Conservatives, under what conditions would you allow universal coverage?

[Darat]

...snip... Occasionally they get it wrong and as always happens, it goes to court and the drug/treatment is either rejected by the courts (and still available for private purchase) or immediately allowed on the NHS.

And it has several times forced the drug companies to either reduce their prices or even enter into agreements in which they (drug companies) will fund the initial treatment. Which of course means we get more for our money.

 

[stokes234]

I think it was you that posted the per capita numbers I used to derive that. They showed a difference between US and Canadian per capita expenditures of 3,000 per capita. Multiplying that number times our population of 308 million gives 945 billion dollars. Using the unweighted average from your table lead to exactly a trillion dollars.

...

It was you who told me that we spend more and get less. Your numbers put the amount "more" at 3,000 per capita. And in the post I'm replying to you only identified about 600 per capita in systemic waste. That 2000+ discrepancy is at least a little evidence. My first post in the thread also linked to several sources of evidence of this (plus some opinion pieces I didn't agree with). Let's say I'm wrong about that though, does it change the claim that if the US removes a trillion from the industry that there aren't many countries or entities that can fill that gap?

So lets say that the removal of administrative costs only saves 300 billion dollars a year for the american economy. Isn't that good enough to justify it?

And as to "a trillion dollars being removed from the industry" - either its 300 billion that gets saved, or a trillion, or somewhere in between, but it's a different industry. I see absolutely no explanation from you as to why this has to be related to medical research. Nobody is arguing for a reduction in medical research spending (at least, not in useful research - some are questioning whether new drugs with a tiny improvement for huge amounts of cash are strictly worth it). Your entire case appears to be you employing the argument from incredulity to say that you cannot believe that administrative costs can be removed without taking research funding with them. You've yet to give anyone an explanation of why not.

 

[Darat]

An interesting extract that highlights the different funding models between the UK and the USA:

http://en.wikipedia.org/wiki/Sunitinib#UK

...snip...
Costs

...snip...

Doctors and editorials have criticized the high cost, for a drug that doesn't cure cancer but only prolongs life.


US

In the U.S., insurance companies have refused to pay for all or part of the costs of Sutent. Because Sutent is an oral therapy, the "co-pay" associated with this therapy can be very substantial. If a patient's secondary insurance does not cover this, the cost burden to the patient can be extreme. Particularly challenging is the "donut hole" for Medicare part D coverage. Patients have to spend thousands of dollars out of pocket to get through the donut hole. If this is done at the end of a calendar year, it has to be paid again at the beginning of the next calendar year which may be burdensome financially.

UK

In the UK NICE refused (late 2008) to recommend sunitinib for late stage renal cancer (kidney cancer) due to the high cost per QALY, estimated by NICE at £72,000/QALY and by Pfizer at £29,000/QALY. This was overturned in Feb 2009 after pricing changes and public responses.

ETA: Should add that because a drug treatment is not recommended by NICE it does not mean the drug is not available. A patient may still find that their local health authority will fund it or there may be a way to "co-pay". The difference between a NICE recommended treatment and a treatment without the recommendation is that you have a legal right to any NICE recommended treatment (if it is medically indicated).

 

[mhaze]

Did you not actually read what TraneWreck posted above?

.....

Hold on a second. I wrote that I also, had experienced that ACTUAL level of "service" at American social security and other offices of government service.

And I wrote that based on that experience base I wouldn't consider handing the health care industry over to those clowns.

What part of "wake up and smell the coffee" have I not woken up and smelled? I've based my opinion on simple extensions of actual institutions in the US, you've done some kind of a "It's great here in Britian, so it'll be great there" assertion.

 

[stokes234]

Hold on a second. I wrote that I also, had experienced that ACTUAL level of "service" at American social security and other offices of government service.

And I wrote that based on that experience base I wouldn't consider handing the health care industry over to those clowns.

What part of "wake up and smell the coffee" have I not woken up and smelled? I've based my opinion on simple extensions of actual institutions in the US, you've done some kind of a "It's great here in Britian, so it'll be great there" assertion.

If you won't accept the european success, then you appear to be implying that american government workers are different to european government workers. Since it's unlikely to be related to pay or benefits (i'm sure you're one of the guys who thinks those should be reduced for government workers, so you can't see much of a correlation), then I have to ask - do you think americans are inferior because of cultural reasons, or genetic? Neither is a particularly nice claim.

 

[RecoveringYuppy]

In the UK, the government (through NICE) decides what drugs are going to be cost effective for the NHS, and buys the ones it think will give the population the best benefit using the budget it has. Drug companies fund drug research themselves and try to sell them to the NHS. If the government wants to increase drug research funding, it can give the NHS a bigger budget to spend on drugs, encouraging the drug research companies to compete for a larger bid by increasing their own expenditure. The same would apply to the US, the effect probably being a good deal greater.

OK. But that doesn't sound like direct control to me, which is what I thought you were saying earlier. It does sound a bit more regulatory than would be ideal IMO but not unreasonably so. BTW are the drug companies in the UK only allowed to deal with the NHS/NICE? I presume not and that these companies are also selling to other countries.

I want to nationalize health insurance not the entire health industry. What you described earlier sounded close to full nationalization or maybe excessive micro management.

 

[stokes234]

OK. But that doesn't sound like direct control to me, which is what I thought you were saying earlier. It does sound a bit more regulatory than would be ideal IMO but not unreasonably so. BTW are the drug companies in the UK only allowed to deal with the NHS/NICE? I presume not and that these companies are also selling to other countries.

I want to nationalize health insurance not the entire health industry. What you described earlier sounded close to full nationalization or maybe excessive micro management.

Yeah, I didn't mean direct control - I don't have a specific problem with private drug research, because I can see the benefits on profit motive even while reading the myriad horror stories about false information, buying academic approval etc (read more of Ben Goldacre's blog for more examples of that). Medical research itself is typically done in universities as I understand, and I can't see a reason for this to be affected by a change in healthcare administration.

However, I do think that the providers of health services themselves should be public, rather than the approach the UK is taking of switching to publicly funded but privately provided healthcare.

 

[RecoveringYuppy]

So lets say that the removal of administrative costs only saves 300 billion dollars a year for the american economy. Isn't that good enough to justify it?

Of course it is, I've said I'm willing (but not needing) to pay more for UHC if need be. I think UHC is justified without cost savings.

BTW I don't think the numbers we've seen in this thread actually justify a claim that we'll have a net saving of 300 billion after implementing UHC. The 300 billion seemed to be a saving we would achieve from our current starting point, prior to extending coverage to everyone. In plainer but loose language it's money we could apply towards extending coverage.

And as to "a trillion dollars being removed from the industry" - either its 300 billion that gets saved, or a trillion, or somewhere in between, but it's a different industry. I see absolutely no explanation from you as to why this has to be related to medical research.

I don't know that it is. And it isn't my problem to explain it. I'm not the one calling for reduced costs. I'm perfectly happy to extend health care to everyone at it's current, or even higher, costs in the interests of not "rocking the boat".

The burden is on people who are claiming we can achieve a great cost reduction. In this there have been several strong implications that we could get in to the range of other countries, in particular Canada. But there has only been handwaving to support that claim.

Nobody is arguing for a reduction in medical research spending (at least, not in useful research - some are questioning whether new drugs with a tiny improvement for huge amounts of cash are strictly worth it).

Right, no one is arguing for that. But there are people arguing for cost savings without saying where they are going to come from. Some people in this thread have offered no explanation other than other countries have done it. Some people have said where but offered no reason to believe there is enough money in that area to get us in to the per capita range that other countries are in. One person just recently put some numbers to it and still left the US well above every other country in the per capita expenditure chart that Tranewreck provided.

Your entire case appears to be you employing the argument from incredulity to say that you cannot believe that administrative costs can be removed without taking research funding with them. You've yet to give anyone an explanation of why not.

That isn't what I don't believe. I believe that administrative costs can be eliminated without taking medical research dollars with them.

What I don't believe is that we can get our per capita expenditure in to the range of other countries on the chart presented before without major impact on health care quality. So my question is directed at people who think we can to explain how they are going to achieve such saving. Look at the chart provided by Tranewreck. It takes cutting our per captia expenditures in half, a trillion dollars gone somewhere, to become average in that chart. It takes about 30% reduction, 600 billion dollars, to even tie for top place in that chart. Glib statements that we are going to achieve that by cutting admin costs or economies of scale aren't adequate explanation.

May I ask why you are arguing with me? Do you have a specific cost saving or per capita number you think UHC in the US should try to achieve?

 

[TraneWreck]

I think it was you that posted the per capita numbers I used to derive that. They showed a difference between US and Canadian per capita expenditures of 3,000 per capita. Multiplying that number times our population of 308 million gives 945 billion dollars. Using the unweighted average from your table lead to exactly a trillion dollars.

These numbers seem defensible but these kind of cuts won't put us anywhere near Canada's per capita. We'll still be at the top of the chart on a per capita basis (not that I think that's a bad thing).

Ah, I see now. I would not imagine that any version of UHC adopted by the states would immediately close that per capita gap. The point with administrative costs, however, is that we spend somewhere between $100 billion and $200 billion a year on completely useless costs compared to countries with UHC and even our own single payer system.

Administrative costs are just one of the endless cost control advantages. The reason I brought those up is because of how totally pointless that expenditure is. It has nothing to do with treating people or research or anything important, it's just a reflection of a totally inefficient system.

The total story of cost control is insanely complicated. For instance, when the debate over Obamacare was raging, I heard a report on Dr. Dean Edell that in areas with more doctors, costs increase dramatically. One would imagine that in a capitalist system, having many doctors practicing in a given area would lower costs through competition. What really happens, however, is that they start referring patients to one another when they could very well treat them at one place.

Obviously there are a thousand different elements at play including the odd system of referrals we use in this country, the fear of being sued, and the fact that areas with many doctors tend to be more wealthy areas and the patients tend to have the sort of insurance that makes multiple referrals very lucrative for doctors.

I have no idea how to estimate how much we pay on a per capita basis because of a feature like that. That sort of activity doesn't go on in UHC countries, for a variety of reasons. A raw number for how much we'd save immediately would be purely speculative, but it's clear that we'd save, at a minimum, hundreds of billions of dollars annually and cover everyone.

It's also before factoring in that we want to extend coverage to tens of millions of people who aren't currently covered.

Remember, we pay for those people already. They get the most expensive type of emergency care and insurance companies reflect that cost through premiums.

When you add in the legal fees from bankruptcy the administrative collection fees and the total social fallout of economically destroying people because they got sick/had an accident, 46 million people without insurance is incredibly expensive. Just punting those people on Medicare tomorrow would (after an initial increase in cost) save quite a bit of money over time.

It was you who told me that we spend more and get less. Your numbers put the amount "more" at 3,000 per capita. And in the post I'm replying to you only identified about 600 per capita in systemic waste. That 2000+ discrepancy is at least a little evidence.

No, I identified about 600 per capita in unnecessary administrative costs. That's just one portion of systemic waste. It's just a clear, easily quantified difference, but hardly the total.

My first post in the thread also linked to several sources of evidence of this (plus some opinion pieces I didn't agree with). Let's say I'm wrong about that though, does it change the claim that if the US removes a trillion from the industry that there aren't many countries or entities that can fill that gap?

Why would we want to fill that gap?

 

[Travis]

Hold on a second. I wrote that I also, had experienced that ACTUAL level of "service" at American social security and other offices of government service.

And I wrote that based on that experience base I wouldn't consider handing the health care industry over to those clowns.

What part of "wake up and smell the coffee" have I not woken up and smelled? I've based my opinion on simple extensions of actual institutions in the US, you've done some kind of a "It's great here in Britian, so it'll be great there" assertion.

And the problems with those institutions is that they have to try and not cover as many people as possible. You consider them "clowns" probably because they have to deal with a byzantine system with multiple rules on multiple levels to try and disqualify as many people as possible while they, as decent human beings, try to get people qualified.

Now imagine them if they just covered everybody and no longer needed those rules.

 

[RecoveringYuppy]

Ah, I see now. I would not imagine that any version of UHC adopted by the states would immediately close that per capita gap.

Then we probably would both be supportive or accepting of the same UHC proposals.

Remember, we pay for those people already. They get the most expensive type of emergency care and insurance companies reflect that cost through premiums.

Not sure about that. The anecdotes from Travis say he doesn't.

No, I identified about 600 per capita in unnecessary administrative costs. That's just one portion of systemic waste. It's just a clear, easily quantified difference, but hardly the total.

Right. Don't think my wording implies you've identified all systemic waste. It just implies that if there is more it's currently unidentified and unquantified. I'm not against plans that can cut identified waste. My issue is with assuming without good reason that we can lower our costs to that of other countries. Some posts in this thread have implied that. I believe I can find one where you implied that, but based on what I've seen since I'm guessing you were just being glib or there simply isn't enough time in the day to explain all your thoughts on a subject every time you make a post.

Why would we want to fill that gap?

Someone needs to tell me what's in the gap before I can answer that. Neither you nor I seem to be advocating UHC proposals that would unthinkingly create such a gap so it's kind of moot point to discuss.

 

[lomiller]

Right, no one is arguing for that. But there are people arguing for cost savings without saying where they are going to come from. Some people in this thread have offered no explanation other than other countries have done it. Some people have said where but offered no reason to believe there is enough money in that area to get us in to the per capita range that other countries are in.

I’ve already explained why US heathcare administration costs are so high but here it is again in greater detail.

Private insurance relies on placing people into risk pools to determine how much they should pay for their insurance and how much coverage they receive. This system is inherently vulnerable to self selection, free riders and fraud, which insurance e companies need to put a lot of effort into enforcement and this not only costs money it ties up doctor/hospital time justifying the treatment they provide.

To explain the self selection and free rider problem a bit more. The basic business of an insurance company is to take people with similar risks of something happening, estimate what that risk is and how much it will cost if it happens. They can then calculate how much they expect to have to pay out in claims and set their premiums so they collect more than that and make a profit on the difference.

With medical insurance what can happen is people don’t buy insurance until they find out they have a condition or their risk of getting a condition increases and not buy insurance until this happens. What this means for the insurance company is that you have fewer people paying premiums but your claims remain the same which means they say by-by to any hope of making a profit. To counteract this they must extensively screen all their clients to make sure they actually belong in the risk pool the company is selling insurance for. If they don’t they end up with more claims then they collect in premiums.

This is why insurance companies prefer to work though employers because it limits the opportunities for this type of self selection. Figures I read a couple years ago suggested in many cases open market individual insurance was running at ~3X what similar policies though employers were running and this is a direct result of this type of insurance being more vulnerable to self selection.

In most other healthcare systems you are not allowed to do this. I.E. you can’t wait until you have a condition before you try to buy insurance, you must participate in a risk pool, you get the coverage defined by that risk pool and you can’t “opt out” of payment until you have a condition you want treated.

 

[TraneWreck]

Not sure about that. The anecdotes from Travis say he doesn't.

Travis was talking about health insurance. If he, without insurance, was in a car wreck, the ambulance would still drive him to the hospital and he would still receive treatment, he'd just leave with $100,000 bill hanging over his head. That labor was already done, the treatment was already done, it's a matter of who pays the hospital back.

Right. Don't think my wording implies you've identified all systemic waste. It just implies that if there is more it's currently unidentified and unquantified. I'm not against plans that can cut identified waste. My issue is with assuming without good reason that we can lower our costs to that of other countries. Some posts in this thread have implied that. I believe I can find one where you implied that, but based on what I've seen since I'm guessing you were just being glib or there simply isn't enough time in the day to explain all your thoughts on a subject every time you make a post.

Whether or not that gap can be entirely eliminated is a separate question from whether it can be narrowed to something within reason. We pay 33% more than the nearest industrialized country, and twice as much as countries who cover everyone and have better health outcomes.

Bringing our spending in line with the world standard, even if we're on the high end, will save us hundreds of billions of dollars a year. I don't understand what feature of America or the American people makes this impossible. How are we different than the combined population of England, France, Germany, Switzerland and Scandinavia?

Again, Medicare has results that are roughly in line with those world standards, and that's the riskiest, most expensive population to insure. I don't see why brining healthier, cheaper people into that risk pool would do anything but improve the average cost and outcome.

 

[WildCat]

administrators=bureaucrats
so, by definition, they don't do anything useful.

What if they're unionized bureaucrats? Then they're useful, right?

The possibility exists.

The possibility that I am banging a woman who looks like Halle Berry's better-looking sister also exists.

You guys do know that was a joke, don't you?

 

[WildCat]

In related news:

Life expectancy at birth for American men was 75.6 years and 80.8 for women in 2007 -- 36th and 33rd in the world -- with wide variation from county to county, researchers said.

County-level life expectancies for men ranged from 15 years ahead of an international average of top-performing nations to more than 50 years behind, Christopher Murray, MD, of the University of Washington in Seattle, and colleagues reported in Population Health Metrics.

The range for women was 16 years ahead to more than 50 years behind.

"The U.S. picture, with its remarkable combination of poor health outcomes despite the highest levels of health spending per capita, is even more stark and disturbing when examined at the local level," Murray and colleagues wrote.

http://www.medpagetoday.com/PublicHealthPolicy/PublicHealth/27081

"The best health care in the world"

 

[bikerdruid]

What if they're unionized bureaucrats? Then they're useful, right?

if cockroaches unionized....they would still be cockroaches.

 

[RecoveringYuppy]

I’ve already explained why US heathcare administration costs are so high but here it is again in greater detail.

Thanks, but you haven't mentioned a single number. That's the detail that determines whether I agree or disagree with whatever you're proposing. Everything you just said about why they are high is non controversial to me.

 

[Dr. Keith]

Of course it is, I've said I'm willing (but not needing) to pay more for UHC if need be. I think UHC is justified without cost savings.

Noted.

BTW I don't think the numbers we've seen in this thread actually justify a claim that we'll have a net saving of 300 billion after implementing UHC. The 300 billion seemed to be a saving we would achieve from our current starting point, prior to extending coverage to everyone. In plainer but loose language it's money we could apply towards extending coverage.

But doesn't that ignore the fact that everyone in the US is covered by our medical system, even if not covered by insurance. A car full of illegal aliens will be treated at the nearest hospital if they get in a wreck. A homeless person passing out on the street will usually end up in a hospital. So, it doesn't make sense to pretend that adding them to "the system" will increase costs so much when we already cover their most expensive treatments.

We just ignore their health.

The changes to the American system to make it even comparable to UHC would be immense and would likely take a decade or more to be fully realized. That we can't point to a specific number of where the savings will come from seems a bit arbitrary. We have several examples of UHC costing less and getting better outcomes in other countries, so the real onus should be on those that claim it will cost more to show why.

So far, I have not seen a very compelling argument that Americans can't have UHC.

 

[lomiller]

Thanks, but you haven't mentioned a single number. That's the detail that determines whether I agree or disagree with whatever you're proposing. Everything you just said about why they are high is non controversial to me.

Others have provided how much more per capita the US spends on administration.

Is seems to me like you disavow your own claims under the guise of “just asking questions” but are insisting on increasing high levels of evidence for any anything you don’t want to hear and simply intend to ask for more and more specific answers until people tire of answering you . This is a common style for proponents of many types of woo...

 

[Rolfe]

However, I do think that the providers of health services themselves should be public, rather than the approach the UK England is taking of switching to publicly funded but privately provided healthcare.

England is in the middle of a big argument about it. Scotland has no intention of going there. Don't think Wales or NI do either.

Don't forget that the four countries that make up the UK each has its own NHS, we just have full reciprocity.

Rolfe.