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Comment by tasty_freeze | Hacker News Reader

One entirely maddening thing is that the ACA was labeled as having "death panels" that would decide who lives and dies. That phrase was powerfully effective in making large group of Americans strongly oppose the ACA. Even if they knew nothing else about the ACA, they knew they didn't want death panels.

But as this article demonstrates, if we care to use the inflammatory "death panels" label, we already have them.

It makes me despondent that we can ever get to a place where our politicians can make rational, informed decisions about complex issues requiring multiple trade-offs. Cheap political rhetoric is not only easy to sell, stoking fear and tribalism is a winning strategy to getting reelected. 30 years ago most voters didn't bother to read a paper and were simply uninformed; now most voters are actively misinformed.

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Canadian here. We also have decision makers that decide what gets covered or not.

It's stupid not to. We shouldn't plunder health care funds on $1m per year of life saved interventions when you can spend that on 100 interventions costing $10k per year of life saved.

It works pretty well (something like 15th longest life expectancy).

Of course, you're always free to pony up your own cash to pay for a treatment that isn't covered by your insurance, so the individual is always their own final death panel.

Logically, yes...

But an acquaintance with Canadian relatives told me he knows a middle aged single man that was denied a knee replacement he needed because of these trade-offs. Left with decades to live, partially disabled, because: "Old? No family? Well fuck that guy then."

Every time this discussion comes up people tell stories of "things they heard" but I hear very little first hand experience that validates them. I have had discussions in the past with my very right wing relatives about social healthcare and quality of life abroad (where I have lived and they have not) and they always had a pocket full of stories they heard from someone that undid anything I said in their minds. A more recent one was a supposed tale from a Danish immigrant to the USA who had told them how terrible the quality of life is in Copenhagen (a city while not perfect as none are, that is consistently rated as one of the highest qualities of life in the world) and how America is objectively better in every way which validated their world view. If people cannot even be realistic about the life on the ground...nothing ever changes.

New Zealander here, and I will speak about cases I have direct experience of (and project a little based on what I've read in media).

Firstly, our social healthcare is actually pretty good for emergency procedures.

But there is only so much money budgeted per year for healthcare, and everyone in need competes for that limited pool, so there is a variety of ways care can be delayed or denied.

"Elective" procedures like hip and knee replacements can have long delays (queues) and seemingly odd requirements. One friend was "too" young: they had to wait for years in severe pain because they "shouldn't" need their hip replaced yet. Another acquantance had a record of hurting their knee as a young child: so they were not covered by ACC for knee replacement even though it was a ridiculous excuse in circumstances. Once a procedure is approved, you get reasonable treatment, and it is free.

There is a certain amount of gaming of the system - if you can find a sympathetic specialist you can jump the queue a bit. However that is a zero sum game, and it benefits those with time, intelligence and contacts (and screws some minorities).

Pharmac has a yearly government budget, and they choose which treatments can be afforded. We do the same with roading - cost benefit analysis is done for all roadworks and the best get funded until the fixed budget is met (small country, so one main roading department).

It is interesting that our two biggest healthcare insurers (maybe covering 80% of private insurance) are non-profit co-operatives: all premiums are either paid out in care or pay administration overhead. I think overhead works out to be about 10%. Fantastic system: pay premiums and don't get sick is winning, getting payouts is often actually losing. It's like a socialist system for everyone that has some disposable income. Private healthcare premiums are extremely cheap compared to the US e.g. "the premium for a member aged 0-21 years on our most popular plan, Wellbeing Two, is just $9 a week", and "Pay for 2 kids, the rest are free*"; you can see what is covered by that plan here: https://www.southerncross.co.nz/Portals/0/Society/EFulfillme...

So the fact you haven't heard any anecdotes means other people's experiences are invalid?

I sympathize, that's exactly what I used to assume. That there are outliers and horror stories for every system and in isolation the stories are inconclusive. Then I met this guy, in person, whose actual Canadian relatives went through this shit. Then it became real. Obviously my internet comment is not the same experience for you, being one step removed and coming from an Internet Random. And yet, having had the experience relatively recently I decided to share.

I apologize if it seemed like a personal jab. I am admittedly sensitive to the issue given my experiences on both sides of the proverbial exam table in the American system. Every time I try and discuss the issue with people in my area they lead with a tale about how terrible it is elsewhere and it put up a wall preventing any discussion. Rather than talking about what can work they shut it down right off the same as they do with anything they don't want to deal with...going right to the failures or abuses.

It is disheartening to see anyone in any system suffer. I am quite sure if I was someone suffering in your example's case it would be hard not to be angry at the system. When it's you hurting you don't care so much if a system if overall better, better for others, or was even better for you 99/100 times thus far, prevents a bigger problem later etc...you just want to stop hurting.

> We shouldn't plunder health care funds on $1m per year of life saved interventions

And we especially shouldn't spend huge amounts of money on meds that don't extend life (or even shorten it), and that worsen quality of life.

> Of course, you're always free to pony up your own cash to pay for a treatment that isn't covered by your insurance

With the big caveat that you cannot pay for "higher quality" of any services that are covered even if you want to.

of course you can, there’s this thing called plane and you jump on in and go to wherever the treatment you want is performed, pay up and get it. There’s absolutely no laws preventing you from getting payed care in the USA or anywhere.

90% of the population lives within 100km of the US border.

Unless it's a life-or-death emergency (where the ED has guidelines to see you right away anyway), every Canadian has the option of paying for any level of service they want, even otherwise covered services.

Then there are the firms that walk the line and charge you as "preventative health" services.

Not every Canadian is admissible to the USA, and as a sovereign nation our policy should stand on its own.

Most are, and for those that aren’t, most other Western countries can't check Canadian police records and readily admit Canadian citizens.

And of course that assumes one can afford the treatment, which for non-covered treatments can be hundreds of thousands of dollars.

Is there strict rules for those death decisions or just some people acting as they want? In the second case level of corruption must be overwhelming.

> you're always free to pony up your own cash to pay for a treatment that isn't covered by your insurance

Is that actually true? AFAIK (from second hand) there is no private insurance in Canada (i.e. far worse than e.g. UK), so you cannot get e.g. MRI by paying for it (and skipping the "official" waiting line of 1+ year).

There's nothing stopping a US insurer from selling an "International" plan to Canadians.

As far as I know, none have tried. Either the demand isn't there, or there's a huge untapped opportunity (doubtful).

There are a few organizations that will arrange for your healthcare in the USA, but the Canadian demand wanting to pay to bypass the Canadian system isn't great. E.g. Cleveland Clinic has a Canadian branch, but just one office in Toronto.

Every possible system will have some kind of rationing.

I'm okay with the notion that tough choices have to be made. Especially if the rules are clear ahead of time.

But that's not the system we now have. The default answer is "no" and patients have to fight to get to "yes".

The real kicker is even people within the system (eg nurses, techs) struggle to get proper insurance and healthcare. If insiders are getting screwed, what chance do the rest of us have?

(FWIW, I've been denied various life saving treatments, scripts, etc. multiple times. I'm fortunate to have had multiple angels in my life who've gone to bat for me. eg FHCRC fredhutch.org)

Seriously. People who aren't aware of the current death panel situation and claim that the aca or future single payer healthcare will bring them are incredibly naive, uninformed, and stupid. They sure as hell haven't lost a relative to our current death panels. But of course, what do they care? Until it's happening to them, they will continue to believe whatever idiotic political bullshit their party or tribe subscribes to and eschew any logic or reason whatsoever. These people comprise most of our electorate, sadly.

"But as this article demonstrates, if we care to use the inflammatory "death panels" label, we already have them."

It's not inflammatory when it's true. When the government runs our healthcare, choices are removed and someone else gets to decide if you should get surgery needed or not...and many times this is life or death.

At least now, if a cancer patient gets denied drugs, they can go to another doctor or get a second opinion.

All of my elderly relatives live in Canada and come over the border for any major surgery. This is mostly because the wait times are sometimes in the years..when they can just get private care in the US and get it done in a matter of weeks.

Doctors are also usually maxed out when it comes to patients, so individual care is lacking and they usually just want to try to push you out the door.

I also feel like I should have a say in someone's behavior, if I'm paying for their healthcare with my tax dollars: smoking, drinking, risky behavior, etc.

I've lived in countries with universal healthcare and the quality is sub-par compared to the US/private care. Sure private care can be improved, but it shouldn't be ripped out and replaced.

>I've lived in countries with universal healthcare and >the quality is sub-par compared to the US/private care.

My experience has been the exact opposite. America's healthcare business ruined my life. As a result I have no insurance and have lost the "privilege" to BUY said American healthcare. I struggle with low income options and programs, all insufficient. The only good care I ever got was in Europe. My experiences with social hospitals and doctors was much better than in the USA where it counts. Places weren't often as fancy looking, but the care was superb. Even the private systems in those countries was far more affordable. a few hundred for an MRI etc rather than a few thousand.

Healthcare and education in America can bankrupt you. That isn't something people in countries with social options have to fear...despite any drawbacks since no place is perfect. I don't know if Americans who are so opposed to doing things like the rest of the first world just need to believe it's always better here so they ignore the benefits...or if they just haven't had to face this issue personally and are incapable of caring until they do. But I do know I had a future and now I do not...and there is no net to catch me or care. Whenever I see comments like yours I just get so upset realizing how it's an unwinnable battle in this country because of these ingrained beliefs.

To add to your anecdote: I have a bill laying around where the asking price for the mri was $21000.

Yeah I was quoted 3500usd cash price recently and that was with the "generous" cash pay/uninsured discount of 10% and a lower income community hospital. Needless to say I did not get the scan. That's how it goes here. I only paid about 150usd in a Central European nation for a more advanced 3d version, and that was in the PRIVATE for-profit system there. American healthcare is a tragedy that I don't see changing sadly since so many people fight any positive change.

Education can only bankrupt you if you choose to go to an expensive university. This is a complete choice and the overall price is known before you take out a loan. Community colleges are a fraction of the price.

"My experiences with social hospitals and doctors was much better than in the USA where it counts. Places weren't often as fancy looking, but the care was superb. Even the private systems in those countries was far more affordable. a few hundred for an MRI etc rather than a few thousand."

I pay for my own insurance in the US. I only pay a couple of hundred/month and most things are covered. My deductibles are very affordable.

There are plenty of option for low-income individuals and pre-existing conditions are no longer something that will prevent you from getting healthcare.

Even if you get a $100,000 bill, you can call the hospital up and negotiate it down to something you can actually pay.

"Whenever I see comments like yours I just get so upset realizing how it's an unwinnable battle in this country because of these ingrained beliefs."

I feel the same way about your comments. You have this ingrained believe that socialized healthcare is the best solution, when private care clearly has advantages.

The majority of people in the US are happy with their healthcare. There should be some additions, so people that can't afford care can get it, but without uprooting the entire system.

Your anecdotes aside, the vast majority of Canadians approve of their healthcare system, something you can’t say about the US.

Which the ACA has made decidedly worse for nearly everyone. The costs have gone though the roof and since at least 2014 or so, I can only get high deductible plans though my employers.

Any system that increase the amount of healthcare being provided without a corresponding increase in supply of healthcare providers would have done the same.

Life was greatly improved for those who didn’t have employer sponsored insurance and pre-existing conditions. And women of child bearing age. Now that they can actually get healthcare, someone has to pay for it, which is everyone.

You can hate insurance prices, and you can hate the ACA, and you can even hate Obama if you so desire, but don't hate the ACA because of insurance cost increases because it SLOWED THEM DOWN.

You're confusing correlation and causation. Health insurance costs have been rising faster than inflation for decades, but the ACA actually slowed that growth through a variety of measures - one of the simplest being that insurance companies had to be paying for healthcare with at least a minimum percentage of what they charged in premiums - prior to that they could deny everything and put the savings into executive bonuses for performance.

Some reference points with links to source information, though you may have to look at news articles for 2018/2019 numbers. The Kiplinger article notes ~5% for 2019, still well below the 9.9% average between 83-92 or the 6.4% average between 93-2010. Post-ACA, prices between 2010-2017 ran ~4.3% average increases, so it has been creeping up since 2017 for some reason cough.

https://www.thebalance.com/causes-of-rising-healthcare-costs... this one has convenient table of annual increases over the past 59 years along with notes of what major event in that year impacted costs. Source is CMS data that's inconvenient to extract on a phone.

https://www.kff.org/other/state-indicator/avg-annual-growth-...

https://www.kiplinger.com/article/insurance/T027-C001-S003-c...

I've lived in countries with universal healthcare and the quality is sub-par compared to the US/private care.

I don't think anyone argues that a royal palace is not a good enough home, the complaint is that only a very very few can live in a royal palace and if that's the country's main form of housing, a lot of homeless people are unhappy with it. You can pay for private healthcare in the UK as well. Pay as much as you like and get as many specialists as you can afford. The NHS doesn't stop that from existing. The NHS is probably lower quality care than that. What the NHS is, is available to everyone. The NHS was built in the 1940s /after/ it was already possible for wealthy people to pay to visit doctors of their own choice. Somehow that didn't translate into healthcare for everyone back in the day, and I'm not aware of any good argument for why it magically will now if we turn the NHS private.(?)

Your elderly relatives in Canada can afford to travel internationally and pay private prices for health care .. so national health care should be dismantled? What about the millions of Canadians who can't afford that, and a long waiting list is better than nothing?

> All of my elderly relatives live in Canada and come over the border for any major surgery. This is mostly because the wait times are sometimes in the years..when they can just get private care in the US and get it done in a matter of weeks.

Unsure of how popular this is. If it were, we'd see a lot more Us insurers offering plans to Canadians, but as far I know, they're non-existent.

Anywho, all this proves is that you can have a public system and a private system a 100km drive away if you have a problem with it.

I live in a country with public healthcare and getting a second opinion from another doctor is by no means unusual.

At best this is an uncommon opinion. I work with a dual citizen republican from Canada. He was almost swayed to your view until he actually used the us health system. We have good us Corp healthcare, & now he says it's similar to ca. He was wondering what would happen if he got hurt and lost coverage in the us.

I can tell him exactly what happens. You are priced out of the "privilege" of healthcare.

You try to make do. Manage as you can with your savings, work you can get and maintain, as the effects of the medical issue continue to limit every aspect of your life and get worse with age and time. The normal decline of age is amplified as a result and your options to earn are further restricted. Eventually there is no way to do it alone or without some outside help.

You are directed to apply for programs that are also "privileges" and not available to everyone as the process is adversarial and not a right. You face many levels and months to years of denials, appeals, and are often completely rejected.Even if you get approved you are mired in bureaucracy, reapprovals, judgement, and your access is extremely limited even in the best case.

Next people you talk to about this will begin to marginalize you and act as if you must have done something wrong because they just cannot believe it's like that. In order to maintain their just-world hypothesis and feelings of security they need to frame this as an individual failure or anomaly and not a systemic and cultural defect.

You then start to get depressed and lose hope because there is no way to regain your quality of life or even obtain a survivable one in many cases. If you are fortunate enough to have caring family you might find some support and have some livable life, even if restricted. If you do not then you end up with more needs and expenses but with the exact opposite situation in resources. Eventually you decide to take a walk off a bridge because there is no real way out.

This isn't even the worst case scenario but rather a fairly median process because needs go up with age and resources decline so without having the time to build a safety net over a lifetime, or a social one being present...you have no options. This is happening to thousands of people right now. I am one of them. I've never met anyone like this who chose it or wanted it. I've never met anyone like this who wants to "sit on their ass and take my tax money" as people in my region assert. Every one of them is someone who had a life, who would love nothing more than independence, but for whom it isn't on the menu and neither is enough assistance to have any quality of life.

That's a horrible thing to face and we need to do better in the us. My mom faced a similar situation. It's beyond stupid and horrible that almost every adult is one accident away from falling into this trip, yet we stubbornly persist in this as desirable.

> At least now, if a cancer patient gets denied drugs, they can go to another doctor or get a second opinion.

This is not true; if your insurance company will not cover a specific drug then going to another doctor will make no difference. And you can’t go to another insurance company outside of open enrolment - assuming your employer even offers plans from more than one insurer.

> At least now, if a cancer patient gets denied drugs, they can go to another doctor or get a second opinion.

You can do this in any country with government provided healthcare by either going private or travelling to a different country.

> I've lived in countries with universal healthcare and the quality is sub-par compared to the US/private care.

Sure. The US spends more than anyone else on healthcare, but has worse life expectancy. https://ourworldindata.org/the-link-between-life-expectancy-...

The rational, informed decision is that the government should run its own medical R&D. But no, we can't do that because muh freedums.

You mean like the National Institutes of Health?

Yes, but more. You guys spend eleventy billion dollars on fighter jets with questionable hovering capability, can't you spend like four billion on nobody having cancer ever again?

Well hell, if you know it's going to be $4B to eradicate cancer, it should be easy to put the plan together and get funding. You'll save everyone billions forever.

Why are you screwing around on Hacker News?

NCI alone has a budget of like $5-6B/yr.

I have a relative who works at the CDC and has had cancer multiple times. Before life and money got in the way, we used to talk regularly on the phone. She bitched a lot about how 99 studies out of 100 were variations on a theme because that's where the funding was. There was very little that was genuinely new and innovative.

I don't know how to solve that.

I've been getting myself well (different condition) for years when that's not supposed to be possible. I'm quite open about that on the internet. I get attacked for talking about it and called crazy. I'm told "Produce studies backing up your claims" when there are none. No one is latching on to my story and going "What if she's on to something? Maybe we can do a study that will open up new treatment modalities for patients!"

I don't think it's as simple to solve this as you think it is. I don't know what needs to happen to break the herd mentality where humans don't seem to want to give any credibility to anything not already proven, which actively interferes with being able to prove anything new.

My grandmother was denied drugs by government-run healthcare and died in severe pain.

That is awful and I'm so sorry to hear. :( It also doesn't invalidate my point, although it highlights that I should have said the government should run its own competent R&D

I believe what you just described is the NIH.

You are right, according to medical journal "The Lancet", 85% of (government-funded) research funding is “avoidably wasted across the entire biomedical research range (e.g., clinical, health services, and basic science)” Government-funded medical R&D (budget for the NIH: $34.4 billion for 2019) needs smarter spending.

What does that have to do with taxpayer funded R&D for medicine?

Presumably, taneq's point was that medicine owned by taxpayers can be sold at the cost to manufacture and distribute it at far lower costs, as opposed to the current system where the owners of the research also needed to be compensated.

Most (if not all) new medicines came out of basic research supported by the NIH. This research was tweaked and patented by companies who profit from selling the drugs. Is start-to-finish government drug pipeline a better solution? Perhaps, but current academic culture doesn't support it. It's not just about pouring more taxpayer money.

Examples of prodects created by government run medical R&D?

Tofacitinib is one that I am familiar with. I am sure there are many more.

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

Also, I think it's a valid question that doesn't deserve downvotes.

>Pfizer worked with O'Shea's [NIH funded] laboratory to define the structure and function of JAK3 and its receptors, and then handled the drug discovery, preclinical development, and clinical development of tofacitinib in-house.

This says the exact opposite...

NASA alone has plenty of good examples. Enriched baby food, CAT scans, heart replacement devices, better thermometers and imaging, and other minor advancements for specific procedures: better fiber optic devices for baby delivery, better lighting for brain cancer operations, improved cooling devices for certain symptoms. And again that's just specifically medical products that accidentally fell out of a space program.

A pop-sci list: https://www.med-technews.com/features/the-nhs-at-70-inventio...

1949: Intra-occular lens

1958: ultrasound for obstetrics

1962: total hip replacement

1978: test tube baby

1986: combined heart, liver, lung transplant

1991: robotic surgery

2000: gene therapy for children with no immune system

2013: bionic hand

There are lots more.

At best those examples are misleading.

The article ignores the R&D which often happened at private institutions and cherry pics the first use or minor refinement that occurred at a government facility.

True. However, there's a difference between death panel singular and death panels plural.

> It makes me despondent that we can ever get to a place where our politicians can make rational, informed decisions about complex issues requiring multiple trade-offs.

It is OK if our politicians can't do this; it just means that, as the information age marches forward, we don't need politicians (or at least, that we don't need the state making these sorts of decisions).

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