single-payer system ... singled out

[Rolfe]

I forgot how simple things seem from the outside.

Well, yes. Those of us who don't even notice what we pay in taxes to fund our healthcare system, and who simply have to show up with a medical need and it is taken care of, are perhaps pre-programmed to expect it to be fairly simple.

Healthcare is much more complicated than that. [....] Every practice has employees whose job it is to get the money out of them. That's what "reimbursement" is about. It's a whole industry in itself, with a complex set of rules and best practices and jargons. They have conventions. It's a career path.

[....] Negotiation occurs. [....] There's drug replacement, and appeals. They won't cover x % of x drug? What about the secondary? File for Medicaid. Swing a deal with the insurer. Go through the contract again, not the insurer's contract with the insured, the practice's contract with the insurer. There are financial counselors, there are account reps, their are insurer reps, there are contract negotiators and auditors and things, and that's not even including the clinical people. Healthcare is a huge industry, did you really think that all the paperwork and bureaucracy and offices full of people pushing paper and fighting for money were all on the insurance side? The insurer wants to keep the money. The provider wants to pry it out. [....]

[....] And as for the department for denied claims, that is totally standard. "Denied claims" isn't what it sounds like exactly. It's not final. It's perfectly normal to have people whose job it is to work the paperwork, and explain how to get the reimbursement from the various companies and government agencies.

[....] It's the doctors who prescribe the drugs, and they have departments full of people dedicated to making sure they get paid for that drug. [....]

Everyone possibly faces bankruptcy with cancer. It's pricey. But as I've said, there are many avenues. [....]

[....] the whole industry is much more complicated than people know. [....] There's the charge, the allowable, the insurance payment, the copay, the deductible, the write off...and then most medical bills come aged, which is further complicating matters. Healthcare is an elaborate dance between patient, provider, insurer, and government, with drug companies wafting in and out. It is not simple. And it's so hard to explain every nuance--even people who've been in the business for years don't know it completely. [....] There can be no simplistic solutions because the system is complex.

I don't think I can possibly explain this any better.

That is perhaps one of the most damning indictments of the US healthcare system I've seen, and it appears to have been intended as a defence.

To repeat. We fund our healthcare by means of our taxes. While our total tax take is probably somewhat higher than yours, it's by no means punitive. I just checked last month's pay slip, and I got to keep 75% of my gross salary after deduction of both tax and National Insurance (which pays for the state retirement pension). Income tax alone was only 17% of my total salary. And I'm in the "higher tax band" category because I have higher than average earnings.

Indeed there are other taxes such as VAT, and everyone likes to moan, but overall our pips are not squeaking.

Then when we need medical care, we show up, and it is delivered. There is a payment for dental treatment (though much lower than for private dental treatment), and if you need glasses or contact lenses you'll pay for these, but that's about it. Oh yes, and a £5 tax for a prescription drug, waived for the over-65s, pregnant women, young children and those on very low incomes. (This to be abolished entirely next year.)

As Architect noted, Herceptin is available on the NHS. The evidence supporting the use of the drug was equivocal, and it took some time to make the decision, and pressure was put on the government during that time. But women are not being denied the drug now (despite the equivocal evidence and the cost).

There is really no possibility of anyone going bankrupt in this country because they have cancer. A few people have decided to throw all their assets towards purchasing very new and expensive drugs that have not yet made it through the formal testing process for general availability (and Herceptin was in that category for a short time), but nobody has to pay a penny for the normal "best practice" standard of care for their condition.

Nobody has to do any of the stressful and debilitating fighting described above. Nobody has to pay anybody else to do it for them. And although people do shout about wasteful bureaucracy within the NHS, there's nothing to touch the "career path" described above, which must be responsible for eating up a significant proportion of healthcare spending.

I have a large extended family, and most of my cousins are older than I am. Just about all of them have had healthcare needs over the years. Two diabetics, one double knee replacement, two cancers, one hip replacement, one oesophageal removal (critical, but I don't know if it was cancerous or not), one chronic respiratory illness from childhood almost permanently on antibiotics and other drugs, not to mention my pneumonia and my mother's glaucoma and pelvic floor repair and appendectomy and gall bladder removal.... The list goes on.

Apart from my mother choosing to pay for her cataract surgery to avoid a year-long wait, nobody has had any complaints about their treatment at all. And even if my mother hadn't been able to pay, she'd have had the cataract surgery in the end.

And then there's the friends and neighbours. Cancer and joint replacements and heart surgery and broken bones put back together, and on and on and on. Nobody having to fight for treatment, nobody being hit with bills they couldn't afford, nobody being denied the treatment their doctor thought they needed.

And see Architect's experience above, with the pleurisy and pneumonia. He told me about that in detail, and it sounded quite scary. But the NHS actually went out of its way to make sure he got the care he needed, because he presented in a way that rang a lot of alarm bells. Nobody needed to know if he was insured or if he could pay - he was a citizen, and caring for him was what they were there for.

The way it goes on the ground, the experience of everyone here, is that you don't even notice what you pay to fund your healthcare. And then when you need it, you get it. No bills, not even any mention of money.

So yes, forgive us if we have difficulty understanding how complicated the US system is. And forgive us if we continue to feel great pity for sick people saddled with that sort of tribulation.

Rolfe.

 

[TragicMonkey]

"Very few" !

I can't speak for every doctor in existence, sorry. I don't know of any who would, but if I had said "no doctor would let someone die for lack of money", I'd have been immediately challenged for making such a broad statement.

 

[TragicMonkey]

That is perhaps one of the most damning indictments of the US healthcare system I've seen, and it appears to have been intended as a defence.

I can only say that the best analogy to the US healthcare system is the traditional adversarial legal system. The "fighting" is in everyone's interests, because everybody gets a champion who knows what they are doing. And yes, deals are made, and the outcome seems to be compromises...but it works. Having a single monolithic system of one entity only means there will be only one interest represented, the system itself. I'd much rather have advocates doing their best to get what I need, even if they don't succeed 100% of the time, than an impartial judge who gets to make all the decisions and won't have to face consequences for failure. Because advocates do--if the practice can't succeed in getting the money out of insurance, it goes under. It's a balance of self-interests. The alternative is to trust in the caring and efficiency of a governmental body that doesn't have to turn a profit and has no direct stake in the matter.

 

[Architect]

You'll forgive me for pointing out that your argument about "fighting" would be more compelling if you in fact enjoyed better healthcare indicators than we do, however this wouldn't appear to be the case - the neutral position we seem to have agreed is that we enjoy comparable standards, otherwise we just end up in an argument about "metrics".

However I have to say that the government not having to turn a profit seems to me to be a positive advantage. We don't have to pay an army of underwriters, claims adjusters, and so on and hence can either (a) deliver the same standards of care for less, or (b) spend the money on extra treatment.

Moreover NICE, the NHS, and others are all subject to judicial review if you disagree with them - the money comes from the legal aid budget and hence the applicant/patient doesn't get hammered with lawyers bills (assuming they have a valid case). Judicial review in cases of medical urgency is usually held straight away, within a couple of weeks of application.

 

[Professor Yaffle]

Argh! Don't you see? The point is that the patient doesn't have to do all that. Their doctors' office takes care of it. It's their job, and they understand all that junk.

Not from what I've been reading on this forum. Have you been following the RSLancaster thread at all? His other half has had an awful lot of stress dealing with the insurance company and having him moved around different facilities.

 

[Professor Yaffle]

What do you want? Free drugs? Free medical care? Want that nurse to work 90 hours a week for free? Want the doctor to spend millions on drugs, give them away without charging even a fraction of the cost, then shut up shop? Mine is one of the more successful practices, but our drug costs alone would put us out of business in a matter of weeks if we didn't get something for them.

I give up. It's not enough that there are teams of people working to get everything paid for, filing paperwork, making appeals, working with the government, making deals with the patients, writing off huge amounts, absorbing costs....people want everything free. Drug X costs your doctor $4,000 a month. Okay, you can have it for free. Of course two office workers have to get fired to cover that, but I'm sure the practice can stay open with fewer and fewer employees. Eventually the patients will be milling around the parking lot of an abandoned building, wondering where they're going to get their treatment, but hey, that's so much better than getting an expensive drug.

Is your problem with healthcare, or with capitalism?

All I want is that healthcare be available to everyone irrespective of their ability to pay. And lucky me, I have it - and so does everyone in the developed world except in the US. Giving care to peole who can't pay is only a problem in your system, not ours.

 

[Ivor the Engineer]

<snip>

There can be no simplistic solutions because the system is complex.

<snip>

Why is the payment system for healthcare in the US complex? Does it have to be as complex as it is?

Other countries do not need the complexity you have described their healthcare system for managing the flow of money from patients to providers.

I think the biggest problem to overcome in the US healthcare industry is the vested interests of physicians, insurance and pharmaceutical companies, etc., who will all start complaining VERY LOUDLY if the boat is rocked too far from their current comfort zone.

 

[Ivor the Engineer]

All I want is that healthcare be available to everyone irrespective of their ability to pay. And lucky me, I have it - and so does everyone in the developed world except in the US. Giving care to peole who can't pay is only a problem in your system, not ours.

I imagine the disconnect is in your view of human nature compared to TM's, who appears to believe the only reason anyone does anything useful for others (accept by accident) is for financial reward. I.e. there are no societal values, only market incentives.

 

[Architect]

Which goes back to my earlier points about this being a fundamentally political or philosophical position; it seems to me that the arguments presented against UHC are primarily ideological with the whole "government couldn't run the proverbial "p***-up in a brewery" type arguments as window dressing.

At the end of the day we, by which I include a significant proportion of the developed world, have decided that UHC is a right and must be provided. Others may - hell clearly do - think otherwise. It's a position I consider to be morally bankrupt, one which ignores any duty we might have - societical, religious, or otherwise - to help those more needy than ourselves.

The previous quote of "from each according to his abilities, to each according to his needs" seems to me a perfect summary.

 

[Rolfe]

What do you want? Free drugs? Free medical care? Want that nurse to work 90 hours a week for free? Want the doctor to spend millions on drugs, give them away without charging even a fraction of the cost, then shut up shop? Mine is one of the more successful practices, but our drug costs alone would put us out of business in a matter of weeks if we didn't get something for them.

I give up. It's not enough that there are teams of people working to get everything paid for, filing paperwork, making appeals, working with the government, making deals with the patients, writing off huge amounts, absorbing costs....people want everything free. Drug X costs your doctor $4,000 a month. Okay, you can have it for free. Of course two office workers have to get fired to cover that, but I'm sure the practice can stay open with fewer and fewer employees. Eventually the patients will be milling around the parking lot of an abandoned building, wondering where they're going to get their treatment, but hey, that's so much better than getting an expensive drug.

Is your problem with healthcare, or with capitalism?

Nobody said it was free. What we said was that the way it is funded, we don't notice the cost. This is because we pay according to what we can afford, and we pay when we are earning well. If we're not earning - say because we're too sick to work - we don't have any financial liability at that stage.

Doctors are well paid. (One of my friends is a doctor, her husband is a consultant surgeon, and I'm very much hoping to be invited to spend a weekend on their yacht again this summer....) Doctors don't buy the drugs, they simply write a prescription which the pharmacy fills, and the NHS (funded as described above) pays the pharmacist. Or in the hospital, the drugs are purchased from the hospital budget, provided by the NHS (funded as above).

....teams of people working to get everything paid for, filing paperwork, making appeals, working with the government, making deals with the patients, writing off huge amounts, absorbing costs....

And none of that has to happen. I'm not saying the NHS doesn't have a lot of expensive bureaucracy, it does, and the things my friend's husband has to say about that would make a sailor blush, but it really isn't close to this league.

Have you any idea what a straw-man that post of yours is? The simple fact is, the more I hear about the US medical system even from those who support it, the more grateful I am that I'll never have to deal with that sort of grief.

Rolfe.

 

[Rolfe]

I can only say that the best analogy to the US healthcare system is the traditional adversarial legal system. The "fighting" is in everyone's interests, because everybody gets a champion who knows what they are doing. And yes, deals are made, and the outcome seems to be compromises...but it works. Having a single monolithic system of one entity only means there will be only one interest represented, the system itself. I'd much rather have advocates doing their best to get what I need, ....

I think what Architect said about this should be repeated, for emphasis.

If a patient believes he has not got the care he should have received under the NHS, he can indeed take this to the legal system. There he will find a champion, an advocate, who will fight his case for him. This may well be funded under legal aid, depending on the circumstances.

However, this happens rarely, because it's rare for anyone not to be given the care they are entitled to. But if it does, emergency judicial review, the whole nine yards. And what's more, if it is a point of principle and the patient is successful, that judgement will be binding on the health service, and subsequent patients in the same situation won't have to go through it all again.

Rolfe.

 

[volatile]

I can only say that the best analogy to the US healthcare system is the traditional adversarial legal system. The "fighting" is in everyone's interests, because everybody gets a champion who knows what they are doing.

Really? Even those poor sods in the gap between Medicare and private healthcare? Who's their "champion"?

 

[Ivor the Engineer]

<snip>

And none of that has to happen. I'm not saying the NHS doesn't have a lot of expensive bureaucracy, it does, and the things my friend's husband has to say about that would make a sailor blush, but it really isn't close to this league.

<snip>

I don't know. If a (non-SNP, obviously) M(S)P owned a yacht, I'm sure we'd want to know exactly how (s)he was funding such a luxurious lifestyle at the taxpayer's expense.

Clive James on yachts:

http://news.bbc.co.uk/1/hi/magazine/7702216.stm

...Nobody with any brains has ever stayed on a yacht an hour longer than necessary...

 

[Rolfe]

Not from what I've been reading on this forum. Have you been following the RSLancaster thread at all? His other half has had an awful lot of stress dealing with the insurance company and having him moved around different facilities.

I think Susan may have been a bit pushy, but who can blame her. She loves Robert and she wants the best for him, and she has never been confident that the system is fighting for him, so what else can she do?

Earlier in that saga, I came across a pdf on the internet with a very detailed description of how stroke patients should be managed in one of the British health authorities (I thik it was in Scotland but I'm not certain). Unfortunately I haven't been able to find it again so I can't link to it now. This document was very hot on best practice from sound evidence-based criteria, and it was by way of information for patients and their relatives to explain to them what care the person would receive at each stage and why.

I didn't link to it in the RSL thread, because I didn't want to upset Susan. It laid out clear and simple the entitlement to everything she was fighting for Robert to receive.

On a number of occasions I have been moved to donate money to US forum members to help them with financial crises caused by medical bills. I really don't think I have been scammed. But can you imagine it? Citizens of the biggest, richest superpower on the face of the globe, having to accept charitable donations from abroad because they don't have a healthcare system that looks after their needs.

You will never find any British poster, or indeed European, Australian, New Zealand or Canadian poster in that position.

Rolfe.

 

[Rolfe]

I don't know. If a (non-SNP, obviously) M(S)P owned a yacht, I'm sure we'd want to know exactly how (s)he was funding such a luxurious lifestyle at the taxpayer's expense.

Clive James on yachts:

http://news.bbc.co.uk/1/hi/magazine/7702216.stm

Sunshine, I know of an SNP member who is now an MSP who had a private aeroplane before he was elected. I don't know if he still has it but I wouldn't be surprised.

[/derail]

Rolfe.

 

[Rolfe]

All I want is that healthcare be available to everyone irrespective of their ability to pay. And lucky me, I have it - and so does everyone in the developed world except in the US. Giving care to peole who can't pay is only a problem in your system, not ours.

Uh, yes. But it seems to me that what you and I want is not what many people in the USA want. I've lost count of the number of US posters who have expressed their disapproval of providing healthcare to people who cannot pay for it.

This seems to be a peculiarly American mindset. Here, you'll find any number of people bitching like mad about social security scroungers, people who manage to get money handouts and housing and so on from the state under dubious pretences. Some newspapers seem to support their entire circulation with such diatribes. But I have never once, in my entire life, heard anyone extend that to suggest that these people should be deprived of healthcare.

Why is the payment system for healthcare in the US complex? Does it have to be as complex as it is?

Other countries do not need the complexity you have described their healthcare system for managing the flow of money from patients to providers.

I think the biggest problem to overcome in the US healthcare industry is the vested interests of physicians, insurance and pharmaceutical companies, etc., who will all start complaining VERY LOUDLY if the boat is rocked too far from their current comfort zone.

I think there's more than a grain of truth in that. But I think there's something else more fundamental at work, related to what I said above. A deep-seated desire to make every individual pay for what they receive, and to insist that they make arrangements, somehow, to be able to do so.

The most basic way to pay would simply be for everyone to put their hand in their pocket and pay for whatever they receive. Decades ago, this was how it worked. But with the increasing ability of medical science to fix things, comes increased costs. With this payment system, only the very wealthy or the very lucky will be able to meet their costs. This also disadvantages the medical providers, who lose out on a huge market of people who would like to purchase their product but simply can't afford it.

So the medical insurance industry was invented. And a very good thing it was too, for its time. I see it now in my own profession, where pet health insurance has allowed many pet owners of only modest means to access cutting-edge treatment for their pets. However, having a pet is not a necessity of life, and human medical bills are routinely an order of magnitude greater than veterinary bills.

The primary feature of the insurance industry is that premiums are set according to risk. So, if you're a young male driver with a bad accident record (no matter how impecunoius) you'll pay more car insurance than a middle-aged woman with a perfect driving record (no matter how wealthy). Fine. Having a car (especially a high-insurance-rated one) is not a necessity of life either, and you do have a choice. However, when that is applied to health insurance the result is that the people who are expected to pay the most are those seen as being at greatest risk of making a claim, with no account taken of whether they can afford to pay more or not. And having healthcare is a necessity of life in many cases.

Employment-based health insurance seems to have been a response to this, with the company pooling the risk of all the employees so that everyone is covered for a similar premium. Better, but of course this leads to the coupling of healthcare provision to employment, with all the problems that introduces (freedom to move jobs, employers going out of business, lack of choice of healthcare plan for the employee, and the employer can withdraw cover pretty much at will).

Some advocates of universal healthcare have suggested that insurance should be available to all at a flat-rate fee, with no variation according to perceived risk. This would remove the coupling to employment, but I question whether it would be practical.

Remember the poll tax? The huge practical disadvantage of this was that if the flat rate was set low enough so that nobody would be unable to pay, then the amount of money raised would not even cover the cost of collection, never mind pay for the services it was supposed to pay for. And the wealthier sections of society would be paying a derisory sum. If on the other hand it was set high enough so that enough money would be raised to fund the services (in this case, things like schools and rubbish collection and road maintenance), then the poorer members of society would simply be unable to pay it. I fear that exactly the same would be true of a flat-rate health insurance scheme.

That brings us to the other way to fund this. Payment due is set not as a flat-rate fee, or varied according to perceived risk, but varied according to ability to pay. In this way sufficient money can be raised to fund the system so that everyone can receive the care they need, and nobody faces a bill that they simply can't meet.

It's how we fund the schools, and the public libraries, and the roads, and the foreign embassies, and the fire brigade, and the museums, and lots of other things. It's how these things are funded in the USA as well.

But the minute you suggest that healthcare be funded like this (and the parallels between healthcare and the fire service are quite strong), a significant proportion of US posters start shouting about communism, and having their money confiscated to pay for other people's bills, and people demanding something for nothing, and even "loss of freedom", and so it goes on.

As I see it, with the irreducible costs of medical treatment being at the level they are today, you either have some system where the wealthy pay more so that everyone can be covered, or you accept that people on low incomes are going to suffer and possibly die for lack of treatment that could save them. I simply don't understand why this is communism, and theft, and slavery and so on. To me it seems merely civilised.

But the US mileage obviously varies, and that's really what we're arguing about.

Rolfe.

 

[Rolfe]

Hmmm. Silence for several hours.

It seems to me that ideological objections to that last system of funding, which frankly seems to me to be the only method of ensuring that the system is funded, may be an insurmountable hurdle for universal healthcare in the USA.

So often, when such a system is described, the main reaction comes down to, "but then the stupid and the lazy and the feckless and the reckless will benefit!" Well yes, they will. Along with everybody else.

Is this right? Well, what's the alternative? Either the people who are better off, more provident and generally luckier pay more (one way or another) so that these people can be treated, or they are left to suffer and die for want of treatment. Insisting that no, you don't want these people to suffer, but at the same time you don't want to pay anything towards their treatment, is simply irrational.

Nevertheless, this method of funding seems deeply unpopular. It's described as communism, slavery, confiscation, theft, loss of liberty, oppression, a threat of violence and I don't know what else. Well, so how come nobody seems to be rioting because the roads and the rubbish collection and the public libraries and the fire service and the foreign embassies are funded in that way?

But somehow, medical care is different. There seem to be a lot of people who will accept this method of funding medical care for the population only over their own dead bodies. And this seems to be fundamentally unrelated to objections about efficiency and choice and quality of care. No matter how often these issues are discussed, it almost always seems to come back to, but it's wrong for the stupid and the lazy and the feckless and the reckless to receive medical care they can't pay for. And it's wrong that the wealthy should be obliged to pay disproportionately more so that low-income people can benefit (disregarding the fire service and the libraries and the embassies and the schools and the roads and all the rest of it).

Experience in just about every other developed country demonstrates that everyone benefits from universal healthcare - even the very wealthy, who get to inhabit their own swanky private hospitals without any interference from the Great Unwashed banging on the doors. But it does have this terrible downside. That same Great Unwashed are provided with medical care. Whether they "deserve" it or not. This seems to be the great dealbreaker for a distressingly large segment of the US population.

I asked Dan Stanley this. Suppose your fairy godmother came along and said, "Dan, you can have anything you want in the world. Your one great dream, the thing you've always wanted, you can have it. There's only one catch. Your worst enemy will also be granted his dearest wish. Do you accept the offer?"

It does seem to me as if the naysayers to universal healthcare in America, at bottom, are in the camp that would decline that offer.

Rolfe.

 

[TragicMonkey]

Hmmm. Silence for several hours.

Because I was at work.

I give up. I've already been accused of having a bad view of human nature, and I cannot possibly defend actual US practices against the socialist utopian vision that the residents of small-population countries claim to enjoy.

My practice just decided to write off several dozen million dollars of costs because we don't want to pass them on to the patients. But we are still mercenary, and evil, and corrupt, and have vested interests.

Funnily enough, our thousands of patients really seem to like us anyway!

So go. Go, with your outsiders' knowledge of how things ought to be, and construct the perfect healthcare system. You won't need to know how the current system works, of course, because you have already decided it doesn't. So you need no further input from me. Go on. What's taking so long? Why haven't you erected paradise from your brilliance? Don't waste your genius in messageboard arguments. Lobby the UN. Write down your plan! The world eagerly awaits your guiding light!

 

[Rolfe]

I don't think you personally are mercenary or corrupt or anything of the sort. And certainly not evil. And I'm sure your patients like you. Also, it wasn't specifically your silence I was remarking on.

However, I find it very hard to understand how you can declare that the system you have "works", when there seems to be so much evidence of US citizens simply falling through the net.

And I don't think the UN or the world needs to know anything that was said here. Most countries are managing reasonably well, though no doubt there can always be improvements. If the USA was one of these, though, we wouldn't be having this conversation.

Rolfe.

 

[Ziggurat]

All I want is that healthcare be available to everyone irrespective of their ability to pay. And lucky me, I have it - and so does everyone in the developed world except in the US.

This is simply false. Care is available to everyone regardless of their ability to pay. What level of care is available to all may differ, but that's not the same thing at all, and it is not uniform outside the US either.

Giving care to peole who can't pay is only a problem in your system, not ours.

No, it's a problem in every system. The exact shape of the problem varies, but every system must ration care, and so unless you actually forbid buying health care services, there will always be cases of people who can't get care for something because they can't pay.