Assuming by free you mean universal coverage that is (almost) free at the point of usage then this is a solved problem. What the United States lacks in order to realize a solution is political willpower and an electorate that is savvy enough to know that wanting such a system does not make one a communist. (And that being a communist does not make one an evil person.)
...also the fact that the electorate generally can't out-compete the big money interests that lobby heavily to keep healthcare a private venture.
It's so easy to blame voters but the reality is that politics is about messaging, and how is the electorate supposed be savvy enough when these companies can spend unlimited amounts of money to keep us fighting each other about this stuff? Make no mistake, Google benefits from this depravity too.
It’s not the lobbyist. There is still a lot of people who don’t want universal healthcare because it might benefit “those lazy people who don’t want to work” and older people on Medicare who “want to keep the government out of healthcare”.
I don’t disagree in general with what you wrote. On the bogeyman of “socialism” I do blame the electorate. The irrational fear of anything remotely related to “socialism” in America has been going on far too long.
And that fear is stoked from the top down. You hear it all the time from the leadership of a certain political party. It's not just something that people fear naturally, it's driven home explicitly by the political messaging of those that benefit the most from our current system.
Yes, I know this. However, in this age of easy information and knowledge about other societies readily available it becomes more a matter of willful ignorance than being duped by propaganda.
You aren't familiar with the propaganda if you think folks duped by it would consider "other societies" with anything other than fear hatred and contempt. The problem with "do your own research" is confirmation bias.
Counter-propaganda isn't the answer. We've already got counter-propaganda, from the other political party. It's not persuading anybody who doesn't already drink that flavor of Kool-Aid.
No, I don't have an answer either. I just know that counter-propaganda isn't it.
If I knew, I'd already be president? The only thing that seems to actually work is slow, one on one, patiently and empathetically working with people where they are. Mass media only seems to be effective at sowing division.
Maybe things were different under the Fairness Doctrine? I don't know.
Well, as I said, in my opinion people can be blamed given the readily available information and in regard to the multi-decade irrational fear of socialism. Willful ignorance is a thing.
I'm not convinced, even with the best of intentions. In fact, I am convinced of the opposite: A) Universal Health program would result in terrible quality health care B) It would lead to longer wait times, and less choices C) It would be insanely costly to fund. We've been busy printing a lot of $. Increased the Federal deficit from $21T to $30 since COVID and there isn't a good way to fund a bloated system in USA, comparisons with smaller nations is ridiculous and misleading.
> Medicaid is the largest source of funding for medical and health-related services for people with low income in the United States, providing free health insurance to 74 million low-income and disabled people (23% of Americans) as of 2017, as well as paying for half of all U.S. births in 2019.
What we should be doing is to fight the regulatory and bigpharma capture of US health system along with the horrible hospital + insurance racket. Google is now going to take advantage of the moat built by Big Gov and never ever allow anyone to compete.
No, we have free health insurance for some of the poor (states that have no accepted the ACA expansion have basically no coverage for adults without dependents.)
Medicaid is not (as a generality) free health care (it can be, in some states, for some recipients). It is free health insurance, which can have copayments, coinsurance, deductibles, etc.
I’m a bit confused on the choice part. Can you explain?
I think if someone can afford better, private care they should be able to. For example I would probably go to the universal healthcare family doctor but if I need a specific surgery I would like to be able to go to the best care I can get.
There are tens of millions of people who have no access to Medicaid because states chose not to expand it under the ACA, and there are plenty of poor people who make more than ~$16k a year, which is the cut-off for Medicaid.
How could it be even more expensive than our current inefficient, half-baked, worst of both worlds system, which is more expensive than socialized systems in other nations? And more expensive per capita, not simply overall.
Regarding (A) and (C), this is the obligatory reminder that:
* The US spends more public money on health care, per capita, than other wealthy nations, while also spending much much more private money than other wealthy nations
* By many measures, the US gets worse outcomes (e.g. life expectancy)
The conclusion that many draw from this is that perhaps a single-payer health care system in the US could dramatically lower private spending, also lower public spending, and perhaps improve outcomes. I don't personally know if that follows, but it's not implausible.
This is counter-intuitive to many, thus comments like your (A) through (C) are common, but might not be correct.
That said, I'm not aware of evidence that your (B) is wrong. That might be part of the trade-off.
As a non-American from America's hat, who has had a few (bigco-insurance-funded) run-ins with US Healthcare, my observations were that
* emergency health care at the no-expenses-spared level in the US was nicer than emergency healthcare up here, and I wouldn't want to pit my doctors vs those US doctors in a quality competition
* US doctors seemed really eager to waste money, like really eager, like it was creepy
> US doctors seemed really eager to waste money, like really eager, like it was creepy
Your last point is purely a function of the liability culture in the states. US physicians are quite aware of what's appropriate and what's inappropriate testing wise. However, as long as a physician can be held personally liable for any oversight - meaning that the results of an entire career can be lost - they're going to over-test.
Purely a function of liability culture? That seems like an extraordinary claim, your claim that there are no other causes. Do you have extraordinary evidence?
I'll note that I do have a few different bits of modest evidence to the contrary. But I wanted to focus my comment on concrete observations (both the large-scale statistical kind, and the personal anecdotal kind), rather than on speculation.
Maybe because the 2/3rds of the population is overweight or obese. It's like the education system in the US, you can spend all the money you want but if the participants aren't actively trying to improve...
It's a solved problem in the sense that it exists, and works[1] and it is available in a lot more places than Canada.
[1] "works" is an interesting point because it isn't clearly defined, and usually means different things to different people.
Ever experience of the system is "unique" - there is this mix of human patient with human provider with finite resources with medical knowledge with time. So there are plenty of examples of long waits, bad service, unfavorable outcomes, even death. It's not hard to cherry pick bad experiences here.
No health system will make everyone live forever. Death comes to us all sooner or late. But universal healthcare works in many places in raising the overall standard of public health, without bankrupting people in the process.
Given that its always spending limited money, and only scales at human rates, its far from perfect. But, at least for some, its better than a "health care level based on your wealth" system.
But the US isn't "healthcare based on your wealth".
You have Medicaid for the poor, heavily subsidized Obamacare for the people who don't get it through their employer (hello $100/month plan!) and Medicare for the retired.
I mean my cousin in the US whose kid has cystic fibrosis get better care through Medicaid than our other cousin in Canada who can't even get access to the latest drugs.
> heavily subsidized Obamacare for the people who don't get it through their employer (hello $100/month plan!)
That $100/month plan will include high deductibles and copays. A weekend visit to an urgent care for a kidney stone will still cost a couple hundred dollars out of pocket.
The naivety is in thinking that if it doesn’t work in Canada then it must not be a solved problem. The naivety is in thinking that if you can find anecdotal evidence that in a particular instance Canada’s system worked worse than the U.S. system then it must be the case that Canada’s system is worse.
The U.S. per capita spends far more on healthcare than any other OECD country. We don’t get correspondingly better outcomes or coverage. Universal healthcare is a solved problem within the context that every system necessarily involves some sort of rationing since there aren’t enough medical resources in any country to do otherwise.
If you don’t want to use the phrase “solved system” then don’t but don’t pretend the U.S. is any way better other than in anecdotal instances. Below is a source for information on per capita spending for OECD nations. You can easily find information on health our outcomes, life expectancy, teen pregnancies, infant mortality, etc.
It’s a solved problem as far as one can get given the constraints involved. As I said, if you don’t want to use that phrase then don’t. I’m not going to quibble over semantics. Human societies are far more complex than programming and the notion of “solved” means something different in the former than in the latter. Use whatever phrase you want. Just don’t think the U.S. system is in any way better. You are the one who brought up an anecdotal experience in favor of the U.S. system over Canada’s system.
You keep talking about the US, but as a former resident of Canada I know that’s the country’s favorite measuring stick. “We’re not as bad as the US so stop complaining” is the favorite ring of politicians.
Doesn’t do much for the people disabled from pain on a 3 year wait list for a hip transplant or my buddy’s cousin’s kid who doesn’t get access to the standard of care of CF.
It’s not solved in the least, every country struggles, so using the word “solved” is, as I said, naive.
Perhaps you don’t understand how words work. Words can have different meanings/connotations depending on situation and context. As I said repeatedly, for me it is correct to say “solved” given the constraints involved. Human societies are complex and one can nitpick the world “solved” and say nothing is solved when it come policies of complex societies. So don’t use that word when it comes to societal issues. I and many others do use that word for certain issues. It’s naive of you to have your pedantic nitpicking on the word and not reflect on what it says about you. Obviously I keep bringing up the U.S. because that’s the context of my starting comment way above. And you yourself have brought up the U.S.
What goal do you wish to accomplish your pedantic nitpicking? You want to get others to believe that my views on national health policies are naive? You want me to realize that in a strict, mathematical sense of the word saying “solved” is incorrect? These are rhetorical questions because I’m not going to read your response. You clearly don’t know much about policy issues and what it means for a society have essentially “solved” an issue (or have found a decent enough solution that it isn’t a dire problem anymore so that some non pedantic people will say it is solved).
Carry forth Don Quixote on your quest to eradicate incorrect usage of what you think “solved” means.
Words have meaning and we should encourage people to use the right ones.
You claim I don’t know policy without knowing healthcare policy is my day job.
Even given the benefit of the doubt that as an outsider looking in you think it’s solved, but as someone who is elbow deep in it everyday “solved” just sounds naive.
Being a communist absolutely makes you an evil person. About 5 times more evil than the group of people they fought against in a war.
As for socialized medicine it makes doctors another arm of the government. In the UK last week (or the week before) one arm of the government ordered another arm of the government to kill a 9 year old. We are also just outside a 2 year stretch of tyranny of governments all over the world giving that arm of government near unilateral power over our freedom at the point of a gun.
I hope you can break from the the intellectual shackles that bind you. I hope you can visit other countries and read from sources of information outside your comfort zone. Subscribing to a belief about which system of economics you prefer does not make one evil.
> Being a communist absolutely makes you an evil person.
Tell me you don't know what communism is without telling me you don't know what communism is.
Yes, every known communist country has been rife with fascism, authoritarianism, and corruption. But those are orthogonal with communism as an economic model. It's like saying socialism is evil because the Nazis were socialist (they really weren't) just because "Socialist" is part of "Nationalist Socialist Party" .
> In the UK last week (or the week before) one arm of the government ordered another arm of the government to kill a 9 year old.
[citation needed], because this sounds like an extremely gross misinterpretation of a situation, likely done deliberately in bad faith.
How incredible would it be if Alphabet spent, say 1% of their total healthcare venture budget, just running models on all of the different ways that the cost of healthcare could be reduced and access to care could increase. And maybe they do this already (we have no idea if they do, it might be nice to share that information if they did). It's just become so clear that many people believe the anti-science stuff that gets thrown around these days because they can't even afford to participate in the healthcare system anymore. And who can blame them? Figuring out how to get medical records systems to talk to each other isn't going to solve this problem.
But no, let's throw billions of dollars at anti-aging instead...
"Running models" can't fix problems that are political conflicts between competing interests. You don't need DeepMind to tell you Certificate of Need laws reduce access and increase price; you need a political coalition that can overturn them.
The certificate of need is literally based on a justification for why those government subsidized hospital beds aren't wasteful. The way to demonstrate that is with a model. A better/cheaper model is the way to go there.
Therefore, an AI that generates good models is valuable.
It's actually not. The CBO already built these models last year and reported that they reduced costs in nearly all cases, across the board[0]. It's only a hard problem because some billionaires want us to believe that it's a hard problem.
From the summary:
> The report makes many sound assumptions but also some questionable ones that are overly pessimistic. Yet, overall, its bottom-line estimates should reassure those concerned about the economic feasibility of single payer: The CBO projects that such reform would achieve universal coverage, bolster provider revenues for clinical services, and eliminate almost all copayments and deductibles—even as overall health care spending fell.
There are political concerns as well. As the article mentions, healthcare spending is 17% of U.S. GDP (which is an absolutely insane figure). Healthcare jobs account for 14% of the workforce according to Census Bureau's 2019 American Community Survey. You can't get the first number down (17% of GDP) without impacting the second number (14% of jobs). I agree that single-payer would be a net benefit, but the U.S. hasn't shown much appetite for such tough political decisions.
The same logic can be applied to literally anything in a capitalist society. If the current way of doing things employs people, we can’t possibly do it any other way.
If you really want to solve it, and have the political willpower, you just do it over time. Nationalize all hospitals and insurance companies, and continue to run them as they currently are, and slowly streamline systems over decades, and don't hire replacements for retirees.
To agree: most wealthy countries spend somewhere between 10% and 12%[1] of GDP on healthcare. The USA is an outlier in %GDP, and total spending per capita[2], for lower life expectancy - check this graph: https://en.wikipedia.org/wiki/File:Life_expectancy_vs_health...
Once you have universal healthcare, it’s still going to be hard. You still have a lot of clever providers trying to extract as much money as possible from the system and an insurer that needs to find out what the right price and cost/benefit analysis is. It’s super super hard, and the US is not used to do that.
It's a hard problem because the real problem is convincing a brain surgeon making $450,000 a year that he should be partially or wholly replaced with AI models.
It's the same reason costs to build subway tunnels has dramatically increased in NYC, labor unions have the process by the throat and will accept not even a cent in reduced labor costs, even when improvements would improve safety or efficiency.
I am not aware of any AI model or technology that functions as anything beyond a toy in the healthcare space. There's very little utility to labelling things in healthcare - even in fields like ophthalmology, dermatology or radiology where companies have made some advances. Humans already do it very well and it's about 1% of the actual battle. Show me an AI that that can make a diagnosis, counsel a patient's family emergently, take the patient to surgery and do a craniotomy then nurse the patient for weeks in the neuro-ICU and I'll be super impressed.
Moreover, it's the patient, not the neurosurgeon that has to make the decision to trust the AI.
Humans are terrible at giving healthcare. There are 8x more deaths in the US due to medical malpractice than from firearms. Clearly humans aren't very good at labeling if they get it wrong a huge portion of the time.
Healthcare isn't expensive because there are huge swaths of spending unexamined by human intelligence that might become tractable with an automated process. On the contrary, it's one of the sectors that has the most eyes and brains pointed at costs and extracting as most money as possible.
On the topic of EMR systems in particular, they suck because the people using them hate them and because the people purchasing them, building them, and mandating them aren't the people using them. If it were just a matter of having enough money to throw at the problem, Epic would have done so already.
Billing is the original sin of healthcare. EMRs (excluding the VA’s old MER VistA) were not developed to improve clinical workflows or outcomes, they were originally conceived to improve and streamline billing. This orientation has massively contributed to the overhead that EMRs like Epic and Cerner introduce.
On the startup and health improve lament side, billing is the rock that so many great ideas break on. It doesn’t matter if the model or business improves care or reduces cost unless it will make a provider more money.
Yes, because what we need is more gerontocracy. People should instead just make peace with the fact that their purpose in life is to reproduce, die within a reasonable time, and hand the world over to the next generation.
I mean, I guess, tell that to every important artist, author, architect, craftsperson, and humanitarian. Paul Farmer and Norman Borlaug both had children, but it's hard to argue that their real purpose in life was to reproduce. Could you get more Paul Farmer time? Seems like a worthy goal.
In a nutshell, your comment illustrates well the issue facing many western nations. The uniqueness of an individual is somehow extended to being applicable to the average person, and then folks hand-wring about why things seem to be trending in a bad direction.
Sure, Paul Farmer was special, but most people are not. To make any policy, or social conditioning, that is fine for an individual but bad for a collective, can result in some pretty terrible consequences, most critically this recent drive to discourage folks from having children due to whatever made-up reason, or cling onto power until others have to pry it from one's cold dead hands.
I'm pro-natalist. I think raising children is intrinsically good. I have two kids of my own (both grown and in college now). I'm not a pro-natal absolutist. I do not think the exclusive purpose of life is to reproduce. That's the sentiment I responded to, and the one you're arguing in favor of.
Well, what we have here is the unique snowflake syndrome or not invented here syndrome. At this point I’ve lost all hope that we’ll see a single payer system in the USA in my lifetime.
And what’s the secret? Having the government do it can’t be the reason, because there’s plenty of government-run things, such as education and transit, where the US pays more to get less, just as in healthcare.
The secret is representative government. In the US there are only two parties, and they have entirely opposite goals. The democrats want more Government spending programs, Republicans want less. So when Democrats are in charge and the US tries to expand things like healthcare, education, and transit, the Republicans step in and do everything in their power to create the most ineffectual legislation that they can. Obamacare is the perfect example of this.
They then use those broken, ineffective programs as evidence of "the governments" incompetence (ignoring the fact they they _are_ the government), bolstering their arguments for rolling back government regulation and spending. This way, private interests are able to dominate the market and the money keeps flowing 'round. I'm convinced this is the mechanism behind both the increasing income/wealth inequality in the US, and the broken state of public infrastructure/services.
The solution is election reform. The data has shown that neither party represents the actual interests of the people, and they only get away with it because of the Game Theory around our election system. Get rid of the Electoral College and FPTP - 1 Person:1 Vote & Ranked-Choice voting would create a cataclysmic shift in US politics in short order.
>> anti-science stuff that gets thrown around these days
It wasn't just anti-science but deliberate attempts to stop Obamacare, the ONLY initiative ever attempted to fix the US healthcare system. Then came the Republicans to stop it.
IMO, the Pacific coast states need to reject national health care, create a health-care pact between states that slowly grows larger by adding new states. If another state doesn't want to join, then, so be it.
Enough of splintered policies that change across state lines. Reduce health care insurance costs by allowing continued and universal care to states that elect this policy. The strength of change is in the states themselves, not the federal level.
> IMO, the Pacific coast states need to reject national health care, create a health-care pact between states that slowly grows larger by adding new states. If another state doesn't want to join, then, so be it.
It blows my mind that they don’t do this. During most of the 20th century, Democrat-run states wanted to tax Republican California to pay for social programs. So doing things at the national level was critical. But now that the states that have all the money are also run by Democrats, that roadblock is gone. California can just tax California to pay for universal healthcare for California. They have no reason to care what Iowa chooses to do.
How do you avoid the obvious adverse selection problem? California can't prevent the most expensive people in the country from moving there, and the system we're talking about would be a powerful incentive for those people to do so.
Education costs are peanuts compared to healthcare costs.
Not to mention that educating children provides a significant economic return to the state in the form of labor when the children grow up. Whereas dialysis and heart surgeries and hip replacements for 70+ year olds is a complete loss.
For examples, a single NICU baby or hemophiliac can easily cost $1M+ per year. Health insurers almost had to stop selling policies in Iowa due to a single hemophiliac who needed $1M/month medications:
There is a reason why universal healthcare is such a political football. It is the single most expensive thing the country spends its resources on, and it is not even universal yet. Hence all the tribes fighting over access to public resources for it, and solutions implemented to ration resources along those tribal lines, via the use of managed care organizations (health insurance companies) and hugely varying reimbursement rules for different programs like Medicare (old), Medicaid (poor), Tricare (military), commercial plans, etc.
All the premium increases people complained about due to ACA are a fraction of the tax increases that would have had to happen for universal healthcare. The other option is pharmaceutical companies, hospitals, and doctors take a huge pay cut.
> All the premium increases people complained about due to ACA are a fraction of the tax increases that would have had to happen for universal healthcare.
So why would I ever want universal healthcare? I was being sold on it being cheaper and more efficient, but now you’re saying that it will also cost more. What’s the point, then?
There's robust disagreement among reasonable people about whether single-payer health care is a good idea in the US or not. The comment you were responding to wasn't overtly advocating for it. There's less reasonable support for acalculiac xenophobia.
My intention was to point out an additional factor in universal taxpayer funded healthcare being a political football, which is
> The other option is pharmaceutical companies, hospitals, and doctors take a huge pay cut.
Bringing healthcare prices down is also out of the league of cities/counties/states. These things require federal action like increasing number of doctor residency funding or spots, reducing patent protection for medicines, or other measures to increase supply of healthcare.
I think you're overstating just how "obvious" this adverse selection problem is, because we haven't seen this play out historically. It sounds like a purely theoretical problem.
Canada established its single payer system provincially, one-by-one, and they didn't have this adverse selection problem. Saskatchewan was the first Province to offer single payer in 1947, followed by Alberta in 1951, etc. By 1961, all Provinces had some form of a single payer healthcare system.
> Taxpayer-funded medicare in Canada did not appear at a single point in time: it emerged over a quarter century from 1962, when physician services were covered across Saskatchewan, to 1987, when the demise of optional “full billing” in Ontario began.
So at any given point in time between 1962 and 1987, there was (in theory) this adverse selection problem among certain provinces; and yet that was never really a major problem in Canada. Even to this day, the Canada Health Transfer which provides block funding to Provinces by the Federal government for the purpose of funding these single payer systems covers ~22% of the cost (https://www.cmaj.ca/content/192/45/E1408).
Additionally, even in present day, the European Union has open borders and free immigration between member states, and certain member states have far more generous welfare systems than others, and you still don't have this adverse selection problem, at least in a manner that meaningfully renders those welfare systems unsustainable. Even domestically, we didn't really see dramatic net migration from states that refused to take the Medicaid expansion to those that did.
The reality is that people don't choose where to live strictly on the basis of which state provides taxpayer funded healthcare. In fact, those that are most likely to do that (poor people) are likely already covered by Medicaid or heavily subsidized ACA plans (https://www.kff.org/policy-watch/millions-of-uninsured-ameri...).
And even if one were to engage with the purely theoretical problem, there are ways to mitigate the adverse selection, e.g. by requiring a minimum number of years of residency in order to qualify. This is what US States do today to establish residency for the purpose of in-state university tuition. Given the plethora of historical (and current) data points that suggests that this isn't really a problem, States can choose to cross that bridge if/when they get there.
Maybe! These are all good points (well, the Canada example, at least). I guess it's down to "running a single-payer system for California would be very expensive, and you might need to make it mandatory in order to deal with the more pressing adverse selection problem" --- I don't know how much of a canard adverse selection is within the context of mandatory single payer, but it comes up.
That's a good idea! Unfortunately, California is subject to the same business interests that the Federal government is also beholden to, so attempts to do so have a hard time getting traction for the exactly the same reason.
It does not work for the reasons tptacek wrote. With freedom of movement, eventually net benefit recipients will move in, and net payers into the system will move out.
If I was a politician in any other state, I would propose exporting high cost patients to California by buying or subsidizing their housing.
It is always the same story with any broad high cost universal benefit offered within a taxing jurisdiction that does not have immigration control. Homelessness (land costs), mental healthcare (legal and labor costs), and healthcare. Even subsidized higher education is not universal, it is restricted to residents.
That is why we do not see these offered anywhere, and why it has to be a federal move.
I don’t see evidence of that. Vermont grew slower than the country as a whole over the last decade, so it’s not like there was an influx of new residents.
It sounds like people in Vermont just wouldn’t put their money where their mouth is and pay the taxes required for universal healthcare. Our German au pair paid almost 40% on her entry level office job. If you want universal healthcare like the Europeans well that’s what it costs.
IMo, The ballooning costs in healthcare are not from not knowing how to reduce the costs or make the system more efficient. There is entrenched interests/ businesses that will lose 100s of billions if it were replaced or shifted. They absolutely will not let it happen. Spending a few billions to buy politicians is justifiable for them. That is the main reason we are in this mess and will always be. May be I am too pessimistic, but Google, Amazon put together is not enough to change it
Step 1) Allow Gov to build up regulations so complex that it requires a force of nature to over come. Step 2) Big Tech builds technology around those regulations and sells it to people. Step 3) Viola! we have a giant massive ocean-like moat that surrounds the Big Gov + Big Tech castle. Never to be breached by the likes of Silicon Valley startups or otherwise.
I see it frequently here... I suppose it comes from French.
Viola means rape(il la viola) or break the law(il viola la loi).
The real one is voilà!
And dropping the accent, is apparently acceptable in English. Voila! ;)
Because we're writing in English, "viola" is neither rape nor lawbreaking, though "violate" can mean either of those. In English, "viola" is the name of a stringed instrument.
Voila, behold a viola! One fourth of a string quartet!
But if you're irked by "viola", it could be worse, they could have written "wallah", which is all too frequent.
Healthcare is not expensive for lack of huge government-entangled corporations monopolizing and commercializing patient personal information. At least not in USA, where healthcare legislation is written by and for the industry (e.g., https://www.theguardian.com/commentisfree/2012/dec/05/obamac...), and total healthcare expenditure is somewhere around double that of most other first world countries with more universal healthcare systems, for worse outcomes in many objective measures (at least of overall social health, I realize the standard of care in America is probably second to none if you can pay for it).
> There are still plenty of expensive threatments like cancer were the diagnosis is also costly just due to the tech used.
> A proper MRI is expensive, the analysis is slow and need experts etc.
I'm sure that's very true. A company that's struggles to keep a rudimentary chat app running for any length of time, spectacularly miscalculated its fiber project, to name a few obvious ones, does not instill any confidence that they would be the one to improve this. The medical industry is far more conservative and far more complicated than what Google has proven it is able to deal with IMO. You can't just move fast and break things, you can make shit up as you go along, you can't invent your own standards.
> There are plenty of things to optimize.
They've also not performed impressively on any kind of "AI" related thing, if that's what they're thinking. Their self-driving cars are still a curiosity and a long way off being revenue positive, if there is even a path to it, for example. Industry and legislative inertia and baggage aside, I don't even think a big old cumbersome dinosaur like Google has the chops to come in and make a big change. Put it this way if some revolutionary new startup company had a really great idea in healthcare, you would be disappointed if Google bought them.
> total healthcare expenditure is somewhere around double that of most other first world countries with more universal healthcare systems, for worse outcomes in many objective measures
I've seen this many times but it makes a meaningless healthcare = health correlation .
America has lots of systemic problems that affect health outcomes that are outside of healthcare. Low quality fast food, food addiction, industrialized farming, corn subsides, food deserts, deceptive food marketing to name a few.
> I've seen this many times but it makes a meaningless healthcare = health correlation .
It doesn't, it's just making an observation.
> America has lots of systemic problems that affect health outcomes that are outside of healthcare. Low quality fast food, food addiction, industrialized farming, corn subsides, food deserts, deceptive food marketing to name a few.
Sure, America has many issues and many more than you've listed. So do other countries. And they all have many differences in healthcare systems. All this makes it impossible to formulate a mathematical proof. Which fortunately I was not trying to do.
So we can't really measure the precise effectiveness of healthcare systems and health expenditure, sure. But surely the burden is on the people who would to claim that 2x healthcare expenditure for worse (or not significantly better) health than many other countries is a reasonable cost efficiency, to come up with some pretty strong evidence to support them.
> 2x healthcare expenditure for worse (or not significantly better) health than many other countries is a reasonable cost efficiency, to come up with some pretty strong evidence to support them.
yes we have healthcare system that treats disease, after that fact. Americans are a sickly group of people. Lionshare of expenditure goes to treating chronic metabolic illness. These people cannot be returned back health once they have metabolic syndromes. So matter how much money you spend on healthcare there is no real way to convert sickly ppl back into healthy people. No doctor has a way to fix diabetes or thyroid dysfunction.
Again, goes back to my original comment. "healthcare" has nothing to with "health".
I'm not sure. I've heard people handwave about this before, but if health industry corporations and their congressmen and senators are going to argue that, it should be explained and funded and voted on explicitly, rather than the alleged massive indirect subsidies via overpriced medicare and medicaid government expenditure if they're going to claim that's somehow the way health corporations fund their cutting edge R&D and high end treatments and clinics.
> IF someone can pull that of while protecting the individuals I believe it's alphabet. Together with deep mind and all the other research they do.
What makes you think they will protect the "individuals"? From a privacy persepctive, I would say they have no clear incentive in doing that, given individuals are the product they sell to companies that need to push ads into society.
you dont disappear. you become embedded. they are metaphorically assigning you a number and stripping you of an identity. It is dehumanizing.
At the end of the day, it's just you by a different name. Instead of owning it and claiming "we have this information on Gehlitio" they say things like "We have these generalizations about anybody who happens to use HN, speaks in English, bought X Y and Z, subscribes to A, <insert 100 more details that effectively fingerprint you>"
I wonder how this will play out in court when a neural net that underpins the tech of a company also can't properly handle health data. Start over?
The right to be forgotten would have to be built into it all right from the get go, wouldn't it? Neural nets embed things, like you said. If Facebook pivoted towards being a hub for healthcare data as oracle seems want to do, could they use all of their facial recognition tech trained from profile pictures now that it is supposed to be detached from any one identity? I'm thinking of the equivalent of github's co-pilot spitting out comments alongside the code.
>I'm thinking of the equivalent of github's co-pilot spitting out comments alongside the code
yes exactly. I am having trouble articulating my underlying point but this is along the lines of it.
A facial recognition algorithm is ultimately saying "you look similar to this specific set of people". If the training set was 1 person, for example, then the algorithm would pretty much just be saying "you look like this photo of this 1 person". Scaling that up does not improve privacy - it only blends you into a population. Additionally, it is distilling out the things about you that separate you from that population (things that make you, you) since those distinguishing features are exactly what the model needs to use as the line to draw on whether or not new data points are similar to the population set or not.
Have you lived with chronic pain, or expected to live the rest of your life disabled?
Because privacy doesn't seem all that important once you actually are going through it.
If you had to pick between being a cripple (say, with your arms or your legs useless) and forgoing your privacy are you really sure you'd give more value to privacy?
Do actually consider what life is like under these circumstances before answering. I don't think there are many quadriplegic people out there who'd pick privacy over being healed.
"X is more important than Y" isn't honest if you never lacked Y and can't even consider a future where you lack Y
I am not sure where I argued that privacy is more important than health. I am saying call it what it is. You are arguing privacy is worth trading for health. I actually agree with that. I dont agree with claims that what google is doing is preserving privacy.
My beliefs are quite the opposite of what you implied about me. I think we should move away from all this embedded bullshit and keep peoples identities intact because the generalizations will never be perfect and it might be useful to know who the actual people are that those generalizations are based on. Maybe that would facilitate human connections. Maybe that would make it easier to reward individuals for sacrificing their privacy in order to improve healthcare. Instead of just pretending they arent sacrificing privacy and are just a drop in the ocean of data providing results.
You are not a drop in the data ocean. Your data is important. There are not a lot of people like you. Google emphasizes generalization because it cheapens the value of your individual data point. Their policy creates an illusion I aim to dismantle.
Also, I do have chronic illness but that is not relevant here. Mine does not directly cause pain, though, full disclosure
All statistics are dehumanizing. I'm no data scientist but I'd imagine including the whole human when doing statistics would produce a pretty low signal to noise ratio.
Statistics are dehumanizing, you are correct. We do not judge individuals based on the statistics of their categorical groups for this reason. Doing so under the obfuscation of a ML model doesn't change that.
Health is very personal. Family history is usually pretty relevant. I am not sure what we gain by pretending we arent talking about actual people, or that by removing your name from all your specific health details it somehow means you cant still be personally targeted. I know Google gains the benefits of less regulations, though.
My post wasnt clear on this, but I support doing whatever we can to ease chronic pain.
I just disagree with the position that Google can do so while preserving privacy. If we are going to trade privacy for cures, let's at least do so openly.
That's the possible upside. The possible downside is "if you ever search for a disease in Chrome, or on your Android device, or at google.com, we will notify your insurance company who will raise your rates".
If the goal is to have society subsidize a subgroup, then either government funding or laws requiring the exclusion of the subsidized criteria for purposes of insurance pricing are the better method. Like ACA did.
Ah, I disagree. Google is a very good steward of personal data, IMO. And I’m pretty sure health care would be markedly improved if all the data were centralized.
So I guess it boils down to a difference of opinion is all.
So if one of my friends has Crohn's and I search for it to understand what I should be aware of, my rates would go up? HIPAA specifically prohibits the sharing of medical information unless needed for care. If there is any one here that we should be annoyed at it's the insurance companies. Hospitals are losing money and the insurance companies are posting record profits.
HIPAA only applies to "covered entities" and "business associates". Covered entities are health care providers, health plans, and health care clearinghouses. Business associates are parties that a covered entity engages to help carry out the covered entities functions.
If you give your medical information to someone/something that is not a covered entity or business associate they do not have to follow HIPAA rules.
I'd expect that Google would be more likely to sell your data on your chronic condition and make you unemployable and uninsurable. They are highly unlikely to worry about protecting individuals.
A merger of technology privacy invading, ai-guiding, rip off processes AND the ability to direct your health for profit. With government lobbyists in both pockets.
I disagree. Alphabet values human life. Sure they may kill products constantly but I trust the company to uphold certain values, especially around humanistic principles.
> Google is also giving health records another whirl. The new initiative, called Care Studio, is aimed at doctors rather than patients. Google’s earlier efforts in this area were derailed in part by hospitals’ sluggishness in digitising their patient records.
Not just digitizing but also in sharing them. Hospital systems are very very reluctant to send out a copy of their records, or even to let you query their system. Especially in the early days of EHRs there was very much a sense that it was their data and they didn't want to let data out because interoperability was a threat to their data moats.
That's good in a privacy sense, but it really did slow down adoption of interoperability initiatives. Finally Medicare/Medicaid basically forced it iirc... if you want Medicare dollars you will send Medicare your encounter data. So now you have to code your records at least good enough to at least get your medicare reimbursements.
> That problem has mostly gone away but another has emerged, says Karen deSalvo, Google’s health chief—the inability of different providers’ records to talk to each other. Dr de Salvo has been vocal about the need for greater interoperability since her days in the Obama administration, where she was in charge of co-ordinating American health information technology. Until that happens, Care Studio is meant to act as both translator and repository (which is, naturally, searchable).
Dead on. It's a hard hard problem though because during the early days we went through a Cambrian explosion in data diversity. Data is often coded very inconsistently or in ways that make it "invalid" to modern schemas. The "miracle of HL7" is basically just a fancy text format, and like the on-table records or XML documents it's still possible to code things in ways that still won't be parseable even if they're syntactially/lexically correct.
There are standardized schemas (f.ex NEDSS schema) available, but they are super over-engineered for a lot of use-cases and can perform quite poorly due to excessive "anything can map to anything" design and field-table-value formats. And again, they suffer from the "there's multiple ways you could code this" thing, just using NEDSS doesn't mean you interoperate with anyone, not close. Not sure what EHRs typically have underneath but it wouldn't surprise me if they all had their own solutions too, EHR software is universally dogshit.
Handling poorly-validated/normalized data from tens of thousands of facilities all doing their own things is a very tough problem, and honestly the only solution is to decentralize it a little bit, facilities have to look at their own data and see if it makes sense the way they're sending it or even if they're storing it wrong. Once it's just another record in a database, if it's not consistent and accurate it likely never will be. It'll just be yet another System-Specific-Record-Identifier in the list for that record, and since it's not coded right nobody will ever be able to read it unless it's patched by someone/some layer.
Data clearinghouses are uniquely positioned to gatekeep that a little bit, and over time there are tools getting written to help various facilities validate their data and see whether it's semantically reasonable. Almost everybody has errors especially if this is their first integration, but they can be brought up to speed on their ongoing record submissions, at least.
I'm sure google would love to be in charge of everyone's health data, or at least to get to see it. Commercial activity isn't notionally allowed but I wonder if HIPAA applies to aggregated data like that, they can probably set up The Business-Purpose Side with a firewall from the Gets To Make Money Querying Anonymized Data side.
It's true that this is a thing where there are intellectual economies-of-scale thoug...
FHIR provides a structure for communicating these data, but does not solve the hard problem in the parent comment about the massive heterogeneity of health care data across institutions (and even within institutions). The same messiness of the original raw data in the proprietary EHR data format can be replicated in FHIR. But at least the mess is available then in an open data format and a bit more regimented on canonical elements (i.e. things like effectiveDate/DateTime).
Have you used HAPI FHIR in production at any scale? Our experience is that it completely falls over under any reasonable strain. Try working with a few thousands patents and ~100M Observations and you will see HAPI work very poorly. It's great that HAPI is very feature rich on the API side--they've implemented most of the spec. But JPA and how they're using it is not a healthcare-scale technology. Google's (Spanner based) and Microsoft's (CosmosDB & SQL Sever based) FHIR API are better at scale but have far fewer features. I'm actually ok with that because the FHIR spec's query functionality is actually much more limited. Google's BigQuery integration really helps here. I'm interested to see where AWS is going with Health Lake. In talking with them I believe they have the best paradigm for their technical implementation.
It is a shame that the open source FHIR servers haven't been great. I think they will probably improve once a scalable paradigm for working with FHIR emerges.
We'll, I tend to silo phi per client to provide for auditable data segregation, so I don't try to scale HAPI up vertically.
FHIR is nice in that you can do uri pointers to external FHIR systems for resources, so it's possible to build up a pretty complex care team and access relationships that way.
I was going down this path and had a lot of it built out, but we ended up changing direction so I never saw it all the way through.
it's much easier to get hospitals to share EHR data than you think. Both from the anecdote level (when switching health care provider companies, my doctor was able to export my EHR from Kaiser and import it to Sutter with a single click. Two completely different systems (which happen to both be running the same underlying software).
At the generalization level, many companies make deals with health providers to get various forms of access to EHRs.
There is another aspect to this. Treating all hospital records as an infallible and comprehensive record of truth, carving them in stone and having them follow you for the rest of your life is plain dangerous. They are to be interpreted in a complex context, and their relevancy fades over time as well.
Easy to imagine: patient records will now include ads for expensive drugs. Doctors can make $ on the side by referring patients to Google Pharma. Drug labs can dig a moat around their products by buying ad placements in doctors' digital prescription pads.
Not sure what you think "the product" is and how it would help your mom. The relevant part of the article is about selling you smartwatches, selling doctors software so they can share your medical history with Google, and selling you potentially better skin moisturizer. None of that will be free.
This already exists:
* there are prescription management companies (middlemen) who already advertise ("recommend") to doctors
* doctors no longer directly get kickbacks, because the FDA
* you don't think drug companies don't already control what doctors see? https://pulsepoint.com/hcp-marketing
* who do you think finances medicine information?
So, pushing treatments you didn't want or need? Yeah we're already there and they've certainly got the government connections to make it very lucrative.
I was thinking more like ad-supported hearing aids with built-in analytics so marketers can ask "Have you heard of this brand before?" for precise ad recall.
Google will succeed at healthcare only after medical decisions can be reduced to A/B tests. That is to say, never.
After wasting many millions on failures like Calico, Google hasn't learned that healthcare is a service that's continuous, custom, and complex. And since the "customer's" health and life are at stake, maintaining health is a damned sight more important and difficult to do sufficiently well than Google's current business: spam.
Tech companies like Google simply don't have the DNA or the persistence to succeed in science-based markets driven by R&D and heavy regulation. They want faster profits driven by higher multipliers and lower standards for accuracy than you can get in healthcare, where accuracy really counts and every case is a little bit different. In medicine it really matters if you get the right answer for your A/B test, otherwise someone may die or they may sue you. That's why so little of healthcare has been automated, and why that's likely to continue.
I have a little experience trying to work with Google in the R&D space at a large pharma. Google and other external R&D agents consistently underestimated the difficulty in getting access to sufficient data from us to employ large scale ML. That data often exists within a pharma's clinical trials, but it's acquired and stored in a way that makes it inaccessible to subsequent mining.
This is a problem for dataminers like me within pharmas too. Most of our clinical trial data is locked up contractually within contract research organizations (CROs) who are responsible for taking specific measurements of it as part of a trial. From what I've seen, dataminers within the company can gain access to only selective bits of that data (one or two features, perhaps) from all the patients in a trial, but never to all the data on each patient, and never data from the trial that spans multiple CROs.
This 'federation' of clinical trial data collection serves the needs of the trial design (and satisfies HIPPA regs), but it makes mining the data or asking new questions of it almost impossible. Too little data is available (and never longitudinal longer-term outcomes, since trial durations are short) to allow mining of more than short-term signals, like immediate response to treatment. Pharmas are unlikely to change that practice, in part because it's easier to federate the analyses and allow the raw data to remain in distributed silos. But federation is also a good way to discourage asking creative yet inessential questions that might later prove awkward or invite lawsuits, since litigation is an omnipresent worry in US healthcare.
How companies like Calico/Google hope to navigate such minefields is a question they have yet to answer successfully.
You didn't answer the question of why Calico is a failure. They have very little to do with Google. Calico is its own independent institute that does exactly what Art and Larry wanted when they set it up- produce world-class research into longevity. I think you mean Verily, which works closely with Google on health care projects.
(note: I worked at google over a decade and work for pharma now. I helped establish Google's move into health care and even launched products intended for pharma users and set up the ethical guidelines to work with private data like clinical records. Unfortunately, Google's Research leadership chose to take their health efforts in a completely different direction so now I focus on stuff that will actually make a difference for pharma).
>Google will succeed at healthcare only after medical decisions can be reduced to A/B tests. That is to say, never.
Never, or literally tomorrow if they take over.
"Personalised medicine" decisions made with "AI" will provide a perfectly unaccountable black box to blame when (if ever) the general public realises that vulnerable and poor people have been getting the B end of the A/B testing.
I agree with the rest of the post but god have mercy on us if these companies take over healthcare. I never thought I'd be living in such a totalitarian state in my life.
This is nothing new. MSFT, Alphabet, AMZN, Oracle have all been making plays for years trying to get into the healthcare industry. It's a huge, bloated industry
This is also an heavily regulated industry in terms of patient data protection, software quality, part availability, etc. It will be interesting to see how big tech will deal with having an overbearing regulator breathing down their neck.
Form outside observation; their software is required to suck by itself, and rely on decade old versions of other software as well. That may not have been the intent of regulation but (as so often happens) appears to have been the outcome.
The FDA have pretty strict standards in terms of project management. Of course it depends on the "class" of the medical device we are talking about. But if the software is used for diagnostics, you will need a whole battery of controls (test, documentation, processes, etc).
I really wish Google would just accept it's a dumb advertising company and forget about these moonshots. It's just to stroke the founders ego. They are big enough. Pay out a huge dividend or something.
Google often has terrible execution when it lies outside their direct core businesses. You are correct they have amazing engineering talent, but that is not the problem here.
NHS is struggling with wait times and staff shortages, no? I have heard a lot of them is in radiology departments. These diagnostic improvements will help there as well, and for a state funded healthcare like NHS, more automation is good.
As much as I don't like for profit companies monetising this, I am not sure if I know of a better path to innovation.
I've been thinking how to enter the medical space with software.
My cousin has EDS, diagnosing the illness is pretty trivial. It took her 15+ years and when she was diagnosed she was already in severe decline. She could have been diagnosed a decade ago but some doctors just have no interest in googling symptoms and listening to patients.
I am so sorry to hear about her but this is the exact reason why I am hopeful with companies like Google entering this space and making diagnosis better.
We have so many smart devices that can record so much data, and it doesn't even have to be auto recording. If you had a headache, if you can mark that and over time based on a pattern it can recommend you to see a specialist or get some tests done.
"dumb advertising company" is trivialising the amazing tech and products Google has. Google has very justified bad reputation around product shutdowns and privacy, but I don't think being dumb is one of them.
I was not calling Google or its engineers dumb, that was not my intent. I am saying their success is attributed to dumb things, aka advertising. Google has a way of sucking in really smart people to work on potentially great things that end up solely existing to feed the dumb advertising machine and heavily exploiting their users in the process. It's really quite evil.
Google may make shitty business decisions for their customers, but their technical innovations is nothing to laugh at. I mean AlphaFold alone killed off entire careers in the protein folding space just because of how good it was at predicting those structures.
I don’t understand these drives. The US is the only developed country without state control of healthcare. How is Google hoping to grow their market outside the US when it’s such a difficult space to navigate?
Medicare, which is under state control, is larger than many other developed country's state-run medical systems. Before criticizing the US system, make a strong attempt to understand the underlying structure.
The US is a big outlier in not having universal healthcare but in terms of government control it's really pretty typical with countries like the UK where the government runs health provision directly rather than just regulating and paying for it are the exception rather than the rule. I've worked for a company selling robots to French hospitals and that really isn't any different than selling to US hospitals.
I'm not against data mining at all, just handing it out to agencies without my say so. I'd be happy for it to be used for this purpose entirely within the NHS but that's not what was assured.
I don't like the approach that you have to opt out, not opt in.
I others may have different tradeoffs, that's fine. This is my view and urge people not to follow what I've done but to decide for themselves. It's your data, if you're in the UK, you can make a choice (not making a choice IS making a choice: for it to be shared).
Edit: and please don't respond with "just you wait..." or "it's going to happen anyway" defeatist juvenile posts.
In Australia we have a similar mechanism, I opted out of sharing my health data. However down under when you opt out, this applies not only to private companies but also to State and Federal health providers. Source https://www.digitalhealth.gov.au/initiatives-and-programs/my...
As somebody who's been blacklisted by Google for no particular reason I can even discover, this terrifies me. I'm not saying they'd hire a hit man and kill me, but tweaking some doses of medicines? This isn't impossible if they get their claws into health care. It's free and easy. And Google is terrible for privacy and has major security problems which are endemic.
So, if you thought it was shitty when your Gmail service abruptly gets suspended for no clear reason or means of recourse, imagine how wonderful it's going to be when your entire range of cloud based medical services and remotely updated internal gizmos goes down the drain because some algorithm decided so....
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[ 2.7 ms ] story [ 246 ms ] threadIt's so easy to blame voters but the reality is that politics is about messaging, and how is the electorate supposed be savvy enough when these companies can spend unlimited amounts of money to keep us fighting each other about this stuff? Make no mistake, Google benefits from this depravity too.
I don't have a good answer to this question, I'm wondering if others do.
No, I don't have an answer either. I just know that counter-propaganda isn't it.
Maybe things were different under the Fairness Doctrine? I don't know.
We already have free health for the poor: https://en.wikipedia.org/wiki/Medicaid
> Medicaid is the largest source of funding for medical and health-related services for people with low income in the United States, providing free health insurance to 74 million low-income and disabled people (23% of Americans) as of 2017, as well as paying for half of all U.S. births in 2019.
What we should be doing is to fight the regulatory and bigpharma capture of US health system along with the horrible hospital + insurance racket. Google is now going to take advantage of the moat built by Big Gov and never ever allow anyone to compete.
No, we have free health insurance for some of the poor (states that have no accepted the ACA expansion have basically no coverage for adults without dependents.)
Medicaid is not (as a generality) free health care (it can be, in some states, for some recipients). It is free health insurance, which can have copayments, coinsurance, deductibles, etc.
I think if someone can afford better, private care they should be able to. For example I would probably go to the universal healthcare family doctor but if I need a specific surgery I would like to be able to go to the best care I can get.
There are tens of millions of people who have no access to Medicaid because states chose not to expand it under the ACA, and there are plenty of poor people who make more than ~$16k a year, which is the cut-off for Medicaid.
How could it be even more expensive than our current inefficient, half-baked, worst of both worlds system, which is more expensive than socialized systems in other nations? And more expensive per capita, not simply overall.
* The US spends more public money on health care, per capita, than other wealthy nations, while also spending much much more private money than other wealthy nations
* By many measures, the US gets worse outcomes (e.g. life expectancy)
The conclusion that many draw from this is that perhaps a single-payer health care system in the US could dramatically lower private spending, also lower public spending, and perhaps improve outcomes. I don't personally know if that follows, but it's not implausible.
This is counter-intuitive to many, thus comments like your (A) through (C) are common, but might not be correct.
That said, I'm not aware of evidence that your (B) is wrong. That might be part of the trade-off.
As a non-American from America's hat, who has had a few (bigco-insurance-funded) run-ins with US Healthcare, my observations were that
* emergency health care at the no-expenses-spared level in the US was nicer than emergency healthcare up here, and I wouldn't want to pit my doctors vs those US doctors in a quality competition
* US doctors seemed really eager to waste money, like really eager, like it was creepy
Your last point is purely a function of the liability culture in the states. US physicians are quite aware of what's appropriate and what's inappropriate testing wise. However, as long as a physician can be held personally liable for any oversight - meaning that the results of an entire career can be lost - they're going to over-test.
I'll note that I do have a few different bits of modest evidence to the contrary. But I wanted to focus my comment on concrete observations (both the large-scale statistical kind, and the personal anecdotal kind), rather than on speculation.
I'd much rather a doctor "waste money" on a test than come up with an incorrect diagnoses based on symptoms only.
[1] "works" is an interesting point because it isn't clearly defined, and usually means different things to different people.
Ever experience of the system is "unique" - there is this mix of human patient with human provider with finite resources with medical knowledge with time. So there are plenty of examples of long waits, bad service, unfavorable outcomes, even death. It's not hard to cherry pick bad experiences here.
No health system will make everyone live forever. Death comes to us all sooner or late. But universal healthcare works in many places in raising the overall standard of public health, without bankrupting people in the process.
Given that its always spending limited money, and only scales at human rates, its far from perfect. But, at least for some, its better than a "health care level based on your wealth" system.
You have Medicaid for the poor, heavily subsidized Obamacare for the people who don't get it through their employer (hello $100/month plan!) and Medicare for the retired.
I mean my cousin in the US whose kid has cystic fibrosis get better care through Medicaid than our other cousin in Canada who can't even get access to the latest drugs.
https://www.verywellhealth.com/your-assets-magi-and-medicaid...
That $100/month plan will include high deductibles and copays. A weekend visit to an urgent care for a kidney stone will still cost a couple hundred dollars out of pocket.
The U.S. per capita spends far more on healthcare than any other OECD country. We don’t get correspondingly better outcomes or coverage. Universal healthcare is a solved problem within the context that every system necessarily involves some sort of rationing since there aren’t enough medical resources in any country to do otherwise.
If you don’t want to use the phrase “solved system” then don’t but don’t pretend the U.S. is any way better other than in anecdotal instances. Below is a source for information on per capita spending for OECD nations. You can easily find information on health our outcomes, life expectancy, teen pregnancies, infant mortality, etc.
https://www.oecd-ilibrary.org/sites/876d99c3-en/index.html?i...
I’m not sure how your reply has anything to do with what I said.
“Better than the US” is not some hurdle that makes a problem “solved”.
Canada is likely better at snow removal but that doesn’t make it a “solved problem”.
Doesn’t do much for the people disabled from pain on a 3 year wait list for a hip transplant or my buddy’s cousin’s kid who doesn’t get access to the standard of care of CF.
It’s not solved in the least, every country struggles, so using the word “solved” is, as I said, naive.
What goal do you wish to accomplish your pedantic nitpicking? You want to get others to believe that my views on national health policies are naive? You want me to realize that in a strict, mathematical sense of the word saying “solved” is incorrect? These are rhetorical questions because I’m not going to read your response. You clearly don’t know much about policy issues and what it means for a society have essentially “solved” an issue (or have found a decent enough solution that it isn’t a dire problem anymore so that some non pedantic people will say it is solved).
Carry forth Don Quixote on your quest to eradicate incorrect usage of what you think “solved” means.
You claim I don’t know policy without knowing healthcare policy is my day job.
Even given the benefit of the doubt that as an outsider looking in you think it’s solved, but as someone who is elbow deep in it everyday “solved” just sounds naive.
As for socialized medicine it makes doctors another arm of the government. In the UK last week (or the week before) one arm of the government ordered another arm of the government to kill a 9 year old. We are also just outside a 2 year stretch of tyranny of governments all over the world giving that arm of government near unilateral power over our freedom at the point of a gun.
Tell me you don't know what communism is without telling me you don't know what communism is.
Yes, every known communist country has been rife with fascism, authoritarianism, and corruption. But those are orthogonal with communism as an economic model. It's like saying socialism is evil because the Nazis were socialist (they really weren't) just because "Socialist" is part of "Nationalist Socialist Party" .
> In the UK last week (or the week before) one arm of the government ordered another arm of the government to kill a 9 year old.
[citation needed], because this sounds like an extremely gross misinterpretation of a situation, likely done deliberately in bad faith.
Google offers services that you don't pay for in cash.
But no, let's throw billions of dollars at anti-aging instead...
Therefore, an AI that generates good models is valuable.
From the summary:
> The report makes many sound assumptions but also some questionable ones that are overly pessimistic. Yet, overall, its bottom-line estimates should reassure those concerned about the economic feasibility of single payer: The CBO projects that such reform would achieve universal coverage, bolster provider revenues for clinical services, and eliminate almost all copayments and deductibles—even as overall health care spending fell.
0: https://www.healthaffairs.org/do/10.1377/forefront.20210210....
[1] https://data.worldbank.org/indicator/SH.XPD.CHEX.GD.ZS?most_...
[2] https://en.wikipedia.org/wiki/List_of_countries_by_total_hea...
It's the same reason costs to build subway tunnels has dramatically increased in NYC, labor unions have the process by the throat and will accept not even a cent in reduced labor costs, even when improvements would improve safety or efficiency.
Moreover, it's the patient, not the neurosurgeon that has to make the decision to trust the AI.
On the topic of EMR systems in particular, they suck because the people using them hate them and because the people purchasing them, building them, and mandating them aren't the people using them. If it were just a matter of having enough money to throw at the problem, Epic would have done so already.
On the startup and health improve lament side, billing is the rock that so many great ideas break on. It doesn’t matter if the model or business improves care or reduces cost unless it will make a provider more money.
Sure, Paul Farmer was special, but most people are not. To make any policy, or social conditioning, that is fine for an individual but bad for a collective, can result in some pretty terrible consequences, most critically this recent drive to discourage folks from having children due to whatever made-up reason, or cling onto power until others have to pry it from one's cold dead hands.
They then use those broken, ineffective programs as evidence of "the governments" incompetence (ignoring the fact they they _are_ the government), bolstering their arguments for rolling back government regulation and spending. This way, private interests are able to dominate the market and the money keeps flowing 'round. I'm convinced this is the mechanism behind both the increasing income/wealth inequality in the US, and the broken state of public infrastructure/services.
The solution is election reform. The data has shown that neither party represents the actual interests of the people, and they only get away with it because of the Game Theory around our election system. Get rid of the Electoral College and FPTP - 1 Person:1 Vote & Ranked-Choice voting would create a cataclysmic shift in US politics in short order.
It wasn't just anti-science but deliberate attempts to stop Obamacare, the ONLY initiative ever attempted to fix the US healthcare system. Then came the Republicans to stop it.
https://www.heritage.org/health-care-reform/commentary/why-t...
IMO, the Pacific coast states need to reject national health care, create a health-care pact between states that slowly grows larger by adding new states. If another state doesn't want to join, then, so be it.
Enough of splintered policies that change across state lines. Reduce health care insurance costs by allowing continued and universal care to states that elect this policy. The strength of change is in the states themselves, not the federal level.
https://www.gov.ca.gov/2020/04/13/california-oregon-washingt...
It blows my mind that they don’t do this. During most of the 20th century, Democrat-run states wanted to tax Republican California to pay for social programs. So doing things at the national level was critical. But now that the states that have all the money are also run by Democrats, that roadblock is gone. California can just tax California to pay for universal healthcare for California. They have no reason to care what Iowa chooses to do.
Not to mention that educating children provides a significant economic return to the state in the form of labor when the children grow up. Whereas dialysis and heart surgeries and hip replacements for 70+ year olds is a complete loss.
For examples, a single NICU baby or hemophiliac can easily cost $1M+ per year. Health insurers almost had to stop selling policies in Iowa due to a single hemophiliac who needed $1M/month medications:
https://www.desmoinesregister.com/story/news/health/2017/05/...
There is a reason why universal healthcare is such a political football. It is the single most expensive thing the country spends its resources on, and it is not even universal yet. Hence all the tribes fighting over access to public resources for it, and solutions implemented to ration resources along those tribal lines, via the use of managed care organizations (health insurance companies) and hugely varying reimbursement rules for different programs like Medicare (old), Medicaid (poor), Tricare (military), commercial plans, etc.
All the premium increases people complained about due to ACA are a fraction of the tax increases that would have had to happen for universal healthcare. The other option is pharmaceutical companies, hospitals, and doctors take a huge pay cut.
So why would I ever want universal healthcare? I was being sold on it being cheaper and more efficient, but now you’re saying that it will also cost more. What’s the point, then?
> The other option is pharmaceutical companies, hospitals, and doctors take a huge pay cut.
Bringing healthcare prices down is also out of the league of cities/counties/states. These things require federal action like increasing number of doctor residency funding or spots, reducing patent protection for medicines, or other measures to increase supply of healthcare.
Canada established its single payer system provincially, one-by-one, and they didn't have this adverse selection problem. Saskatchewan was the first Province to offer single payer in 1947, followed by Alberta in 1951, etc. By 1961, all Provinces had some form of a single payer healthcare system.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3110239/
> Taxpayer-funded medicare in Canada did not appear at a single point in time: it emerged over a quarter century from 1962, when physician services were covered across Saskatchewan, to 1987, when the demise of optional “full billing” in Ontario began.
So at any given point in time between 1962 and 1987, there was (in theory) this adverse selection problem among certain provinces; and yet that was never really a major problem in Canada. Even to this day, the Canada Health Transfer which provides block funding to Provinces by the Federal government for the purpose of funding these single payer systems covers ~22% of the cost (https://www.cmaj.ca/content/192/45/E1408).
Additionally, even in present day, the European Union has open borders and free immigration between member states, and certain member states have far more generous welfare systems than others, and you still don't have this adverse selection problem, at least in a manner that meaningfully renders those welfare systems unsustainable. Even domestically, we didn't really see dramatic net migration from states that refused to take the Medicaid expansion to those that did.
The reality is that people don't choose where to live strictly on the basis of which state provides taxpayer funded healthcare. In fact, those that are most likely to do that (poor people) are likely already covered by Medicaid or heavily subsidized ACA plans (https://www.kff.org/policy-watch/millions-of-uninsured-ameri...).
And even if one were to engage with the purely theoretical problem, there are ways to mitigate the adverse selection, e.g. by requiring a minimum number of years of residency in order to qualify. This is what US States do today to establish residency for the purpose of in-state university tuition. Given the plethora of historical (and current) data points that suggests that this isn't really a problem, States can choose to cross that bridge if/when they get there.
https://www.npr.org/2022/01/31/1077155345/california-univers...
https://en.wikipedia.org/wiki/Vermont_health_care_reform
It does not work for the reasons tptacek wrote. With freedom of movement, eventually net benefit recipients will move in, and net payers into the system will move out.
It is always the same story with any broad high cost universal benefit offered within a taxing jurisdiction that does not have immigration control. Homelessness (land costs), mental healthcare (legal and labor costs), and healthcare. Even subsidized higher education is not universal, it is restricted to residents.
That is why we do not see these offered anywhere, and why it has to be a federal move.
It sounds like people in Vermont just wouldn’t put their money where their mouth is and pay the taxes required for universal healthcare. Our German au pair paid almost 40% on her entry level office job. If you want universal healthcare like the Europeans well that’s what it costs.
And there’s even more giants:
https://www.theverge.com/2022/6/10/23162503/oracle-cerner-he...
https://www.fiercehealthcare.com/health-tech/oracle-cerner-p...
We are already in a dystopian time.
Voila, behold a viola! One fourth of a string quartet!
But if you're irked by "viola", it could be worse, they could have written "wallah", which is all too frequent.
https://wallawalla.org
Or a flower.
Are you mixing French and Italian articles?
As an addendum wiktionary[0] is always useful when searching other meanings of a word
[0]https://en.wiktionary.org/wiki/viola
I haven't learned French since high school, but here's how I would translate the examples:
il la viola "He raped her"
il viola la loi "He broke the law"
[0](https://en.wiktionary.org/wiki/il#French)
Price controls and disconnecting it from employment.
A proper MRI is expensive, the analysis is slow and need experts etc.
There are plenty of things to optimize.
And when we are done with us, it has to reach the next level to become so cheap and easy to use that everyone on our planet has access to it.
> A proper MRI is expensive, the analysis is slow and need experts etc.
I'm sure that's very true. A company that's struggles to keep a rudimentary chat app running for any length of time, spectacularly miscalculated its fiber project, to name a few obvious ones, does not instill any confidence that they would be the one to improve this. The medical industry is far more conservative and far more complicated than what Google has proven it is able to deal with IMO. You can't just move fast and break things, you can make shit up as you go along, you can't invent your own standards.
> There are plenty of things to optimize.
They've also not performed impressively on any kind of "AI" related thing, if that's what they're thinking. Their self-driving cars are still a curiosity and a long way off being revenue positive, if there is even a path to it, for example. Industry and legislative inertia and baggage aside, I don't even think a big old cumbersome dinosaur like Google has the chops to come in and make a big change. Put it this way if some revolutionary new startup company had a really great idea in healthcare, you would be disappointed if Google bought them.
Google maps was and still is free, available and changed lives.
GCP is extremely innovative. From full end to end encryption including encryption on rest.
Google workspace works like a charm.
They have well working ML in all newer pixel phones for images etc.
They have tons of bleeding edge research papers on so many different ml topics (are you aware of their research blog?)
Google has one of the best / if not the best certified cloud env in the world. They already work with the biggest health service provider in the USA.
Yes.
I've seen this many times but it makes a meaningless healthcare = health correlation .
America has lots of systemic problems that affect health outcomes that are outside of healthcare. Low quality fast food, food addiction, industrialized farming, corn subsides, food deserts, deceptive food marketing to name a few.
It doesn't, it's just making an observation.
> America has lots of systemic problems that affect health outcomes that are outside of healthcare. Low quality fast food, food addiction, industrialized farming, corn subsides, food deserts, deceptive food marketing to name a few.
Sure, America has many issues and many more than you've listed. So do other countries. And they all have many differences in healthcare systems. All this makes it impossible to formulate a mathematical proof. Which fortunately I was not trying to do.
So we can't really measure the precise effectiveness of healthcare systems and health expenditure, sure. But surely the burden is on the people who would to claim that 2x healthcare expenditure for worse (or not significantly better) health than many other countries is a reasonable cost efficiency, to come up with some pretty strong evidence to support them.
yes we have healthcare system that treats disease, after that fact. Americans are a sickly group of people. Lionshare of expenditure goes to treating chronic metabolic illness. These people cannot be returned back health once they have metabolic syndromes. So matter how much money you spend on healthcare there is no real way to convert sickly ppl back into healthy people. No doctor has a way to fix diabetes or thyroid dysfunction.
Again, goes back to my original comment. "healthcare" has nothing to with "health".
>the standard of care in America is probably second to none if you can pay for it
How sure are we that these two things are unrelated?
Because I do and you know how scattered the field of medicine is?
There is one realistic way of getting more people with chronic issues new threatments and it's data. Lots and lots of it.
IF someone can pull that of while protecting the individuals I believe it's alphabet. Together with deep mind and all the other research they do.
What makes you think they will protect the "individuals"? From a privacy persepctive, I would say they have no clear incentive in doing that, given individuals are the product they sell to companies that need to push ads into society.
They know how they make their money and don't hide it. But they make you as an individual disappear.
It's a much better compromise than from any other company and they drive this topic for years.
At the end of the day, it's just you by a different name. Instead of owning it and claiming "we have this information on Gehlitio" they say things like "We have these generalizations about anybody who happens to use HN, speaks in English, bought X Y and Z, subscribes to A, <insert 100 more details that effectively fingerprint you>"
The right to be forgotten would have to be built into it all right from the get go, wouldn't it? Neural nets embed things, like you said. If Facebook pivoted towards being a hub for healthcare data as oracle seems want to do, could they use all of their facial recognition tech trained from profile pictures now that it is supposed to be detached from any one identity? I'm thinking of the equivalent of github's co-pilot spitting out comments alongside the code.
yes exactly. I am having trouble articulating my underlying point but this is along the lines of it.
A facial recognition algorithm is ultimately saying "you look similar to this specific set of people". If the training set was 1 person, for example, then the algorithm would pretty much just be saying "you look like this photo of this 1 person". Scaling that up does not improve privacy - it only blends you into a population. Additionally, it is distilling out the things about you that separate you from that population (things that make you, you) since those distinguishing features are exactly what the model needs to use as the line to draw on whether or not new data points are similar to the population set or not.
Because privacy doesn't seem all that important once you actually are going through it.
If you had to pick between being a cripple (say, with your arms or your legs useless) and forgoing your privacy are you really sure you'd give more value to privacy?
Do actually consider what life is like under these circumstances before answering. I don't think there are many quadriplegic people out there who'd pick privacy over being healed.
"X is more important than Y" isn't honest if you never lacked Y and can't even consider a future where you lack Y
My beliefs are quite the opposite of what you implied about me. I think we should move away from all this embedded bullshit and keep peoples identities intact because the generalizations will never be perfect and it might be useful to know who the actual people are that those generalizations are based on. Maybe that would facilitate human connections. Maybe that would make it easier to reward individuals for sacrificing their privacy in order to improve healthcare. Instead of just pretending they arent sacrificing privacy and are just a drop in the ocean of data providing results.
You are not a drop in the data ocean. Your data is important. There are not a lot of people like you. Google emphasizes generalization because it cheapens the value of your individual data point. Their policy creates an illusion I aim to dismantle.
Also, I do have chronic illness but that is not relevant here. Mine does not directly cause pain, though, full disclosure
Health is very personal. Family history is usually pretty relevant. I am not sure what we gain by pretending we arent talking about actual people, or that by removing your name from all your specific health details it somehow means you cant still be personally targeted. I know Google gains the benefits of less regulations, though.
I disagree on this sentiment, I don't care if there is an dehumanizing number for me in a ad context. I would prefer it over a personal id.
Anyway I still care much more for having a cure for my chronic pain.
Good for you if you don't need this.
I just disagree with the position that Google can do so while preserving privacy. If we are going to trade privacy for cures, let's at least do so openly.
I do, but I can think of no more obvious examples of a Faustian pact than having Alphabet get involved in this field.
So I guess it boils down to a difference of opinion is all.
If you give your medical information to someone/something that is not a covered entity or business associate they do not have to follow HIPAA rules.
More information here [1].
[1] https://www.hhs.gov/hipaa/for-professionals/covered-entities...
A merger of technology privacy invading, ai-guiding, rip off processes AND the ability to direct your health for profit. With government lobbyists in both pockets.
What could go right?!?
Sarcasm aside I can't think of a company I'd trust less than Alphabet (maybe Meta) with managing healthcare.
You mean like, "Don't be evil"?
/s
And that's why they censored the web via the Project "Project Dragonfly"? [1]
Never forget that you are a product for Google, and Google likes to kill it's products.
[0] https://theintercept.com/2018/05/31/google-leaked-emails-dro...
[1] https://en.wikipedia.org/wiki/Dragonfly_(search_engine)
> Google is also giving health records another whirl. The new initiative, called Care Studio, is aimed at doctors rather than patients. Google’s earlier efforts in this area were derailed in part by hospitals’ sluggishness in digitising their patient records.
Not just digitizing but also in sharing them. Hospital systems are very very reluctant to send out a copy of their records, or even to let you query their system. Especially in the early days of EHRs there was very much a sense that it was their data and they didn't want to let data out because interoperability was a threat to their data moats.
That's good in a privacy sense, but it really did slow down adoption of interoperability initiatives. Finally Medicare/Medicaid basically forced it iirc... if you want Medicare dollars you will send Medicare your encounter data. So now you have to code your records at least good enough to at least get your medicare reimbursements.
> That problem has mostly gone away but another has emerged, says Karen deSalvo, Google’s health chief—the inability of different providers’ records to talk to each other. Dr de Salvo has been vocal about the need for greater interoperability since her days in the Obama administration, where she was in charge of co-ordinating American health information technology. Until that happens, Care Studio is meant to act as both translator and repository (which is, naturally, searchable).
Dead on. It's a hard hard problem though because during the early days we went through a Cambrian explosion in data diversity. Data is often coded very inconsistently or in ways that make it "invalid" to modern schemas. The "miracle of HL7" is basically just a fancy text format, and like the on-table records or XML documents it's still possible to code things in ways that still won't be parseable even if they're syntactially/lexically correct.
There are standardized schemas (f.ex NEDSS schema) available, but they are super over-engineered for a lot of use-cases and can perform quite poorly due to excessive "anything can map to anything" design and field-table-value formats. And again, they suffer from the "there's multiple ways you could code this" thing, just using NEDSS doesn't mean you interoperate with anyone, not close. Not sure what EHRs typically have underneath but it wouldn't surprise me if they all had their own solutions too, EHR software is universally dogshit.
Handling poorly-validated/normalized data from tens of thousands of facilities all doing their own things is a very tough problem, and honestly the only solution is to decentralize it a little bit, facilities have to look at their own data and see if it makes sense the way they're sending it or even if they're storing it wrong. Once it's just another record in a database, if it's not consistent and accurate it likely never will be. It'll just be yet another System-Specific-Record-Identifier in the list for that record, and since it's not coded right nobody will ever be able to read it unless it's patched by someone/some layer.
Data clearinghouses are uniquely positioned to gatekeep that a little bit, and over time there are tools getting written to help various facilities validate their data and see whether it's semantically reasonable. Almost everybody has errors especially if this is their first integration, but they can be brought up to speed on their ongoing record submissions, at least.
I'm sure google would love to be in charge of everyone's health data, or at least to get to see it. Commercial activity isn't notionally allowed but I wonder if HIPAA applies to aggregated data like that, they can probably set up The Business-Purpose Side with a firewall from the Gets To Make Money Querying Anonymized Data side.
It's true that this is a thing where there are intellectual economies-of-scale thoug...
Also, it's complex to implement.
Fortunately, we have HAPI [1] and it's very good, but has deployment complexity only a java developer could love.
There's been a couple false starts on a nodejs based FHIR server, but nothing open source and production ready that I've found.
[1] https://hapifhir.io/
Have you used HAPI FHIR in production at any scale? Our experience is that it completely falls over under any reasonable strain. Try working with a few thousands patents and ~100M Observations and you will see HAPI work very poorly. It's great that HAPI is very feature rich on the API side--they've implemented most of the spec. But JPA and how they're using it is not a healthcare-scale technology. Google's (Spanner based) and Microsoft's (CosmosDB & SQL Sever based) FHIR API are better at scale but have far fewer features. I'm actually ok with that because the FHIR spec's query functionality is actually much more limited. Google's BigQuery integration really helps here. I'm interested to see where AWS is going with Health Lake. In talking with them I believe they have the best paradigm for their technical implementation.
It is a shame that the open source FHIR servers haven't been great. I think they will probably improve once a scalable paradigm for working with FHIR emerges.
FHIR is nice in that you can do uri pointers to external FHIR systems for resources, so it's possible to build up a pretty complex care team and access relationships that way.
I was going down this path and had a lot of it built out, but we ended up changing direction so I never saw it all the way through.
Shame.
At the generalization level, many companies make deals with health providers to get various forms of access to EHRs.
After wasting many millions on failures like Calico, Google hasn't learned that healthcare is a service that's continuous, custom, and complex. And since the "customer's" health and life are at stake, maintaining health is a damned sight more important and difficult to do sufficiently well than Google's current business: spam.
Tech companies like Google simply don't have the DNA or the persistence to succeed in science-based markets driven by R&D and heavy regulation. They want faster profits driven by higher multipliers and lower standards for accuracy than you can get in healthcare, where accuracy really counts and every case is a little bit different. In medicine it really matters if you get the right answer for your A/B test, otherwise someone may die or they may sue you. That's why so little of healthcare has been automated, and why that's likely to continue.
This is a problem for dataminers like me within pharmas too. Most of our clinical trial data is locked up contractually within contract research organizations (CROs) who are responsible for taking specific measurements of it as part of a trial. From what I've seen, dataminers within the company can gain access to only selective bits of that data (one or two features, perhaps) from all the patients in a trial, but never to all the data on each patient, and never data from the trial that spans multiple CROs.
This 'federation' of clinical trial data collection serves the needs of the trial design (and satisfies HIPPA regs), but it makes mining the data or asking new questions of it almost impossible. Too little data is available (and never longitudinal longer-term outcomes, since trial durations are short) to allow mining of more than short-term signals, like immediate response to treatment. Pharmas are unlikely to change that practice, in part because it's easier to federate the analyses and allow the raw data to remain in distributed silos. But federation is also a good way to discourage asking creative yet inessential questions that might later prove awkward or invite lawsuits, since litigation is an omnipresent worry in US healthcare.
How companies like Calico/Google hope to navigate such minefields is a question they have yet to answer successfully.
(note: I worked at google over a decade and work for pharma now. I helped establish Google's move into health care and even launched products intended for pharma users and set up the ethical guidelines to work with private data like clinical records. Unfortunately, Google's Research leadership chose to take their health efforts in a completely different direction so now I focus on stuff that will actually make a difference for pharma).
Never, or literally tomorrow if they take over. "Personalised medicine" decisions made with "AI" will provide a perfectly unaccountable black box to blame when (if ever) the general public realises that vulnerable and poor people have been getting the B end of the A/B testing.
I agree with the rest of the post but god have mercy on us if these companies take over healthcare. I never thought I'd be living in such a totalitarian state in my life.
AFAIK, crickets.
... at least it isn't facebook. Oh, sorry """Meta"""
[0] https://hbr.org/2021/01/why-haven-healthcare-failed
There is huge scope in healthcare for automation, pre-emptive diagnosis and raising the bar for precision.
It is mostly going to be done by a company with good AI chops, I would put my money on Google, from what I have heard about their efforts.
The business logic is broken.
I am not sure what you mean by commercialised.
What it means is I was one step behind :)
As much as I don't like for profit companies monetising this, I am not sure if I know of a better path to innovation.
My cousin has EDS, diagnosing the illness is pretty trivial. It took her 15+ years and when she was diagnosed she was already in severe decline. She could have been diagnosed a decade ago but some doctors just have no interest in googling symptoms and listening to patients.
We have so many smart devices that can record so much data, and it doesn't even have to be auto recording. If you had a headache, if you can mark that and over time based on a pattern it can recommend you to see a specialist or get some tests done.
That just means that for a given region there's only one buyer to deal with.
Link is here if you want
https://www.nhs.uk/using-the-nhs/about-the-nhs/sharing-your-...
A few points:
I'm not against data mining at all, just handing it out to agencies without my say so. I'd be happy for it to be used for this purpose entirely within the NHS but that's not what was assured.
I don't like the approach that you have to opt out, not opt in.
I others may have different tradeoffs, that's fine. This is my view and urge people not to follow what I've done but to decide for themselves. It's your data, if you're in the UK, you can make a choice (not making a choice IS making a choice: for it to be shared).
Edit: and please don't respond with "just you wait..." or "it's going to happen anyway" defeatist juvenile posts.