Paul Krugman endorses Death Panels

[joobie]

How many people come up against the boundaries of coverage in the US system, I wonder?

i have better heath coverage than nearly anyone i know, and still cannot afford the co-pays for treatment i need.

 

[Meadmaker]

You may be told to stop smoking if you want your cancer operation, because the surgery is too high-risk on a smoker. You may be told to lose weight if you want to have your joint replacement, because the mechanical joint is simply not going to work beyond certain tolerances.

Are these things that really happen, or are they hypothetical examples of things that might happen?

Are there examples where NHS actually restricts care based on patient lifestyles?

 

[Rolfe]

I don't like the idea of allowing the government to get involved in every stinking decision of my life, that's not freedom. Collectivism by itself makes me sick to my stomach.

That's a bit strong! Healthcare is not "every stinking decision of my life". I don't know about you, but I can go a long time without needing to access healthcare at all. Getting ideologically aerated about a system that delivers the goods without asking me to part with a penny in return seems a bit of a waste of emotional energy. (And being able to access any doctor I want/need, at whatever hospital I choose, with no restrictions on the care I can receive, seems uncommonly like freedom to me.)

In any case, what the government is mostly doing is paying for it. The doctors make the decisions. I'd far rather have that, than have some insurance claims assessor quibbling about every cotton-wool ball or aspirin tablet.

But you said that preexisting conditions aren't covered, so you don't have that option?

And I'm going to take a bit of convincing that your system works the way you say it works, in the light of the numerous heartrending threads I've read on this very forum about Americans at the end of their tether because they can find no way to access treatment they need.

The same thing happens in our system. The doctor doesn't necessarily give you all the options, just the options they prefer or are familiar with. Quite often people receive second opinions. Is this allowed or does this happen very frequently in your system? It makes sense both systems experience this because the medical facilities are made of people that choose how to run their business; they aren't controlled by an organization that says exactly how they should conduction business.

Indeed, people can have second opinions to their heart's content. A doctor not being familiar with all the options seems to be something that can happen in any system, though I think given the volume of "best practice" guidelines disseminated to NHS doctors emanating from the top specialists' committees, it's less likely in our system.

I was actually talking about differing views being held by different doctors as to the usefulness of a particular procedure. Nobody is dictating to the doctors what they have to do, and they have their personal preferences. The physio, knowing that I was medically qualified myself, told me which doctor had which preference so that I could choose the one likely to offer a treatment that I might prefer. (I didn't prefer it, having actually been awake in the relevant pharmacology lecture, so we dropped the subject.)

What I'm trying to get through to you is that the NHS aims to offer all viable, evidence based options, and to allow the patient to choose. It's practically a matter of dogma. It actually upsets some patients. They don't want to be faced with all these decisions, they want a doctor who knows best and takes charge and makes them feel safe. But the doctors have to "involve the patient in the decision-making process" whether the poor bloody patient wants to be involved or not!

Because you have a choice of more than on provider, otherwise you don't have a choice at all. Allowing the insurance providers to be diverse is a good thing. Would it make sense to nationalize medical providers?

I just don't see it. Why make things so complicated, forcing people to switch providers to access different options? I cannot for the life of me see what's wrong with having all the options available under the umbrella of a single provider.

Nationalise? I don't know, it's your country. I think it's something the USA is unlikely to do. Maybe you need to look at how countries using an insurance-based system manage to deliver effective universal healthcare. I don't have familiarity with how all that works, but there's no doubt that there is a wide variety of systems out there, and it's the US system that stands out as costing the earth and leaving so many people without cover.

This was an issue in our current model. Now, based on my limited understanding, if you are insured with company A for 12 continuous months with no lapse in coverage, then you can not be denied insurance from company B, which has different coverage.

I fear I'm going to take a bit more convincing than that. To put it at its most simplistic, you feel healthy, so you take cheap cover from cheap company A, which doesn't cover certain expensive drugs you think you'll never need. You'd rather not go for expensive company B that covers these drugs. Then you get sick, and you need the expensive drugs after all. So you go to company B, and say, I insist you cover me for this condition I already have, so I can get the expensive drugs I'll definitely need.

How does that work? Company B is being asked to take on a definite loss. The only way they're going to do that is if the government has passed a law insisting they have to do it. I thought you didn't like government interfering in your life? Isn't that a bit iniquitous, legally forcing a commercial company to do something that will guarantee a loss?

I suspect the catch in this is what company B might then charge you for coverage under these circumstances, though hopefully some US citizens might come on and explain the detail to us. You're sick, maybe you can't hold down your job any more, or if you can it's a struggle, but to get the coverage from company B, you have to pay them more than your monthly income. Is that how it works?

I still think this talking point is flawed. This is exactly how a lot of government programs work, you pay taxes for something you might not personally benefit from.

Indeed. Paying for schools, when you have no children, is a good example. However, I've come across a lot of Americans who don't like this concept at all.

You have to understand the context of the observation. American critics of the NHS come along and chastise us because the NHS gives us no "choice". We don't have "freedom". We point out that Britain has a range of private health insurance providers and we're completely free to take out cover with any of them if we want to.

The instant come-back is, ah, but if you do that, you can't stop paying the tax to fund the NHS! You're in shackles! Well, no. We can't stop paying the tax to find the NHS, just as Americans can't stop paying the tax to fund the government-funded healthcare in the USA. And we know that the US tax take for that purpose (per capita or as % GDP) is rather more than the British tax take for the NHS.

We're pretty much even as far as being taxed to fund healthcare is concerned. And neither of us can choose to opt out of that tax. The difference is that in Britain we have the right to access the service our taxes pay for, while in the USA most taxpayers can't access the service their taxes are paying for, and are forced to pay out all over again to make private arrangements.

Which in my book makes us more free, and with better choices.

I agree. It's unfortunate that it's difficult to make comparison between countries.

Indeed. However, you were claiming that cancer statistics in the USA are better than in Britain, and inferring that the possible availability in the US of some hyper-expensive drugs that have a marginal effect on survival times, which aren't available on the NHS, might be the reason for this.

I'm pointing out that the lack of a public healthcare system in the USA means that it's impossible to access reliable statistics to make such a comparison. It appears that in the USA, statistics are collected mainly from the patients who are actually in the system. Those who cannot access the system, who are forced just to live with their problems, don't get counted.

While I don't necessarily agree with homeopath, this is one reason why I don't want a national health care system. I wan't diversification in the system. I want us to be able to learn the pros/cons from trying different things. This is very important to continue to learn, grow and improve.

I have absolutely no idea at all why you think we can't "learn the pros/cons from trying different things" without having a bunch of competing insurance companies making obscene profits from people's illness. Where is the NHS lacking as regards research and innovation, that having insurance companies involved would rectify?

To be quite honest, that remark (and indeed quite a lot of your other remarks) appear to be driven by an ideology that has no basis in the real world.

Our current system has to be changed. I've never said (meant to say) otherwise. Just like journalist stories get twisted in the UK, the same thing happens here.

Yes, your current system is a mess, and people are suffering. Some of them are JREFers, so we know quite a bit about it. You're not doing so well as regards changing it though, are you? And again it seems to me that blind ideology is in the way here. You have no idea how competing insurance companies might allow more innovation and progress than a single-payer system (hint, it doesn't), but you've got that so fixed in your head that you can't see past it.

I answered this above.

No, I don't think you did. I think you misunderstand the situation, as I explained. You seem to think that anyone who is insured even with El-Cheapo Inc, who needs a drug so expensive and so new that NICE hasn't yet approved it, could in America simply switch insurance providers with that pre-existing condition, and get that drug, no muss no fuss. You're saying that you can choose ahead of time, deliberately, not to insure yourself against a certain need, and then when you have that need, demand to receive it anyway. And you think your government has legislated to force businesses to give it to you, at a guaranteed loss. And you think you could afford what that business might decide to charge you for that.

Thanks, but I'll place my faith in the NHS every time.

Rolfe.

 

[kellyb]

Are these things that really happen, or are they hypothetical examples of things that might happen?

Are there examples where NHS actually restricts care based on patient lifestyles?

Patients are told to lose weight in the US before getting hip replacements, too:

http://orthoinfo.aaos.org/topic.cfm?topic=a00377

Weight Loss
If you are overweight, your doctor may ask you to lose some weight before surgery to minimize the stress on your new hip and possibly decrease the risks of surgery

 

[Rolfe]

Are these things that really happen, or are they hypothetical examples of things that might happen?

Are there examples where NHS actually restricts care based on patient lifestyles?

See, you're not getting it. Have you been reading the Daily Mail?

Certain lifestyle choices actually put certain medical options off the table. Smoking can render particular surgery too high-risk to perform. Obesity, too. If you are a smoker, or obese, then you may not be able to have certain surgical procedures - not because anyone is "restricting care based on patient lifestyles", but because the bloody operation either won't work or will kill you.

This must happen in the USA as well. It's inevitable.

For example. A friend of mine, who had been extremely overweight for many years (many failed diet attempts) needed gall bladder surgery. It was explained to her that a keyhole procedure was by far the best operation for her, but that it couldn't be done unless she was under a certain weight. So she was given a crash diet, just shakes and the odd biscuit, all carefully balanced for nutritional requirements (and yes she was given this - bye-bye grocery bills!), and the weight just fell off. She said she felt great, better than she'd felt in years.

That's how it works. Or doesn't work, if the patient doesn't stick to the diet. And if they don't, and they can't have the procedure as a result, a certain type of person will run to the tabloid journalists and complain that the horrible judgemental NHS is denying them their operation because they're a fatty. And the Daily Fail will obediently print a story about how patients are being denied treatment if they are obese.

It's one of the problems of the openness and accountability of the NHS. People complain, and demand, and lobby. Often the best-organised complainers get what they want, even if only to stop the bad headlines, while those who can't complain (think geriatric mental health for example) miss out.

But you still won't get your delicate arterial surgery if you smoke, because it would all just unravel. The solution is to quit the weed, not to go running to the tabloids.

Rolfe.

 

[Rolfe]

This must happen in the USA as well. It's inevitable.

Patients are told to lose weight in the US before getting hip replacements, too:

http://orthoinfo.aaos.org/topic.cfm?topic=a00377

See, I told you! The only difference is that in the USA, aggrieved patients don't go running to the tabloids complaining that they're being denied treatment because someone disapproves of their lifestyle.

Then US posters find these articles online, and go round telling everyone that "socialised medicine" won't treat you if you're overweight.

Rolfe.

 

[IchabodPlain]

Regardless, the criticisms you made of the single-payer system were either false or non-unique.

Well, I guess if you assert it...

 

[IchabodPlain]

Well, isn't it lucky nobody's suggesting you do that, then.

There are plenty of people in the US who would prefer a single-payer system. In fact, I know a few posters here who openly advocate for it.

British citizens are telling you that the NHS works pretty damn well and they want to keep it that way. They don't feel deprived of choice or anything else. And those who understand how things work - or rather don't work - in America, would rather gnaw off their own legs than live under such a system.

I am not asking the UK to change it's health care system. Rather, I was replying to your question.

But most of the incredulity is, given all the different ways of delivering universal healthcare that can be found in different countries, why the hell doesn't America sort itself out.

A multitude of reasons exist as to why America can't sort itself out. None of which were contained in my post which you were replying.

 

[Meadmaker]

See, you're not getting it. Have you been reading the Daily Mail?

Certain lifestyle choices actually put certain medical options off the table.

Dude, it was a question.

You mentioned hip joint replacement. Replacement hip joints work just fine, even in obese people. I suppose maybe they might not work in people that are over 200 kg or so, but in plain old obese people....yeah, they work fine.

On the other hand, obesity might be a factor in current and future joint pain, with or without replacement. I can easily see someone saying, "Losing 50 pounds would help your knees a lot more than knee surgery. If you aren't going to bother helping yourself, why should we help you?"

Blood pressure medication is a classic example. We have lots of drugs to treat high blood pressure, and they will lower the risk of death from heart disease in people who take them. On the other hand, an awful lot of fat, sendentary, people take blood pressure medication, at great expense to the people who pay for it. For that segment of the population, diet and exercise would be more effective for treating blood pressure. In some cases, diet and exercise alone would be adequate. In other cases, diet and exercise in conjunction with medication would further lower the risk.

So, my question is whether the NHS would ever, in such a case, deny treatment based on a lifestyle factor. I am not talking about a case where the physical condition (like being obese or having nicotine in the bloodstream) would render the treatment ineffective. I am talking about a case where there is a lifestyle change (like eating less) that would, if followed, render the treatment unnecessary. Would NHS ever deny payment for treatment in such a case?

 

[kellyb]

So, my question is whether the NHS would ever, in such a case, deny treatment based on a lifestyle factor. I am not talking about a case where the physical condition (like being obese or having nicotine in the bloodstream) would render the treatment ineffective. I am talking about a case where there is a lifestyle change (like eating less) that would, if followed, render the treatment unnecessary. Would NHS ever deny payment for treatment in such a case?

I live in the US but have been following international healthcare debates for years, and I'm pretty sure the answer is "no." I'm positive the answer is "not overtly".

In the US, we have "covert rationing" of healthcare. The NHS's NICE overtly (at least in recent years) rations care, and never, ever, have they deemed "lifestyle factors" grounds for denial of care.
There is a chance, however slim, that the NHS has done this covertly, tho.
But OTOH, the US insurance companies and the public programs a few can join, very openly deny healthcare to people (by "pricing them out") based on "lifestyle".

See:
http://www.consumerismcommentary.com/higher-health-insurance-premiums-for-overweight-discrimination/

So US citizens worried about what it's like in the UK are "projecting", I think.

 

[kellyb]

There are plenty of people in the US who would prefer a single-payer system. In fact, I know a few posters here who openly advocate for it.

I'm one of those people.

Even tho you oppose a single payer system (or a "triple payer" system as I like to think of it, since in Kellytopia there's a good system available to all, but the freedom to pay more for extra/better service is open, too) would you agree that we need to figure out where all the Medicare money is going? Like, some bi-partisan investigation into how UHC systems elsewhere are only half as expensive needs to happen. We need facts, and we lack them.

I know we don't collectively bargain for drugs (eew, "collectivism", I know.)

Our rationing is covert and thus both more creepy and more costly.

What else?

 

[ServiceSoon]

That's a bit strong! Healthcare is not "every stinking decision of my life". I don't know about you, but I can go a long time without needing to access healthcare at all. Getting ideologically aerated about a system that delivers the goods without asking me to part with a penny in return seems a bit of a waste of emotional energy. (And being able to access any doctor I want/need, at whatever hospital I choose, with no restrictions on the care I can receive, seems uncommonly like freedom to me.)

In any case, what the government is mostly doing is paying for it. The doctors make the decisions. I'd far rather have that, than have some insurance claims assessor quibbling about every cotton-wool ball or aspirin tablet.

Healthcare represents 1/6 of the economy in the US. That's a large portion of everyday life. And government continues to grow at a high rate. I know that that doesn't concern you, but there are a lot of American's that do care.

All of my personal records will be at the tips of government bureaucrats fingers. There goes another piece of the privacy pie. I know that that doesn't concern you, but there are a lot of American's that do care.

Something else I don't like about single-payer is the government becomes the ultimate authority on winners and lose everything in this industry; medical devices, pharmaceutical companies, biotechnology, alternative medicine (I know that makes your skin crawl), etc. Your success will be determined solely on your approval by the governmental agency, rather than letting the free market decide. I think this would reduce the amount of innovation.

And I'm going to take a bit of convincing that your system works the way you say it works, in the light of the numerous heartrending threads I've read on this very forum about Americans at the end of their tether because they can find no way to access treatment they need.

The change I speak about preexisting conditions won't take effect for adults until 2014.

Indeed, people can have second opinions to their heart's content. A doctor not being familiar with all the options seems to be something that can happen in any system, though I think given the volume of "best practice" guidelines disseminated to NHS doctors emanating from the top specialists' committees, it's less likely in our system.

The US has the same thing called associations.

Nationalise? I don't know, it's your country. I think it's something the USA is unlikely to do. Maybe you need to look at how countries using an insurance-based system manage to deliver effective universal healthcare. I don't have familiarity with how all that works, but there's no doubt that there is a wide variety of systems out there, and it's the US system that stands out as costing the earth and leaving so many people without cover.

Since you have nationalized health insurance and love it, I was just curious if you though the medical providers should be nationalized.

I fear I'm going to take a bit more convincing than that. To put it at its most simplistic, you feel healthy, so you take cheap cover from cheap company A, which doesn't cover certain expensive drugs you think you'll never need. You'd rather not go for expensive company B that covers these drugs. Then you get sick, and you need the expensive drugs after all. So you go to company B, and say, I insist you cover me for this condition I already have, so I can get the expensive drugs I'll definitely need.

How does that work? Company B is being asked to take on a definite loss. The only way they're going to do that is if the government has passed a law insisting they have to do it. I thought you didn't like government interfering in your life? Isn't that a bit iniquitous, legally forcing a commercial company to do something that will guarantee a loss?

There will probably be some of that. I can assure you that preexisting conditions will now be covered for adults effective 2014. This will fix a lot of the complaints that you read on the JREF from American's. This law will apply equally to all insurance providers, as it should.

I suspect the catch in this is what company B might then charge you for coverage under these circumstances, though hopefully some US citizens might come on and explain the detail to us. You're sick, maybe you can't hold down your job any more, or if you can it's a struggle, but to get the coverage from company B, you have to pay them more than your monthly income. Is that how it works?

AFAIK health insurance is still tied heavily to employment status. This is something we still need to work on.

I have absolutely no idea at all why you think we can't "learn the pros/cons from trying different things" without having a bunch of competing insurance companies making obscene profits from people's illness. Where is the NHS lacking as regards research and innovation, that having insurance companies involved would rectify?

I'm unsure. Everything in life is a trade-off and we lack the empirical data to make reliable assertions. The US spends twice as much as the UK per capita for medical research. Could this be part of the reason why the US pays more for medical expenses per capita compared to other nations?

Yes, your current system is a mess, and people are suffering. Some of them are JREFers, so we know quite a bit about it. You're not doing so well as regards changing it though, are you? And again it seems to me that blind ideology is in the way here. You have no idea how competing insurance companies might allow more innovation and progress than a single-payer system (hint, it doesn't), but you've got that so fixed in your head that you can't see past it.

Progress is painfully slow.

Thanks, but I'll place my faith in the NHS every time.

Rolfe.

Since you have no choice, it's a good thing you feel that way.

Patients are told to lose weight in the US before getting hip replacements, too:

http://orthoinfo.aaos.org/topic.cfm?topic=a00377

Your article says if you are overweight your doctor may ask you to lose a few pounds before surgery.

With the government in charge I see mandates to weight loss like in Japan. That's not freedom.

I'm one of those people.

Even tho you oppose a single payer system (or a "triple payer" system as I like to think of it, since in Kellytopia there's a good system available to all, but the freedom to pay more for extra/better service is open, too) would you agree that we need to figure out where all the Medicare money is going? Like, some bi-partisan investigation into how UHC systems elsewhere are only half as expensive needs to happen. We need facts, and we lack them.

I know we don't collectively bargain for drugs (eew, "collectivism", I know.)

Our rationing is covert and thus both more creepy and more costly.

What else?

I agree we need facts, furthermore I say we need them before we do anything to radical.

 

[kellyb]

Your article says if you are overweight your doctor may ask you to lose a few pounds before surgery.

With the government in charge I see mandates to weight loss like in Japan. That's not freedom.

No, that wouldn't be freedom, but insurance companies denying care based on lifestyle factors isn't freedom, either.

I agree we need facts, furthermore I say we need them before we do anything to radical.

I completely agree.

Also, I think we need to fix stuff like this as part of "fixing Medicare".
http://covertrationingblog.com/rest...es-it-limiting-individual-prerogatives-part-4

 

[TraneWreck]

Your article says if you are overweight your doctor may ask you to lose a few pounds before surgery.

With the government in charge I see mandates to weight loss like in Japan. That's not freedom.

This is such a bizarre understanding of the word "freedom" that it's difficult to have a conversation.

All surgery is a balance of cost and benefit. What are the advantages, what are the risks. Carrying too much weight may increase the risks to the point that it's no longer ethically responsible to perform the surgery.

Whether pinko-commie-scum or invisible-hand-job capitalist, that balancing test still exists. It's less one of economics than what a doctor can responsibly recommend.

It may be unfortunate to hear that your lifestyle choice (or hell, just being fat beyond your control) eliminates the availability of certain treatments, but that's true of smoking and being too thin and having cystic fibrosis and a million other variables.

The fact of the matter is that treatments are more likely to be denied based on ability to pay than on some imagined situation with a scary government official pulling down his black sunglasses to look at your chart then telling the doctors you're too fat to get a nose-job.

Insurance companies are already making those decisions. You don't have "freedom" as you've defined it right now. Unless you're rich, and that won't change in the world of socialized medicine. Find a place and time where things sucked for rich people. Unless the answer is "revolution" or "war," you're not going to have a lot of success.