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I'm a Brit and America, your health care system is torturing me

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Re: I'm a Brit and America, your health care system is torturing me

#41

Post by dragonwriter »

tptacek wrote: post #37
kasey_junk wrote: post #35

Earlier quoted context omitted.

Both of those are classic examples of the outcomes being directly related to how we fund our medical care. In the first instance it's a tension between the providers trying to maximize service, insurers trying to minimize risk and the user having little agency in the outcome. The second example is a straight up agency problem. None of that changes the argument, it is a perfect storm of badness and even if nationalize…

There are a bunch of ways to rebut that argument. First, you can look at private systems that don't have these problems (ie: all the rest of the private systems). Second, you can note that Medicare, our single-payer system, interacts with the same structurally inefficient provider system. And, of course, if we switch to single-payer tomorrow, we're still going to be doing most care on an outpatient basis (because we…

> Second, you can note that Medicare, our single-payer system,

Medicare is not a single payer system, but a partial-subsidy voucher system for highly-regulated private insurance with (for the core inpatient and outpatient components) a fully-paid public option.

Re: I'm a Brit and America, your health care system is torturing me

#42

Post by 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.

Re: I'm a Brit and America, your health care system is torturing me

#43

Post by tptacek »

dragonwriter wrote: post #41
tptacek wrote: post #37

Earlier quoted context omitted.

There are a bunch of ways to rebut that argument. First, you can look at private systems that don't have these problems (ie: all the rest of the private systems). Second, you can note that Medicare, our single-payer system, interacts with the same structurally inefficient provider system. And, of course, if we switch to single-payer tomorrow, we're still going to be doing most care on an outpatient basis (because we…

> Second, you can note that Medicare, our single-payer system, Medicare is not a single payer system, but a partial-subsidy voucher system for highly-regulated private insurance with (for the core inpatient and outpatient components) a fully-paid public option.

Fair enough. Consider my rebuttal so revised.

Re: I'm a Brit and America, your health care system is torturing me

#44

Post by kasey_junk »

kasey_junk wrote: post #35
tptacek wrote: post #34

Earlier quoted context omitted.

Two examples of structural problems with our health care systems: 1. We lead the world in transitioning from inpatient to outpatient care; for instance, I read a source last night that said the majority of hernia repairs in the NHS were inpatient, and the overwhelming majority of them in the US were outpatient. That's good, but an unintended consequence of it is that it's easier to route a patient to a surgical proce…

Both of those are classic examples of the outcomes being directly related to how we fund our medical care. In the first instance it's a tension between the providers trying to maximize service, insurers trying to minimize risk and the user having little agency in the outcome. The second example is a straight up agency problem. None of that changes the argument, it is a perfect storm of badness and even if nationalize…

The VA is the best example of single payer system in the US, it does not suffer from either of these problems (though for demographic reasons it suffers from a host of others).

As for the private options do any of them have the weird employer provided health care indirection?

Re: I'm a Brit and America, your health care system is torturing me

#45

Post by DanBC »

Simulacra wrote: post #12

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?

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-...

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-...

> 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.

Re: I'm a Brit and America, your health care system is torturing me

#46

Post by tptacek »

kasey_junk wrote: post #44
kasey_junk wrote: post #35

Earlier quoted context omitted.

Both of those are classic examples of the outcomes being directly related to how we fund our medical care. In the first instance it's a tension between the providers trying to maximize service, insurers trying to minimize risk and the user having little agency in the outcome. The second example is a straight up agency problem. None of that changes the argument, it is a perfect storm of badness and even if nationalize…

The VA is the best example of single payer system in the US, it does not suffer from either of these problems (though for demographic reasons it suffers from a host of others). As for the private options do any of them have the weird employer provided health care indirection?

I think employer-provided insurance at scale is a uniquely American problem, and agree that it is problematic, but I don't see how it produces more overconsumption and less centralization than a purely individual market would. In fact, if you maintain a system of private providers (even with a public payer), I don't see a connection between funding and these structural problems at all.

Re: I'm a Brit and America, your health care system is torturing me

#47

Post by tptacek »

DanBC wrote: post #40
rayiner wrote: post #10

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 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 l…

This is absolutely not true, as you've been told before. The fact you keep repeating this is fucking annoying. You're making some assumptions: i) that expensive treatment is good treatment, ii) that expensive treatment is not available and that iii) it is available for people with insurance. Not one of those is correct. Also, the cancer drugs fund (mentioned in your link) provided access to drugs that were very expen…

There needs to be a way for you to rebut someone you disagree with, even if your argument is ironclad, without dipping into incivility.

Re: I'm a Brit and America, your health care system is torturing me

#48

Post by sethev »

tptacek wrote: post #31
deogeo wrote: post #30

Earlier quoted context omitted.

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

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 sign…

In Switzerland, the basic insurance plan is defined by the government and everybody is required to participate in at least that plan. Everybody has the same deductible and out of pocket maximum and premiums (as paid by individuals) are capped at 8% of income.

If you don't sign up the penalties can actually be higher than premiums and if you persist in not getting insurance the government will sign you up and allow the insurance company to sue you for any unpaid premiums.

This system is nothing like what "private" means in the US. This would be called communism in our current political discourse.

Re: I'm a Brit and America, your health care system is torturing me

#49

Post by deogeo »

tptacek wrote: post #31
deogeo wrote: post #30

Earlier quoted context omitted.

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

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 sign…

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 : "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".

Re: I'm a Brit and America, your health care system is torturing me

#50

Post by rayiner »

DanBC wrote: post #40
rayiner wrote: post #10

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 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 l…

This is absolutely not true, as you've been told before. The fact you keep repeating this is fucking annoying. You're making some assumptions: i) that expensive treatment is good treatment, ii) that expensive treatment is not available and that iii) it is available for people with insurance. Not one of those is correct. Also, the cancer drugs fund (mentioned in your link) provided access to drugs that were very expen…

So this was your response if I recall our prior discussion correctly:

> This is simply untrue.

> There's too much wrong with your link to debunk it. It's almost entirely wrong. Mostly, there is a different QALY threshold applied when drugs are used for people with life expectancy of under 24 months, and also they're using an unsourced value for QALYs.

"There's too much wrong with your link to debunk it" isn't much for me to go on to change my assessment of the story.

Moreover, I don't think any of your assertions can change the result, for several reasons:

1) The BBC article I linked to says: "NICE aims to spend less than £20,000 to £30,000 per Qaly. That is not a hard limit; it will go almost twice as high for end-of-life drugs."

You say that "there is a different QALY threshold applied when drugs are used for people with life expectancy of under 24 months."

But if life expectancy is under 24 months, the total amount NHS spends is correspondingly limited, even if the per-year threshold is higher. Even if NHS would pay 60,000 pounds per QALY for end-of-life care, with a 2-year life expectancy, you're not coming close to the $500,000 the U.S. insurance company paid.

2) My estimate is conservative to begin with. The course of treatment actually cost more than $500,000 (the lady paid hundreds of thousands of dollars during the two-year period after exceeding the lifetime limit). I also estimated British costs at half of U.S. costs. But if most of the costs in this situation were due to drugs subject to a higher QALY limit, the that would be an overly conservative assumption, since cutting-edge cancer drugs aren't half the price in the U.K. as in U.S. (while services may be).

In this particular case, probably over 500,000 pounds was spent to extend this person's life by maybe a year if that. I don't think anything you've provided suggests that NHS would have spent that much, or even the 400,000 pounds the U.S. insurance company actually spent.

I also don't understand your point about my "assumptions." I'm not assuming expensive treatment is good treatment. I'm saying expensive treatment is what people want, and U.S. insurance companies are willing to pay for it, and NHS is much less willing to pay for it. That's my point. Here in the U.S., the outrage is why the insurance company didn't pick up the tab for the other couple of hundred thousand dollars. Nobody is willing to suggest that maybe we do what the NHS would have done, and deny such expensive treatment for someone with such a bad prognosis.

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