
I'm a Brit and America, your health care system is torturing me - Osiris
https://www.cnn.com/2019/01/04/opinions/american-health-care-system-torturing-me-crilly/index.html
======
rayiner
I favor nationalized health insurance, but I worry American idealism would
screw up implementation. The British are aggressive about rationing care. They
aim to pay around 20-30,000 pounds per quality adjusted life year:
[https://www.bbc.com/news/health-28983924](https://www.bbc.com/news/health-28983924)

There was an article on HN the other day that talked about how much debt a
woman had incurred for her husband’s cancer treatment after she hit her
insurer’s lifetime limit. But it turns out that in the UK, the expensive of
that course of treatment compared to prospects would have been far above what
NHS would have been willing to pay.

If you have socialized care, you need to ration it, ideally focusing on
maximizing QALYs for younger individuals with years of productive life left. I
fear our political system in the US wouldn’t let us do that.

EDIT: Here is the article: [https://www.npr.org/sections/health-
shots/2017/08/10/5425892...](https://www.npr.org/sections/health-
shots/2017/08/10/542589232/widowed-early-a-cancer-doctor-writes-about-the-
harm-of-medical-debt). The insurance policy's lifetime limit was $500,000, or
about 400,000 pounds. Even if we assume British healthcare costs half as much,
under NHS's policies, the expected benefit of treatment would have to be 6
QALYs for NHS to have paid even as much as the U.S. insurance company paid.
But it was a rare, aggressive cancer and the lady's husband died in less than
two.

~~~
tptacek
Another problem is that for a variety of reasons, some of them structural,
Americans consume significantly more medical services (diagnostics,
procedures, visits) than Europeans do, without improved outcomes. There are
fundamental inefficiencies in our system --- for instance, incentives have led
to the creation of lots of small hospitals that see poor utilization --- that
lead to this, and will be baked into any single-payer system we devise.

This concerns me enough that I oppose nationalized health insurance. I think
the _status quo ante_ of the ACA was intolerable, and that the system needs
dramatic improvements (high on my list would be price transparency
regulations), but that the core problem we have in the US is not that health
care isn't universal, but that we pay too much for it, and baking that quietly
into our taxes is an alarming proposition.

~~~
bb88
> (high on my list would be price transparency regulations)

Why didn't the republicans do that over the past two years in the US? It seems
like it would be great for the free market, and also encourage competition. Or
do they believe in large company profit "protectionism"?

~~~
tptacek
I don't know, except to say that national health policy has become a political
football. I don't think there's an ideological reason for the decisions
Congress has made; the system we have now was the Republican's proposed system
in the 1990s (and was even a policy plank the the 1996 Republican Platform).

~~~
pcwalton
It's very easy to explain Republican opposition to the ACA. The 2016 election
has made it clear that the GOP is motivated not by outcomes, not even by
ideology (the current GOP, driven as it is by one person, has no coherent
ideology), but by tribalism. Obama was and still is considered an enemy who
cannot be allowed to score a victory at any cost, and so Republicans had to
oppose the ACA.

I know that this take is likely to be viewed as extremely uncharitable to
Republicans, but there really is no other logical way I can see to explain the
party's anti-ACA plank.

(I think it's actually quite counterproductive to the conservative movement,
because by abandoning ideology in favor of naked partisanship the GOP has
guaranteed that Democrats will never give them a seat at the table when health
care reform comes up again while Dems are in power. As a liberal, I couldn't
care less, of course, but I can't help but note the irony...)

~~~
tptacek
That's an argument I'm familiar with and sympathetic to, but not something I'd
necessarily argue in mixed company, which is what I think of HN as. I don't
understand the current coherent argument the GOP has regarding health care but
I'm open to there being an ostensible argument and would only ask that
Republicans recognize that whatever the new argument is, it's distinct from
the original argument, which is that we should have a system that looks
basically exactly like the ACA.

~~~
bb88
This is what I don't understand either. I understand the desire to cut
medicaid to reduce taxes and the size of government argument. But weren't
there free market incentives they could have done as well?

Here's one: tax cuts to insurance companies based upon the number of people
they insure over time, to help offset the cost of insuring sick people.

This seems like a no-brainer republican solution, which probably would have
gotten a fair number of democrats on board.

------
growlist
Meanwhile, here in the UK the NHS - weaponised by the left and virtually above
criticism/reform as a consequence - tortures people by making them wait
months/years for treatment due to rationing of care, this rationing in no
small part being due to the fact that care is free at the point of delivery,
which leads some people to abuse the service. Even a token £10 charge for GP
visits, for example (subsidised for the genuinely incapable of paying) -
similar to the Netherlands - would likely deter many of the unnecessary
visits, and raise desperately needed revenue. I would gladly pay. But any/all
genuine reform is blocked by the left raising the spectre of privatisation. So
let's not pretend we have the all the answers here in the UK.

~~~
aequitas
Here in the Netherlands we are not charged for visiting the GP (thanks Theme
Hospital for learning me this term). Only for specialist treatments or
medicine after diagnose you pay either a deductible if it falls within base
insurance or 'normal' prices if you're not additionally insured.

This is so nobody is discouraged from visiting the doctor for help.

------
jjeaff
This is more of a sidenote, but after having way, way more experience in
healthcare system over the past few years, I thought I would share my
experience.

The Affordable Care act made some big changes in health insurance.
Unfortunately, making it "affordable" was not one of the things.

But, if you do have money, you have the option now to have absolutely great
health care.

For about $1300 a month, you can cover a family of 3 in california. That
amount is less if you qualify for subsidies. And that is not a budget option.
This is a premium silver PPO from a large provider. All your normal medical
needs are covered with copays. $40 for doctor visits. $80 for specialists and
$350 for an E.R. visit. Your max out of pocket is $7500 per person or $15k
total. So $30,600 a year is your absolute worst case maximum that you would
have to pay if everyone in the family had serious medical issues in one year.

Now, I agree, that's expensive. But we are on a plan like this and it is very
good coverage (and it's likely not much more than companies pay for their
employee plans). While sometimes navigating everything has been a beurocratic
nightmare, it has never denied us coverage and almost every doctor we have
come across is in network. It also pays about $600 a month (after $80 in
copays) for our regular, ongoing prescriptions.

It also covered the $600 a month eyedrop Rx I needed for about a year for dry
eyes.

The quality of care is top notch and we have never had to choose anything less
than the absolute best when it comes to treatment.

Anyway, my point is, American quality of care is some of the best in the
world. If not the best... If you have money.

~~~
zaarn
In 2017, the median income of households in the US was 61'000 $.

Meaning half the population has to pay half their income (maximum) into this
healthcare plan. And 61'000$ income isn't being dirt poor either. In some
economic models this is the lower middle class in terms of income.

For people who only graduate high school and no college, this is 80% of their
income. If they go to some college about 70% (14'000$ left of the income).
This group makes up about 30 to 40% of the US population.

In my own country, I would pay 350€ a month for a 60'000€ yearly income. The
equivalent of an ER visit copay for you and it covers all my medical needs for
a month.

~~~
jjeaff
With a multi-person household and $60k income, you would qualify for subsidies
to reduce the premiums and out of pocket costs.

------
tptacek
This is a weird article that starts out with a customer service problem and
ends up extrapolating an entire new health system out of it. The problem this
person has is that they signed up for an HMO instead of a PPO, which is what
most people in the US have. HMOs subject you to additional red tape in
exchange for lower premiums; PPOs allow you to walk in to a specialist (though
most Americans will see their GP first anyways).

Whether you get an HMO or a PPO, it is far easier to see a specialist in the
US than it is in the UK. In fact, most health care economists would argue that
it is in fact _too easy_ to get specialist care in the US, and we as a result
overconsume services without obtaining better outcomes.

------
ConfusedDog
"Rather like when the British rail system ground to a halt because of the
wrong type of snow, the American health care system apparently is beset by the
wrong type of patients: ill ones." That is so true. I'm not sure if the
betterment of health insurance industry would be the solution, or the health
insurance industry itself is actually the problem.

------
deogeo
Related:
[https://en.wikipedia.org/wiki/Health_system#International_co...](https://en.wikipedia.org/wiki/Health_system#International_comparisons)

~~~
taurath
Thats a good quick chart I can use to pull up when arguing for a single payer
system.

I think the biggest problem with single payer in the US is cultural, not even
political - people simply don't trust the national government to do anything
at an acceptable level (except when it comes to defense, the post office (74%
approval rating), and the CDC).

~~~
tptacek
How does this chart address the question of how we should fund our health care
system? The problem is how much we're paying, not whether we pay for it in
payroll taxes or out of pocket.

~~~
deogeo
The chart shows a strong correlation between government funded healthcare,
cost-efficiency, and effectiveness - that's how.

~~~
tptacek
Correlation isn't causation. Switzerland's health spending is in line with
that of Canada, France, and Germany, has roughly the same (better in some
cases) life expectancy outcome, and is an entirely private system.

Life expectancy is also a poor way to compare health care systems, because
major factors decreasing life expectancy have nothing to do with quality or
access to care --- for instance, one of the most significant hits we take to
life expectancy in the US is the prevalence of traffic fatalities.

~~~
deogeo
You asked how the chart 'addresses' the question, not how it unambiguously
proves single-payer will save US healthcare - if that's your standard, I'm
afraid I, nor anyone else, can meet it.

And it has life expectancy, infant mortality, and preventable deaths - I guess
they're all poor comparisons?

Finally, the Swiss system is private only by the standard that insurance
companies are privately owned. If you look at how they must operate, and how
patients pay for insurance, it's practically government run. From
[https://en.wikipedia.org/wiki/Healthcare_in_Switzerland](https://en.wikipedia.org/wiki/Healthcare_in_Switzerland)
: "private health insurance is compulsory", "covers a range of treatments
detailed in the Swiss Federal Law on Health Insurance", "not allowed to make a
profit off this basic insurance, but can on supplemental plans", "The insured
person pays the insurance premium for the basic plan up to 8% of their
personal income. If a premium is higher than this, the government gives the
insured person a cash subsidy to pay for any additional premium".

~~~
tptacek
The part of this comment that bears rebutting, I rebutted in your sibling
comment. :)

------
Simulacra
I think universal single payer healthcare would be wonderful, but the issue of
healthcare is politicized enough as it is. With a private company I can fight.
I might lose, I might have to go elsewhere, but I have a choice. With the
government I have no choice, and I have no recourse. When has that ever led to
better outcomes?

~~~
DanBC
For England: You can usually chose your doctors in the NHS. Here's the patient
facing info: [https://www.nhs.uk/using-the-nhs/nhs-
services/hospitals/nhs-...](https://www.nhs.uk/using-the-nhs/nhs-
services/hospitals/nhs-e-referral-service/)

Here's the bureaucratic document for commissioners of general practice
(primary care doctors) (sorry you need to ctrlF for "choice".) This document
also tells you where in law patient choice is detailed:
[https://www.england.nhs.uk/publication/primary-medical-
care-...](https://www.england.nhs.uk/publication/primary-medical-care-policy-
and-guidance-manual-pgm/)

> and I have no recourse.

If the treatment is negligent and causes harm you can sue. There are cultural
and legal differences, but suing the NHS is possible.

------
flossball
It is stupid to blame Obama or Trump even for the current state of Obamacare.

The parties involved right now are resulting in a much worse than medicare
solution as it is similar to the three wolves one sheep version of democracy
(which is the whole premise of libertarian concerns about democratic
socialism). It is an attempt to obfuscate the otherwise obvious corruption and
theft that is healthcare. Here the wolves are the AMA(doctors), insurers,
pharma, and the politicians claiming to want to solve healthcare. The AMA and
insurers have insane billing policies based on assuming inept doctors and
corrupt patients.

Most insurance today is just passing on the discounted (actual) price on to
the insured co-pay or deductible. They cover very little normal costs of
medicine nor do they provide any actual services for their premium.

The main reason we don't have universal medicaid/medicare is similar to why
the IRS doesn't do electronic filing themselves. Billions of dollars of
middleman and tens of thousands of otherwise worthless jobs are on the line.

We need a private/public system. It will initially look costly and it will
suck (differently) for doctors and hospitals. However, in five to ten years
the costs will stabilize and insurance and other services will be more honest
as they will have real competition.

Also, he should try to just fly back to the UK for non-emergency issues. Most
foreign friends I have just keep insurance in their home countries as it costs
usually 100-200 a year. A $1k flight back to see your family is cheaper than
any surgery in the US.

------
tomc1985
The HMO system is misery. PPOs are better but costly :/

~~~
virusduck
Are you in an area where Kaiser Permenente operates? It has been, on the
whole, a great healthcare provider. The level of integration of their centers
is great--I can walk downstairs for an MRI or Xray or lab test (no waiting for
one doctor's office to phone in authorization/orders). Electronic records are
fully and usefully integrated. Costs are relatively low, and there are several
options of locations in my area--small, neighborhood office; a larger,
integrated facility; and a 24-hour hostpital-like facility. They also have
partnerships with other hospitals in my area, so I can go to other hospitals
and be treated fully under KP insurance. There are so many advantages, I've
kept my KP plan over several employers (including a stint on the Healthcare
marketplace).

~~~
pkaye
I'm using the KP health system. Its pretty awesome. Everything in integrated.
I can use the website or phone app to check any of my test results. I can
message my doctor for a e-consult at no extra cost. They usually reply within
half day. I can book most appointments online. If I went to a specialist, I
can continue messaging them in the future. And since the doctor is gate
keeper, you just need them to approve a procedure and it will happen.

