might be identified as overused, and such findings would underscore the importance of fashioning policies that provide incentives to shift practice toward more cost-effective delivery of health care.
Your article says we need to carefully target which interventions are worthwhile, cut the ones that aren't, and refocus on the underused ones that are. That's not disagreeing with me at all!
>>> By "speculate" I mean it didn't demonstrably improve health, but the authors speculate that maybe it will later.
It's a fair assumption. Treating an illness with the approved medicine that worked well in the past tends to work in the future too.
It takes a lot of mental gymnastics to dismiss both increased diagnoses and treatment as anything but conclusive.
>>> Try to follow the discussion. We were originally discussing the statement "You have a concern - you go to the doctor"
It doesn't matter what the original point is, I was strictly replying to what you said, with quotes. Are you following?
>>> Your own source - a political op-ed published in a medical journal, disagrees with this claim:
The quote you posted really isn't. It says some save money, some don't. I gave examples what the study found to be cost effective, while the majority were not. Sometimes the answer is not black and white.
>>> Telling people to stop smoking and being obese != "you have a concern - you go to the doctor".
Isn't?
Free-at-the-point-of-use obviously does increase usage of services, meaning people will be told to stop smoking more often. Those two concept are directly linked.
>>> Your article says we need to carefully target which interventions are worthwhile, cut the ones that aren't, and refocus on the underused ones that are. That's not disagreeing with me at all!
Again, isn't? It clearly says some interventions are worthwhile and some not.
So let me get me straight, you think that if giving away nicotine replacement drugs is costing more money than cancer treatment, we should stop telling people to stop smoking?
That's the way it works now I live in Germany. It's very cheap an easy to go to the doctor here, and they are keen to do tests that get them early warning problems. This is all a way of clawing money back from the compulsory roughly "Obamacare" style insurers.
But it was much worse when in the UK. The providers get funding for you, but once you are registered, it seems actual service is a pure cost to them. My GPs practice in London only allowed same day-appointments and only pretended to allow them over the phone.
My cousin there got sicker and sicker for months in because instead of testing her, they just gave her the wrong medicine. In the end she flew to Sri Lanka where she got tested, rediagnosed and operated on within 48 hours.
For lots of Americans, the copay on that CT scan is 100%.
I guess if they are getting over cancer they might be lucky enough to have met their out of pocket maximum for the year.
edit: Why is this controversial? I literally paid out of pocket for 2 CT scans last year. They both applied against my deductible (so they were 'medically justified' or whatever, not done at my insistence or something). Is being sarcastic about the high cost of healthcare in the US so absurd?
That's how high deductible plans are supposed to work! In exchange for much lower premiums, you pay the first few thousands of dollars out of your own pocket. If you have a severe illness, the insurance covers the rest.
Usually high deductible plans come with a tax free savings account. You sock a little money away each month so when something happens you have a cushion to fall back on.
They certainly aren't for everyone, but if i was young and in good health I'd probably go that route.
Sort of. The premiums aren't all that low (they are intentionally high to subsidize care for other patient groups) and the fees have only a vague connection to the costs of providing the services.
We have an insane system where mandated government care is underfunded and then the hospital is expected to make up the difference by charging the people that need medical care. People that are having a bad day pay for the people that are having a bad year.
Of course I have no way of giving any weight to such a statement, but I'm pretty sure I would have paid 1/3 to 1/5 as much in a reasonably competitive marketplace...
The last time I looked, a low deductible plan might cost $500-700/month for an individual. A high deductible plan can be under $200/month depending on the state. That's a pretty reasonable decrease.
Otherwise, yes, I agree that the private system is subsidizing the public system, particularly Medicaid.
Some doctors suck, no matter what country you're in. I've heard similar stories from people in the US, India, everywhere. You have a right to a second opinion in the UK - use it if you're unsure.
What kind of trivial are we talking about? i went with concerns about changes to my bowel habits and the GP had me to a specialist with a camera up my arse within two weeks.
> If you've had blood in your poo or looser poo for the last three weeks, tell your doctor. Chances are it's nothing serious, but you're not wasting anyone's time by getting it checked out. Call your GP today.
Blood tests, to get second opinion. GP disagreed with patient suggestion, and had loundry list of treatments to try first (including shrink and accupuncture).
Three months is reasonable number if you have no GP (have to register first), bad english and live in poor neighbourhood.
You can get a second opinion from another GP. You can ask to see anyone in your practice without issue - you're registered to the practice, not a specific doctor. If your entire practice is filled with awful doctors... there's an issue, but I've yet to see that. (You can also register with another practice if you have issues with your nearest one.)
What kind of trivial are we talking about? i went with concerns about changes to my bowel habits and the GP had me to a specialist with a camera up my arse within two weeks.
I've got to argue with that. If it's important, you can get to see a specialist in less than two weeks, at least in Scotland, and that was for something classified as "mental health" in my case. If it's something you can manage on your own for a while before seeing a doctor, yes, you get stuck on a waiting list.
> To receive this care all my cousin had to do was provide her name and birthdate. No copayments, no preauthorizations, no concerns about the radiologist or orthopedic surgeon being out of network
For the vast majority of people in the developed world, that's how heath care works.
I'm an american that lived/worked in Japan for about 10 years. This aspect of healthcare in Japan was hands down my favorite. Just being able to walk into any doctors office and know that my insurance would be accepted.
I might be an outlier in that all my of coverage while employed in the U.S. has been fantastic.
This kind of article is a nonsense puff piece. Giving an example of receiving good or bad care in a health system is of no value. I have had incredibly positive and negative experiences with US hospitals and doctors but my experience is simply a data point.
As for the NHS the mother of a friend died due to negligence while being transported home. So it's not all good, which is why the system cannot be judged this way.
He's not saying that the systems are the same, just that good and bad experiences are had in both. Thus, a recounting of one smooth experience in the UK cannot be used to say that their system is inherently better than the American system.
The post basically says, "Wow, we got medical care and didn't have to pay for it!" Everyone already knows that Britons pay for health care out of their taxes and not at the time of service, so it doesn't really bring anything to the table, and certainly doesn't make a case for or against one system or the other.
luckily, there are statistics on patient satisfaction available for individual hospitals and the NHS as a whole which shows a good degree of satisfaction.
Of course no system is perfect and their are a number of hospitals in 'special measures' which means their management is replaced and they are in turnaround. I'm very sorry to hear about your friends mother. I assume it triggered a full investigation?
How do you compare satisfaction rates across countries? It's not easy.
As someone who has sxperienced the US and Canadian healthcare systems, I can confidently say most Americans would be deeply unsatisfied with aspects of the Canadian system. Yet Canadians love their system.
The waiting times for certain procedures in Canada, the lack of provider choice and the lack of access to the latest drugs/tech are just accepted in Canada. One reason why the US system is so expensive is the expectation of a lot of Americans that they get the absolute best healthcare out there, costs be damned
And yes, I'm generalizng with the comments. No need to call that out.
I have had two family members die from NHS mismanagement. If they had been in the US system (which I have experienced first hand) they would most likely still be alive.
Those hospital wheelchairs are difficult to use, but it's possible to safely push them.
> The only real issue was people who show up for care that is clearly not even semi urgent never mind emergent.
People do love the NHS. And they trust A&E. Companies would kill to get that kind of brand loyalty. So the answer is to co-locate walk-in doctors and minor injuries with A&E departments, and have fierce triage on entry to divert the people who don't need it away from A&E.
I know rhis isn't the main impediment to policy change, but I kinda want to require that all doctors and nurses study/be a resident abroad, just so most people in any US hospital know what we're missing.
The problem with socialized medicine is not with regards to the routine (broken ankle, high cholesterol) but instead with regards to the even slightly unusual. The economic incentive is not there for highly trained specialists.
Nothing about this article is surprising, despite the author's tone. Any modern industrialized country should be able to quickly treat a routine broken ankle. Where that's not possible in the US it's a travesty. Now compare the care of extremely rare diseases in the US and UK and you have something more interesting to talk about.
I have to disagree with this. If there were no private hospitals this might hold true, but as it is the better off will continue to pay for their expensive treatment, keeping the economic incentive for doctors, while the poor will at least have basic treatment available (at no cost, no less).
As for comparing rare disease treatment, I can't say but would like to see some more information.
I just about died from scarlet fever a year ago in the US because they wouldn't prescribe me antibiotics since the strep antigen tests kept coming back negative. I didn't get better until two weeks later when they finally gave me the antibiotics anyway. This was despite that fact that I displayed all the classic symptpoms: 107.5F fever, full body rash, chest pain, and blood in my urine.
In my experience the only thing exceptionally good about US healthcare is its astoundingly effective PR team.
I just about died from scarlet fever a year ago in the US because they wouldn't prescribe me antibiotics since the strep antigen tests kept coming back negative. I didn't get better until two weeks later when they finally gave me the antibiotics anyway. This was despite that fact that I displayed all the classic symptpoms: 107.5F fever, full body rash, chest pain, and blood in my urine.
In my experience the only thing exceptionally good about US healthcare is its astoundingly effective PR team.
I've worked in the NHS, for several different organisations at different levels of the hierarchy (PCTs, SHAs, CCGs etc), as a contractor, over several years.
I would privatise it tomorrow. The amount of waste in terms of time and money were eye-watering, every time. The amount of politicking was immense. A project that should take a few weeks could easily expand into a couple of years. I resigned from my last contract because it actually felt immoral to be taking a large amount of cash to either sit around twiddling my thumbs, fight with people, or do work at the slowest possible pace in the most ineffective way. I'd rather do something else. Basically, I've never worked for a private company that was anything like that, even the worst ones, and I find it hard to believe any private company would survive very long working that way.
I'll add, my Japanese girlfriend and her friends are utterly unimpressed with the level of service. As was my Spanish girlfriend, who also worked on a hospital's grounds as a medical researcher.
I'm not saying we should copy the Americans, no way, but the Japanese system is private, the German system is private, the Dutch and French systems are also private. Going private does not mean chucking the idea of universal healthcare on the fire, it means properly separating the regulator from the provider and removing the kind of conflict of interest that led to the cover up of high mortality rates, among other things. There is more than one way to skin a cat.
And no, I'm not a Tory. Try picking up a copy of Private Eye if you want to divest yourself of the notion that the NHS is a saintly institution. Or work there.
How much of that inefficiency was caused by the part-privatisation? Much much paperwork is caused by the inefficient but politically-attractive internal market successive governments have tried to set up.
Approaching zero. It wasn't paperwork holding things back, but people who knew there was no problem with poor performance. The contractors knew it and would milk it as long as they could, and the permanent staff treat it like a sacred way of life. Trying to get them to work quicker through good practice was impossible.
I'd rather get health care from employees who are a bit too comfortable on the job that health care from management that treats me as a cost item of their profit making entity.
At least the lazy employees of the public health care system will not rush me out of hospital hours after a major surgical procedure as some other private health care systems do.
Now of course you might disagree but that's more of a matter of opinion than some objective fact.
I currently have Kaiser insurance. As an HMO, they integrate a lot of services, which has really helped save a lot of time for us (like using email to talk to a doctor, who calls the specialist, then replies, without making a visit).
However... when we do go in for a visit, I get the distinct feeling that there is a lot of pressure to keep appointments within a specific time interval and basically get patients in and out as fast as possible.
Overall though, the integration of doctors, specialist, labs, and hospitals does create a smoother and less stressful experience.
> The contractors knew it and would milk it as long as they could
That would be one of those inefficiencies introduced by part-privatization... So it's hard to believe it's approaching zero. Not to mention that you have no real basis for making that statement from personal experience alone...
No it isn't. Contractors milking their customers isn't an inefficient introduced by privatisation: as brightshiny pointed out, the entirely state employed people were even worse.
Contractors milking their clients is something that competent buyers are supposed to prevent, but NHS procurement is a disaster-zone, as is commonly the case in the public sector. Just look up the different prices paid for basics like rubber gloves.
Contractors milking their customers is an inefficiency introduced by privatization, because without privatization it doesn't happen... How state employees behave or the competency of the buyer is irrelevant.
Saying that the inefficiencies due to privatization are "approaching zero" is a bit disingenuous.
Just replacing contractors with employees just means it's the employees milking the NHS instead, but now with the downside that they're unionised and hard to switch to an alternate provider.
> The amount of waste in terms of time and money were eye-watering, every time. The amount of politicking was immense.
Have you ever worked at a reasonably large private organization? It's exactly the same there. It's a complete fairy tale that large private organizations are somehow more efficient than large state-run ones.
It's doesn't logically follow that every business that has internal inefficiencies will stop making a profit. They may make less profit than they could if they were more efficient. My father-in-law works for a very large corporation and he's always complaining about the wasted time to get simple tasks done, but they aren't going out of business any time soon.
Every company I've worked at with lots of red tape got there because they were actually trying to solve a problem due to the lack of "regulations" or rules.
I think this is usually because their profit engine breaks rather than being overwhelmed by waste. All big orgs seem to have one part of the business printing money while the rest tries to burn it. So long long as the printer prints, the bonfires burn.
Only if those competitors can arise. If the established players are all happy to keep their market share and increase profits by raising prices, you won't see the same race to the bottom.
Companies require capital to start. The level of capital to start a company differs depending on the industry. One of the main reasons you see far more startups in IT than in telecommunications (think Verizon, AT&T, etc...) is due to the difference in cost of entry into those markets.
That's a very simplistic view: it assumes that the product in question is an easily-compared commodity, the business has low barriers to entry, and that there aren't other factors (long-term contracts, regulatory requirements, natural monopolies, etc.) which would make switching hard.
In the case of healthcare, consider the cost of entering a competed space: nobody is better at everything so you won't have a clear advantage for many patients, the startup costs (time, money, permits, staff, etc.) are massive, people like to keep their existing doctor and won't change without cause, and the complexity of the problem defies simple solutions. You can't save on staff costs without losing in-demand professionals, things like billing are both intrinsically complex and disastrous if you get them wrong, and so are all of the safety and other regulatory compliance issues. You might be able to shave bits here and there but it'll take time, have indirect costs, and it's going to be a modest percentage over time.
Exactly. It is also interesting for as much as free market and competition is touted as the golden standard of organizing things, most large multinational companies are really run in hard line Communist style command economy: top down bureaucracy and planned allocation of resources.
I wouldn't call it communist, it's more of a centralized dictatorship in practice [1]. Which is particularly interesting because of how it completely contradicts the general political mainstream that says that more democracy is always good.
[1] Although one that still, from time to time, listens to the people at the bottom who actually know their stuff.
As a European who lives in Japan now, the regulated-private system also has a lot of pitfalls. Costs are regulated, so hospitals will drag out procedures over more visits than are required to milk extra money out of the public insurance to game the system (they're professional enough not to avoid important stuff, but it's especially pronounced in stuff like dental care where stuff can wait). I still prefer it over the completely fucked-up US system, but it has both advantages and downsides compared to the European systems that deserve to be debated.
I wouldn't say any country has healthcare "solved", but I don't know how anyone can look at the US system and say that it's a good situation for a developed country.
Yes, healthcare is "as long as a piece of string" in so many ways that I don't think it's a solvable problem, but definitely could do with a better level of debate than the sacred cow of the NHS vs the straw man of the US system.
I'm possibly moving to Japan soon, so I guess I'll get a better comparison soon enough.
You've worked as a private outsourcer. The problems you see, this politicking, waste, gerrymandering is all because of forcing everything out to tender. Or having PFI interests.
The NHS needs to work hard to in-house more stuff. There's fat to be cut, for sure, but it's the existing private elements where most of the real waste comes.
This pattern of waste echoes throughout British government, national and local, Thatcher onwards. That's when we stopped governments being able to do stuff.
Companies like Serco, G4S, ATOS and Capita have all supplanted "failing" public services by either promising to be cheaper or replacing another company that submitted a wildly inaccurate bid and themselves under-delivered.
I highlight "failing" there because many of these failures aren't organic; a government has broken them and then threw them under the bus.
After a few years of substandard services and a daily ragging in the Telegraph, the magical tenets of tender and PFI are just too tempting. We paint this picture of the lean bulging muscles of private industry, but it's the same problems with added layers of obscurity and greed.
Worse is the transition from cooked-in-house school/hospital meals to having them driven in from a factory 200 miles away is you replace so much infrastructure that there's simply no going back. You used to have a kitchen full of ovens and hobs and staff who knew how to operate them. Now you have a room full of freezers and microwaves and the cheapest possible immigrants interfacing between the two. To reverse that requires hiring and training and investment. Who's going to invest in that when they could just keep selling them [awful] ready-meals?
Or you sold your land to a PFI so they could give you a hospital. The catch? They get super high rents and "maintain it" at huge expense. After 20 years you've spent more than twice the amount it would have cost to build and maintain it yourself. It's loan-sharking.
The tragic thing here is that many public services are the ultimate embodiment of lean. They do so much with so little and are forced to be transparent. They are people so there's obviously some variance but we've spent so long villainising these organisations that we've forgotten how good some of them really were before it was too late.
This country needs to find a way to start fixing this.
If I were king for a day, I'd start with a new nationalised housebuilding scheme. That would raise revenue (means tested rents, fair price sales), create jobs, lower poverty and homelessness, create new markets for local services.
"so much waste" is always the excuse for privitisation of public corporations. I fail to see why it matters when after privitisation you get the added profit motive and costs go up.
The Dutch health care system is a prime example. After partial privisation costs went up.
Because it's possible for the efficiencies gained to be larger than the profits. For that you normally need competition to keep profits in check. Governments are quite bad at 'designing' markets to have adequate levels of competition but it can happen.
Privatised telecoms markets are the canonical example of this. Not many would go back to the days of state-run telco monopolies.
Sure there is going to be waste, but once you privatise, the 'waste' will continue in the form of profit taking by insurance companies and all the other private actors in the system.
I know it feels unfair that there is waste. But IMO profit in healthcare is another form of 'waste' anyway, one that is made worse by the fact that it distorts the incentives away from providing care.
> Sure there is going to be waste, but once you privatise, the 'waste' will continue in the form of profit taking by insurance companies and all the other private actors in the system.
Profit-seeking isn't unique to private entities. State-run programs are still subject to the exact same economic forces; the difference is solely in how they're accounted for.
It's similar to the situation with state-run prisons: the profits are divvied up between the vendors who supply the prisons, the unions representing the correctional officers, and other entities who are required to make a prison actually operate. And even in state-run prisons, these entities have incentives to lobby for the expansion of the prison-industrial complex (which they do). Vendors, suppliers, and LEOs extract massive financial benefit off of the entire system, but because the program itself is state-run, we don't talk about that as 'profit'. Instead, we talk about that as the 'budget' (with a surplus/deficit).
But suppose we turned the state-run system overnight into a vertically integrated, private system, with all the roles served by the exact same people. That is, all the correctional officers are the same (making the same amount of money), all of the suppliers vendors are the same (but many are now owned by the private system). Suddenly, from a discursive (and accounting) perspective, we get 'profit'. The amount of money being traded hasn't changed. The steady-state flow of money hasn't even really changed[0]. The only thing that's changed is which entities we group together as units. But they all work symbiotically in the exact same way, no matter whether you view them as a single entity or a composite system.
As for the NHS - you absolutely bet that there is a profit motive amongst providers (and the agencies themselves). The language is different, and the way it gets assigned to the entities who comprise the system is different, but the fact that it's a state-run program doesn't mean that all that 'profit' magically goes back to the taxpayer.
[0] There would be an overnight, single-time transfer of cash due to the overnight privatization (same thing that happens anytime a company spins out a subsidiary into a separate private entity), but the ongoing cashflow would be the same.
>But they all work symbiotically in the exact same way, no matter whether you view them as a single entity or a composite system.
That sounds like a utopia. None have been seen in the wild. Factions can form inside vertically integrated systems as well.
I also never claimed that there can't be profit taking in the nationalized system.
I only said that if there's going to be waste, I'd rather have it come from a system that isn't structured to deny care, or to make it prohibitively expensive.
Nobody likes people who are cheap. Did you ever go to somebody's house for dinner where they measure out wine with a graduated cylinder, and put out tiny portions?[1]
How about people who a cheap with the necessities of care for their loved ones? I'd rather treat everyone at the hospital like royalty, and not be cheap.
We can afford it. Just cut back on true waste like astronomical defense budgets for starters.
[1] Excluding cases where the hosts are truly poor.
The staff make profits. If they weren't making profits then someone would assess how much they needed to live and pay their bills and that'd be the amount they got paid. In practice they get paid, some of them like senior doctors get paid large sums of money that they can then spend as they see fit.
The unions make profits. They charge membership fees and then justify those fees by organising industrial actions in order to increase the profits of the staff.
The equipment manufacturers make profits. Often by charging wildly varying prices for the same goods to different hospitals.
The drug manufacturers make profits. They have to, otherwise they'd not be able to do the research they do. University research is really no substitute.
By profit I mean charging a patient for treatment.
Everyone should get paid of course, and even handsomely including doctors, but what I meant was that no private company should be able to bill a patient for treatment.
You have a really weird set of arbitrary lines in the sand.
So it's totally OK for a single doctor to make huge profits off the NHS when they charge patients for treatment, but if those doctors form a company to share the load and amortise overheads, then suddenly it's a terrible evil that must be forbidden?
And don't get confused by simple word changes: when a doctor turns up at a hospital and does work in return for a large paycheque he is very much "charging a patient for treatment". The fact that the charges come in the form of taxes and take a long route to get to the patient's wallet doesn't alter the fact that the money comes out of the patient's pocket and ends up in the doctor's pocket!
Many of the problems are due to the internal market, with NHS staff encouraged to work in their own self-interest rather than in the interests of the patient, which in practice means they game the system. This, and the reasons behind it, are explained in a 3-part documentary called The Trap by Adam Curtis.
The NHS is good value for (taxpayers') money: it's about half the price of the American system for the same quality of care.
It's a fairly open secret that the Government is encouraging patient dissatisfaction and privatizing the NHS by stealth. It's only a matter of time before patients have to pay for treatment.
My experience of it as a patient is generally favourable. I usually get seen promptly, and it's free at the point of use. I've experienced the health services in two other countries (Hong Kong and Belgium).
French guy here, I wouldn't say the french system is private, It's a mix between public and private actors. If you want more detail wikipedia seems a good start:https://en.wikipedia.org/wiki/Health_care_in_France
By the way, I've been living in the UK and spain, the small experience I had with NHS was ok. But I managed to get confused with the system to the point I started crying in front of a medical secretary after spending a day trying to get an appointment with a doctor.
Dutch guy here. I wouldn't say the Dutch system is private either. It's a mix of private and public as well. Users of the system have a similar experience as described in the article. Also the Dutch system consistently ranks top of Europe [1].
When I moved to live in the US as an expat, my insurance company said they had to double my monthly payments because of the cost of health-care in the US. All other countries would be normally covered. My stomach medication and my daughter's birth control both cost us more than 10 times what we paid at home. (Anecdotal of course). My spotty experience with the health care is that the systems are of comparable quality.
BTW France's system is also held in high regard here.
It's interesting that you note the amount of waste in terms of money that you experienced (which is extremely anecdotal, obviously) and yet the publicly run healthcare systems are often substantially cheaper than the private ones in terms of overall cost.
The German system is not really private in that sense though. What is covered by insurance and what isn't is proscribed by law, and how much a hospital/provider can charge for it is too. And whether you are allowed to treat under insurance is organized, too, limiting the number of doctors per location. It's also more expensive than the NHS.
In reality it is a different way to administer single payer health care that leaves the doctors and hospitals (and the patients) some more freedom, but at increased cost.
From a micro perspective large organisations are often dysfunctional. You need to look at the statistical measures to compare them against other systems. And the NHS manages to give universal coverage at half the cost of the US system.
> The amount of waste in terms of time and money were eye-watering, every time.
While there is waste in any organization, overall the NHS is perhaps the most efficient healthcare system in the developed world. The US spends as much on public healthcare as the UK yet large numbers are left uninsured (while spending the same again on private healthcare.) [1]
> I'm not saying we should copy the Americans, no way, but the Japanese system is private, the German system is private, the Dutch and French systems are also private.
If we want Japanese/German/Dutch/French levels of service then we have to be willing pay what the Japanese/German/Dutch/French in their health service, around 11% of GDP instead of the UK's 9% of GDP.
Yet despite spending significantly less than Germany/Franch/Netherlands the UK mostly compares favourably on health outcomes. [2] [3] [4]
Should the UK spend more on healthcare? Probably some. But it may not be the best way to improve health outcomes. Infant mortality is higher in the UK than France or Germany (though not nearly as bad as the US.) Given infant mortality is highly correlated to inequality it may be more effective to spend more on redistribution than health care.
As populations age, and the need for healthcare increases commensurately amd efficiency becomes vital in healthcare provision. Insurance based system (as in France and Germany) cost more for equivalent outcomes.
She had two options: go through the GP-based system where treatment can take anything from days to months, or take the initiative by jumping the line and go to A&E.
Going to A&E is like having your tech support handled by engineers. Going through the GP system is like calling a support line. She got a positive outcome because she went with the option that costs the most.
I'm pointing this out as someone who has gone through both methods. Don't believe the hype that you read about the NHS. It's good to have, but it's not amazing and if everyone went through A&E, the system would probably collapse.
It's not really a case of GP or A&E. They are two different things with different purposes. The A&E is designed for problems that shouldn't wait. Your GP is for ongoing issues that aren't crucial to be sorted right away. It's called Accident and Emergency for a reason.
The NHS is far from perfect but I don't know what a better system would be.
Just pointing out that what people experience from A&E is vastly different from what people experience from the GP system.
This article highlights the best part of the NHS, whereas the GP system is like being caught in limbo. If you are rich enough and plan in advance, it can be avoided by going private, otherwise it can mean months, even years of suffering through long waits.
> if everyone went through A&E, the system would probably collapse.
I don't understand how this is a bad thing about the system. Yes, if everyone went through the most expensive system designed for urgent things, the system would presumably collapse. But they don't, because the system includes something for less urgent cases, and thus doesn't collapse. Doesn't that just mean that aspect is well designed to avoid collapse that would apparently be inevitable if it were less well designed? Isn't that a good thing?
I don't think he's saying it's a bad thing, just that it's not a good idea to say "See I got my injury sorted in 4 hours!" and use this as an example of how great the NHS is.
i.e. If the article read: "I had an issue with my ankle, waited two weeks to see a GP, then was in the waiting room for an hour after my appointment was meant to start, then had to wait a week to a referral for a scan." It wouldn't be such a clickbaity story.
I find the NHS is good for the little things, gets worse as you go for the more complicated things.
My dad had pancreatic cancer and went to the doctors, did every sort of cheap test they could. They didn't believe him, and said it was psychological and sent him to a psychiatric hospital instead. Again nothing worked
After constant complaining, eventually they went for the expensive scan, and found that it was pancreatic cancer wasting several months.
The article is nice but a specific comment caught my attention which was "I honestly live in fear of having an accident or getting sick here in America."
This. No matter what we claim about American healthcare, this points resonates so well with most of us in America. It absolutely is scary to imagine being sick even with insurance. Without insurance, forget about it. Then comes the maze of crazy terms like co-pay, co-insurance, deductible, pre-authorization, in-network, out-network, Specialist referral and god knows what else.
Now may I rant about the Insurance companies if I may ? Obamacare was supposed to fix healthcare but it added to the red tape further. No real solutions. Insurance companies still have too much power and they call the shots, not the doctors/hospitals. Good luck fighting a denied claim unless you can shell good amount of lawyer money.
I don't know the solution though. America still has one of the best facilities in the world and even though the process is too bureaucratic and downright idiotic in many cases, the care that is actually provided is still pretty good. And I say this as someone who is aware of medical tourism and countries such as India.
One solution could be to get rid of insurance scam (yes I call it a scam) and then lets hospitals/doctors compete with transparent pricing in a free market. For catastrophic events, let insurance companies exist. I hate it that to even get an X-Ray, I need insurance and without it, they will look at you as if you came from some strange land. And if you do end up getting a service without insurance, good luck looking at the bill when it finally comes. You can be a crypto expert but won't be able to figure that one out.
However, in Canada, a debilitating injury might necessitate bankruptcy because of bills that you can't pay thanks to a medical condition which precludes your usefully working.
In America, a debilitating injury might necessitate bankruptcy because of bills that you can't pay thanks to a medical condition which precludes your usefully working AND an usurious hospital bill.
Are you sure it is the number one reason in Canada? The first source I could find that provide a percentage breakdown was from 2011 and had medical reasons as #4:
Most countries apart from the US? Really? Most of them?
A. It's not most. Not even close.
B. If you take the countries that do have socialized medicine, and add the criterion that the funding is not in constant jeopardy, there are very, very few countries that "manage it".
This is true, but if you have a chronic condition (unmanaged diabetes, mental illness, .. cancer) you'll just get enough to put you in a stable condition and out you go
Great for childcare if your kid camps out in the NICU, for burns that require 3 weeks to be walkable again... Really, why would anyone want to streamline delivery of care when we can dispense it in the most staggeringly expensive and inefficient way possible? It's just a mystery to me.
I was replying to a message saying "Americans live in fear of getting in an accident".
Everyone lives in fear of getting in an accident. Therefore, I assumed that what codegeek meant was that Americans live in fear of getting in an accident because they won't get treatment. But that is obviously not the case, so I'm not sure what codegeek's point was.
As a first time visitor to this country many years ago I went an clinic because I had severe strep throat. Waited 1 hour, then some intern saw me for 5 minutes. Gave me a codeine pill and later sent me a bill for $400. That was 1990's $400 dolars, and I had a stipend of only $200 month as a student.
That right there is fucked up. Actually, I would rather they just turned me a way -- "Sorry bud, this will be more than you can afford".
I know what people will say "Oh you don't have to pay, declare bankruptcy or call and haggle with the hospital". But you know where you haggle with the hospital -- in a 3rd world country when you are bribing the doctors to not kill you. You haggle there as well, and you also have to haggle here to get he "special, I can't pay" rate.
Ah yes, the good old "let's hold up the most inefficient and expensive delivery mechanism known to man", and ignore that every hospital in America would shut their ER down if they could, because they lose money faster than the Pentagon.
The only reason those ERs are open in the first place is that you can't be accredited as a general hospital without one (which has specific tax benefits). Anyone who uses this example is either woefully ignorant or a troll.
Even so... It's a struggle to get them to pay. I am convinced that they "accidentally on purpose" file the wrong paperwork the wrong way to delay claims in hopes of not having to pay them out.
> One solution could be to get rid of insurance scam (yes I call it a scam) and then lets hospitals/doctors compete with transparent pricing in a free market.
I don't understand the American (and it is American) obsession with having a free market in healthcare.
Why do Americans not look at public provision, paid for via your tax system? Canada does it, so it demonstrably does work in North America, Europe does it, with varying degrees of efficiency, but it basically works.
No-one in Europe or Canada lives "in fear having an accident or getting sick" because they know healthcare is provided by the state in the same way as education, fire services and police service are all provided as a public service, for the general good of society, via taxation.
Americans are happy to send their children to school, to be able to call the fire department or the police (we'll set aside the clear problems of US policing - you generally still call the police when you see a bank robbery, so there is a degree of confidence in them still).
So why is healthcare the exception? What sort of mentality says I am to blame for getting sick and told if I cannot afford medical treatment, I should not have become ill?
You have a point. But Americans generally are not convinced that a Govt. provided healthcare (paid through taxes) is the right solution. I personally don't have a problem with that as long as the main problem of "fear" is resolved. Whatever it takes. The problem is that we are not able to get out of the whole "insurance-company-being-the-middleman-in-everything" business.
>Why do Americans not look at public provision, paid for via your tax system?
Because raising taxes is bad, obviously one day you'll be big and don't want to pay health care for all the people down there. And of course it's a slippery slope. Today it's health care, tomorrow it's minimum wage and the day after you find yourself in a Gulag /s
Just look at how hard republican states tried to push against Medicaid.
>> "I don't understand the American (and it is American) obsession with having a free market in healthcare."
I think part of it is the culture of believing you can be anything you want to be. It's the same reason the poor often vote against their interests in the US - they believe that soon they'll be rich and want low taxes and few regulations. That they are the exception.
Surely nobody can be tricked onto supporting positions contrary to his interests. That would be impossible, since people are rational, educated and perfectly informed.
There is a minority of people who are actually completely out of touch with reality, so-called demagogues and populists, and to a less extent all politians: they are completely deluded in thinking that by repeating a point a thousand times they can mislead those perfectly informed masses.
If someone continuously keeps getting tricked into voting against their own self-interests, with the belief that their vote will actually benefit them, then yes, they absolutely deserve contempt.
As the saying goes: "Fool me once, shame on you. Fool me twice, shame on me." A large part of the American populace has been getting fooled repeatedly for decades.
If someone continuously keeps getting tricked into voting against their own self-interests
It has not been established that they are voting against their own self-interests. You are just assuming you know what their interests are better than they do.
It's the same reason the poor often vote against their interests
Wow, into being condescending much? How about this... maybe, just maybe those people know what "their interests" are better than you or I. Have you considered that?
Not sure why this offends you so much, but drive an hour outside the Triangle and it is pretty easy to find people at or near poverty level who want the government to cut social programs and taxes even though they are the ones who mostly benefit.
Nobody's arguing they aren't possibly voting for something that isn't in their immediate economic interests. But we can argue about their motivations.
Someone's said that it's because one day they think they'll be rich, and suggested that this was foolish. An alternative explanation is that they're voting for it because they've considered the question very carefully and are voting for what they think is morally the right thing, even though it'll harm them. In which case it's far from foolish.
I think the offence was taken in assuming the foolish explanation instead considering the one where people were making a sacrifice to do what they think is the right thing.
I'm not offended at all, just wondering why somebody would choose such a condescending tack. Again I ask, have we considered that maybe those poor people that you're referring to, know what is in their "best interests" better than we do. Perhaps they have perfectly rational reasons, maybe other than simple economic self interest, for voting against social programs and taxes.
This whole mindset of "you're too stupid to know what's good for you, so just let us smart people be in control and make things OK" is something that is very condescending and is repugnant to many (most?) Americans. Which is one good reason it's hard for politicians pushing such policies to gain ground. It might be better to actually, you know, talk to those people and try to understand what their principles, goals, and motivations are, instead of assuming that they're stupid.
>>Again I ask, have we considered that maybe those poor people that you're referring to, know what is in their "best interests" better than we do.
I have considered that notion for a long time, but ultimately dismissed it as pure nonsense. The fact of the matter is that people can be tricked and be taken advantage of. It is not condescending to point that out when it happens.
If someone gets conned into transferring all the money in their bank account to a stranger in Nigeria on the belief that it will "free up" millions that will be theirs, you cannot possibly make the argument that pointing out they got conned is condescending, that maybe that person knew what was actually in their best interest. They thought they knew, but they were, frankly, wrong.
The exact same thing happens with many poor people in our society: they get conned into voting for politicians who will absolutely screw them over. Furthermore, it doesn't happen once or twice. It happens repeatedly. And again, pointing this out is not condescending. It's just the truth.
I have considered that notion for a long time, but ultimately dismissed it as pure nonsense.
Alright, glad we have you here to save all the stupid poor people from themselves. After all, if someone is poor, they must be stupid. Or lazy. Or both. FSM knows, they need some philosopher-kings to come along and show them the light.
You realise you're the only person in this thread that is classifying poor people as 'stupid'? Nobody else has. You're the one making lazy generalisations and it's not adding anything to the discussion.
Let's not get into silly quibbling over language... "I didn't explicitly use the word stupid, so I didn't say they were stupid". Right. Language doesn't work that way. If you say somebody is stupid in an indirect fashion, you're still saying they're stupid.
I think part of it is the culture of believing you can be anything you want to be. It's the same reason the poor often vote against their interests in the US - they believe that soon they'll be rich and want low taxes and few regulations. That they are the exception.
Implied in every single sentence of this paragraph is and underlying sentiment of: "this is a false belief and they are stupid for holding it."
And ALL of that aside, nobody has really responded to my question of "why assume these people are wrong?" Except that camel guy who basically said "no, they're stupid so there is no reason to consider that."
So we're back where we started. I say that poor people who vote for lower taxes and the like, may actually be making a perfectly rational decision. It may not be a optimal decision if you only take financial outcomes into consideration but it may still be rational... because the people making the decision may not be basing it on financial considerations to exclusion.
I live in the Triangle, and driven to such far-flung locales in NC as Advance, Roxboro, and Eden. The people I've interacted with (however limited) are ardently political in the conservative direction for reasons other than fiscal.
Many are hunters, or serve(d) or have family in the armed forces, or just grew up around guns. They remember, before the big-box stores came along, when the town hardware and general stores sold shotguns, rifles, and ammo. They see the liberals in SF Chicago and NYC wanting to stop their multi-generationally deep and rich tradition in hunting and defending and baring arms. If there is one rail that should never be touched, one single-issue that will move that type of voter, it is preserving the 2nd amendment. I mean, sure, you don't have to worship it and Hillary won't have to sit there holding an AKM-74 with 100-round drum mag to pander for votes, but just don't go after it with such vigor and I can bet dollars to donuts that you can win over at least 40% of the voters 1 hour outside the Triangle.
They vote republican not for their non-existent tax breaks or wait in bated breath for their drip of the trickle-down. They're savvy enough that that junk has been tried all over the country and has mostly failed (in the case of Kansas, utterly and miserably with negative job growth). They just don't want you to mess with their traditions.
I mean, these folks don't even care to fight over marriage equality, either. You don't see much gay-bashing in these areas. They simply don't care. Ditto abortion. Sure, there are ardent bible-thumpers, but on the whole, they are nuanced enough to know that we don't want a nation filled with unwanted children.
So, really, don't mess with THEIR rights (guns), and they won't vote against their own interests. I can't get why a lot of democrats (both politicians and voters) can't see that. I _know_ that democrats and liberals are about as far from single-issue voters as you can get, so they'll be kinda-sorta bummed that guns aren't the big focus for legislation, but it would certainly NOT be the end of the world.
Reasons are historic and idelogical. A free market is considered sort of a religion here. In other words we don't usually evaluate and consider things based on their own merit (what is the best way to provide healthcare, what is the best way to fix infrastructure, like bridges, etc), but rather how will this make free market happy. We treat it as sort of a deity and if we don't abide by its likes we'll be severely punished.
The healthcare "market" is anything but free. From insurance companies, negotiated prices, all the way down to the AMA limiting the supply of doctors and all the other things they do to keep prices high. It seems the only thing free about it is the freedom to get screwed over.
So in those terms, I'm not sure what sort of diety it is that we're worshipping.
Are you arguing that 'negotiated prices' are not part of a free market? I mean, sure, negotiated prices are a way to hide information, but as far as I can tell, the less regulated a market is, the more "negotiation" is involved in pricing.
Frankly, it's one of the larger reasons why I don't want to be in business for myself. As a consumer? At least outside of healthcare, most of the prices are set, more or less, the way commodities are. There are laws saying that when I get to the cash register, I'm entitled to the lowest marked price in the store. Hell, even with things like cars, which are notorious for ripping off consumers, you are paying at most like 20% more than your neighbor. If you are buying, say, bandwidth, or nearly anything else sold to businesses? It is completely normal for the initial quote to be 200%-400% more than what you end up paying after negotiation.
Now, how much does this have to do with it being a business, and thus having the expectation that you have professionals on hand to do the money-dance, and how much of this is that there's a lot less regulation in the business sphere than in the consumer space? I don't know. I don't think it has as much to do with the cost of the goods involved as you think; I think the biggest contract I signed was around a third of a million bucks for a five year lease; Well under twice what someone doing what I do, only as a worker would pay for rent in my area. Most of my contracts were in 'mid-priced car' range, and still there was a tremendous difference between initial quote, and what I was actually expected to pay.
If you want a market make it transparent not "free". Patients have no chance participating in the US health care market because they have insufficient information.
And it's impossible to get "sufficient information" or negotiate anything when you're being loaded into an ambulance. The whole idea of negotiating healthcare at the personal level is patently absurd.
I Lived in Spain for a couple of decades, and I much prefer their government run hospitals to the way the US works. However, I do not believe that the US could just flip a switch and go to a public hospital system, so I would be happy with a more transparent, more competitive hospital system.
The question here is not what system to create in a vacuum, but the road in the middle. I live surrounded by a whole lot of ultra-expensive, luxurious hospitals, staffed by extremely well paid professionals (and not so well paid residents), which, in many cases, have six figures worth of debt for the privilege. To move to a public system, all of those things would have to change: Those luxurious, privately owned hospitals are never going to give great prices to a single payer system. The doctors are not going to be happy with lower wages. Medical schools would have to change drastically, so they can actually provide a number of doctors that resembles the rest of the western world. This level of disruption is what makes major changes like that in a system that employs so many people unpopular: It's a bit like how the US military can't take big cuts, as they are political suicide.
So overall, the change would be huge, and would be hard to make slowly. Therefore, I'd much rather solve it in the US through markets. Once the system has a whole lot less rent seeking behaviors, and the incentives are better aligned, a public option would actually be easier than from the catastrophe we live on now, where prices are secret, and yet, a hospitalization will often involve 10 to 20% coinsurance.
You do a public system for all and then a private system for whomever wants to buy in. You incentivize the private option by levying a tax on those in upper incomes who do not buy private health cover. This is the Australian system and it's the most reasonable option for the US but I guess in America we can never admit to looking to other countries and have to pretend nobody else has figured out healthcare.
Two-tier systems work well in a lot of places, for instance in France.
Doctors everywhere else are public servants. They do their jobs because the love it, because it's their calling and because they still get paid very, very well. Canada pays their doctors $232,000 to $676,000 gross (speciality averages, low to high).
Then because malpractice insurance is also socialized (Canadian Medical Protective Association), their costs are significantly lower too. OB/GYNs usually pay the most, and in Manhattan their annual malpractice insurance premium is $125,000. $176,000 in Long Island. [1] The highest in Canada is Ontario, at $44,000 CAD ($34,000 USD).
The public hospitals in Australia are often really good and prestigious institutions used for teaching as well. So, while you don't get a private room and luxurious amenities you do see top doctors. I can't comment as to why they stick around the public hospitals. I don't know that they make less money doing that.
Procedures under the public system are scheduled by urgency, so for example you might have a 9 month wait for a torn ACL surgery. That's why most will carry private insurance. Private cover starts around $70 a month so it's much more affordable than US insurance and importantly much simpler to navigate.
> I guess in America we can never admit to looking to other countries and have to pretend nobody else has figured out healthcare.
There are some problems which exist in America which don't exist in other countries.
Take for instance, when the rest of the world talks about how they ban guns and therefore they have no gun crimes, giving that advice to America is like if Chinese people were giving advice to Australia that they banned Kangaroos, and now they don't have a Kangaroo problem, so why can't Australia do the same?
America will not have universal healthcare like all these other countries for many reasons, which are very American in nature:
* Americans won't accept the huge tax rates which will follow it, calculations show that there would be a 20% tax increase across all income groups to fund it.
* Universal Healthcare would be the single biggest issue on which Democrats and Republicans will fight, win/lose elections, on whether to cut its funding, whether to expand it.
* America is ethnographically different than other countries. Currently our biggest 'universal' service is Courts and Police. Add Healthcare to it, and next thing we know there is an added accusation of systematic racism against certain minorities.
I dont believe there would need to be a 20% tax rate increase because we already pay far more per person in the US than anywhere else in the world (mostly)
I think it's mostly not going to work here because a lot of people will have to take paycuts (not just doctors / nurses but "administrators" "billing co-ordinators" drug companies and drug resellers, etc etc ...) always follow the $$$
Because it's worked pretty well for Medicare and Medicaid? Large portions of both were privatized through Medicare Advantage and Managed Medicaid. The gov't pays private companies a flat rate per patient who selects their plan.
A majority of Medicare coverage is provided through private companies (100% for the drug benefit). Last I saw 80%+ of Medicaid patients are covered by a private plan.
What are the benfits? The private companies take on the risk. If the lump sum the gov't gives them isn't enough to cover costs, tough, the company takes a loss. Gov't loves it as it makes budgeting easy.
The other benefit is choice. A patient can select from a multitude of plans that benefit them the most. Want a top doctor? Pick a plan where his/her hospital is in network. Have a chronic disease where you take a lot of meds chronically? Pick a plan with better drug benefits.
Medicare Part D - the drug benefit created in 2005 that is entirely private - came in dramatically under cost forecasts.
> Because it's worked pretty well for Medicare and Medicaid? Large portions of both were privatized through Medicare Advantage and Managed Medicaid. The gov't pays private companies a flat rate per patient who selects their plan.
Yeah, Original Medicare is pretty awful - I wouldn't recommend it to anyone who's able to get a Medicare Advantage plan. It's not just the cost-of-care and the overall expense to the patient (even though Medicare Advantage tends to win out on both of those aspects as well). It's that Original Medicare is a horribly frustrating experience for the patient as well.
Of course, most people (especially most people under the age of 65) don't understand the difference, and when they think about Medicare, they think of a publicly-run program, even though around 40% of the Medicare population is on a Medicare Advantage plan.
> Why do Americans not look at public provision, paid for via your tax system? Canada does it, so it demonstrably does work in North America, Europe does it, with varying degrees of efficiency, but it basically works.
One of the reasons why Americans are so vehemently against Universal Healthcare because once you go there, you don't easily get to come back.
Once govt starts to provide a certain service, it kills the private sector market for that. Then no matter how terrible govt service is, there isn't much which can be done about it.
It should also be remembered that various levels of the American government have a record with public provision that is at best mixed. Walter Reed, anyone? Psychiatric institutions in the 80s and before?
When you have a distressingly high chance of getting a terrible system, you wind up somewhat skeptical of people who want to tear down what's already in place and do public provisioning. Good and pure intentions are not an adequate substitute for competence.
Depends a great deal on one's definition of "competent". If you define it by outcomes for those with access to service, it does reasonably well. If you define it by access to service, it does poorly.
The fear is that a system that works for some will be replaced by system that everyone can access but works for nobody.
The US has far more diversity than most of the Western European nations, though this is obviously changing.
Socialism really doesn't work here as well when 'other' people are getting more benefits than you. I'm sure part of it xenophobic, but part of it is actually legitimate.
For example, a bad accident left my credit ruined in my early 20s due to medical bills. I do remember, several times, waiting in agonizing pain in an emergency room full of people who could not even speak English. Essentially, the reason my bills were so high was because the hospital was allowed to recoup the nonpayers' bills by upping mine.
It would cost the average taxpaying couple tens of thousands of dollars to have a child in the US. So we have declining birthrates amongst educated people. In contrast, undocumented (illegal, whatever) purposefully come to the US to have an anchor baby. Those playing by the rules pick up the tab. This can rub even the most socially progressives the wrong way. Same with public education, unemployment benefits, and social security.
I think that you are going to see many social services cut, and move towards the US style, in places like Canada, Western Europe, and Australia as more and more immigration creates a less homogeneous population. The fact that many immigrants purposefully head to the nations like Sweden and Germany with the most generous social systems shows that the end results will not be good for the native population.
I do not have an ideological bent towards having a public health care system.
But what this article indirectly points out, is the sheer, utter incompetency of US health care providers.
The whole justification for a private system is supposed to be greater efficiency. In many markets, for whatever reason, this seems to work. Goods became cheaper and better due to competition, the invisible hand, etc. etc.
"My cousin was triaged immediately. Within two minutes a nurse checked her ankle, gave her codeine, and then sent her off to an urgent care clinic. She wasn’t even registered in the ER."
"The urgent care clinic had a few people ahead of us. It took about 10 minutes to check in and then no more than 15 minutes to be seen. A lovely nurse named Leslie triaged my cousin and agreed an x-ray was in order and made the arrangements. My cousin did not need to see a doctor or a nurse practitioner to get an x-ray. I’m not sure I’ve ever seen that happen in the U.S."
"The nursing triage was wonderful and actually doing nursing (I hate seeing nurses relegated to charting)."
In our wonderful US free market system, we have very highly trained professionals spending staggering amounts of their time on bureaucratic paper work and busy work, while the NHS just skips straight to treating patients efficiently and professionally.
With a system this bad, people at every level of the health care industry should be getting fired every day for their gross incompetency. From the insurance companies to the health care executives to the health care professionals, they simply suck at their jobs and need to be held accountable.
If a public system can deliver the benefits in reality that a private system is supposed to deliver in theory, let's go with the public system.
Which is very near the top of my list with annoyances with the Republican party, by the way. They are so obsessed with the theory and ideal of private market capitalism, they don't care to observe whether their theory matches up with reality.
"My cousin did not need to see a doctor or a nurse practitioner to get an x-ray. I’m not sure I’ve ever seen that happen in the U.S."
I've had a few internet discussions with this particular doctor before and what I've learned is that she's used to things in California because what she describes above is definitely something that I've seen and experienced in the US.
Kid fell off bike. We went to ER. Doc & tech met us in triage. Went right back to x-ray. We were in and out of the ER with imaging taken care of in less than 90 minutes.
Also, being punted to urgent care isn't always a good thing. This is how Kaiser missed a damaged disc in my lower spine. They had a habit of turfing me to urgent care and brushing it off as sciatica. It was when I moved to Texas that a Baylor ER did an MRI, revealing the true source of the problem, and was shocked that in all the years before, nobody had ever done that.
Health care systems aren't identical in every state, as I've found out the hard way.
"The nursing triage was wonderful and actually doing nursing"
This might be another reason things are so expensive. Not every single aspect of emergency department care needs a full blown RN to take care of it. But when attempts by other levels of provider (LVN, LPN, EMT-Paramedic) are made, nursing unions come in like a hawk and lobby to crush whatever efforts are being made. It's frustrating to see happen.
This simply shows the power of a union. If physicians operated more effectively there would be no NPs prescribing.
It cuts both ways. I do not begrudge nurses their income, they sure as hell earn it for the most part. Put an investment banker in a nurse's job at County and see how long they last, then tell me it costs too much.
and it shows what happens when you lack a union too. :/ Us folks in EMS run into this often. There's IAFF which we can join, but they actively seem to hate any private EMS at all. Yet fire departments don't want to do the stuff that us in private EMS do. so we're kind of caught in between.
Texas recently made some legislative changes that will allow facilities to utilize paramedic level providers to their full scope in an emergency room setting, though. that's a huge plus.
Not everything here is perfect but there are a lot of things that I like. Good example in my line of work is that it's a "delegated practice" state, like South Carolina. This means that different EMS services can use their own medical director instead of how it was in California where the county had one that all of the providers had to use. This allows a lot more flexibility and for more progressive pre-hospital protocols.
> while the NHS just skips straight to treating patients efficiently and professionally.
NHS clinicians have brutal amounts of paperwork. That tends to be done out of sight of patients, but it's there.
Some things are helping: digital dictation; "mobile working" (community staff being able to do electronic paperwork on laptops in the car between appointments).
So do clinicians in our system. When a senior attending who is also a full professor in an academic medical center is still filing reports at 11pm on a Friday (not on service), something is rotten. Especially when that's every Friday.
> Canada does it, so it demonstrably does work in North America, Europe does it, with varying degrees of efficiency, but it basically works.
Without going into the politics, size and population/density are two major differences:
- Canada has about 10% of the population of the US with much of it clustered around a handful of major cities so the vast majority of citizens can be covered by having good systems in a handful of places.
- Compared to Europe, the difference is even more striking. Just considering Texas: it is roughly the size of France but with half the population despite having 3 of the top 10 biggest US cities. And that's still not even 10% of the US population.
Whatever approach is tried in the US needs to take these differences into account.
There's no secret to solving this problem, and it works basically the same way everywhere
Yes, in France you might be 1h/2h by car from a hospital depending on what you need
You have a tiered system: 1st level is "everyday stuff", 2nd level is regional centers (so you get routine surgeries and more complex stuff), and at the 3rd level you got your excellence centers for specialized stuff (think transplants, major surgeries, etc)
In the US case yes, you might want to have a 3rd level center per state (might not be exaustive)
Per state? Try per region. My department serves a tertiary referral facility and there's another one across town. Of course, "town" is 18 million people, but you get the idea.
I guess I could see having one tertiary center to serve say VT and NH but if memory serves even they have one apiece.
The US "free market" health care system doesn't fix this. Outlying areas still have shitty hospitals and major cities still have world-class hospitals clustered together. If you're too sick for your local small town hospital they pop you in an ambulance and take you to the city.
Texas might be "roughly the size of France" but a huge chunk of that is uninhabited desert.
Note the Bernie phenomenon in the current election. He pulled the entire Democratic party to the left, including public provision of health care. Also note, if current polls are a good indicator, Trump and the Republicans could be headed towards an historic drubbing on election day.
And Bernie drew overwhelming support from young people.
So I think that politically, the US may very well be moving towards supporting public health care.
If the polls are any indication, Trump is heading for a drubbing, and the Senate might go to the Democrats, but I very much doubt they'll win the House (the House favours Republicans for a variety of reasons, but you almost certainly won't get single payer with a Republican House).
"It absolutely is scary to imagine being sick even with insurance. Without insurance, forget about it"
Hospitals are required to take care of you, even if you have no insurance in the US. If you get a bill you cannot afford, you can negotiate a much lower rate with the hospital (I have done this and my family members have also done this).
I run my own business and so I need to pay for myself and my spouses healthcare. Obamacare actually made things worse for me. It doubled my costs (which was promised not to happen) and I was forced out of an otherwise great plan.
Getting sick is not even an issue. Medication is fairly inexpensive and if I have major surgery, I will only be out a couple thousand (the cost of a laptop).
I have many relatives in Canada and the only reason the system works there is because it borders the US. They get all of their regular care paid for by their taxes and the middle class drive over the border and get major surgery done.
The waiting lines are pretty long for most major surgeries and many older people die before they actually get it. The government there continues to promote getting checkups for specific diseases and disorders later and later in life because they don't have the facilities to get it done in a timely fashion for everyone.
NHS isn't the panacea everyone makes it out to be. There are no free lunches and when it comes down to it, a finite resource like healthcare has to have a filter/limiter. Since the majority of government run services are not that efficient and will not be able to keep up with demand or technology, it's much better to have a free-market/private care solution.
I agree with the sentiment of your post. We need to get rid of the bloated government-supported insurance companies and let the free market decide the price of everything..and offer a form of insurance to the poorest.
"Hospitals are required to take care of you, even if you have no insurance in the US."
Trouble is, that only applies to emergencies. If you just want to see the doctor about the funny lump you have to pay first.
"We need to get rid of the bloated government-supported insurance companies and let the free market decide the price of everything."
So when I break a leg I should pay the ambulance to drive around different hospitals collecting quotes for the treatment? This doesn't work for a number of reasons:
1: Most obviously, urgent treatment is urgent. Collecting quotes will take time.
2: Hospitals won't give a quotation for medical treatment. They prefer a cost+ situation, partly because they then make money no matter the outcome, and partly because the costs are so variable that you can't estimate the cost. Just how much is that funny lump going to cost? After a few $K of tests you might be able to put a lower bound on it, but not an upper bound.
3: Medical costs for something serious are bankruptingly large for most people. One serious illness and you have to remortgage your house. Insurance is the only option, but then people at serious risk of illness or injury are more likely to take out insurance, and people who are already ill can't get it or change it. Imagine if you have epilepsy: every few months you wake up in ER and they hand you a $5,000 bill. No insurer will touch you.
>Medication is fairly inexpensive and if I have major surgery, I will only be out a couple thousand (the cost of a laptop).
Have you actually ever had a major medical problem? Medication can run in the thousands (or be $5, it varies) and even minor surgery is several thousand dollars out of pocket minimum and certainly more expensive than any laptop. It's also a struggle to afford even the premiums for some people
I don't know how accurate this is but I recall hearing that something like 40% of personal bankruptcies in the US are due ot medical debt.
I'm speaking from experience. If I wasn't high income I dont know how I'd be able to afford my bout of illness.
>Medication is fairly inexpensive and if I have major surgery, I will only be out a couple thousand (the cost of a laptop).
Okay, now what if you don't have a couple thousand lying around? There are many people who can't afford a laptop.
>I have many relatives in Canada and the only reason the system works there is because it borders the US. They get all of their regular care paid for by their taxes and the middle class drive over the border and get major surgery done.
Yeah, this is the shitty part of single-payer, public healthcare. That's why many countries in Europe have a hybrid private/public system. Canada, as you mentioned, effectively has one too.
However, the point of a single-payer system is to ensure that everyone can afford the most crucial, urgent treatment. We're talking about being in an ambulance and being driven down to the ER.
If you live in Canada and suddenly require urgent treatment, you can go to the hospital nearest you, because there's no such thing as "out-of-network" or "in-network". You can get treated by any doctor. And you'll get the same consistent billing everywhere you go, precisely because it's a single payer system.
> if I have major surgery, I will only be out a couple thousand
I'll tell that to my buddy who is a general contractor. He put off major ankle trauma surgery for 6 weeks until his insurance kicked in. The alternative was $40,000 out-of-pocket.
Sounds like you really don't like the single-payer system. Let me recommend Paul Starr's "Social Transformation of American Medicine". I'm pretty sure he hates the system more than you do, but his book walks through the history of how we got here while other countries got to other outcomes. It becomes undeniably obvious that opinions like yours were manufactured by agents of the political parties and the medical industry without your realization.
As a skeptical small business owner, I really encourage you to get some more facts, do a lot of homework. Go read that book. Because this system will bankrupt you. It has bankrupted major American corporations. You alone, as busy as you are, cannot win against millions of smart people who have a century of law and public signalling to have crafted the information environment that created the system of thought in your brain right now.
Heh. Be sure not to get in an accident (very often another party's fault) and require multiple surgeries or PT. The person to whom you responded sounds young, like someone who has never seen what cancer or a bad car accident will do to a body. Let alone what walks into a county hospital.
News flash, folks: physicians in the UK and Canada still make a bit above a living wage. It's the insurers that suddenly have to compete, like when a school district finally gets its shit together and parents start wondering why they're paying $40k a year for equal or worse outcomes.
Granted plenty of Canadian plastic surgeons split to practice in the US, but that's a different (and competitive) market.
Having grown up middle class in Canada, I don't know anybody that went to America for "major surgery". Generally speaking where that does happen is with elective surgery, because wait times can be long in some places. Those people are usually not middle class either, I don't know many middle class Canadians with $40k on hand to drive down to the states for surgery.
We bitch and complain about the NHS in the UK but bloody hell I can't think of other systems that are better. I worry about losing my job and looking after gf/son in the aftermath like when I was made redundant from CSCO last year. But i've never had to pile on top of those worries having to worry about an illness taking my redundancy money and savings.
Well in some places it is, in some places it isn't.
I have had to stop considering the USA a country in the same way I view most other places. I have a suspicion that China may be the same kind of entity but I am not knowledgeable enough to say for sure.
" Insurance companies still have too much power and they call the shots, not the doctors/hospitals."
This is where the plan that Trump has makes sense. It takes away a lot of the decisions from the insurance companies and puts it back with the healthcare providers. In addition to letting the existing insurance companies compete across state lines.
> America still has one of the best facilities in the world...
Not really, at #31 in the WHO rankings [1], it's not even close to the best. At #1 in per capita expenditures, it's also wildly inefficient.
For half the per-capita expenditure Canada covers all its citizens. The US spends $8713 per person, per year on healthcare, where Canada spends $4429. [2] The result is a very comparable quality healthcare system (#30 vs. #31 in [1]) that covers everyone.
The truth is allowing for profit in a social security program is by definition allowing for inefficiency. Socialized systems do not need to spend money on advertising, on individual billing/accounting systems, or on profits. Nor should they, IMO. Social programs are for everyone. There's plenty of other businesses out there people can profit from. Caring for people when they need it most shouldn't be one of them.
We get a lot for the money, compared to the cost of other systems. I absolutely don't want to see more privatisation of the system despite most governments nudging towards this. All is not perfect though. Every government wants to be seen to be "doing something", so fiddles. Constantly. Staff is overworked and mostly underpaid.
Emergency and cancer care seems to be very good. I'd recommend not needing a non-emergency or mental health treatment in some of the poorer regions of the country though.
For instance. If you need Aspergers help for your child, or referral to some CBT for depression in some places you can wait 12 months. Sometimes more.
Even so I prefer it to anything like the US system as you can;t fall through the gaps entirely for being broke. I'm glad to pay more tax as a result, rather than an insurance premium or in-work benefit.
Had 3 visits so far in London hospitals, regarding recurring pain around heart area. Doctor solution was making me keep pain diary as NHS has no money for diagnostics...
I think they thought I am eastern european freeloader. The pain is manageable and tends to disappear when I stop drinking, which suggests liver swelling. But then my arms sometimes feel numb.
I've moved from UK since. To a place where immigrants pay just as much tax, but do not get free healthcare like citizens do.
I was in London last summer. Got sick. Waited about 9 days for it to get better. No signs of change so went to NHS. Wait one hour. Was led into consultation room and was told I could wait another 90 minutes if I wanted but that I could only see a nurse and regardless of what the nurse found she could not prescribe any medicine. Or, I was told by the same NHS person I could go about a 10 minute walk to a private clinic and see a doctor probably immediately and as a doctor they could prescribe medicine if needed.
So ... Yea, wasn't a good first impression of NHS.
Not saying USA's system is better.
In Japan it's easy to see a doctor but at least in my experience about 30% of them are quacks.
Also if you need surgery and you want a good doctor you need to bribe them. This is so common it's a normal part of most medical dramas.
I'm scared of getting the giant bill in the USA. But I'm scared of getting hurt by the doctor in Japan if I need any surgery. I don't know the solution.
I'm in a private group for what is collequally called previvors (specifically Young previvors - though some people have had/current do have breast/ovarian cancer, including a few who are dying of it). I need specialized DNA testing for complicated reasons in my family history for risk assessment. It isn't covered. We have UK and European Members. I see who their doctors ares, what research they publish. I know what they pay. ($0) I know that for patients like me, European doctors are way more proactive, even for joining studies, because they can afford to be.
I know factually that if I were in europe that test would have been done LAST YEAR. Instead I'm still looking around for one doctor outside of my regular provider to do this one DNA test under research protocols.
Doing this one test could potentially save the medical system thousands of dollars. That's what baffles me the most: The insurance companies wants me to use a certain amont of services, but only so much, in the US
It is like they actually don't want me to be healthy - and I am not sure why.
The NHS is massively overstretched. I'd be terrified of having to go to A&E at Worcester hospital, where I live, but the system we have doesn't allow for me to take my business elsewhere so there's no competition.
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[ 5.5 ms ] story [ 215 ms ] threadEDIT: If you've got more time/interest I'd recommend the documentary Sell-Off:
https://m.youtube.com/watch?v=ultKvnw2h3Q
To give another example, look at what has been happening with the Land Registry recently, there has been talk of privatising the functions that the Land Registry performs, even though the Land Registry is a profitable institution that makes money for the government.
http://www.independent.co.uk/news/uk/home-news/land-registry...
To be fair, New Labour also overused PFI to fund hospitals (PFI expanded under New Labour), so it's not completely one sided.
1) Successive governments reorganising it (including privatising services), and
2) Successive governments underfunding it.
The rest is pretty fine.
As I understood it, the shares turned out to be underpriced by about 80% and were primarily sold to a secret list of short time investors that made bank.
Have I misunderstood what went down? If not, how is this possible in the UK without any political repercussions?
I'm also not overly familiar with mainstream news media in other countries, but if you had to point the finger at any one group in terms of why there hasn't been more resistance in the UK to the dismantling of public institutions, a large portion of the blame lies with our crap mainstream news media. The public aren't kept informed about matters of substance, they're distracted by misinformation and personality politics. It may be a problem we share with other countries (from the outside, the US mainstream news media seems similar/worse), but it doesn't have to be this way. We could have mainstream news outlets that gave people a chance to get better informed about the issues being faced in their country/community. It's an essential part of society that is sadly missing, I don't think you can have an effective democracy (effective in the sense of standing up for public interest) without a well-informed public.
I think people just care a lot less about the postal service since we stopped writing personal letters with the advent of email and social media. It's just not the lifeline it once was. Postal services are now in the business of delivering junk mail.
We should probably break the news to her that there is no "drivers ed" in the UK.
But she is right. The NHS can be great, but the way the government is fucking with it at the moment will prove disastrous. It is education, not privatisation, those are the answers to the problems of the NHS.
NB Some schools (at least here in Scotland) do offer classes on the theory part of the driving test as "interest" courses.
Edit: I eventually found the quote that sums up the approach that is being taken with the NHS:
"Only a crisis - actual or perceived - produces real change. When that crisis occurs, the actions that are taken depend on the ideas that are lying around. That, I believe, is our basic function: to develop alternatives to existing policies, to keep them alive and available until the politically impossible becomes the politically inevitable.”
Milton Friedman
Of course, the crisis that created the NHS was WW2 - I remember my father (who served in the RAF in WW2) being pretty clear that returning to the pre-war status-quo was not an option that anyone was interested in, which is why there was such a resounding defeat of Churchill at the polls when the war ended.
https://en.wikipedia.org/wiki/National_Health_Service
This is already starting to happen, but is still regionalized and very fragmented.
This is exactly how the Tories do things: they get agents on the inside to sabotage a system, run it down, give it a bad reputation until it can be killed-off with the public's blessing. The BBC is also being sabotaged.
"Identifies the reasons why governments in a number of different countries have chosen to privatise their nationalised industries. The opposition to privatisation and the techniques used to overcome this opposition are also analysed."
https://books.google.co.uk/books/about/Privatising_the_World...
The NHS will never not be broke. Your position is typical of the British left but is entirely meaningless: the government could go into Greek style debt to double the budget of the NHS tomorrow and 10 years later it'd be once again constantly broke.
As I said in a different comment, many of the problems in the NHS have come from privatisation. If you want the NHS to cost less, take a look at what's happening with PFI. Just by stopping PFI funding of hospitals and going back to the old funding model of government loans at low interest rates could save huge sums of money.
http://www.telegraph.co.uk/news/nhs/11748960/The-PFI-hospita...
It's also not the case that the UK vs US comparison is one of government vs capitalism. All healthcare systems have heavy government involvement and distortion of the healthcare market, and this is fine, because developed societies always choose these problems over the much larger problem of poor people being unable to afford healthcare.
PFI schemes have not been good value for money and were essentially a trick to hide the ballooning costs of the NHS from a population that can't treat the topic rationally. Unfortunately, too many people in the UK look at this sort of thing and instead of saying "wow our government is really bad at public procurement, we should give them less power" conclude something along the lines of "oh noes, they should have guessed that trying to buy things from companies would lead to disaster - the solution is a fully state run economy!"
All kinds of organisations manage to procure services and investment from the private sector, all over the world, every day ... without problems. PFI boiled down to a complicated kind of loan that let Labour do what it always seems to try and do: massively increase spending on the public sector without raising taxes. No surprise that they paid a very high interest rate for such a thing.
I'm glad you could admit that the NHS wasn't the worst system out there. As for better systems, I'm not saying the NHS is perfect, what I am saying is that it can be improved by stopping the drive towards privatisation, as this drive is making the NHS less efficient at spending money on healthcare, not more efficient. Furthermore, even with these inefficiencies, the NHS continues to offer a cost-effective service, and I don't even need to use the US healthcare system to compare it to. The UK spends less per person on healthcare than France and Germany, for example:
https://en.m.wikipedia.org/wiki/List_of_countries_by_total_h...
The NHS isn't a money pit, it's a bargain. If you made it more efficient by getting rid of the privatisation efforts, it could be even more of a bargain.
> "PFI boiled down to a complicated kind of loan that let Labour do what it always seems to try and do: massively increase spending on the public sector without raising taxes. No surprise that they paid a very high interest rate for such a thing."
This is where your partisan bias is blinding you. PFI wasn't just popular with New Labour, it's been popular with the Conservatives that replaced them in power. If the Conservatives are supposedly more fiscally responsible, why do they continue to use expensive PFI schemes to fund government spending?
http://www.theguardian.com/politics/2011/apr/18/george-osbor...
https://www.gov.uk/government/uploads/system/uploads/attachm...
PFI reached its peak in 2007. Current number of deals being added are at the level they were at in 1995.
It's worth asking why any new deals are being signed at all, but when we're down to the level of 8 per year (vs 65 at the peak of New Labour) it's fair to say that they're much less popular than they once were.
"Starve the beast" and other traditional conservative anti-public-service techniques are functionally sabotage, yes. I'm not sure what other concept might succinctly describe "cut as much funding as you can, then highlight the resultant disaster as proof that the private sector can do better". The cultural acceptance of the practice doesn't change what the practice is.
I'm not sure what you meant by this, can you explain further?
Overall this crisis, imo, was caused by the pro-privatization advocates arguing for deregulation. The wikipedia article addresses this to some extent.
First laden the public services with excessive regulations and budgetary constraints to make it crack, loudly publicizes the resulting failures, claim TINA on privatization/deregulation of the market, laugh all the way to the (offshore) bank.
This is not some neoliberal conspiracy, it is the natural consequence of any system which allocates money without sufficient accountability.
There isn't? Care to explain?
I've both UK and US licenses - did drivers ed in illinois in the 90's, aged 15. Watching gruesome films didn't make me a better driver, and I remember being stunned when I was told I'd passed - we didn't even go on a public road!
At least, that's the process to get a license before you're 18, I think after 18 you just need to pass the practical test. And since usually the person filling out the 50 hours sheet is one of your parents it's definitely possible to just lie about it.
Just for comparison, here in Germany, you have to take a 14 hours of theory lessons and then do a theoretical test (which has a 25%+ failure rate). Once you passed that, you have to take 20 hours of mandatory driver training with a certified instructor. The instructor will decide if you need additional training hours (up to another 8 hours). The practical test then consists of 25-30 minutes of driving and parking (in a real parking spot, not cones). This practical test also has a 25%+ failure rate. Also, all that happens in a car with manual transmission.
No. It's literally driving around a few streets, stopping at a stop sign / stop light, and (maybe) parallel parking. I had to do it with real cars, which in retrospect were junkers that the DMV had for the purpose.
> Are there any numbers what the failure rate is?
Massachusetts provides a list of drivers ed schools with their pass rates - it seems to vary from 50% to 90%. Cutting that in half and adding a little bit, (the highest pass rates come from large, successful schools) the pass rate seems to be around 75% or so.
However, this is for teenagers who went through driver's ed - adults have a much, much easier time with the test because they're more mature.
Also, it greatly depends on the state. When I was in the Marines, I had the wonderful task of teaching boots how to drive so that they could get an Arizona driver's license. Their test was literally just driving around the block, no parallel parking involved.
I took the test in a manual because that's what my dad had, but most take it in an automatic. In all seriousness, though, a manual really isn't that hard once you spend a few hours stalling at every stop sign in a suburban neighborhood.
The driver's test is still easier in the US than in the UK.
Many do it soon after they can, many do it later as adults, and many never do. In UK only ~35% of adults aged 17-20 and ~65% of 20-29 have a driving licence; I assume that this is a bit different in USA.
It's a private school. Most kids learn by their parents teaching them. If the parent can not do it for whatever reason, then they register with a drivers ed school, and the teacher teaches them.
In some states if you take the theory classes [not the road practice] you get a discount on your insurance - that sometimes is part of highschool.
Every state is different though, some require a logbook with road hours, some don't, some have more theory classes, some less. It varies a lot.
About five months after I was issued my driver's license by the state of Florida, we moved to North Carolina, where driver's education is compulsory for people under 18. They would not issue me a North Carolina driver's license unless I completed driver's ed., even though I was already licensed in the state of Florida.
As a result, I enrolled in driver's ed. via my high school. Classes took place in the afternoon after all my regular classes were finished. Then, while my classmates were waiting for their rides, I got in my car and drove myself home. For the on-road portion of the coursework, I drove myself to and from the school on Saturday mornings and hopped in the "Student Driver" car. My instructor, knowing I already knew how to drive pretty well, just had me drive him on his errands -- grab a coffee at McDonald's, return some tapes to Blockbuster, deposit his paycheck at the bank, etc.
It was bullshit, but I had to do it to obtain an NC driver's license.
Of course, after college I moved to northern Virginia for work, and getting my VA license was as easy as filling out a form and showing them my NC license. Done! The VA DMV puts the NC DMV to shame in many ways, including efficiency. (In NC, we also have separate DMV offices for licenses and tags. Pain in the ass!)
But there is "cycling proficiency"!
When it comes to long term or weird and wonderful stuff - not so great. I've been bouncing around referrals for five years, and the lack of digital records means that they have to mail 30lbs of paper to each other before I show up. If the records didn't arrive, I have to dictate my case. Again, and again, and again. Still undiagnosed. One particularly spectacular SNAFU ended up with me having unnecessary surgery, because someone read the wrong notes.
Their core infrastructure is in dire need of modernisation. The government seem to think the answer is creeping privatisation. If they hadn't wasted £14bn on lining their chums pockets, the NHS would probably be pretty unassailably brilliant by now. https://en.m.wikipedia.org/wiki/NHS_Connecting_for_Health
The fact that the NHS is still fundamentally paper based, in 2016, is exactly the kind of problem that leads politicians to want more use of the private sector. In many private industries, even highly regulated ones like finance, the people who first successfully transitioned the industries to computer based systems are now dying of old age. The NHS hasn't even started. In fact it's fair to say that the NHS has shown no ability to fundamentally improve itself. It deploys new medical techniques and drugs (developed in the private sector) but when it comes to changing the organisation or adapting to new business ideas, like computerisation, it has utterly failed.
This is very frustrating for the politicians who are ultimately held accountable for the performance of the NHS. They sit right at the very top and can hardly influence anything - all they can do is set general directions like "use computers for medical records", and then watch helplessly as the incompetent staff below them screw it up, over and over again. Meanwhile they watch as Google or Facebook go on to build self driving cars and global communication networks.
Worse, as students of politics, they know full well what the reason is: the NHS is a classic, communist style top down command-and-control system. Deep institutional rot is exactly what to expect from such an arrangement. Yet they can't change it because the British have an irrational knee jerk reaction to anything that implies people in the private sector can be equally or more competent than people in the public sector.
They started a year ago: http://www.kingsfund.org.uk/blog/2015/08/will-nhsuk-be-next-...
But then I think about how often I intend on being at the hospital and will gladly pay 8 hours every time if it means nobody has to find a co-pay to learn if their cancer is back.
Btw the reason was even more frustrating:
A us doctor (turned out nurse/practitioner) told my GF that all the obvious reasons are not the cause of her short breathness. So it might be a deadly one - we needed an xray to make sure - we had an xray with us but she wasnt comfortable looking at it because of missing education. She offered us an ambulance to the ER. We had no issues whatsoever - she just tried to cover her ass in case of.
I live with an ER doctor, and the problem with US ERs is EMTALA: https://www.verywell.com/emtala-the-emergency-medical-treatm.... If you want a better ER experience you must fight that first (or get a concierge doc, which is another route).
If it makes you feel better many doctors are themselves disillusioned with the system: http://jakeseliger.com/2012/10/20/why-you-should-become-a-nu... and I have heard many ER docs complain about how they don't have enough time to adequately see, understand, and diagnose each patient. And the rants against EMRs are epic. One friend said that he chose a hospital because they still use T-sheets.
Not really ;)
They can't because the solution is more money and more doxtors and nurses, which isn't easy to solve in the duration of their mandate as a politician.
Imagine if the solution is possible but you won't detect it for 10-15 years. That's not going to get you re elected in 4.
The reason the EU model works is that people treat their problems early.
You have a concern - you go to the doctor.
NHS - with all it's short comes - has the same principle
But the NHS keeps telling us to not go to the doctor!
"See a nurse rather than a doctor! See a pharmacist rather than a doctor! Phone a helpline rather than see a doctor! Go to your high street chemist rather than see a doctor! Self-treat rather than see a doctor!".
Telling people not to go to a doctor is dangerous but i can understand the intend.
Eg: (Can only judge with Austria/Germany experience)
Pharmacists are extremely highly trained there. They are implicitly used as a simple doctor. We do the same. You feel bit weird you go to the pharmacy just to gauge what it could be and how serious they take it. If serious enough you go to a doctor asap.
They must be very confident pharmacists. If anyone ever asked me 'do you think I should see a doctor' I would say 'yes' every time.
What happens if you get it wrong? Doctors are protected by major institutions, insurance, legal precedents. What about someone working in Boots (UK high street pharmacy chain) who tells you not to bother seeing a doctor and then you die?
2) If they are unsure they will tell you.
3) If the judgement is the same as any one else would have done i dont think it could be considered grossly negligent.
Admittedly their advice would be "You probably don't need to see a GP for this, but if you're at all worried you should make an appointment".
http://www.nhs.uk/NHSEngland/AboutNHSservices/Emergencyandur...
http://www.payscale.com/research/UK/People_with_Jobs_as_Phys...
http://www.payscale.com/research/US/People_with_Jobs_as_Phys...
"You have a concern - you go to the doctor" is a waste of money. We've done randomized controlled trials to study this question and the result is more money spent with no increase in health.
https://www.nber.org/oregon/
http://www.rand.org/health/projects/hie.html
I'm not sure if you were posing this as a problem or not but as long as doctors want to work for the NHS it isn't one.
Might also be worth comparing the cost of qualifying as a medic in the UK and the US!
Tangentially, if anyone proposes UK-style solutions to health care problems in the US without proposing 50-66% wage cuts for doctors/nurses, they are lying to you.
NB Regarding the "socialism" part, from NHS founder Aneurin Bevan:
"A free health service is pure Socialism and as such it is opposed to the hedonism of capitalist society."
I always think it is worth noting that the title of Bevan's book on the NHS was "In Place of Fear" - which I think sums it up nicely.
https://en.wikipedia.org/wiki/Aneurin_Bevan
In practice that's just not politically feasible in the US. An illustrative example: a few years ago, a major study found that mammograms before age 50 are financially wasteful and medically harmful. Congress passed a law requiring insurance companies to pay for them anyway.
https://www.bloomberg.com/view/articles/2012-07-31/in-mammog...
http://www.uspreventiveservicestaskforce.org/Page/Document/U...
It's one of the reasons that out of pocket costs are so high.
Exactly. This is the hidden secret about US healthcare that very few people are aware of. Even providers usually don't see this anymore, because they're so removed from the billing process (especially now that most providers are salaried and not running their own practices).
Medicare and Medicaid are the reasons that sticker prices for treatment in the US are absurdly high. Incidentally - and most people don't know this - if you're uninsured and self-paying, you almost never have to pay the sticker price. Hospitals really don't care, and if you just tell them that you're self-paying and can only afford (say) 10% of what they billed you for, they'll almost always immediately agree to a 90% discount. The only reason they're showing you that bill is that they need to present high bills to private insurers (to make up for the loss on Medicare/Medicaid reimbursements) and they're not legally allowed to present differently-priced initial bills to patients based on their insurance status.
http://data.worldbank.org/indicator/SH.XPD.PCAP
http://www.usgovernmentspending.com/year_spending_2014USbn_1...
For us to underfund it to UK levels, we'd have to expand medicare or medicaid to every single person while simultaneously cutting the total government budget for health care by 2.5%.
Using a definition like "meets the costs of providing the services it mandates" inherently contradicts this philosophy since in the US, all sorts of crazy services will be mandated. E.g., mammograms for women under 50.
The US government actually tracks mammograms in the US through the Breast Cancer Surveillance Consortium. http://www.bcsc-research.org/
Their research basically has it come down to a massive case of Simpson's Paradox among many important subgroups needing early screening (black women, ashkenazi women, previous radiation to the chest) that suddenly disappears when they are added together en masses.
The US Preventative Service Task Force, however, is not in the business of explaining stats: it is basically a guidebook of what insurance will or will not cover, and they went with the rating they did as a compromise over the simpson paradox over the fear that these subgroups would lose coverage in high deductable plans
In exchange, they actually did cause problems by not doing comprehensive DNA testing and ONLY covering BRCA testing - which is bad science.
So, actually, yeah, you probably could move to a UK style solution, with the same per-capita spend as in the US while still preserving the seemingly very high wages for doctors and nurses.
The figures suggest you are wrong. The substantial majority stay in the NHS
Current under-funding of the NHS means there's a shortage of consultants (especially in A&E and mental health) and a shortage of nurses.
Some A&E units are being downgraded and closed at night because of these shortages of staff.
Some, although I don't know how many, definitely are, though, especially after the junior doctors contract change.
1) I cant believe that it's only the doctor costs.
I see people with all kinds of health problems in the US that should be treated early. Classic example is people with foot problems not treating them asap -> soon stumbling, crutch, amputee.
2) Comparing salaries in the US to the UK/EU are super hard. We have by usually lower costs of livings in europe (health, education, housing).
eg SE: http://www.payscale.com/research/US/Job=Software_Engineer/Sa... http://www.payscale.com/research/UK/Job=Software_Engineer/Sa...
Personal anecdote: i could earn half my money i earn in california and would still be top paid in germany/austria. i would be able to save more money though.
3) I am unsure how much doctors should earn. They earn very good money in Europe. But maybe that's just my "it's a mandatory service not a privilege" pre-trained mindset speaking.
Again, I linked to RCTs showing that improving access to health care doesn't improve health and does increase costs/utilization. Do you have any evidence to the contrary?
2) The UK is 6% more expensive than the US. I don't know where to find the exact PPP factors, but you can back them out of GDP statistics by dividing GDP(PPP) per capita / GDP(nominal) per capita.
https://en.wikipedia.org/wiki/List_of_countries_by_GDP_(nomi...
https://en.wikipedia.org/wiki/List_of_countries_by_GDP_(PPP)...
Where do people get the crazy idea that the US is more expensive than the EU? Is it just personal experience from their vacation to NYC?
Yes, it's true at the far extremes there are people that can both afford and choose to pay personal doctors, but it's very rare, even among "the rich". Most people don't consider that a good use of funds.
It's illegal for American hospitals to deny necessary medical care due to inability to pay. I've gone to American hospitals both when I was indigent and when I was well off, and I feel the service quality was identical. In fact, hospitals usually have a designated administrative employee who handles the billing; the actual health professionals involved in treatment will often have no idea what your financial situation is and/or whether you even have insurance.
It is now illegal for Americans to fail to carry some form of health insurance. If someone absolutely can't afford it, there's Medicaid, the government-sponsored insurance program, which is actually really good. For people in-between, there's the government-subsidized health exchanges.
Healthcare in the US is a complete mess, but it's not as simple as "rich v. poor". Practically, most of the poor continue to get medical care, and if they don't manage their insurance or care properly, they just take big hits to their credit. Which, don't get me wrong, is not good either, but it's definitely recoverable and survivable.
Wrong, depending on the angle. Prevention is the key, it's the same with computer bugs
Correct, don't send them to a doctor for anything that shows up, that's why the initiatives are to have Nurses evaluating the problem and escalating if it's a bigger/more urgent issue
theoretically people should go to the ER only when it's urgent or life-threatening
In US you need to get paid more, so you can afford health insurance for you and your family, pay for daycare and school and college for your kids. In Europe you get these mostly free, so you can get the same quality of life with a lower salary.
I linked to numbers elsewhere in this thread showing that cost of living is higher in the UK.
US ER doc: $209,161 - $5,000 = $199,161.
UK ER doc: $60,504 - $0 = 60,504. ($57,709 after adjusting for purchasing power, which is lower in the UK.)
This really doesn't change my conclusion at all. (PPP factors, salaries are taken from links I've posted in other comments.)
HN will be full of Googlers and startups with funny money who can throw around gold plated plans to their people but in the real world this is how it is, and premiums are getting worse every year.
They also don't get sued so much. Or have crippling depth to pay of.
>>> You have a concern - you go to the doctor" is a waste of money
It's called preventive care and it actually saves money in the long run.
Strangely, not a single person telling me I'm wrong has cited a single source or done a single back of the envelope calculation.
The Oregon trial was only two years long and it actually did report some health improvements, diabetes and depression in particular. It also found improvements across a lot of other medical issues, they were just considered statistically insignificant (given it was only two years, not really a surprise).
The RAND experiment found that money does reduce unnecessary medical treatment (and therefore reduces costs). But it also found that it reduced necessary treatment too.
I agree that the exact numbers and costs are controversial, but basically everyone aggress that it improves the quality of life for everyone. And even if preventing disease is costlier, isn't better that fewer people get a serious disease in the end?!
Also, here's a study that supports preventative care. There's many more if you just look for it. http://www.medscape.com/viewarticle/735245
You are correct that having insurance made people feel better. So what?
It also found improvements across a lot of other medical issues, they were just considered statistically insignificant...
And you've just demonstrated that you have goals here other than finding truth, or perhaps you just don't understand hypothesis testing.
Your medscape article is just a press release parroted by some innumerate reporter. Further, the article is focused on stuff like "stop smoking" and "stop drinking" support, not medical interventions. The full study isn't even linked.
It increased the rate of diagnosis of diabetes. And what do you mean speculate? What's the point of giving medication if it doesn't help?
>>> You are correct that having insurance made people feel better. So what?
Treating depression is part of healthcare.
>>> And you've just demonstrated that you have goals here other than finding truth
I don't think so. I just thought it's an interesting observation. Combined with the fact that it was a short term experiment it makes one think. But you're right, it's not significant.
>>> "stop smoking" and "stop drinking" support, not medical interventions
Stopping smoking and drinking is part of healthcare. At least in the UK. Perhaps you don't think preventive care works because you don't think improving ones wellness is part of it? Why are insurance companies including preventative care in their packages if it actually costs them money?
Here's a study that found a list of preventative measures that do save money: vaccinating children and adults, smoking cessation, daily use of aspirin, and screening for issues with alcoholism, obesity, and vision failure.
http://www.nejm.org/doi/full/10.1056/NEJMp0708558#t=article
But you're right. In part. Other preventative measures do not save money. Like preventing heart attacks by treating hypertension early on with drugs did not save money in the long run. It's more cost effective to let people have heart attacks. But at least the insurance company saves a few bucks (rolls eyes).
By "speculate" I mean it didn't demonstrably improve health, but the authors speculate that maybe it will later.
Stopping smoking and drinking is part of healthcare. At least in the UK.
Try to follow the discussion. We were originally discussing the statement "You have a concern - you go to the doctor". andreasklinger proposed that this is why EU medical systems are cheaper.
https://news.ycombinator.com/item?id=12331398
Your own source - a political op-ed published in a medical journal, disagrees with this claim:
Our findings suggest that the broad generalizations made by many presidential candidates can be misleading. These statements convey the message that substantial resources can be saved through prevention. Although some preventive measures do save money, the vast majority reviewed in the health economics literature do not.
The fact that obesity reduction might improve health is great, but totally unrelated to the topic at hand. Telling people to stop smoking and being obese != "you have a concern - you go to the doctor".
No one disputes that your health will go up if you eat right, exercise and stop smoking. You are arguing against a straw man.
Also, your own source does not address the marginal question that I asked. I asked for evidence that "providing more preventative care will either save money or make people healthier".
Your article says: In addition to determining which preventive measures and treatments are most efficient, it will be necessary to identify those that are not yet fully deployed and those that could serve a large population and bring about substantial aggregate improvements in health at an acceptable cost. Findings that some cost-saving or highly efficient measures are underused would indicate that current practice is inconsistent with the efficient delivery of health care. Other services might be identified as overused, and such findings would underscore the importance of fashioning policies that provide incentives to shift practice toward more cost-effective delivery of health care.
Your article says we need to carefully target which interventions are worthwhile, cut the ones that aren't, and refocus on the underused ones that are. That's not disagreeing with me at all!
It's a fair assumption. Treating an illness with the approved medicine that worked well in the past tends to work in the future too.
It takes a lot of mental gymnastics to dismiss both increased diagnoses and treatment as anything but conclusive.
>>> Try to follow the discussion. We were originally discussing the statement "You have a concern - you go to the doctor"
It doesn't matter what the original point is, I was strictly replying to what you said, with quotes. Are you following?
>>> Your own source - a political op-ed published in a medical journal, disagrees with this claim:
The quote you posted really isn't. It says some save money, some don't. I gave examples what the study found to be cost effective, while the majority were not. Sometimes the answer is not black and white.
>>> Telling people to stop smoking and being obese != "you have a concern - you go to the doctor".
Isn't?
Free-at-the-point-of-use obviously does increase usage of services, meaning people will be told to stop smoking more often. Those two concept are directly linked.
>>> Your article says we need to carefully target which interventions are worthwhile, cut the ones that aren't, and refocus on the underused ones that are. That's not disagreeing with me at all!
Again, isn't? It clearly says some interventions are worthwhile and some not.
So let me get me straight, you think that if giving away nicotine replacement drugs is costing more money than cancer treatment, we should stop telling people to stop smoking?
But it was much worse when in the UK. The providers get funding for you, but once you are registered, it seems actual service is a pure cost to them. My GPs practice in London only allowed same day-appointments and only pretended to allow them over the phone.
My cousin there got sicker and sicker for months in because instead of testing her, they just gave her the wrong medicine. In the end she flew to Sri Lanka where she got tested, rediagnosed and operated on within 48 hours.
Some GPs are bad, and in general GPs are under a lot of pressure, but you can change your GP surgery at any time, for any reason.
And let's not forget that your "NHS GP" is not employed by the NHS, but is employed by a private company that does work for the NHS.
GPs are shit because of the fucking awful semi-privatisation they've been forced through.
I guess if they are getting over cancer they might be lucky enough to have met their out of pocket maximum for the year.
edit: Why is this controversial? I literally paid out of pocket for 2 CT scans last year. They both applied against my deductible (so they were 'medically justified' or whatever, not done at my insistence or something). Is being sarcastic about the high cost of healthcare in the US so absurd?
Usually high deductible plans come with a tax free savings account. You sock a little money away each month so when something happens you have a cushion to fall back on.
They certainly aren't for everyone, but if i was young and in good health I'd probably go that route.
We have an insane system where mandated government care is underfunded and then the hospital is expected to make up the difference by charging the people that need medical care. People that are having a bad day pay for the people that are having a bad year.
Of course I have no way of giving any weight to such a statement, but I'm pretty sure I would have paid 1/3 to 1/5 as much in a reasonably competitive marketplace...
Otherwise, yes, I agree that the private system is subsidizing the public system, particularly Medicaid.
I strongly recommend to anyone with 'mysterious' long term illness to visit doctor in other country.
https://www.nhs.uk/be-clear-on-cancer/symptoms/bowel-cancer
> If you've had blood in your poo or looser poo for the last three weeks, tell your doctor. Chances are it's nothing serious, but you're not wasting anyone's time by getting it checked out. Call your GP today.
https://www.gov.uk/government/news/government-launches-its-f...
Three months is reasonable number if you have no GP (have to register first), bad english and live in poor neighbourhood.
Visiting foreign doctors is cheaper and faster.
For the vast majority of people in the developed world, that's how heath care works.
I might be an outlier in that all my of coverage while employed in the U.S. has been fantastic.
As for the NHS the mother of a friend died due to negligence while being transported home. So it's not all good, which is why the system cannot be judged this way.
The post basically says, "Wow, we got medical care and didn't have to pay for it!" Everyone already knows that Britons pay for health care out of their taxes and not at the time of service, so it doesn't really bring anything to the table, and certainly doesn't make a case for or against one system or the other.
Of course no system is perfect and their are a number of hospitals in 'special measures' which means their management is replaced and they are in turnaround. I'm very sorry to hear about your friends mother. I assume it triggered a full investigation?
As someone who has sxperienced the US and Canadian healthcare systems, I can confidently say most Americans would be deeply unsatisfied with aspects of the Canadian system. Yet Canadians love their system.
The waiting times for certain procedures in Canada, the lack of provider choice and the lack of access to the latest drugs/tech are just accepted in Canada. One reason why the US system is so expensive is the expectation of a lot of Americans that they get the absolute best healthcare out there, costs be damned
And yes, I'm generalizng with the comments. No need to call that out.
NHS was excellent growing up. OHIP/Ontario Health Care was excellent. The US is contrived and awful.
contrived. having an unnatural or false appearance or quality
What?
> The only real issue was people who show up for care that is clearly not even semi urgent never mind emergent.
People do love the NHS. And they trust A&E. Companies would kill to get that kind of brand loyalty. So the answer is to co-locate walk-in doctors and minor injuries with A&E departments, and have fierce triage on entry to divert the people who don't need it away from A&E.
Nothing about this article is surprising, despite the author's tone. Any modern industrialized country should be able to quickly treat a routine broken ankle. Where that's not possible in the US it's a travesty. Now compare the care of extremely rare diseases in the US and UK and you have something more interesting to talk about.
As for comparing rare disease treatment, I can't say but would like to see some more information.
In my experience the only thing exceptionally good about US healthcare is its astoundingly effective PR team.
In my experience the only thing exceptionally good about US healthcare is its astoundingly effective PR team.
I would privatise it tomorrow. The amount of waste in terms of time and money were eye-watering, every time. The amount of politicking was immense. A project that should take a few weeks could easily expand into a couple of years. I resigned from my last contract because it actually felt immoral to be taking a large amount of cash to either sit around twiddling my thumbs, fight with people, or do work at the slowest possible pace in the most ineffective way. I'd rather do something else. Basically, I've never worked for a private company that was anything like that, even the worst ones, and I find it hard to believe any private company would survive very long working that way.
I'll add, my Japanese girlfriend and her friends are utterly unimpressed with the level of service. As was my Spanish girlfriend, who also worked on a hospital's grounds as a medical researcher.
I'm not saying we should copy the Americans, no way, but the Japanese system is private, the German system is private, the Dutch and French systems are also private. Going private does not mean chucking the idea of universal healthcare on the fire, it means properly separating the regulator from the provider and removing the kind of conflict of interest that led to the cover up of high mortality rates, among other things. There is more than one way to skin a cat.
And no, I'm not a Tory. Try picking up a copy of Private Eye if you want to divest yourself of the notion that the NHS is a saintly institution. Or work there.
Sorry, but that's the way it was.
At least the lazy employees of the public health care system will not rush me out of hospital hours after a major surgical procedure as some other private health care systems do.
Now of course you might disagree but that's more of a matter of opinion than some objective fact.
However... when we do go in for a visit, I get the distinct feeling that there is a lot of pressure to keep appointments within a specific time interval and basically get patients in and out as fast as possible.
Overall though, the integration of doctors, specialist, labs, and hospitals does create a smoother and less stressful experience.
That would be one of those inefficiencies introduced by part-privatization... So it's hard to believe it's approaching zero. Not to mention that you have no real basis for making that statement from personal experience alone...
Contractors milking their clients is something that competent buyers are supposed to prevent, but NHS procurement is a disaster-zone, as is commonly the case in the public sector. Just look up the different prices paid for basics like rubber gloves.
Saying that the inefficiencies due to privatization are "approaching zero" is a bit disingenuous.
Have you ever worked at a reasonably large private organization? It's exactly the same there. It's a complete fairy tale that large private organizations are somehow more efficient than large state-run ones.
Every company I've worked at with lots of red tape got there because they were actually trying to solve a problem due to the lack of "regulations" or rules.
This is especially true of health care where there's not much salient differentiation or other dynamics that would naturally produce monopolies.
Companies require capital to start. The level of capital to start a company differs depending on the industry. One of the main reasons you see far more startups in IT than in telecommunications (think Verizon, AT&T, etc...) is due to the difference in cost of entry into those markets.
In the case of healthcare, consider the cost of entering a competed space: nobody is better at everything so you won't have a clear advantage for many patients, the startup costs (time, money, permits, staff, etc.) are massive, people like to keep their existing doctor and won't change without cause, and the complexity of the problem defies simple solutions. You can't save on staff costs without losing in-demand professionals, things like billing are both intrinsically complex and disastrous if you get them wrong, and so are all of the safety and other regulatory compliance issues. You might be able to shave bits here and there but it'll take time, have indirect costs, and it's going to be a modest percentage over time.
[1] Although one that still, from time to time, listens to the people at the bottom who actually know their stuff.
I wouldn't say any country has healthcare "solved", but I don't know how anyone can look at the US system and say that it's a good situation for a developed country.
I'm possibly moving to Japan soon, so I guess I'll get a better comparison soon enough.
How?
I mean what model of commercialisation would you use? And how do you propose to convince the electorate that your model would be an improvement?
The NHS needs to work hard to in-house more stuff. There's fat to be cut, for sure, but it's the existing private elements where most of the real waste comes.
Companies like Serco, G4S, ATOS and Capita have all supplanted "failing" public services by either promising to be cheaper or replacing another company that submitted a wildly inaccurate bid and themselves under-delivered.
I highlight "failing" there because many of these failures aren't organic; a government has broken them and then threw them under the bus.
After a few years of substandard services and a daily ragging in the Telegraph, the magical tenets of tender and PFI are just too tempting. We paint this picture of the lean bulging muscles of private industry, but it's the same problems with added layers of obscurity and greed.
Worse is the transition from cooked-in-house school/hospital meals to having them driven in from a factory 200 miles away is you replace so much infrastructure that there's simply no going back. You used to have a kitchen full of ovens and hobs and staff who knew how to operate them. Now you have a room full of freezers and microwaves and the cheapest possible immigrants interfacing between the two. To reverse that requires hiring and training and investment. Who's going to invest in that when they could just keep selling them [awful] ready-meals?
Or you sold your land to a PFI so they could give you a hospital. The catch? They get super high rents and "maintain it" at huge expense. After 20 years you've spent more than twice the amount it would have cost to build and maintain it yourself. It's loan-sharking.
The tragic thing here is that many public services are the ultimate embodiment of lean. They do so much with so little and are forced to be transparent. They are people so there's obviously some variance but we've spent so long villainising these organisations that we've forgotten how good some of them really were before it was too late.
This country needs to find a way to start fixing this.
If I were king for a day, I'd start with a new nationalised housebuilding scheme. That would raise revenue (means tested rents, fair price sales), create jobs, lower poverty and homelessness, create new markets for local services.
The Dutch health care system is a prime example. After partial privisation costs went up.
Privatised telecoms markets are the canonical example of this. Not many would go back to the days of state-run telco monopolies.
I'm glad you aren't in charge then :-)
Sure there is going to be waste, but once you privatise, the 'waste' will continue in the form of profit taking by insurance companies and all the other private actors in the system.
I know it feels unfair that there is waste. But IMO profit in healthcare is another form of 'waste' anyway, one that is made worse by the fact that it distorts the incentives away from providing care.
Profit-seeking isn't unique to private entities. State-run programs are still subject to the exact same economic forces; the difference is solely in how they're accounted for.
It's similar to the situation with state-run prisons: the profits are divvied up between the vendors who supply the prisons, the unions representing the correctional officers, and other entities who are required to make a prison actually operate. And even in state-run prisons, these entities have incentives to lobby for the expansion of the prison-industrial complex (which they do). Vendors, suppliers, and LEOs extract massive financial benefit off of the entire system, but because the program itself is state-run, we don't talk about that as 'profit'. Instead, we talk about that as the 'budget' (with a surplus/deficit).
But suppose we turned the state-run system overnight into a vertically integrated, private system, with all the roles served by the exact same people. That is, all the correctional officers are the same (making the same amount of money), all of the suppliers vendors are the same (but many are now owned by the private system). Suddenly, from a discursive (and accounting) perspective, we get 'profit'. The amount of money being traded hasn't changed. The steady-state flow of money hasn't even really changed[0]. The only thing that's changed is which entities we group together as units. But they all work symbiotically in the exact same way, no matter whether you view them as a single entity or a composite system.
As for the NHS - you absolutely bet that there is a profit motive amongst providers (and the agencies themselves). The language is different, and the way it gets assigned to the entities who comprise the system is different, but the fact that it's a state-run program doesn't mean that all that 'profit' magically goes back to the taxpayer.
[0] There would be an overnight, single-time transfer of cash due to the overnight privatization (same thing that happens anytime a company spins out a subsidiary into a separate private entity), but the ongoing cashflow would be the same.
That sounds like a utopia. None have been seen in the wild. Factions can form inside vertically integrated systems as well.
I also never claimed that there can't be profit taking in the nationalized system.
I only said that if there's going to be waste, I'd rather have it come from a system that isn't structured to deny care, or to make it prohibitively expensive.
Nobody likes people who are cheap. Did you ever go to somebody's house for dinner where they measure out wine with a graduated cylinder, and put out tiny portions?[1]
How about people who a cheap with the necessities of care for their loved ones? I'd rather treat everyone at the hospital like royalty, and not be cheap.
We can afford it. Just cut back on true waste like astronomical defense budgets for starters.
[1] Excluding cases where the hosts are truly poor.
The staff make profits. If they weren't making profits then someone would assess how much they needed to live and pay their bills and that'd be the amount they got paid. In practice they get paid, some of them like senior doctors get paid large sums of money that they can then spend as they see fit.
The unions make profits. They charge membership fees and then justify those fees by organising industrial actions in order to increase the profits of the staff.
The equipment manufacturers make profits. Often by charging wildly varying prices for the same goods to different hospitals.
The drug manufacturers make profits. They have to, otherwise they'd not be able to do the research they do. University research is really no substitute.
Without profit the NHS wouldn't exist anymore.
Everyone should get paid of course, and even handsomely including doctors, but what I meant was that no private company should be able to bill a patient for treatment.
So it's totally OK for a single doctor to make huge profits off the NHS when they charge patients for treatment, but if those doctors form a company to share the load and amortise overheads, then suddenly it's a terrible evil that must be forbidden?
And don't get confused by simple word changes: when a doctor turns up at a hospital and does work in return for a large paycheque he is very much "charging a patient for treatment". The fact that the charges come in the form of taxes and take a long route to get to the patient's wallet doesn't alter the fact that the money comes out of the patient's pocket and ends up in the doctor's pocket!
It comes out _partly_ from the patient's taxes, and the rest from everyone else's taxes.
The cost is spread. That makes a big difference.
The NHS is good value for (taxpayers') money: it's about half the price of the American system for the same quality of care.
It's a fairly open secret that the Government is encouraging patient dissatisfaction and privatizing the NHS by stealth. It's only a matter of time before patients have to pay for treatment.
My experience of it as a patient is generally favourable. I usually get seen promptly, and it's free at the point of use. I've experienced the health services in two other countries (Hong Kong and Belgium).
By the way, I've been living in the UK and spain, the small experience I had with NHS was ok. But I managed to get confused with the system to the point I started crying in front of a medical secretary after spending a day trying to get an appointment with a doctor.
[1] https://en.m.wikipedia.org/wiki/Healthcare_in_the_Netherland...
There are plenty of examples in this thread of how good the emergency treatment is, and some bad examples of GP treatment.
In the UK your "NHS GP" is paid for by the NHS, but is employed by a private company.
The private bits of the NHS fucking suck.
In reality it is a different way to administer single payer health care that leaves the doctors and hospitals (and the patients) some more freedom, but at increased cost.
From a micro perspective large organisations are often dysfunctional. You need to look at the statistical measures to compare them against other systems. And the NHS manages to give universal coverage at half the cost of the US system.
While there is waste in any organization, overall the NHS is perhaps the most efficient healthcare system in the developed world. The US spends as much on public healthcare as the UK yet large numbers are left uninsured (while spending the same again on private healthcare.) [1]
> I'm not saying we should copy the Americans, no way, but the Japanese system is private, the German system is private, the Dutch and French systems are also private.
If we want Japanese/German/Dutch/French levels of service then we have to be willing pay what the Japanese/German/Dutch/French in their health service, around 11% of GDP instead of the UK's 9% of GDP.
Yet despite spending significantly less than Germany/Franch/Netherlands the UK mostly compares favourably on health outcomes. [2] [3] [4]
Should the UK spend more on healthcare? Probably some. But it may not be the best way to improve health outcomes. Infant mortality is higher in the UK than France or Germany (though not nearly as bad as the US.) Given infant mortality is highly correlated to inequality it may be more effective to spend more on redistribution than health care.
As populations age, and the need for healthcare increases commensurately amd efficiency becomes vital in healthcare provision. Insurance based system (as in France and Germany) cost more for equivalent outcomes.
[1] http://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT
[2] http://www.commonwealthfund.org/publications/fund-reports/20... (full report http://www.commonwealthfund.org/~/media/files/publications/f...)
[3] http://ec.europa.eu/eurostat/statistics-explained/index.php/...
[4] http://ec.europa.eu/eurostat/statistics-explained/index.php/...
Going to A&E is like having your tech support handled by engineers. Going through the GP system is like calling a support line. She got a positive outcome because she went with the option that costs the most.
I'm pointing this out as someone who has gone through both methods. Don't believe the hype that you read about the NHS. It's good to have, but it's not amazing and if everyone went through A&E, the system would probably collapse.
It's not really a case of GP or A&E. They are two different things with different purposes. The A&E is designed for problems that shouldn't wait. Your GP is for ongoing issues that aren't crucial to be sorted right away. It's called Accident and Emergency for a reason.
The NHS is far from perfect but I don't know what a better system would be.
This article highlights the best part of the NHS, whereas the GP system is like being caught in limbo. If you are rich enough and plan in advance, it can be avoided by going private, otherwise it can mean months, even years of suffering through long waits.
I don't understand how this is a bad thing about the system. Yes, if everyone went through the most expensive system designed for urgent things, the system would presumably collapse. But they don't, because the system includes something for less urgent cases, and thus doesn't collapse. Doesn't that just mean that aspect is well designed to avoid collapse that would apparently be inevitable if it were less well designed? Isn't that a good thing?
i.e. If the article read: "I had an issue with my ankle, waited two weeks to see a GP, then was in the waiting room for an hour after my appointment was meant to start, then had to wait a week to a referral for a scan." It wouldn't be such a clickbaity story.
My dad had pancreatic cancer and went to the doctors, did every sort of cheap test they could. They didn't believe him, and said it was psychological and sent him to a psychiatric hospital instead. Again nothing worked
After constant complaining, eventually they went for the expensive scan, and found that it was pancreatic cancer wasting several months.
Awful.
This. No matter what we claim about American healthcare, this points resonates so well with most of us in America. It absolutely is scary to imagine being sick even with insurance. Without insurance, forget about it. Then comes the maze of crazy terms like co-pay, co-insurance, deductible, pre-authorization, in-network, out-network, Specialist referral and god knows what else.
Now may I rant about the Insurance companies if I may ? Obamacare was supposed to fix healthcare but it added to the red tape further. No real solutions. Insurance companies still have too much power and they call the shots, not the doctors/hospitals. Good luck fighting a denied claim unless you can shell good amount of lawyer money.
I don't know the solution though. America still has one of the best facilities in the world and even though the process is too bureaucratic and downright idiotic in many cases, the care that is actually provided is still pretty good. And I say this as someone who is aware of medical tourism and countries such as India.
One solution could be to get rid of insurance scam (yes I call it a scam) and then lets hospitals/doctors compete with transparent pricing in a free market. For catastrophic events, let insurance companies exist. I hate it that to even get an X-Ray, I need insurance and without it, they will look at you as if you came from some strange land. And if you do end up getting a service without insurance, good luck looking at the bill when it finally comes. You can be a crypto expert but won't be able to figure that one out.
However, in Canada, a debilitating injury might necessitate bankruptcy because of bills that you can't pay thanks to a medical condition which precludes your usefully working.
In America, a debilitating injury might necessitate bankruptcy because of bills that you can't pay thanks to a medical condition which precludes your usefully working AND an usurious hospital bill.
http://www.creditcards.ca/credit-card-news/top-ten-reasons-w...
1. Overextension of credit (22 per cent of all Canadian bankruptcies).
2. Seasonal employment (15 per cent).
3. Job loss (12.8 per cent).
4. Medical problems (11.3 per cent).
...
A. It's not most. Not even close.
B. If you take the countries that do have socialized medicine, and add the criterion that the funding is not in constant jeopardy, there are very, very few countries that "manage it".
Most developed countries. In fact, I'd go as far as to call it a qualifier to be a developed country.
Everyone lives in fear of getting in an accident. Therefore, I assumed that what codegeek meant was that Americans live in fear of getting in an accident because they won't get treatment. But that is obviously not the case, so I'm not sure what codegeek's point was.
As a first time visitor to this country many years ago I went an clinic because I had severe strep throat. Waited 1 hour, then some intern saw me for 5 minutes. Gave me a codeine pill and later sent me a bill for $400. That was 1990's $400 dolars, and I had a stipend of only $200 month as a student.
That right there is fucked up. Actually, I would rather they just turned me a way -- "Sorry bud, this will be more than you can afford".
I know what people will say "Oh you don't have to pay, declare bankruptcy or call and haggle with the hospital". But you know where you haggle with the hospital -- in a 3rd world country when you are bribing the doctors to not kill you. You haggle there as well, and you also have to haggle here to get he "special, I can't pay" rate.
The only reason those ERs are open in the first place is that you can't be accredited as a general hospital without one (which has specific tax benefits). Anyone who uses this example is either woefully ignorant or a troll.
When it's provided. If you have employer health insurance, you're usually fine. Otherwise ...
I don't understand the American (and it is American) obsession with having a free market in healthcare.
Why do Americans not look at public provision, paid for via your tax system? Canada does it, so it demonstrably does work in North America, Europe does it, with varying degrees of efficiency, but it basically works.
No-one in Europe or Canada lives "in fear having an accident or getting sick" because they know healthcare is provided by the state in the same way as education, fire services and police service are all provided as a public service, for the general good of society, via taxation.
Americans are happy to send their children to school, to be able to call the fire department or the police (we'll set aside the clear problems of US policing - you generally still call the police when you see a bank robbery, so there is a degree of confidence in them still).
So why is healthcare the exception? What sort of mentality says I am to blame for getting sick and told if I cannot afford medical treatment, I should not have become ill?
Because raising taxes is bad, obviously one day you'll be big and don't want to pay health care for all the people down there. And of course it's a slippery slope. Today it's health care, tomorrow it's minimum wage and the day after you find yourself in a Gulag /s
Just look at how hard republican states tried to push against Medicaid.
I think part of it is the culture of believing you can be anything you want to be. It's the same reason the poor often vote against their interests in the US - they believe that soon they'll be rich and want low taxes and few regulations. That they are the exception.
Or then again, maybe they just have a different opinion than you on what is important to them?
There is a minority of people who are actually completely out of touch with reality, so-called demagogues and populists, and to a less extent all politians: they are completely deluded in thinking that by repeating a point a thousand times they can mislead those perfectly informed masses.
As the saying goes: "Fool me once, shame on you. Fool me twice, shame on me." A large part of the American populace has been getting fooled repeatedly for decades.
It has not been established that they are voting against their own self-interests. You are just assuming you know what their interests are better than they do.
Wow, into being condescending much? How about this... maybe, just maybe those people know what "their interests" are better than you or I. Have you considered that?
Someone's said that it's because one day they think they'll be rich, and suggested that this was foolish. An alternative explanation is that they're voting for it because they've considered the question very carefully and are voting for what they think is morally the right thing, even though it'll harm them. In which case it's far from foolish.
I think the offence was taken in assuming the foolish explanation instead considering the one where people were making a sacrifice to do what they think is the right thing.
We don't know unless we ask them, of course.
This whole mindset of "you're too stupid to know what's good for you, so just let us smart people be in control and make things OK" is something that is very condescending and is repugnant to many (most?) Americans. Which is one good reason it's hard for politicians pushing such policies to gain ground. It might be better to actually, you know, talk to those people and try to understand what their principles, goals, and motivations are, instead of assuming that they're stupid.
I have considered that notion for a long time, but ultimately dismissed it as pure nonsense. The fact of the matter is that people can be tricked and be taken advantage of. It is not condescending to point that out when it happens.
If someone gets conned into transferring all the money in their bank account to a stranger in Nigeria on the belief that it will "free up" millions that will be theirs, you cannot possibly make the argument that pointing out they got conned is condescending, that maybe that person knew what was actually in their best interest. They thought they knew, but they were, frankly, wrong.
The exact same thing happens with many poor people in our society: they get conned into voting for politicians who will absolutely screw them over. Furthermore, it doesn't happen once or twice. It happens repeatedly. And again, pointing this out is not condescending. It's just the truth.
Alright, glad we have you here to save all the stupid poor people from themselves. After all, if someone is poor, they must be stupid. Or lazy. Or both. FSM knows, they need some philosopher-kings to come along and show them the light.
I think part of it is the culture of believing you can be anything you want to be. It's the same reason the poor often vote against their interests in the US - they believe that soon they'll be rich and want low taxes and few regulations. That they are the exception.
Implied in every single sentence of this paragraph is and underlying sentiment of: "this is a false belief and they are stupid for holding it."
And ALL of that aside, nobody has really responded to my question of "why assume these people are wrong?" Except that camel guy who basically said "no, they're stupid so there is no reason to consider that."
So we're back where we started. I say that poor people who vote for lower taxes and the like, may actually be making a perfectly rational decision. It may not be a optimal decision if you only take financial outcomes into consideration but it may still be rational... because the people making the decision may not be basing it on financial considerations to exclusion.
Many are hunters, or serve(d) or have family in the armed forces, or just grew up around guns. They remember, before the big-box stores came along, when the town hardware and general stores sold shotguns, rifles, and ammo. They see the liberals in SF Chicago and NYC wanting to stop their multi-generationally deep and rich tradition in hunting and defending and baring arms. If there is one rail that should never be touched, one single-issue that will move that type of voter, it is preserving the 2nd amendment. I mean, sure, you don't have to worship it and Hillary won't have to sit there holding an AKM-74 with 100-round drum mag to pander for votes, but just don't go after it with such vigor and I can bet dollars to donuts that you can win over at least 40% of the voters 1 hour outside the Triangle.
They vote republican not for their non-existent tax breaks or wait in bated breath for their drip of the trickle-down. They're savvy enough that that junk has been tried all over the country and has mostly failed (in the case of Kansas, utterly and miserably with negative job growth). They just don't want you to mess with their traditions.
I mean, these folks don't even care to fight over marriage equality, either. You don't see much gay-bashing in these areas. They simply don't care. Ditto abortion. Sure, there are ardent bible-thumpers, but on the whole, they are nuanced enough to know that we don't want a nation filled with unwanted children.
So, really, don't mess with THEIR rights (guns), and they won't vote against their own interests. I can't get why a lot of democrats (both politicians and voters) can't see that. I _know_ that democrats and liberals are about as far from single-issue voters as you can get, so they'll be kinda-sorta bummed that guns aren't the big focus for legislation, but it would certainly NOT be the end of the world.
It is "free" in the propaganda domain. That it is sold to the voters as "free, therefore efficient and better than government controlled"
Frankly, it's one of the larger reasons why I don't want to be in business for myself. As a consumer? At least outside of healthcare, most of the prices are set, more or less, the way commodities are. There are laws saying that when I get to the cash register, I'm entitled to the lowest marked price in the store. Hell, even with things like cars, which are notorious for ripping off consumers, you are paying at most like 20% more than your neighbor. If you are buying, say, bandwidth, or nearly anything else sold to businesses? It is completely normal for the initial quote to be 200%-400% more than what you end up paying after negotiation.
Now, how much does this have to do with it being a business, and thus having the expectation that you have professionals on hand to do the money-dance, and how much of this is that there's a lot less regulation in the business sphere than in the consumer space? I don't know. I don't think it has as much to do with the cost of the goods involved as you think; I think the biggest contract I signed was around a third of a million bucks for a five year lease; Well under twice what someone doing what I do, only as a worker would pay for rent in my area. Most of my contracts were in 'mid-priced car' range, and still there was a tremendous difference between initial quote, and what I was actually expected to pay.
The question here is not what system to create in a vacuum, but the road in the middle. I live surrounded by a whole lot of ultra-expensive, luxurious hospitals, staffed by extremely well paid professionals (and not so well paid residents), which, in many cases, have six figures worth of debt for the privilege. To move to a public system, all of those things would have to change: Those luxurious, privately owned hospitals are never going to give great prices to a single payer system. The doctors are not going to be happy with lower wages. Medical schools would have to change drastically, so they can actually provide a number of doctors that resembles the rest of the western world. This level of disruption is what makes major changes like that in a system that employs so many people unpopular: It's a bit like how the US military can't take big cuts, as they are political suicide.
So overall, the change would be huge, and would be hard to make slowly. Therefore, I'd much rather solve it in the US through markets. Once the system has a whole lot less rent seeking behaviors, and the incentives are better aligned, a public option would actually be easier than from the catastrophe we live on now, where prices are secret, and yet, a hospitalization will often involve 10 to 20% coinsurance.
Doctors everywhere else are public servants. They do their jobs because the love it, because it's their calling and because they still get paid very, very well. Canada pays their doctors $232,000 to $676,000 gross (speciality averages, low to high).
Then because malpractice insurance is also socialized (Canadian Medical Protective Association), their costs are significantly lower too. OB/GYNs usually pay the most, and in Manhattan their annual malpractice insurance premium is $125,000. $176,000 in Long Island. [1] The highest in Canada is Ontario, at $44,000 CAD ($34,000 USD).
[1] https://www.excellusbcbs.com/wps/wcm/connect/b7cdbf66-dd6b-4...
[2] http://www.amednews.com/article/20100503/profession/30503993...
Procedures under the public system are scheduled by urgency, so for example you might have a 9 month wait for a torn ACL surgery. That's why most will carry private insurance. Private cover starts around $70 a month so it's much more affordable than US insurance and importantly much simpler to navigate.
There are some problems which exist in America which don't exist in other countries.
Take for instance, when the rest of the world talks about how they ban guns and therefore they have no gun crimes, giving that advice to America is like if Chinese people were giving advice to Australia that they banned Kangaroos, and now they don't have a Kangaroo problem, so why can't Australia do the same?
America will not have universal healthcare like all these other countries for many reasons, which are very American in nature:
* Americans won't accept the huge tax rates which will follow it, calculations show that there would be a 20% tax increase across all income groups to fund it.
* Universal Healthcare would be the single biggest issue on which Democrats and Republicans will fight, win/lose elections, on whether to cut its funding, whether to expand it.
* America is ethnographically different than other countries. Currently our biggest 'universal' service is Courts and Police. Add Healthcare to it, and next thing we know there is an added accusation of systematic racism against certain minorities.
I think it's mostly not going to work here because a lot of people will have to take paycuts (not just doctors / nurses but "administrators" "billing co-ordinators" drug companies and drug resellers, etc etc ...) always follow the $$$
A majority of Medicare coverage is provided through private companies (100% for the drug benefit). Last I saw 80%+ of Medicaid patients are covered by a private plan.
What are the benfits? The private companies take on the risk. If the lump sum the gov't gives them isn't enough to cover costs, tough, the company takes a loss. Gov't loves it as it makes budgeting easy.
The other benefit is choice. A patient can select from a multitude of plans that benefit them the most. Want a top doctor? Pick a plan where his/her hospital is in network. Have a chronic disease where you take a lot of meds chronically? Pick a plan with better drug benefits.
Medicare Part D - the drug benefit created in 2005 that is entirely private - came in dramatically under cost forecasts.
Yeah, Original Medicare is pretty awful - I wouldn't recommend it to anyone who's able to get a Medicare Advantage plan. It's not just the cost-of-care and the overall expense to the patient (even though Medicare Advantage tends to win out on both of those aspects as well). It's that Original Medicare is a horribly frustrating experience for the patient as well.
Of course, most people (especially most people under the age of 65) don't understand the difference, and when they think about Medicare, they think of a publicly-run program, even though around 40% of the Medicare population is on a Medicare Advantage plan.
This article presents a good argument for why Single Payer won't work well in the US: https://www.bloomberg.com/view/articles/2014-04-30/single-pa...
> Americans are happy to send their children to school
Americans are, on average not happy to send their children to public schools
One of the reasons why Americans are so vehemently against Universal Healthcare because once you go there, you don't easily get to come back.
Once govt starts to provide a certain service, it kills the private sector market for that. Then no matter how terrible govt service is, there isn't much which can be done about it.
When you have a distressingly high chance of getting a terrible system, you wind up somewhat skeptical of people who want to tear down what's already in place and do public provisioning. Good and pure intentions are not an adequate substitute for competence.
The fear is that a system that works for some will be replaced by system that everyone can access but works for nobody.
Socialism really doesn't work here as well when 'other' people are getting more benefits than you. I'm sure part of it xenophobic, but part of it is actually legitimate.
For example, a bad accident left my credit ruined in my early 20s due to medical bills. I do remember, several times, waiting in agonizing pain in an emergency room full of people who could not even speak English. Essentially, the reason my bills were so high was because the hospital was allowed to recoup the nonpayers' bills by upping mine.
It would cost the average taxpaying couple tens of thousands of dollars to have a child in the US. So we have declining birthrates amongst educated people. In contrast, undocumented (illegal, whatever) purposefully come to the US to have an anchor baby. Those playing by the rules pick up the tab. This can rub even the most socially progressives the wrong way. Same with public education, unemployment benefits, and social security.
I think that you are going to see many social services cut, and move towards the US style, in places like Canada, Western Europe, and Australia as more and more immigration creates a less homogeneous population. The fact that many immigrants purposefully head to the nations like Sweden and Germany with the most generous social systems shows that the end results will not be good for the native population.
But what this article indirectly points out, is the sheer, utter incompetency of US health care providers.
The whole justification for a private system is supposed to be greater efficiency. In many markets, for whatever reason, this seems to work. Goods became cheaper and better due to competition, the invisible hand, etc. etc.
"My cousin was triaged immediately. Within two minutes a nurse checked her ankle, gave her codeine, and then sent her off to an urgent care clinic. She wasn’t even registered in the ER."
"The urgent care clinic had a few people ahead of us. It took about 10 minutes to check in and then no more than 15 minutes to be seen. A lovely nurse named Leslie triaged my cousin and agreed an x-ray was in order and made the arrangements. My cousin did not need to see a doctor or a nurse practitioner to get an x-ray. I’m not sure I’ve ever seen that happen in the U.S."
"The nursing triage was wonderful and actually doing nursing (I hate seeing nurses relegated to charting)."
In our wonderful US free market system, we have very highly trained professionals spending staggering amounts of their time on bureaucratic paper work and busy work, while the NHS just skips straight to treating patients efficiently and professionally.
With a system this bad, people at every level of the health care industry should be getting fired every day for their gross incompetency. From the insurance companies to the health care executives to the health care professionals, they simply suck at their jobs and need to be held accountable.
If a public system can deliver the benefits in reality that a private system is supposed to deliver in theory, let's go with the public system.
Which is very near the top of my list with annoyances with the Republican party, by the way. They are so obsessed with the theory and ideal of private market capitalism, they don't care to observe whether their theory matches up with reality.
I've had a few internet discussions with this particular doctor before and what I've learned is that she's used to things in California because what she describes above is definitely something that I've seen and experienced in the US. Kid fell off bike. We went to ER. Doc & tech met us in triage. Went right back to x-ray. We were in and out of the ER with imaging taken care of in less than 90 minutes.
Also, being punted to urgent care isn't always a good thing. This is how Kaiser missed a damaged disc in my lower spine. They had a habit of turfing me to urgent care and brushing it off as sciatica. It was when I moved to Texas that a Baylor ER did an MRI, revealing the true source of the problem, and was shocked that in all the years before, nobody had ever done that.
Health care systems aren't identical in every state, as I've found out the hard way.
"The nursing triage was wonderful and actually doing nursing" This might be another reason things are so expensive. Not every single aspect of emergency department care needs a full blown RN to take care of it. But when attempts by other levels of provider (LVN, LPN, EMT-Paramedic) are made, nursing unions come in like a hawk and lobby to crush whatever efforts are being made. It's frustrating to see happen.
It cuts both ways. I do not begrudge nurses their income, they sure as hell earn it for the most part. Put an investment banker in a nurse's job at County and see how long they last, then tell me it costs too much.
Texas recently made some legislative changes that will allow facilities to utilize paramedic level providers to their full scope in an emergency room setting, though. that's a huge plus.
It's been a pretty good system.
NHS clinicians have brutal amounts of paperwork. That tends to be done out of sight of patients, but it's there.
Some things are helping: digital dictation; "mobile working" (community staff being able to do electronic paperwork on laptops in the car between appointments).
Without going into the politics, size and population/density are two major differences:
- Canada has about 10% of the population of the US with much of it clustered around a handful of major cities so the vast majority of citizens can be covered by having good systems in a handful of places.
- Compared to Europe, the difference is even more striking. Just considering Texas: it is roughly the size of France but with half the population despite having 3 of the top 10 biggest US cities. And that's still not even 10% of the US population.
Whatever approach is tried in the US needs to take these differences into account.
Yes, in France you might be 1h/2h by car from a hospital depending on what you need
You have a tiered system: 1st level is "everyday stuff", 2nd level is regional centers (so you get routine surgeries and more complex stuff), and at the 3rd level you got your excellence centers for specialized stuff (think transplants, major surgeries, etc)
In the US case yes, you might want to have a 3rd level center per state (might not be exaustive)
I guess I could see having one tertiary center to serve say VT and NH but if memory serves even they have one apiece.
Texas might be "roughly the size of France" but a huge chunk of that is uninhabited desert.
Note the Bernie phenomenon in the current election. He pulled the entire Democratic party to the left, including public provision of health care. Also note, if current polls are a good indicator, Trump and the Republicans could be headed towards an historic drubbing on election day.
And Bernie drew overwhelming support from young people.
So I think that politically, the US may very well be moving towards supporting public health care.
Hospitals are required to take care of you, even if you have no insurance in the US. If you get a bill you cannot afford, you can negotiate a much lower rate with the hospital (I have done this and my family members have also done this).
I run my own business and so I need to pay for myself and my spouses healthcare. Obamacare actually made things worse for me. It doubled my costs (which was promised not to happen) and I was forced out of an otherwise great plan.
Getting sick is not even an issue. Medication is fairly inexpensive and if I have major surgery, I will only be out a couple thousand (the cost of a laptop).
I have many relatives in Canada and the only reason the system works there is because it borders the US. They get all of their regular care paid for by their taxes and the middle class drive over the border and get major surgery done.
The waiting lines are pretty long for most major surgeries and many older people die before they actually get it. The government there continues to promote getting checkups for specific diseases and disorders later and later in life because they don't have the facilities to get it done in a timely fashion for everyone.
NHS isn't the panacea everyone makes it out to be. There are no free lunches and when it comes down to it, a finite resource like healthcare has to have a filter/limiter. Since the majority of government run services are not that efficient and will not be able to keep up with demand or technology, it's much better to have a free-market/private care solution.
I agree with the sentiment of your post. We need to get rid of the bloated government-supported insurance companies and let the free market decide the price of everything..and offer a form of insurance to the poorest.
Trouble is, that only applies to emergencies. If you just want to see the doctor about the funny lump you have to pay first.
"We need to get rid of the bloated government-supported insurance companies and let the free market decide the price of everything."
So when I break a leg I should pay the ambulance to drive around different hospitals collecting quotes for the treatment? This doesn't work for a number of reasons:
1: Most obviously, urgent treatment is urgent. Collecting quotes will take time.
2: Hospitals won't give a quotation for medical treatment. They prefer a cost+ situation, partly because they then make money no matter the outcome, and partly because the costs are so variable that you can't estimate the cost. Just how much is that funny lump going to cost? After a few $K of tests you might be able to put a lower bound on it, but not an upper bound.
3: Medical costs for something serious are bankruptingly large for most people. One serious illness and you have to remortgage your house. Insurance is the only option, but then people at serious risk of illness or injury are more likely to take out insurance, and people who are already ill can't get it or change it. Imagine if you have epilepsy: every few months you wake up in ER and they hand you a $5,000 bill. No insurer will touch you.
Have you actually ever had a major medical problem? Medication can run in the thousands (or be $5, it varies) and even minor surgery is several thousand dollars out of pocket minimum and certainly more expensive than any laptop. It's also a struggle to afford even the premiums for some people
I don't know how accurate this is but I recall hearing that something like 40% of personal bankruptcies in the US are due ot medical debt.
I'm speaking from experience. If I wasn't high income I dont know how I'd be able to afford my bout of illness.
Okay, now what if you don't have a couple thousand lying around? There are many people who can't afford a laptop.
>I have many relatives in Canada and the only reason the system works there is because it borders the US. They get all of their regular care paid for by their taxes and the middle class drive over the border and get major surgery done.
Yeah, this is the shitty part of single-payer, public healthcare. That's why many countries in Europe have a hybrid private/public system. Canada, as you mentioned, effectively has one too.
However, the point of a single-payer system is to ensure that everyone can afford the most crucial, urgent treatment. We're talking about being in an ambulance and being driven down to the ER.
If you live in Canada and suddenly require urgent treatment, you can go to the hospital nearest you, because there's no such thing as "out-of-network" or "in-network". You can get treated by any doctor. And you'll get the same consistent billing everywhere you go, precisely because it's a single payer system.
I'll tell that to my buddy who is a general contractor. He put off major ankle trauma surgery for 6 weeks until his insurance kicked in. The alternative was $40,000 out-of-pocket.
Sounds like you really don't like the single-payer system. Let me recommend Paul Starr's "Social Transformation of American Medicine". I'm pretty sure he hates the system more than you do, but his book walks through the history of how we got here while other countries got to other outcomes. It becomes undeniably obvious that opinions like yours were manufactured by agents of the political parties and the medical industry without your realization.
As a skeptical small business owner, I really encourage you to get some more facts, do a lot of homework. Go read that book. Because this system will bankrupt you. It has bankrupted major American corporations. You alone, as busy as you are, cannot win against millions of smart people who have a century of law and public signalling to have crafted the information environment that created the system of thought in your brain right now.
I suspect that not everyone would think this is a small amount of money. From this article:
http://www.theatlantic.com/magazine/archive/2016/05/my-secre...
"Nearly half of Americans would have trouble finding $400 to pay for an emergency."
News flash, folks: physicians in the UK and Canada still make a bit above a living wage. It's the insurers that suddenly have to compete, like when a school district finally gets its shit together and parents start wondering why they're paying $40k a year for equal or worse outcomes.
Granted plenty of Canadian plastic surgeons split to practice in the US, but that's a different (and competitive) market.
AFAICT it's pretty rare, and usually done to receive a 'experimental' treatment not approved in Canada.
> The waiting lines are pretty long for most major surgeries and many older people die before they actually get it
Source?
AFAICT the wait times are bad for things like hip replacements and cataract surgery. Not so for things like cancer.
We bitch and complain about the NHS in the UK but bloody hell I can't think of other systems that are better. I worry about losing my job and looking after gf/son in the aftermath like when I was made redundant from CSCO last year. But i've never had to pile on top of those worries having to worry about an illness taking my redundancy money and savings.
(I'm a Brit btw)
Hmm, I live in fear of getting sick in Cameroon or Honduras. Maybe we're afraid of different things.
I have had to stop considering the USA a country in the same way I view most other places. I have a suspicion that China may be the same kind of entity but I am not knowledgeable enough to say for sure.
This is where the plan that Trump has makes sense. It takes away a lot of the decisions from the insurance companies and puts it back with the healthcare providers. In addition to letting the existing insurance companies compete across state lines.
Not really, at #31 in the WHO rankings [1], it's not even close to the best. At #1 in per capita expenditures, it's also wildly inefficient.
For half the per-capita expenditure Canada covers all its citizens. The US spends $8713 per person, per year on healthcare, where Canada spends $4429. [2] The result is a very comparable quality healthcare system (#30 vs. #31 in [1]) that covers everyone.
The truth is allowing for profit in a social security program is by definition allowing for inefficiency. Socialized systems do not need to spend money on advertising, on individual billing/accounting systems, or on profits. Nor should they, IMO. Social programs are for everyone. There's plenty of other businesses out there people can profit from. Caring for people when they need it most shouldn't be one of them.
[1] https://en.wikipedia.org/wiki/World_Health_Organization_rank...
[2] https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...
Emergency and cancer care seems to be very good. I'd recommend not needing a non-emergency or mental health treatment in some of the poorer regions of the country though.
For instance. If you need Aspergers help for your child, or referral to some CBT for depression in some places you can wait 12 months. Sometimes more.
Even so I prefer it to anything like the US system as you can;t fall through the gaps entirely for being broke. I'm glad to pay more tax as a result, rather than an insurance premium or in-work benefit.
I did get some basic blood checks though.
I think they thought I am eastern european freeloader. The pain is manageable and tends to disappear when I stop drinking, which suggests liver swelling. But then my arms sometimes feel numb.
I've moved from UK since. To a place where immigrants pay just as much tax, but do not get free healthcare like citizens do.
I was in London last summer. Got sick. Waited about 9 days for it to get better. No signs of change so went to NHS. Wait one hour. Was led into consultation room and was told I could wait another 90 minutes if I wanted but that I could only see a nurse and regardless of what the nurse found she could not prescribe any medicine. Or, I was told by the same NHS person I could go about a 10 minute walk to a private clinic and see a doctor probably immediately and as a doctor they could prescribe medicine if needed.
So ... Yea, wasn't a good first impression of NHS.
Not saying USA's system is better.
In Japan it's easy to see a doctor but at least in my experience about 30% of them are quacks.
Also if you need surgery and you want a good doctor you need to bribe them. This is so common it's a normal part of most medical dramas.
I'm scared of getting the giant bill in the USA. But I'm scared of getting hurt by the doctor in Japan if I need any surgery. I don't know the solution.
I'm in a private group for what is collequally called previvors (specifically Young previvors - though some people have had/current do have breast/ovarian cancer, including a few who are dying of it). I need specialized DNA testing for complicated reasons in my family history for risk assessment. It isn't covered. We have UK and European Members. I see who their doctors ares, what research they publish. I know what they pay. ($0) I know that for patients like me, European doctors are way more proactive, even for joining studies, because they can afford to be.
I know factually that if I were in europe that test would have been done LAST YEAR. Instead I'm still looking around for one doctor outside of my regular provider to do this one DNA test under research protocols.
Doing this one test could potentially save the medical system thousands of dollars. That's what baffles me the most: The insurance companies wants me to use a certain amont of services, but only so much, in the US
It is like they actually don't want me to be healthy - and I am not sure why.