This is how you healthcare: American Death in London
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The one thing I noticed, and it was a rule that didn't have a single exception, was that everyone I talked to could give at least one example of a time when either they or somebody they personally knew had been faced with a ruinous bill for healthcare. People who'd been bankrupted, people who'd fled to another state or even left the country to get away from a hospital bill.
And yet even after seeing whole families' lives literally torn apart, first-hand, they still were against any healthcare reform.
I tried then, and I've tried in the years since, but I simply cannot understand where they're coming from. How anyone can support a healthcare system in this day & age that can, and does, bankrupt or refuse to treat people.. I just can't understand it.
A major issue with the american health care system is there is a severe shortage of front line care outside of the ER. This is a side effect of the way doctors are compensated. There is no financial incentive to be a GP, so there aren't enough GPs.
Yes there is. It's called a "primary care provider", and many of them have their offices right there in the hospital. Though the ones who operate out of separate clinics can often be less expensive, if not more conveniently located.
If you don't already have one, you really should. The emergency department really hates it when people clog up their waiting rooms by going there with non-emergency issues instead of seeing a PCP. And your health insurance (assuming you have it) really hates it when you drive up their costs by going to the ED instead of seeing a PCP. And, if there were any price transparency in the American system, then your fellow citizens would also really hate it when you force the health insurance company to drive up their costs by going to the ED instead of seeing a PCP.
If you do not have effective access to care until all they can do is give you a bunch of pain killers, they are effectively "refusing to treat people".
I have a friend (Canadian) who had an internship in the US. He got a major (and quite serious) bout of the flu, and although he was insured (by a Canadian company) absolutely refused to see him until he coughed up a hefty (multi-hundred) deposit - evidently they didn't find the Canadian firm trustworthy enough.
This is a pretty core issue in US healthcare - early-stage care is routinely denied to people, either economically before they walk through the door, or at the door itself. This pushes a lot of health issues to ERs where costs are high and effectiveness reduced.
What this means is that in the USA it's common for people to have to allow earlier-stage, less expensive to treat problems develop into serious problems before finally going into the ED to seek treatment. Which increases all of our health care costs overall. Not only does the problem that eventually gets treated end up being more expensive than it needed to be, but the place where the care is provided is also the most expensive option. And since they don't pay, health care providers are forced to raise everyone else's rates to cover the cost of this unnecessarily expensive care that they had to provide.
Long story short, the range of things that health care providers have to treat is much wider in countries with more socialized systems than it is in the USA. And that is yet another reason why the USA has such enormously high health care costs despite providing poorer quality of care.
Let's not play with words like that. People in the US get treatment—you even say so later, despite your ominous lead sentence. They just get it later, via the ED, after prevention goes un-performed. That's abominable enough, and that's what we should talk about, not the (false) specter of non-treatment.
You two aren't disagreeing.
You say we should talk about the epidemic of people unable to afford primary care, pushing treatment later and later, eventually into the ER where they may not even be able to be saved - and even if they do, suffer long-term health effects due to the delay in treatment.
And he's saying that this is because the system does refuse to treat people - especially at the primary care level.
These two topics seem to line up just fine.
My primary point was that while most things can be debated, it's absurd to claim that people don't get treated in the US.
This isn't actually accurate at all. Hospitals with emergency departments must stabilize patients in an emergency. Thats it. The emergency room has no responsibility to treat the underlying cause. It isn't a loophole that people take advantage of because you still don't get treatment. I suppose you could show up to multiple emergency rooms and hope one treats you but that isn't something you do if you are chronically hurt.
People who can't afford to get treatment or aren't on medicaid or charity care don't get treated period. You can test this by just comparing the emergency room rates in Massachusetts before and after coverage expansion. More people went to the emergency room once they had coverage than previously.
There's a hospital in the town where I grew up which managed to shave millions off of the cost of operating their emergency department in a rather instructive way: They identified their most expensive repeat patients, and started just paying to send them in for regular medical care for whatever health problems it was they had. Yeah it meant that they were giving out free health care to these folks, but that turned out to be nothing compared to the cost of having them show up in an ambulance every other week.
Implying the NHS refuses to treat people?
The thing that gets me is the attitude is that some people don't deserve free(-at-point-of-use) healthcare. For whatever reason; they haven't paid their taxes, or they've made mistakes in life. It seems unspeakably sad to me. Surely a civilised society should help everyone, regardless? It's the humane thing to do. It's as simple as that.
I agree that a civilized society should help everyone, but don't agree that the USA is a civilized society. There is definitely an attitude that poor people don't "deserve" stuff. That's been an American notion since the first settlers arrived and won't change anytime in the near future.
True, but what if it's something less serious? Some people would rather be ill than bankrupt. And then what if it gets worse, and then it's too late? People shouldn't have to make that choice, especially because most people--not being doctors--are going to make bad decisions about when something is serious enough to get checked out.
Long live the NHS, and yay for Obamacare - it seems like a step in the right direction at least.
That's not to say there aren't horrible things about Obamacare (i.e. terrible business model) but yes, it's a start.
Neither of those is to say that necessarily Obamacare is the wrong solution but its certainly not the only path.
Insurance is designed to protect the policy holder from an unlikely, catastrophic event they cannot afford otherwise - coverage of everyday costs is not insurance. Notice your insurance company doesn't pay to rotate your tires or change your oil.
Health care, no matter which country you go to, is more of the latter than the former. They aren't primarily insuring against unlikely catastrophic events - that's only a small part of their purpose - they are very obvious ways to spread costs around.
You can't treat health insurance like real insurance, even if they share a name.
They are extremely unpopular for many reasons, which center primarily around paying out of pocket for normal services:
For the purposes of this argument I'm going to use "health plan" to refer to what most people call "insurance" - to avoid confusing the two concepts.
- The out of pocket costs for a no-plan person is extremely inflated. Where your insurance company might pay $60 for a doctor's visit, the cost for someone not on a health plan may be $200-300. This makes the notion of paying out of pocket for routine services unrealistic for the majority of the population.
- These out of pocket costs are expensive because the status quo is for everyone to be on an employer-sponsored health plan. Those who can afford to pay, are on a health plan - the bulk of those who aren't on a plan are financially compromised and likely to default on their debts. This encourages a wild inflation of quoted cost to compensate.
- This further drives people to health plans. Barring the ultra-rich, no one is able to afford health care at "free market" prices, making health plans the only reasonable route forward.
In short, what's wrong with people paying out of pocket for basic services is that "basic services" at market rates will set you back $300 for sore throat.
For example, in some locales you can subscribe to a "direct primary care" practice for a family of four (2 adults, 2 kids) for around $150 per month, and visit your primary care provider as much as you need, paying only for supplies or possibly a token per-visit amount. This, combined with a legitimate "insurance" plan with a high deductible, might set a family back less than half as much as a traditional all-inclusive health plan. (This is what I had in Seattle, with Qliance as my direct primary care provider.)
My son recently needed a physical to start school. As a self-pay patient now located in Denver, I called around to independent clinics in my area and was able to get a fairly good price ($110 total out of pocket, paid up front.) My wife was recently able to be treated for an ear infection for around $80.
If you're actually paying out of pocket it can be a little bit of work, but there are ways to get your costs down to close to "free market" levels.
In a system where you can't sue your healthcare provider for egregious malpractice because they're a governmental body and are thus subject to the same citizen-sues-state rules as law enforcement or any other public service, I fear for the quality of our healthcare.
In one instance in the 1970s I had a great uncle who came into a local clinic complaining about crushing chest-pain, and was told to come back the following day because the attending physician was out for the day. He died on the street of a heart attack while walking home. Why he wasn't immediately rushed to a hospital is beyond me.
More recently, my grandmother, who died in 2004, was wait listed for over a year to get medical imaging and biopsy performed on what she (correctly) assumed was a tumor on her neck. By the time the scan was performed it was determined that she had metastasized lymphoma and the tumor was plainly visible to anyone who could fog a mirror. She died in hospice within a couple of months of being diagnosed.
So what are we to sue for there? Clearly both instances of complete and utter NHS incompetence (and sadly, complacency on the part of my UK relatives) but it's incompetence by omission and rationing, not a doctor embedding a scalpel into someone's tibia.
Had either of my relatives lived in the US, they would have had a much better fighting chance at living than they did at the hands of the NHS.
Second clearly sounds like a fuck up. Current "wait to first treatment" target is 2 weeks. What happened when you tried to sue?
I hope you'll forgive me if I sound callous in this post - I certainly don't mean to, but I also recognise that this is a touchy subject when talking about someone's own family.
In the case of your great-uncle the problem is likely that it was the 70s and fourty years ago there was nowhere near the same awareness of the symptoms of cardiac arrest amongst non-physicians. If the doctor wasn't there, chances are it wouldn't have been picked up on. Even had he been rushed to hospital, his chance of survival would have been pretty low - heart attacks are still a major killer in the 2010s where even in London, which has the highest survival rate in the UK for heart attacks that occur outside a hospital, the survival rate is only 30%. Keep in mind though that survival rates have increased significantly over the last fourty years with advances in diagnostics and treatment as well as improved defibrillators etc.
Your grandmother's case is a more clear cut case of failure. Waiting times have long been a problem in the NHS, but it's a matter of resource contention, and it's a problem which they're trying to improve with the guarantee that patients should start treatment within 18 weeks of their first appointment and that tests should be done within six weeks. The only, very rough, numbers I can find for the US suggests that scans and tests are normally done within seven to twenty weeks when cancer is suspected. Even in the US, the problem of resources exists - there's only so many hospitals that can perform certain types of scans, and only so many doctors who are capable of properly interpreting the results. The thing I can't comment on is whether or not the physician who saw your grandmother should have treated it as a higher priority or if, given the symptoms that were presented, it would be reasonable to assume that there was a benign cause and it being cancer was pretty remote possibility. If it's the case that his prognosis was obviously wrong given the symptoms, then there's a case to be made for malpractice, or at least a complaint to the GMC and/or NHS trust.
That's nonsense, hospitals and NHS Trusts are routinely sued for malpractice, along with the doctors involved. There's nothing special about any part of the NHS that makes it impossible for them to be sued - they're not part of the state, they're just state funded. Hell, you can sue most government bodies in the UK since there's no restrictions on suing the state, only against suing the Crown.
It makes your 'multiple relatives' claim seem somewhat suspect.
I have seen people ruined with medical bills.
There are many reasons why the system is dysfunctional, and I'm aware of nearly all of them.
Did you know that a round of cancer treatment in the US can cost over $500,000, and even if you are fully insured with a good policy you can have a 20% copay required, meaning that with insurance you still personally have to pay $100,000 or more? That sort of thing is what is bankrupting people and is why most medical bankruptcies involved people who were fully insured.
That's assuming your insurance policy wasn't subject to "recission", which is legal retroactive cancellation of the policy as soon as you have any condition like cancer that would cost a lot to treat.
We have a for-profit medical industry, and a for-profit insurance industry and both are motivated to increase profits, and reducing care is often a way to do it. Even non-profit hospitals will price gouge. Non-profit status does not mean that the executives working there aren't paid large salaries, it doesn't mean that things are delivered at cost, or with minimal mark up.
The "reform" is mandating people buy insurance from for-profit insurance companies, with no cost controls. Thus we end up with policies that can cost a family $20,000 a year in premiums, while still having large co-pays that can bankrupt you. The parts of the law that would have provided socialized care for the poor were gutted by the Supreme Court review, and by the executive office rule directives interpreting the law.
The answer to the problem is single-payer. The reform system is a further bailout for industry and is already driving up costs and reducing the number of insured.
Your posts presents those of us who support a reasonable working solution of single-payer as a position of hypocrisy, inconsistency, and/or ignorance, because we don't accept a non-working solution that retains and increases out of control costs and profits for industry.
Not supporting a specific, bad solution does not mean one does not see there is a serious problem and reform is necessary.
I would briefly point out that the $20,000 a year plans you refer to was an example number that the IRS used to illustrate how the law works and not a projection of the cost of healthcare plans in the exchange.
Single-payer seems from scan of Wikipedia to be "government pays the bills" - in other words an NHS like solution.
Which seems to me a position the others in the thread are advocating (ie our current system is barbaric, bankrupts people we must fix it)
So I am a little confused why your post seems to be defending itself from posts that as an outsider I would see as firmly in your camp?
Single-payer means that health care institutions remain private, government does not run or employ any doctors directly, and everything works much like it does today, except pricing is unified and the government pays all bills.
This is different from nationalized health care, especially on paper, where it can preserve market-style competitive pressure that a wholly nationalized system would not. Doctors and hospitals would still be on the hook for attracting customers.
Beyond all that, single-payer fixes prices for an industry that represents a huge chunk of the total economy.
No question at all that we badly need a new system of health insurance in the US (I'm hoping that Obamacare, carefully and aggressively executed, will be it), but single-payer health care is a radical change.
I find it curious and odd that you can't understand another philosophy on the role of government and the individual.
I guess I understand the philosophical argument, from a purely logical perspective, that an individual must stand or fall on their own. But I don't get how people can seriously hold that opinion without living in a cabin in the woods, or in a bubble.
Such matters - often literally of life and death - are not something that ever could be trumped by philosophies about 'roles'.
Yes the market works well in most other spheres, yes economic freedoms are important, but no, economic freedoms (or justice) do not trump human life and death, where avoidable (in a civilized society). Economic freedom is just one of the many things people need for happyness. Health and healthcare are another, that is at least as important. And thus the value of economic freedom needs to be balanced out against healthcare.
The government just is the mediator. Taxing one sphere of life (economic activity) to ensure justice and security in another that fares better if guided by other principles than profit extracted from individual patients.
(individual GPs do profit in the UK system. They, for example, get a bonus if they can make a patient stop smoking, etc. ...speaking of preventative healthcare. They just have less incentive to exploit individual patients (by having them come back later with lung cancer for example) and then charge them to their limit)
Give it 50 years and they'll never go back. The Tories in the UK were opposed to the NHS (AFAIK).
For the same reason that you don't go to jail just because your brother robs a bank? Hey it is nice when family helps out, but they shouldn't have the legal obligation.
Having gone thru something kind of similar yet different with my own older relatives, the hospital has a blindingly obvious financial motivation to "help" elderly / senile patients with the paperwork, and therefore there are people on staff walking the halls doing precisely that. Seen it with my own eyes, this is not theoretical. As long as the dollars you can haul in from properly filled out medicare forms exceed the cost of hiring a ombudsman or coordinator or advocate or whatever the job title was...
Two years later my wife's sister gave birth in a top notch Manhattan hospital and my wife was there for support. Man, the stories she tells about how every part of the procedure was initiated with waivers being signed and questions asked about insurance to her sister who was squirming in pain and was several hours into labour. And how the impatient doctors tried to upsell her sister to a C-section... After that her sister shared a tiny room for a night with some other woman and was then sent home. Luckily, most of the 40,000 dollar bill was covered by her insurance.
There's a difference.
Our European income taxes are not higher than NYC's combined taxes, though, and European healthcare is vastly cheaper than American healthcare.
I'm not going to defend the US healthcare system, which is a charming mixture of the worst aspects of monopoly markets and socialism.
Of course our taxes also went for other things like welfare, education, administration and defense, and as we all know many European governments have run deficits for years.
"This leaves the last theory: do we pay higher prices for the same care? Among prescription drug costs, we pay far more than any other country, at least 20% more than Canada and over 60% more than New Zealand. For the same MRI’s and CT scans, we also pay more: $1,080 is the commercial average cost for an MRI in the U.S. as compared to $599 in Germany; at CT of the head costs $510 on average in the U.S. versus $272 in Germany. For a hip replacement, we again pay the most: $1,634 among public payers and $3,996 among private payers, versus $1,046 and $1,943 respectively in Australia. And physicians’ incomes are the highest: $187,000 on average among primary care doctors in the U.S. versus $93,000 in Australia; and $442,000 among orthopedic surgeons in the U.S. versus $154,000 in France."
Here in the U.S. we pay roughly double FOR THE EXACT SAME PROCEDURES AND SERVICES.
And, probably not coincidentally, doctors make roughly twice as much here as other countries.
It seems we keep going round and round trying to attribute the differences between the U.S. and other systems to some philosophical differences, but the bottom line is we are simple being price gouged by an entire industry.
- While it's heart-warming, it is unrealistic to think that a public program can spend infinite amounts of money on citizens who a) have paid "little or no" taxes and b) "throat cancer suffers who quit smoking four years afterwards". The math just doesn't add up.
- The fact that the US has a pseudo market-based healthcare system is what allows drug / device companies to make money on innovations that ultimately save lives in other countries (like the UK) where these drugs / devices may not even break even. If you create a system in the US where it's impossible to make money in healthcare innovation, we'll see far fewer technological developments in healthcare, which will lead to worldwide increases in infant mortality / decreases in life expectancy.
That said, we should have a way in the US to provide basic healthcare for the uninsured. The answer is not, however, a single-payer system.
Confusing more or less a 2nd, 3rd or maybe 4th derivative of a value with the value itself.
"unrealistic to think that a public program can spend infinite amounts of money on citizens"
I read the article, and they cut him off virtually everything when recovery was deemed impossible. Tapering off the drugs, non-interference directive when he therefore codes... he was taking up a bed, not much else. Not quite the same as euthanasia (although not too far) but hardly an infinite amount of money, either.
"have paid "little or no" taxes"
In a civilized society, should the police, fire, military, educational, and environmental monitoring organizations cut off poor people as a primary goal, rather than as a scandal when they rarely do it anyway?
- The other modernized nations you speak of are all running deficits, with the exception of small countries with tremendous natural resource wealth (e.g. Scandinavia) and Germany (which has a tremendous manufacturing sector that I don't fully understand.) That said, the US also is running huge deficits, but a lot of that is due to a ridiculously disproportionate military budget.
- Again, the profitability that comes to drug and device companies from the US market largely subsidizes the cost of these goods in other countries. Cut off the profitability in the US, and the costs for drugs and devices go up in every other market.
I would love to see a way for the US to be able to provide full healthcare coverage to all its citizens, but as someone with a graduate degree in healthcare economics who has studied the problem in depth, I just don't see it.
That said, we shouldn't be turning away the uninsured that need basic healthcare. We have to figure out a way to provide that coverage in a more efficient way than the ER.
Not really. He was fine with other people paying for his hip replacements.
I'm not sure that culturally people are willing to accept the idea that we aren't going to do "everything we can" for someone because it isn't worth it to society (the payer). In the case described here, we might have implanted an electronic device to resynchronize the patient's heart and prevent the CHF from trashing the rest of his organs for a few more months (or years) at the cost of $200k.
Are we at a place where people in the U.S. will accept not doing that that?
I think that a single payer with a base level of free care is the right thing for society to do, but the possibility of making private insurance illegal (as it is in some places and some groups in the U.S. are advocating for) is terrifying to me.
The affordable care act basically ensures that we will arrive at a single payer system sooner or later, but how do we change our culture to be more accepting of our own mortality and the limitations placed on extreme measures to extend life?
Unless a central "system" is going to indemnify GPs, there won't be a flood of them entering the pool, since their rates will be fixed by central rate tables (maybe, if they are lucky, adjusted for regional cost-of-living) even if only indirectly by maximum benefits needed to maintain minimal legal coverage levels; if they are to remain privately run and thus administratively independent.
He was a charming, damaged, charismatic, fiercely intelligent, dissolute individual, who lived entirely on his own terms. As a professional gambler, it is unlikely he paid much if any tax in 37 years. He had no will, no funeral plan. He never did fill out the forms necessary to vote in the last election, or the one before that, as I discovered. He just hated forms. I could sympathise. Had he stayed in the US, it is – how you say – dollars to doughnuts he wouldn’t have got it together to fill out the forms, and would have had no health insurance. He considered the US system “absolutely unmanageable”.
However long this goes on for, they'll continue throwing resources at this individual and never show a single sheet of figures to any of his relatives. Not because they'll get anything back, but because this is what the NHS does. It’s free care for throat cancer sufferers who only gave up smoking four years afterwards, for drinkers who were told 35 years ago that if they didn’t quit drinking they’d die. Free care for American immigrants, for jerks and gents. Free care for parents whether they showed up or not. Free care for guys who tried to try. Free care for the only father I will ever have.
So here comes the TANSTAAFL argument: I don't think anyone argues that what the OP describes is a "bad thing"...in fact, I think it's probably the dream scenario that people optimistically assume is the case before they have their first encounter with an emergency room.
But the reason why it doesn't happen is because of cost, plain and simple. And to be concerned about cost is not just the domain of greedy insurers and fat cat cost cutters, but of reasonable people who understand that preventive care is less dramatic than end-of-life care, but is surely as deserving of resources and attention. And both types of care rely on the same limited pot of funding.
It's easy to be emotionally invested in the personal case of a man who is lucky enough to have a loved one so eloquent with words. But what about the hundreds, thousands of routine cases that are treated by NHS with a protocol governed by cost limitations, limitations that will inevitably be imposed by the decision to give blue-chip treatment to the untreatable?
These routine cases don't pull at the heart strings because it is the nature of the human mind not to realize/dwell on how an exam/procedure not scheduled two years ago is the main factor in the chronic disease one suffers today. And yet these people are just as deserving of optimal treatment as OP's Bill. The way that OP judges the value of healthcare, though, means that the Bill's will get a greater share of a finite set of resources. Is this really the way an optimal healthcare system should work?
This is not to say that the U.S. or any other system is currently better than the NHS. It's just to point out that fashion in which the OP (positively) judges the NHS is susceptible to being ignorant of the problems that occur earlier in the pipeline of health.
This is a tension that keeps effective health care reform from moving forward, but it's still a tension that should weigh as heavily in a debate as an emotional appeal.
The test involved a bunch of basics (weight, exercise, blood pressure, etc.) and two blood tests (for cholesterol and blood sugar level). They will repeat this every five years.
I do not think the NHS is the greatest possible system (in fact, I preferred the French system when I lived there), but by many measures it is good.
In 1993 Republicans did an interesting analysis. They found that Clinton's health care plan would work, and would be popular. If it passed, they believed that Republicans would be losing national elections for a generation. But they also figured out that if they derailed it, then they could turn fears about it into a potent election issue. They did, and it was. They tried the same thing with Obama's plan. Whether the other half of their prediction comes true is yet to be decided.
For the actual Republican analysis from 1993, see http://delong.typepad.com/egregious_moderation/2009/03/willi....
They found nothing of the sort. Did you even bother to read their analysis at your link? You can disagree with someone without misrepresenting their motives.
Its interesting in the post-1945 election in the UK very few voters strongly supported the NHS but once it passed it developed bipartisan support. The chances of a party taking every house of congress a supermajority in the senate and the presidency to have the ability to move legislation is incredibly small in our system as compared to a parliamentary one. I'm not suggesting that our system is always worse but in this instance it certainly is.
My father in law in the UK got a cataract done privately.
If you have the money, you can get what you want.
The UK also allows you go privately and pay yourself and choose your won doctor and hospital and treatment if you want and have the money.
For most of us, the money can be attained, as evident by the electronic devices littering our homes and offices.
Related, I've found that many young people don't want to know what their credit card or bank balance is, for fear of seeing how little money they have left (or saved).
Terrible way to live.
The most peculiar part of the whole situation is service cost and individual personal wealth is never an issue WRT national military "defense" or police coverage or fire department coverage or admission into a church or the (admittedly failed) K12 education system or EPA enforcement or OSHA enforcement or ... thus the real question is why cost should be a concern almost exclusively for sick care. My point being that you need to convince not merely that cost is an issue, but that cost should only be an issue for healthcare specifically.
I think we have happily gotten over the idea of needing insurance company plaques on your building in case of fire, and soldiers rarely defend only the rich parts of cities.
Thank you, very well put.
That is what I took away from this article.
Info about the venture:
http://techcrunch.com/2011/10/14/vescere-bracis-meis/
Founder reflects on the venture half a year after launch:
http://pandodaily.com/2012/05/07/nsfw-corp-hmtl5/
3000 subscribers at 99 cents per single issue or $26 per 52 issue year as of recently:
http://betabeat.com/2012/09/nsfw-corp-paul-carr-war-nerd-joh...
There's no tax on winnings while gambling in the UK anyway.
As someone who should be dead four times over, I find the American health care system quite functional, effective, and satisfactory. No worship thereof necessary.