There’s another factor about US healthcare. What’s the point of getting the world’s best treatment if it leaves you $300,000 in debt and so stressed that it ultimately reduces the quality and quantity of your life?

The 42m number from the US is one of those great headline-grabbers but does have three well-known issues: (1) as pointed out, that it includes a group of mainly younger people who choose against medical insurance, to take the risk; (2) a small number of rich people who effectively self-insure because they have the wealth to cover the costs; and most important, (3) people whose insurance lapses through temporary unemployment. On the last point, the 42m number covers everybody who is uninsured at any time during the year.

Not that I’d be in favour of a laissez-faire approach to healthcare, but it’s worth noting that the US is most emphatically NOT operating a free market in healthcare. Direct public spending on healthcare (Medicaid and Medicare) is not so far away from European levels, plus there’s a massive subsidy to employer-provided medical care, which distorts the market – explaining in part why spending across the sector has ballooned to 13% GDP.

The problem in healthcare more generally is as you (Andrew) refer to – the growth is all in the luxury, more optional end of the system. Here as everywhere, we want more customised, more complex, and (consequently) more costly services. The problem is that while most of us are happy to pay for our poor neighbour’s cancer treatment, we’re less eager to ensure he gets his Viagra at our expense.

The three systems under discussion have all had difficulties in handling this, although it sounds to me like the French system did best: the British system is inflexible and ends up making arbitrary categorical distinctions as to what is and isn’t allowed; the US system is flexible at the top-end, but also heavily subsidised, while the low-end system has contained costs by limiting the numbers covered; the French system has contributed to cost inflation through subsidy, but has been flexible enough to cope with different changes through cost-sharing.

The problem with the Tory plan at the last election (or any opt-out scheme), and a problem in the US system, is the move to create a residual system for the poor. This creates a high-cost private market, because the bargain consumers aren’t buying, and consequently (and even worse) a means-test trap, where those just above ‘poor’ end up paying top-dollar charges on their limited incomes. Over time, those at those on the fringe use political leverage to pauperise the public system because they don’t like paying for what they don’t get when they struggle to get by. It’s divisive, and it leaves the poor in a crap system and the lower-middle-classes facing risks (financial and health) that are difficult to bear. (This is even worse in the US because of the tax-preference for employer coverage, which means losing your job becomes particularly dangerous.)

Better to change the system for everybody, and ensure adequate coverage for the poor under the same regime as the middle classes. I might post on this myself one day, but a few points from me on what any new model might need to address: (1) finding the right divide between ‘core’ and ‘optional’ care; (2) the role of compulsion over that core care and public support for optional care; (3) the level and model for redistribution (by income and characteristics); (4) the balance between public funding, private insurance, and charging; (5) structuring charging and co-payments to incentivise personal health and patient cost-control; and (6) the role of lifetime coverage, to deal with the back-ended nature of healthcare costs (at least for future generations).

One last point: opticians’ services are now effectively privatised with a supporting public subsidy system, and to my knowledge work pretty damned well. That isn’t to say we can just do the same with healthcare more generally: only that the heavens won’t necessarily fall as a result of a reforming the system.

And what’s this about Yanks going to Mexico for dentistry? We go to Canada and Mexico for prescriptions, not dentistry. Dentists we go without completely if we can’t afford it or have no dental insurance. Your dentists, btw, don’t charge that much compared to Americans, except for the one in London that charged £80 for a two minute poke in my daughter’s mouth.

The right to treatment can only be funded by extortion.

No thanks.

You’re thinking in absolutes. The world isn’t perfectly correlated like that. You’re also considering individual cases, when you have to look at the average behaviour of a society.

But they don’t wear condoms and keep shagging truckstop whores regardless.

You’re assuming a minimum level of awareness about HIV which may or may not exist in Tanzania. Also, different people place different values on different things. Maybe the value of sex, right now, is worth more than the value of a long and boring life in Tanzania?

Even diseases that are strongly correlated with lifestyle, such as diabetes, are subject to other factors – genetics, chance, environment.

But the factors that are correlated with lifestyle are manageable, in some sense. The taxi driver analogy doesn’t hold – his concern is for his own insurance, not yours. Sure, it’s a bitch if he hits you, but that’s what the minimum (state-provided) safety net cover would be for.

do you refuse to wear a safety belt on the grounds that it will give you an incentive to choose the airline you fly with more carefully?

Now you’ve totally lost me.

Anyway, there is plenty of evidence to show that the cost of getting ill doesn’t condition people’s behaviour. Take – say – Tanzania, where user fees for healthcare were introduced at IMF behest. Surely, surely, surely people would refrain from HIV-risky behaviour given that a) they have to pay to even see a doctor, out of desperately small incomes, b) that they will die in agony, and c) that they will be unable to work and thus destitute?

But they don’t wear condoms and keep shagging truckstop whores regardless.

Another key point: you know, and I know, that the Glenn Hoddle principle doesn’t hold. Even diseases that are strongly correlated with lifestyle, such as diabetes, are subject to other factors – genetics, chance, environment. I doubt many London taxi drivers will slow down for the sake of my insurance premium when they don’t for the sake of my safety at the moment.

And finally: do you refuse to wear a safety belt on the grounds that it will give you an incentive to choose the airline you fly with more carefully?

Additionally, let’s take dentistry. It is expensive, many Yanks go to Mexico; many Brits can go to Hungary. Laser surgery – hop on a plane to India or South Africa.

I would also say the NHS gives out pills on prescription wastefully. We need a two-tier prescription payment. If you genuinely need it, it is free or almost-free. If you don’t, pay market prices.

No, because all other things are not equal. The comparison isn’t with other countries – it has to be with the UK in the absence of free health care. Not easy to do, but hey ho…

Leaving aside the dubiousness of arguing that, in effect, disease is a manifestation of poor moral character

Straw man. No one brought morality into it. It is clear (to me, at least) that free health care allows its users to make bad choices. Choices that they would not necessarily make if they had to pay insurance, the pricing of which was dependent on those choices. Nothing to do with morality – everything to do with mortality.

The NHS financially encourages people to make poor health choices.

The NHS is funded by punishing the financially succesful.

The NHS is rationed by beurocrats.

The NHS is the WORST treatment, funded in the WORST possible way.

Rob, if free health care encourages people to make poor health choices, wouldn’t that predict that rates of conditions associated with people’s “choices” would be higher in countries where health care is not free?

Leaving aside the dubiousness of arguing that, in effect, disease is a manifestation of poor moral character (call it the Glenn Hoddle theory, after the former England manager’s fatal assertion that disabled persons were suffering for their prior incarnations’ bad karma), let us take a condition that is a good proxy for “choice”. Obesity.

Your theory would predict that America is a nation of slender muesli-addicts, rather than the home of the world’s highest obesity rate. It would further predict that the UK would be far fatter, to say nothing of other European states who are in reality thinner yet. When the facts are this discrepant, it’s usually time to review your assumptions.

You can’t spell “bureaucrat”.

Finally, let’s take a look at the remarkable assertion you finished with. The worst possible treatment? Really? Let’s put some skin in the game. You need surgery. (I agree that the Glenn Hoddle principle may make this hard for you to accept.) Do you take a notional average NHS hospital (the worst possible treatment), or, say, the best available treatment in Kinshasa? Agreed, that’s a reductio ad absurdum, but then, your completely unsupported assertion was absurd to start with.

which you’re going to have to spell out, I’m afraid. I disagree. This blind faith in expert opinion is misguided.

Whats more, I think providing every member of society a decent level of healthcare is morally right, even if I didn’t think the economics of the US system were completely fucked (which they are).

I don’t like to legislate on the basis of morality, on the simple grounds that almost everyone disagrees. I’d prefer a logical case that goes a bit further than: “Won’t someone please think of the poor?!”

But we actually come to much the same conclusion:

But privatizing healthcare outright is just nuts.

And no one is suggesting that we do that.