Health policy – an experiment
I blog partly because I like to write, partly because I’m arrogant enough to believe people will read what I write and like it, and partly for interactivity. I’m not a professional writer (no cheap cracks please…), so I like to play around with writing and words without being too constrained by any conventions of particular media. This post is a bit experimental, and I’m focussing on the interactivity aspect of blogging. Part of the reason that The Sharpener was set up was to create a forum for proper debate between lots of people who disagree, whether it stems from party political tribalism, from genuinely differing axioms / prejudices / Bayesian priors / fundamental views, or from different logical paths stemming from those priors. In view of that, I thought I’d set out my views on healthcare in the UK, a subject which both interests me ideologically and academically, and which affects me personally, as my wife works deep within the bowels of the NHS. What I want you to do is to read it, disagree, and tell me why you think I’m wrong. Then, I’ll tell you why you’re mistaken.
Past
First, though, a description of the current system, and why it doesn’t work. The NHS, I believe, is unique in that it is a state-run system that both pays for and also, critically, provides healthcare services. Most other Western nations that provide some form of healthcare for their citizens just pay for it – they don’t provide it. Historically, the NHS was put together just after the second world war, in 1948. Prior to this, healthcare in the UK was privately provided. There is some dispute over how comprehensive and effective this all was, and it tends to be overplayed and highlighted by champions of the NHS on the left that anyone poor couldn’t get healthcare and was left to die, on the street, of some terrible, but easily cured affliction. People like me point to the large amounts of charity, the fact that consultants often gave their time for free to those who couldn’t afford it, the building of hospitals purely to provide free healthcare to those who couldn’t afford it (like the Royal Free), and so on. As with all political statistickery, the truth is probably somewhere in between. It is probably fair to say that provision was patchy, and that quality varied. That said, you could make the same statement today. Provision is now rationed, rather than patchy, but if you’ve got 3 months to live and you’re at the end of a 6 month waiting list, the difference is almost completely academic.
The founding principles of the NHS were that it should be:
i) free at the point of delivery,
ii) funded from general taxation,
iii) available to all, regardless of status (including visitors to the country, incidentally).
and these principles have largely held, although charges were introduced for prescriptions and glasses in the 50’s, the dental service has been de facto privatised, and the provision of optician’s services has been actually privatised, over time. The third principle has also been watered down slightly, and now you have to be a citizen to qualify for free healthcare, or your country of origin has to have a reciprocal agreement with the UK for tourists.
Present
So, what’s wrong with all this? It all sounds great, doesn’t it? Healthcare is free, available to all, and paid for by everyone in society. It’s a kind of social insurance policy. Wonderful. Except that it doesn’t really work that well. Like all things that are ‘free’, healthcare in the UK is heavily in demand, which means that the only sensible thing the provider with a fixed budget can do is to limit supply by rationing. This is achieved in all kinds of ways, but none of them are good for patients – restriction procedures by waiting list, restricting funding for certain procedures, restricting funding for expensive drugs, etc. I don’t particularly want to go through a list of measures for the overall quality of the NHS and give it a good kicking in the post, but feel free to raise them in the comments, and we’ll have a knockabout debate about it. It also isn’t good for the staff who work within it, although this is partly an argument against the strength of the unions in a monopoly provider. Broadly, compensation bears very little relation to actual performance, so there is little incentive to excel beyond that oft-quoted, and rapidly disappearing, phenomenon of public-sector pride and professionalism.
Future
Bizarrely, and somewhat irritatingly to someone of my political persuasion, I think New Labour are making some decent steps on the long road of reform. Introducing, or rather, expanding, the purchasing of healthcare from the private sector, is necessary to introduce competition, to shake up established bureaucracy, and to make the political climate favourable to independent provision. I’m amazed that it is a Labour government who are doing it, but I guess only Nixon could go to China, and only Tony could start to seriously dismantle the NHS. Let’s face it – we can’t afford to pay for universal healthcare for all. We’re all living longer, getting sicker, and getting more demanding in terms of our lifestyles. We have got to the point where Viagra, IVF, and even cosmetic surgery are available on the NHS. This is, frankly, ridiculous.
Where I would like to get to is a system where the state pays for a minimal safety net level of healthcare, which is completely provided by the private sector. The rest should be covered either by direct payment, or by health insurance, but universal safety net coverage would be available to all from general taxation. I think this retains the best intentions of the founding principles of the NHS, while acknowledging the failings of a centralised, bureaucratised system that will run out of funding at some point in the near, but not-so-near, future.
Over to you, commenters – let’s flesh out a healthcare policy. Why, where and how am I wrong?
Work in from from the extremes. What can (almost) everyone agree be done, in one way or another, by the government? (public health e.g. control of infectious diseases, toxic pollutants…… What else?) What can (almost) everyone agree should not be done, at all, by the government? (Viagra, IVF, tattoo removal….)
What other roles for the government: to protect us from abuse of monopoly position of the BMA and other unions?
Token foreign perspective: from someone who has used French, British AND American health care systems. (Careful, this is going to be long…)
In America, if you’re lucky, your employer pays for your health insurance directly, and that of your family, on top of your salary. This is on the decline, especially the kind of benefits that you are entitled to, and more and more people buy their own insurance, or top-up insurance. You also pay, as part of your taxes, into the pool for those who can’t afford this, and the elderly, medicare and medicaid rspectively. You will probably never see that money again. It’s not for you.
However, in 2002 there were 42 million Americans without any kind of health insurance. That’s, like, England. They’re not left in the street to die, but their family is generally subsequently crippled by debt. Thanks to a strong culture of philanthropy, things aren’t that extreme, but you can’t always rely on charitable funds being accessible to you. It’s a bit like pre-war Britain if you don’t have health insurance.
As a student, my health cover cost me $1100 a year. Because I paid this extortionate sum I was damned if I wasn’t getting my money’s worth: I had thorough checkups, gyno, dental, dermatologist, STDs, blood tests, THE LOT once a year, whether I thought I needed them or not. This is in the HMO’s interest, as it means people are caught in the early stages (ie less expensive to treat) of diseases. Americans also take a lot of responsibility for their health: do you know what your relative levels of LDL and HDL are? I do.
Contrast this with a conversation I recently had with an NHS nurse who specialises in terminal, child cancr patients. I had mentioned that I went to the gyno once a year, and she scoffed and said “what does a person your age need with that? You should only be going once every three years!” Never mind that a classmate was diagnosed early with ovarian cancer on an annual visit. If she had waited another two years, she may not have overcome it so easily.
France: (sorry this is so long…) only recently have they instituted a system where you need to go through a GP to see a specialist – before you could just call up a specialist and make an appointment, and many French did. Now they are registered with a GP who rubber stamps referrals – aping the British system. (yay we do something right!)
You get health care by paying into the big health care pot from your salary, the SAMU, and you get basic healthcare free. Providers are predominantly “private,” but heavily overseen and regulated by the state. Every service has an agreed upon price that the government will pay, to anyone, regardless. There are doctors that charge this amount, and doctors that charge more than that, and it is up to the consumer to choose whether to top it up. You are billed at point of service, and are subsequently reimbursed for that amount by the state, with the option of paying the rest through private insurance. So, basically Howard’s plan in the 2005 election – whatever else the New Labour made it out to be.
Take from this what you will, I just respect these things in each system. In the US: the emphasis on preserving health over curing sickness, and the personal conscientiousness inspired by that. In France: the fact that people, at the point of service, are aware that what they are doing costs money, are given a specific amount from the state that is adequate, that they can add to and take elsewhere if they wish.
Finally (almost there!) – what do I do in Britain? Well, I rely on the NHS for most things, because I’m poor, with one exception: I have health insurance specifically for any life-threatening or long-term disease. Because I don’t expect the NHS to put me at the front of the line, but I do when I’ve paid for it.
In time, once I make somewhat above minimum wage, I intend to have entirely private health care. Partly because I am willing to pay on top of social security contributions for better service (thanks france) but also partly because I happen to believe it is my responsibility as a wealthier person to remove myself as a burden from state providers and therefore free up resources (thanks America) so that the NHS can improve overall without my taxes going up.
Sorry this was so long: I drank a bit much coffee… Just my two cents. Well, twenty bucks really.
It’s good to get a foreign perspective actually. The NHS is the ‘third rail’ of British politics, so independent views are hard to come by, domestically.
I intend to have entirely private health care. Partly because I am willing to pay on top of social security contributions for better service (thanks france) but also partly because I happen to believe it is my responsibility as a wealthier person to remove myself as a burden from state providers and therefore free up resources (thanks America) so that the NHS can improve overall without my taxes going up.
It’s not actually possible to have entirely private health care in the UK, as chronic conditions are essentially uninsurable, as far as I am aware. So unless you’re willing to pay for that kind of treatment, which would be quite crippling, financially, it has to be done on the NHS.
Also, that’s a very altruistic attitude, but not everyone thinks that way, and it ignores the funding problems of the NHS – demand is rising far faster than supply, and always will as long as it is free at the point of delivery, comprehensive and universal. The NHS will not, and cannot, be constituted in the same way as it is currently in 10-20 years.
Plus, 42 million Americans as a percentage of the population (a better comparative) is not like England. More like Cornwall.
It’s social security (pensions) in the US. And laicite (pretending religion doesn’t exist) in France. The third rail I mean. But both countries currently have people grabbing that rail with both hands, which is more than anyone else has done, whether you agree with Bush and Sarkozy or not.
I don’t think it’s very altruistic: I’m making a deal with the government to keep taxes down. Thanks for the correction, but I’m just assuming no chronic conditions arise. Arrogance of the young and all that.
42 million: I know, it was a lame, like, joke. As was that.
I know. So was Cornwall… Anyway, back to healthcare:
But the third rail bit is quite interesting. My wife, whilst treating a Conservative MP, suggested to him that the best thing that could happen to the NHS was privatisation. He looked at her as if she were quite mad. If a Tory MP isn’t prepared to grab that rail, God help us all.
Another point: the US model is not an example of efficiency. They spend more per head but don’t get universal provision from that – go figure, as they say.
But one thing both the French and US models have in common is a strong financial interest in supporting HMOs, drug companies etc: under the old French procedure, you could literally see any doctor and demand any treatment you felt you wanted, which was great for producers and hypochondriacs but not so great for taxpayers of all kinds. In the US version, the HMO model means the healthcare industry is in a strong position to up-sell to everyone who’s in the system. Once you’ve paid, there’s a strong incentive to visit your friendly local endocrinologist twice a year.
Regarding the “I can pay, so I should go private to help the system” – this is the fallacy of composition in action. Private sector consultants usually work for the NHS too, so increasing the demand in the better-paying sector will effect a one-for-one cut in the NHS’s resources. And, presumably, as more people then go private, the pay differential increases still further as we race to failure
increasing the demand in the better-paying sector will effect a one-for-one cut in the NHS’s resources.
Not necessarily true – a consultant may do overtime to cover private work.
Once you’ve paid, there’s a strong incentive to visit your friendly local endocrinologist twice a year.
But this is equally true of GPs in the NHS – they’re a gateway to treatment. It makes financial sense for me to visit my GP as often as possible, to get value for my taxes.
Agree with them or not, Bush and Sarkozy are at least respected for taking the tough route and talking about something that nobody’s dared talk about: it’s provoking actual debate on issues that have been dead (but seething) for years. Who to do it in Britain? Not Patricia Hewitt.
Hmm, alex, I never said it was efficient, I said, that for those who are in the system, it was effective. I expressly said that for those NOT in the system, it sucks. Very different things.
I’m not an expert, but I’m just wondering what aspects of their health care system the French complain about? It’s not a statistically sound method, I know, but it’d be interesting to know what problems people who live there have with it. In Britain, we hear complaints about waiting lists, inability to get to see a GP etc, in the US it’s the cost of insurance, what it does/doesn’t cover, HMOs etc but what issues do the French have with theirs? I’d ask my brother (he lives in Paris) but I’d get nothing but praise from him as it saved his life…
Well, there’s always stories in the papers (a la daily mail) about people dying in poverty from hospital charges because their reimbursement didn’t arrive in time, or got caught up in bureaucracy. The system is constantly in debt – pulling money from elsewhere to pay itself – but people seem ok with this.
The complaints I’ve heard are from health professionals. Of course, this may be because my best French friend is a medical student.
First, you might have noticed that all the surgeons went on strike and came to Britain for a wee holiday/symbolic exile. Their problem is reproduced across the services: the government’s “prices” that they set and reimburse means that health professionals can’t really raise rates without suddenly losing all their business – or most anyway – because people know they can get it elsewhere cheaper. Also, as everywhere, insurance premiums are sky-high to protect against an increasingly litigous society. The cost of being a doctor is rising without the benefits rising too.
Then, the change to make GPs your first point of call has revealed that there just aren’t enough GPs. French medical schools graduate people into professions by rank, so the top 10% become surgeons, the next 10% pediatricians, and so on down to the second from bottom cut(the bottom cut get kicked out: at the end of six years of hell), who become generalistes. The French government, in an attempt to raise the numbers of GPs, has raised the barrier for NOT being a GP, meaning people who get the same grades as, say, psychiatrists last year will be GPs this year. The students are pissed, as being a generaliste is considered academic failure. They don’t like that here.
French medical school is also astonishingly brutal, competitive and selective. They kick out half their intake over the six years. There aren’t enough new doctors making it through this hell to replace the ones retiring. It’s not at critical point yet, but give it five ish years, and there’ll be a super shortage.
I just looked up some interesting statistics: France has 8.5 hospital beds per 1000 of the population, roughly double the UK. They spend 9.5% of GDP on healthcare, compared with US 13.5%.
So yeah, overall it’s really good, but there are some time bombs that everyone’s got their fingers in their ears and humming the marseillaise about. Except the surgeons, who are sunbathing in Camper Sands.
PS – The French generally love to complain about their HEALTH, rather than the system.
Little language lesson:
La rhume: a cold
La grippe: a cold
La bronchite: a cold
La pneumonie: a cold
I remember reading somewhere that a significant proportion of the uninsured in the US are young, single relatively wealthy people essentially taking a punt that they can meet any medical expenses they might have because they don’t expect to get sick in their prime. I don’t know how significant this factor is, (or if indeed it’s true!) but it’s worth bearing in mind.
Once you’ve paid, there’s a strong incentive to visit your friendly local endocrinologist twice a year.
But this is equally true of GPs in the NHS – they’re a gateway to treatment. It makes financial sense for me to visit my GP as often as possible, to get value for my taxes.
You’re joking again, I take it. I know in theory we’re all homo economicus and monitor every penny that either goes out or gets skimmed off with the same hawklike assiduity, but I don’t believe anyone actually thinks in terms of “getting value for [their] taxes”. I certainly can’t imagine setting a personal quota of visits to my GP for no other reason than to get value for money. The great thing about tax (or any other form of long-term upfront payment) is that it takes payment – and cost/benefit calculations – out of the equation from that point on. I understand that this is part of what Conservatives hate about it, but I’ve never really understood why.
demand is rising far faster than supply, and always will as long as it is free at the point of delivery, comprehensive and universal.
You could have cut that sentence at the first coma, and it would have still been valid. Demand for healthcare is unlimited, and will always exceed supply in any system. The question for healthcare policy is, how should supply of healthcare be rationed? By doctors? By politicians? By insurance companies? You can only sensibly approach the healthcare problem by asking, not whether to ration, but how to ration.
An actual American chimes in: Medicaid (for the very, very poor only) is being slashed by many states, to the point where it is almost non-existent. What do folks do? Go to the emergency room when they have the flu. Which, as an ER doc who ran for Congress used to say, is like firing up a 747 for a trip across town. (Medicare, for the elderly, works similarly to Social Security, and didn’t until recently include perscriptions, and now only does to a certain extent and at huge cost.)
And no, most of those 42 million are not wealthy; they’re working poor and middle class who can’t pay $1000 a month for insurance and hope desperately they don’t get ill. (Your student yearly rate of $1100 was subsidized. If you’re not part of a group plan you pay many times that.)
Second, (third?) if you pay out of pocket for a treatment at a U.S. hospital, you pay many times what your insurance company will pay for the same treatment, because the insurance co. will negotiate for a lower rate. Most people don’t even know this, and pay with their first born, figuratively, until they are bankrupt, which now is no longer legal even for medical expenses. (Our Congress and Senate are funded by credit card companies, btw.)
Also, assuming someone will go for a medical visit just because they’ve paid for it is bollocks, as you say here. I’ve had free health care (paid for ironically by the U.S. govt. because my husband was active duty military) and would only go to the doc on pain of death. Or for a yearly gyn exam in order to get a refill on BC pills. It’s no fun to go to the doc, as every child knows.
Also, there’s a myth widespread in America that it’s malpractice claims that are raising prices, and driving “good docs” out of the system. That has been proven to be false, yet it’s the popular perception behind the move for “tort reform”.
About the French and every other European nation: there’s a casualness to health care that bugs Americans. A friend here (UK) couldn’t get a doc to do a strep culture; that’s routine in the states. My s-i-l in France couldn’t get a doc to examine her baby when she was turning blue from breath holding. Minor stuff, maybe, but in America medical professionals go all out to provide treatment, when and only when it’s paid for by insurance companies. If not, then you go to the emergency room because they cannot legally turn you away.
Despite problems with your NHS, it’s far, far superior to a system that only works for a few–namely, the insurance companies, who as the middle man do pretty well in the American system and lobby to keep it. Those who say competition is needed make the mistake of thinking health care (and I’ve also hear it used in regards to education) is like making hamburgers, and the best, and cheapest will be preferred. It’s simply not analogeous.
That said, NHS does need to be improved, but please don’t toss the baby out with the bathwater–at least not before doing a strep culture.
BH: I read something similar. I think the main group of people effectively uninsured in the US are the lower middle-classes, who don’t get healthcare through work benefits, can’t afford to buy it privately, and aren’t quite poor enough to qualify for government benefits.
Phil: Sure, we’re not all rational people in the economic sense, but GPs will tell you that they have a group of regulars who abuse the system in exactly that way. I’m sure it’s partly hypochondria, but it’s certainly rational behaviour in one sense. The abuse of A&E facilities is similar – many people turn up to A&E with minor ailments, that really don’t warrant emergency treatment. That’s why it was renamed from Casualty. Alas, people have paid for it, and they know their rights. Yes, the link is less strong because you don’t pay directly, but I’d bet there is a link. Of course, I can’t prove it.
On the removal of cost-benefit type calculations from tax payment, I’d guess the reasons that Conservatives dislike it is because it’s senseless paying for something for which cost exceeds benefit (however benefit is defined). It removes the choice from taxpayers to make rational decisions about where money should be spent (in the sense that voting for a candidate is some kind of implicit approval for their parties spending policies). Of course, the flipside is that most people are bastards, and would probably vote to cut things that society deems worthy of spending money on, like incapacity benefits or public sector bureaucrats, given the cost-benefit figures. That’s probably why Labour supporters like tax. It disempowers voters.
Iain: Demand for healthcare is clearly not unlimited. If I’m not sick, my demand for healthcare is zero. The question actually then becomes: what is healthcare? Is preventative medicine healthcare? Are anti-smoking campaigns healthcare? Is IVF healthcare? Is the Atkins diet healthcare? And so on… And of course, I would argue that demand for healthcare should be rationed in the only logical and fair manner – by price.
I’ll back up the regular medical visits if it’s “free” thing. At school mild hypochondria and an inexplicable love of vitamin C tablets (which they handed out for free) led to weekly visits to the sanitorium. In the last ten years I’ve seen a doctor about three times – once to get some antibiotics for bronchitus and twice to check out some cuts and gashes after I came off my bike. If something’s free and (moderately) convenient, people will take advantage of it – especially if they’re old and lonely and have nothing better to do.
Ezra Klein did a whole series of posts on various national health systems a while ago, which were veritable mines of information, and came to the conclusion that whilst the British system is roughly about as effective as the American system (according to average years of life lost, I think), it costs about half as much. This seems to me to mitigate heavily against moving towards an American-style safety-net and then private provision type system, although its resemblance to the the American system, and hence efficiency, would presumably depend on the content and scope of the safety net.
I’m also skeptical about the wisdom of introducing government-paid-for private provision for any safety net, because of both the potential for profiteering it introduces, and because of the way in which competition amongst those providers seems likely to me to, given that in order to ensure stability in the system and allow long-term planning and so the need for relatively long-term contracts, result in cost-cutting exercises and the underprovision of unprofitable but important services. I may be wrong about this, and if anyone can provide me with an argument otherwise, I’m more than willing to concede, because I’m not an economist.
Finally, on the uninsured in the US, the proportional equivalent is about 8 million (42/296 is about 13% or about 1/7). That’s every person in Scotland, Wales and Northern Ireland, or every Londoner.
Andrew, what do you mean when you say you want the NHS to provide a “minimal safety net of healthcare” ? What kind of operations and procedures does this definition encompass ?
Eddie: The devil is in the details, of course. If I were a politician, I’d bat that question aside by referring to an inquiry I would set up into that very critical question. Personally, I’d probably include any life-threatening chronic condition (cancer, etc…), anything immediately life threatening, and thus all emergency care. I would explicitly exclude anything elective. I’d probably exclude most acute, non-emergency cases, preferring to put that onto the private sector. I’d exclude anything that wasn’t life-threatening (back pain, diagnostic tests, etc…), although this is where the grey areas start to creep in, I’d guess. Your mileage may vary.
So, simple distinction: Life threatening, included. Not life threatening, not included. By life threatening, I’d take a strong definition: Something that can kill you (on balance of probabilities), i.e. I would exclude something that would just render you unable to work (as an example). I would include easily treatable forms of cancer with a high survival rate, for example, on the grounds that it could be life threatening. Please feel free to pull apart the arbitrary nature of these distinctions.
I think it’s in a health service’s interest to include diagnostic tests, simply because otherwise something easily treatable could develop into something life-threatening and thus, more expensive. HEALTH, not sickness, service.
Well I’ve certainly learned that our NHS would be wise to introduce a large “merit payment” for doctors who speak fluent French, so that we can tempt those well-trained frogs to our side of the channel.
We should have an subsidised but individual insurance system whereby the government subsidises you what it would cost to insure a healthy person at your age and sex, but you make up the remainder.
OTOH There’s no reason not to allow opt-outs from the NHS i.e. an optional tax-cut to provide a service yourself, and let people find their own solutions.
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.
Nosemonkey:
I’ll back up the regular medical visits if it’s “free†thing. At school mild hypochondria and an inexplicable love of vitamin C tablets (which they handed out for free) led to weekly visits to the sanitorium. In the last ten years I’ve seen a doctor about three times […] If something’s free and (moderately) convenient, people will take advantage of it
Only if the ‘something’ is positively gratifying in itself, which most visits to the GP aren’t. (I’m enough of a hypochondriac – and I’ve got a good enough GP – to have come out of the surgery on an enduring high on several occasions, but I’d still postponed those visits for as long as I felt I could.)
especially if they’re old and lonely and have nothing better to do.
I don’t think frustrating lonely old hypochondriacs is a way to deliver major benefits to the health service.
Katie: Okay, but then I’d draw a line between diagnostics for life-threatening conditions versus spurious testing for testing’s sake. Although I guess the US suffers as doctors tend to over-test to cover their asses. Maybe not such a great idea.
Phil: I think it depends on your mindset. I know my local GP has a group of regulars, who aren’t all old and lonely, but who do tend to be bored and unemployed, who he sees far more regularly than is necessary.
I don’t think frustrating lonely old hypochondriacs is a way to deliver major benefits to the health service.
No, but it’s a nice fringe benefit. ;)
On a serious note, I think we need to get away from the mindset that things should be done for the health service as a system. The evils of this become apparent when people start talking about banning things to preserve the glorious NHS. There’s a lot that is done within the NHS that is there to perpetuate the system. I think that’s the wrong focus – it should be all about the patient. Everything else is a bonus.
I looked into this when Krugman started writing about the US system in the NY Times. Does seem that the French system is a decent solution to a difficult problem (although with the provisos above).
I have a feeling that this is the way the way Blair is trying to push it, in the same way that the Tory school voucher idea seems to be a direct copy of the Swedish system.
Both sides have, for a change, looked around the world, seen what works and tried to introduce it. Pity they won’t just come out with it though, admit what they’re doing.
Interesting discussion. Another American (well, dual citizen living in the US) chiming
A couple points:
The US system sucks if you make under $40,000 (or thereabouts) a year – which probably includes a good portion of the population. While something like 40 million people are uninsured, that is only at one particular time. The number of people who have been uninsured at *some point* in the last two years is much higher.
Right now I am in graduate school and I have gone through substantial periods without a job in which case I have no health insurance and have to pay exhorbinant rates ($100 – 60 pounds – for a month’s worth of a prescription). I’m lucky I’m fairly health. If one needs a serious medical procedure without health insurance, it is quite common to go 10s of thousands of dollars in debt. Of course, people without insurance can’t afford to pay that, so they go into bankruptcy which in turn, jacks up insurance rates (thus making it even harder for those without insurance to purchase it in the first place) and thus the vicious cycle repeats.
Basically, the problem with trying to tie health to the market is that medical problems aren’t conducive to the market mechanism. One simply can’t make a rational choice in dealing with many (probably most) things one goes to a doctor, for a variety of fairly obvious reasons. 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).
The only reason the US system is the way it is ideological. Basically, people in the US are in fact in favor of moving towards something like what the French or the Canadians have (ie single payer, where the government pays private practicioners), if polling data is to be believed. Its just that every time the issue comes up, the medical and insurance lobbies with their right wing allies scream “socialism” and the effort collapses because they’re simply aren’t enough committed people on the other side of the issue to persevere – ie majorities are in principle in favor of some form of universal healthcare, but aren’t bothered enough to do what it takes to win, while the opponents are willing to fight tooth and nail.
So, all in all:
I actually think the move in Britain towards a more flexible system is a good thing. In other words, Britain should move towards a system in which practicioners operate in the private sphere, but where the government pays those in the private sector (within reasonable limits – obviously no government provided plastic surgery and so forth – one can argue about the proper limits here) But privatizing healthcare outright is just nuts. And this comes from someone who is by no means a socialism and generally believe privately run institutions are more efficient. In the case of healthcare, this just isn’t so – and the American example is a good example of why.
To clarify:
Medical providers operating in the private sector, at least to some extent, is probably a good thing.
Having no real government system (except for the elderly (Medicare) and (very minimally) the very poor (Medicaid)) providing insurance is not.
I’m hoping the British system is fixed for purely selfish political reasons: it’s constantly referred to as an example of a system that doesn’t work, that “rations” health care. I’ve heard this many times on the campaign trail (I worked for a doctor/candidate who very much supported universal health care) and it would be nice to take away some of the ammunition, although the rejoinder was, of course, that we had a rationed system too.
So I’m glad to see discussions like this, and hope to hear them in Parliament, or wherever it is you guys do your business.
Basically, the problem with trying to tie health to the market is that medical problems aren’t conducive to the market mechanism. One simply can’t make a rational choice in dealing with many (probably most) things one goes to a doctor, for a variety of fairly obvious reasons.
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.
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.
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?
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.
I will chime in briefly as this is a topic I want to write about in more length at my own blog. The NHS has two major problems:
1) Too much paper-work and managers
2) It provides too many cosmetic & non-medical procedures. These include breast augmentation, male impotence, sex-change ops, abortions, infertility treatment, providing free contraception, amongst others. Ultimatly these are all individual lifestyle choices and areas where people can get their own pills or procedures.
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.
Well, if it doesn’t predict that not-paying for your healthcare makes you sicker, it also doesn’t predict that paying for it makes you any healthier; this poses the question, what’s the point?
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?
Well, if it doesn’t predict that not-paying for your healthcare makes you sicker, it also doesn’t predict that paying for it makes you any healthier; this poses the question, what’s the point?
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.
Does the “right” to treatment, outweight the right of workers to work for themselves?
The right to treatment can only be funded by extortion.
No thanks.
I’m a health nut, and one of the few privileged Americans with totally free health care. Go figure.
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.
Late arrival (been on holiday), but a long and windy comment…
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.
Everyone in the UK is entitled by law to free eye exams. But most of us pay (for convenience). KathyF, Americans do go to Mexico for dentistry. Obviously not everyone but anyone smart who needs work that may cost in the $000s in the US but only a few $00s in Mexico. The difference is Brits may go to places like Hungary forboth cost reasons as well as expedience/convenience.. Americans go for the financial reasons only.
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?