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Comment by jaymzcampbell | Hacker News Reader

Fellow European (UK) here. From what I understand one argument often given, is that there's a mistrust of the government for anything like this and people prefer to "shop" for it themselves. By making their own choice (even if all that actually means is picking from 1 or 2 options given to them by their employer) - they feel empowered and in control of it. There is a general feeling of "if you want it, pay for it".

This StackExchange answer sums up it up succinctly: https://politics.stackexchange.com/a/16372. I find it immensely saddening; the same goes with the general population's attitude to education (in many countries) or providing housing.

For what it's worth I know a lot of people with private healthcare in the UK with the attitude that the NHS is complete trash (something I very much disagree with) - I fear this sort of mindset is spreading. "Pull the ladder up jack" as they say.

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Unfortunately the NHS is, in many ways, pretty bad. They're pretty good at dealing with pregnancies, cancers, and emergencies but try getting seen for a chronic pain and you'll follow this rough timeline:

- Try see your GP. Wait 2 weeks until your appointment.

- GP will give a cursory examination and recommend a dietary change, taking ibuprofen/paracetamol, and to come back if problem persists.

- Problem persists. Book in with your GP and wait another 2 weeks.

- GP will actually examine you this time. They may then refer you to the local hospital, and so you should await a letter.

- about 2 weeks later, the a will arrive saying that you should phone up to make an appointment.

- within 8 weeks you should get another letter telling you when your appointment is, which will be within 4 weeks.

At this point you have spent 20 weeks just to get seen by a specialist. And that's assuming everything goes ok. Admin may not update your details, so the letters go to an old (or wrong) address. They may just entirely forget to make an appointment for you. Probably if you try phone them they just won't pick up the phone.

There's a fetishisation of the NHS in this country that protects it from a lot of criticism. Some will say "well you should put up with that because it's free" or some similar rubbish, ignoring that it costs £2200 per person.

None of these issues are restricted to the NHS. Any large organisation will have such issues. But it's utterly frustrating stuff like this that makes me consider going private - I shouldn't have to spend hours on the phone figuring out why I haven't been assigned an appointment despite being referred 3 months ago.

In contrast, to America working for a good employer:

1. Schedule with GP. Say I am in pain. Get in within 2 days.

2. Get a referral to Physical Therapy. Asked if I have any preference where to go. My doctor knows my network and gave me a number of choices that were within network (a number of which were within walking range of where I lived).

3. Call PT office. Schedule an appointment. They apologize that their next opening is a week away. Gladly accept.

Physical Therapy is interesting in that it is semi-free market and rather competitive, so it tends to work a bit better than some other scenarios.

To be fair that's usually how it works in England too, with maybe a bit longer to wait for physiotherapy, and the addition of weight loss programmes.

> In contrast, to America working for a good employer:

> 1. Schedule with GP. Say I am in pain. Get in within 2 days.

> 2. Get a referral to Physical Therapy. Asked if I have any preference where to go. My doctor knows my network and gave me a number > of choices that were within network (a number of which were within walking range of where I lived).

> 3. Call PT office. Schedule an appointment. They apologize that their next opening is a week away. Gladly accept.

> Physical Therapy is interesting in that it is semi-free market and rather competitive, so it tends to work a bit better than some > other scenarios.

Speaking from recent experience, on Obamacare:

1. Live with pain for 6 months because you know you're not getting out of a specialist's office for less than $750.

2. Cave in when the pain becomes unbearable and see a specialist.

3. Make an appointment for PT with a provider who doesn't take insurance at all, because the transparent pricing means no surprises.

4. Pay out of pocket for PT appointments.

5. Spend the next 4 months getting bills for your one specialist visit. Half of these are coded wrong so insurance won't pay. Spend 2h every week on the phone trying to get it sorted out.

If you talk to whoever does the specialist's billing at any point, you'll find that they're totally unable to estimate the cost of services. You might as well not even try to figure out how much it costs in advance.

Just to add another perspective also working in America for a good employer:

1. Schedule with GP, get appointment very quickly.

2. GP has no idea who is "in network" for you and doesn't seem to care very much. They also don't understand the different insurance plans so have no idea if you're covered for certain types of referral.

3. Schedule appointment with a specialist. Ask for up front cost estimate for consultation/procedure given your insurance plan. Unable to answer.

4. Go to appointment anyway as you don't have many other choices.

5. Receive astronomical bill for some obscure billing code that is not covered by your health plan.

6. Spend time calling doctors office and insurer to figure out the situation and try to avoid or reduce bill.

I've experienced the NHS too - for all its flaws, the peace of mind living in the UK from a health standpoint is worth every penny of the associated taxes IMO.

I've never had a GP that doesn't care about their patient's in-network costs. Get a new one.

That is in only the very best US health care.

Chronic pain is an extremely tricky phenomena. A lot of US health care been "dealing" with it by handing out opioids and we can see the devastating effect of that. Even a given physical therapist may not be able to help a given patient (assuming some body of some sort could at all).

Similarly, a smart consumer may be able to find a massage therapist with skills in a bodywork subdiscipline that happens to really help them (I favor trigger point and Shiatsu massage after sample a bunch in my area). This is cost effective compared to just about everything and something I imagine someone in UK could find in the larger cities.

Two days to schedule with a GP? That's insane... In Australia (with our universal healthcare) it's pretty much always same-day for a GP... X-rays and blood tests are generally same day and free, I've even had an MRI scheduled for next-day (just a knee thing, not an emergency) and again no out of pocket cost.

Another Australian report - I don't go to the doctor often, but can usually get a GP appointment the same day (they're often running late and waiting is boring, but that's the worst of it). When I recently needed a blood test, I showed up without an appointment and was finished and out of there within 10-15 minutes.

GP is same day for anything important, and if I am willing to see any GP I can go to a walk in clinic (urgent care). My GP is rather popular a it can take a day or two to get in and see her. The 20+ minute appointments are super nice though.

Tests are all same day.

This is very true, but, what saddens me the most is that rather than attempt to fix it (for all of society), the failings are used as an excuse to push further privatisation.

It feels to me that we in the West are going ever faster backwards over fairness in issues like education, health and housing. I'm lucky to be well off & healthy enough to not (yet) be affected by a poor performing NHS but I wish we, as a country, would pull together on this - from top to bottom. Unfortunately, I just don't see it happening anytime soon, we seem to be increasingly more divided - religiously, economically, politically - than ever before.

Society feels increasingly like a "Mad Max" movie in operation. This is only going to end badly for everyone. There is way too much "me me me" from all levels. I find it emotionally exhausting to think about.

I don't begrudge anyone who has the means to get private health care from doing so (my girlfriend and many friends do) - so please don't think I am saying nobody should - I just wish there was a more proactive and pragmatic desire to fix the root issues. Of course, I realise I am living in cloud cuckoo land on that.

I should add that I can certainly empathise and can agree with your comment about chronic pain. My father is suffering from sciatica and it has been over a year to get an operation scheduled. This will involve him travelling from Northern Ireland to the Midlands because there is an even longer (multi year) wait to be seen in NI.

> They're pretty good at dealing with pregnancies, cancers, and emergencies

I agree with everything you say, except the part about cancer.

Even by European standards, the NHS is actually quite terrible at dealing with cancers - even "routine" cancers (like breast cancer and prostate cancer), let alone rare cancers. The five-year survival rate for prostate cancer in the UK is 55%, whereas in the US it's upwards of 90%. (Prostate cancer is an incredibly treatable form of cancer; for most people, as long as it's detected early and managed appropriately, they will die with prostate cancer as opposed to from it).

Of developed countries, only Japan, Portugal, and Denmark have worse five-year survival rates for prostate cancer.

I'm unfamiliar with how the US stats get collected - is that 90% of "everyone who had prostate cancer" survives 5+ years; or is that "everyone who had prostate cancer and private medical insurance"? If so then that is rather shocking.

Prostate cancer may be something of an outlier given the hesitation people have in discussing it. This is something that has only really recently been attempted to be addressed in the UK. Campaigns fronted by comics like Bill Bailey have tried to make it normal to talk about. The British as a society are still so reserved that I imagine thousands die of preventable cancers and diseases simply out of embarrassment.

Edit - I've just had a look at Cancer Research's figures[1], [2] and, using data from 2010/11 - prostate cancer had a UK survival rate of ~84% or so - i.e. nearly the same as the US.

[1] http://www.cancerresearchuk.org/health-professional/cancer-s...

[2] http://www.cancerresearchuk.org/health-professional/cancer-s...

> I'm unfamiliar with how the US stats get collected - is that 90% of "everyone who had prostate cancer" survives 5+ years; or is that "everyone who had prostate cancer and private medical insurance"? If so then that is rather shocking.

It's looking at people with prostate cancer, regardless of insurance status.

> Prostate cancer may be something of an outlier given the hesitation people have in discussing it.

It's not limited to prostate cancer; for survival rates, the NHS does pretty terribly on almost every form of cancer compared to the US. I picked prostate cancer because it's something that's very treatable - the upper limit is close to 100% for five-year survival, which makes the UK's outcomes that much more unacceptable. But the story is the same for all other common cancers (let alone rare cancers, which the NHS is not optimized as a system to treat).

It's survival rate from point of diagnosis. Obviously, insurance and access will affect whether and when diagnosis occurs, but the effects aren't as simple as just limiting the scope to the insured or not.

And yet the UK life expectancy is 81.2 vs 79.3 in the US. For men in the two nations, the gap is even bigger - 79.4 vs 76.9.

https://en.wikipedia.org/wiki/List_of_countries_by_life_expe...

> And yet the UK life expectancy is 81.2 vs 79.3 in the US.

I don't understand the point you're trying to make. [Treatable] cancer isn't the leading cause of death in any country[0], so no matter how good (or bad) a country is at treating cancer, you wouldn't expect that to be visible in the overall life expectancy rates.

[0] Ordinally, cancer is #2, but that includes untreatable cancers, and the tail is very long, so getting better at improving five-year survival rates for cancers won't budge your life expectancy at all, outside of the margin-of-error.

> The five-year survival rate for prostate cancer in the UK is 55%, whereas in the US it's upwards of 90%.

Such survival rates are from date of diagnosis; IIRC, because prostate cancer detected early usually doesn't have interventions that are less harmful than the cancer is likely to be, there's considerable debate about the utility of screening; there has been considerable argument that the US tends to overscreen and over-intervene for prostate cancer.

If the UK doesn't do that and tends to screen in a way that tends to catch less of the less-imminently-dangerous prostate cancers, it would have a lower 5-year survival rate simply by not diagnosing prostate cancer where the diagnosis isn't usefully actionable; this doesn't mean they are actually worse at dealing with it.

> Prostate cancer is an incredibly treatable form of cancer; for most people, as long as it's detected early and managed appropriately, they will die with prostate cancer as opposed to from it

Prostate cancer is very often an extremely non-aggressive cancer with interventions that can have significant negative impacts, which is why, even when it's diagnosed “watchful waiting” or “active surveillance” are often the preferred management approaches; quite a lot of people will die with, rather than from, prostate cancer with no active intervention.

Population-wide 5-year survival rates from diagnosis are probably not a good metric for comparing countries with different screening practices; mortality rates are a better comparison metric, but also don't tell the whole story.

Last sentence in your post: would I be right in assuming that the incidence (e.g. cases per 100000 men) of prostrate cancer should be lower in UK than USA because more men in UK die with un-diagnosed prostrate cancer?

> Such survival rates are from date of diagnosis; IIRC, because prostate cancer detected early usually doesn't have interventions that are less harmful than the cancer is likely to be, there's considerable debate about the utility of screening; there has been considerable argument that the US tends to overscreen and over-intervene for prostate cancer.

Over-intervention and over-screening are two different problems, particularly for prostate cancer, where screening is low-cost and low-risk. In the US, most cases of prostate cancer do not require invasive intervention if detected early, but they will begin treatment, as well as more regular monitoring of the cancer. When screening costs are low, overscreening is not particularly problematic as long as it doesn't result in overtreatment (which is demonstrably true for prostate cancer in the US)

Again, this is not limited to prostate cancer. The difference is the most stark there because the screening costs and risks are both low, but the UK still does a much worse job at treating breast cancer, colorectal cancer, lymphoma and leukemia, which are the other deadly common cancers.

For all cancers, not just prostate cancer, the US over-screens a small amount, but the UK underscreens by a massive amount, resulting in many people detecting cancer when the window of optimal treatment has long passed. That's the reason that the UK is close to last place among developed countries for five-year cancer survival across all common forms of cancer, not just prostate cancer.

> Over-intervention and over-screening are two different problems, particularly for prostate cancer, where screening is low-cost and low-risk

They are distinct but not unrelated, particularly in a system where treatment decisions are highly patient driven, especially for patients with financial means.

But my point is less about over screening than that differences in screening practices naturally produce difference in five-year survival statistics even in cases when they have no meaningful outcone in terms of disease progression, mortality, and quality of life, because more screening will detect more cases of disease earlier, even cases for which intervention would never be clinically indicated. If you do a lot better job at diagnosing cases for which there would never be intervention, you get a better 5-yesr survival rate but haven't done any better at dealing with the disease.

Note that I'm not arguing about whether the UK does deal with prostate cancer well, in fact what I've seen using mortality rates suggest they are a bit worse than the US, though much less bad then you'd think from 5-year survival rates. I'm just staying there 5-year survival rates aren't great metrics for systems that are different in conditions that lead to diagnosis.

> I'm just staying there 5-year survival rates aren't great metrics for systems that are different in conditions that lead to diagnosis

I agree. That's why looking at all common cancers as well is important. Leukemia and lung cancer are the opposite end of the spectrum - early intervention is critical for leukemia and most lung cancers. And the UK does a much worse job at treating those than almost all other developed countries, and particularly the US.

So yes, some portion of the difference can be attributed to differences in screening practices, but screening practices are a relevant aspect of the entire system, and screening practices alone can't explain the UK's abysmal record for treating the more aggressive cancers which they do detect.

2/3 of prostate cancer occurs in men over 65. That's the results of being on Medicare, the largest single payer health care system in the world.

> 2/3 of prostate cancer occurs in men over 65. That's the results of being on Medicare, the largest single payer health care system in the world.

First: no, the England branch of the NHS is still larger than Original Medicare (~53 million in England compared to 46 million on Original Medicare).

And that might be a reasonable way to interpret the data, except that two-fifths of Medicare patients (and growing) are not on Original Medicare - they use Medicare Advantage, which is privately run. Coincidentally, Medicare Advantage outperforms Original Medicare on medical outcomes across the board, including cancer treatment.

So no, the fact that the US is drastically better at keeping prostate cancer patients alive cannot be explained by the claim that Original Medicare is so phenomenally better that it accounts for the difference.

Do you have a better source for this data than, well, a bunch of numbers you posted to HN? In particular, an explanation by a researcher or other expert who has actually studied the difference and can explain it?

It's very easy to draw conclusions from statistics. It's much harder to draw correct conclusions from them.

> ignoring that it costs £2200 per person

So... less than 1/3rd of what the US pays on a per capita basis? I'd be cool with that...

It is interesting that people go straight to single payer in their mental model when they think of changing the healthcare system. Germany has a multi payer system (although the government does provide a large % of the total funds) that seems to work for them. Why do so many in the US look to single payer systems as the ideal model?

Because all the other English speaking countries have single payer. They dont know what happens in Germany/Holland/Singapore etc.

Wow, in New Zealand on a similar public system it's quite different. Having had chronic pain myself I've been through this.

- Book a GP appointment. Generally get in the same day (costs $20-$80 depending on your GP. I have private insurance that pays up to $38) - GP orders blood tests, these are free. Clinic is on-demand, just show up. Wait times are around 30 minutes. Also prescribes ibuprofen ($5 for 100 tablets) and paracetamol (non-subsidised. $10 for 100 tablets). - GP will assess you and refer to a public or private specialist depending on your preference. In my case a public rheumatologist would have taken around a month to see, so I chose private. This cost $180 for the consultation and $120 for follow-up (insurance paid 80%). - Specialist refers more tests. For me this was an MRI. Public wait times were around 3 months because the machine needed replacement and they'd only pay for serious cases to go to the private clinic. I went private, this cost $1400 (insurance paid 80%). - Specialist orders more blood tests, still free.

And they still didn't find anything conclusive.

Personally I'd like GP visits to be free. They can be for people under a certain income level with the right GP. The public system also needs more funding, but in NZ we spend less per capita on socialised healthcare than the US, and the US has to add private insurance on top of that.

Unfortunately the NHS doesn't have the resources it needs right now. Blame the government right now who would rather sell it off to their mates.

Not that I think the our system (US resident) is all that great but our government runs two of the worst systems that exist in the country, the Veterans Administration which nearly everyone hears about but also the Indian Health Service which sadly flies under the RADAR.

so it is a very hard sell to get more Federal involvement when we have constant stories of VA issues and more available just by searching. throw in rules that actively prevented insurers from making multi state offers and the system was bound to be a mess.

however one of the problems not discussed is that many receive their health insurance from their employers and while this has been going away slowly, this idea like income taxes, tends to remove the cost component from people's minds. you don't see the cost in whole or in large lump sums so its easy to not think about it.

the big hurdle will be convincing people there will be limits of what can be treated. the US infant mortality statistics are one area of exaggeration to the bad simply because to the extent money will be spent to save a newborn that many other system won't

> From what I understand one argument often given, is that there's a mistrust of the government for anything like this and people prefer to "shop" for it themselves

As a data point: the patient satisfaction scores for Original Medicare (government-run) are drastically lower than every single major provider of Medicare Advantage (privately-run).

As much as people dislike insurance companies, people in the US are even less happy with the government-run programs, compared to their private counterparts.

On the other hand, patient satisfaction correlates with increased rates of hospitalization, higher expenses, and increased mortality. You'd want to dig a little deeper than patient satisfaction before drawing any conclusions regarding medicare vs. medicare advantage, I would think.

> On the other hand, patient satisfaction correlates with increased rates of hospitalization, higher expenses, and increased mortality. You'd want to dig a little deeper than patient satisfaction before drawing any conclusions regarding medicare vs. medicare advantage, I would think.

I didn't in my previous comment, because we were talking about the overall public perception, which may or may not be connected to the tangible metrics that we actually want a healthcare system to focus on.

As it turns out, though, Medicare Advantage also consistently outperforms Original Medicare on medical outcomes, and it comes in under-budget for identical coverage. Medicaid options vary much more (and they're different in every state, because Medicaid is administered at the state level), but the equivalent private plans for Medicaid coverage also typically perform much better than the public ones.

Hacker News readers aren't generally in the demographic for Medicare[0], but for anyone who is: there's really no reason to use Original Medicare. Every jurisdiction should have Medicare Advantage plans that cost you the same amount as Original Medicare does, and your experience (and overall care) will be vastly improved.

[0] people over the age of 65, or people of any age who are on dialysis for more than two years, etc.

> Medicaid options vary much more (and they're different in every state, because Medicaid is administered at the state level), but the equivalent private plans for Medicaid coverage also typically perform much better than the public ones.

I'd be interested to see these findings. Do you have links?

As far as Medicare Advantage is concerned, it's not the least bit surprising that patient satisfaction is higher. But I wouldn't go treating that as some kind of referendum on Government-run healthcare:

"Many private [Medicare] plans require no additional monthly premiums, yet the government pays an average of $849.90 in monthly subsidies to insurance companies for a person on Medicare Advantage, according to the Kaiser Family Foundation. That is about 14 percent more than the government spends on people with standard Medicare, according to the nonpartisan Medicare Payment Advisory Commission."

MA was supposed to demonstrate that private insurers could deliver care at lower costs than Medicare, and it hasn't done that. Basically, for every $1.00 the gov spends on a medicare patient, it pays $1.14 in subsidies for an MA patient, with the evidence indicating a lot of that goes straight into the pockets of insurers as profit [2]

[1] http://www.washingtonpost.com/wp-dyn/content/article/2009/10... [2] http://theincidentaleconomist.com/medicare-advantage-cuts-on...

> Many private [Medicare] plans require no additional monthly premiums, yet the government pays an average of $849.90 in monthly subsidies to insurance companies for a person on Medicare Advantage, according to the Kaiser Family Foundation

That might be a reasonable comparison if Medicare's claims rates were self-sustaining, but they're not. As I explained in another comment on this thread, private insurers subsidize Original Medicare with their own payouts in claims, and that comes out a few orders of magnitude larger than 14% per Original Medicare patient.

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