Rationing By Any Other Name?

by John Holbo on August 11, 2009

Megan McArdle has a post up grousing about how ‘but we have rationing already’ arguments are facile. Pardon me for not seeing her point (although I am willing to concede there may be overuse of the term, as we shall see). Let’s say the rationing in question is some guaranteed minimum coverage (public option). Obviously minimum is not maximum. That’s what people mean when they call it ‘rationing’, and that’s an ok use of the word. But lets start by noting that, paradigmatically, rationing needs two elements: it provides a minimum for everyone in a group by forbidding anyone from getting more than a certain maximum. Rationing means using the latter mechanism to ensure the former result. In that sense, the proper thing to say is that the guaranteed minimum coverage doesn’t really involve rationing.

Suppose, instead, we were talking about a guaranteed minimum income (as was proposed in the 70’s, and as such free market luminaries as Milton Friedman thought made a certain amount of economic sense, if memory serves.) Lots of folks would be opposed to guaranteed minimum income today (to put it mildly), but would anyone say a guaranteed minimum income was bad economics because it would amount to ‘rationing of the money supply’‘? And fiat rationing (as McArdle says) is inefficient. I don’t think economists would see this as a problem. Why not? Because there is no reason why the volume of money overall should be a function of – critically constrained by – some minimal income provision. That’s just not how the money supply would be determined: there wouldn’t be some iron economic law that there couldn’t be more money than everyone times the minimum.

Guaranteed minimum healthcare doesn’t forbid anyone to seek more on the private market – paying out of pocket, extra insurance. No more so than a guaranteed minimum income would forbid you to get a job to earn more than the minimum. So guaranteed minimal healthcare doesn’t ensure its minimum by positively forbidding anyone to get more. So it isn’t really rationing. (Is any of this getting through?) To put it another way: rationing is a response to scarcity. But the scarce item in the healthcare case isn’t healthcare, it’s money. (If you want to accuse the goverment of rationing taxpayer money, that would be closer to the truth, but still a weird way to talk, I say.) There just isn’t going to be any attempt by the government to ration healthcare, as opposed to its own spending of taxpayer money. Because: why would there be?

Let’s try again. McArdle is worried about decline in quality. Why would that happen? The government mandates that every patient is entitled to two aspirin (let’s say this is as far as the public option extends, after the Blue Dogs have done with it). But the government is only willing to reimburse doctors 1 cent to provide those aspirin (I see the penny-pinching Blue Dogs at work again!) Now you have a problem of doctors cutting aspirin with sawdust to make ends meet.

We have an underfunded public mandate.

But this isn’t what McArdle says she is worried about. She has apparently mistaken concern about an underfunded public mandate for a public mandate of private underfunding and sort of mashed them together in her mind. That is, she thinks the government will drive doctors to sell shoddy aspirin and at the same time (very likely? surely?) forbid the sale of better aspirin on the private market. But where the hell is that second bit coming from? Unless I’m missing something, it’s as crazy as the ‘killing old people’ alarmism, because it’s just as divorced from any potential motive lawmakers might have. What possible motive could legislators have to force people not to top up their own healthcare on the private market to the degree that they deem prudent? What would be in it for the legislators, even the most Machiavellian of them? “If you design a formula to deny granny a pacemaker, knowing that this is the intent of the formula …” Now here McArdle has to be talking, not just about a formula that omits to promise granny a pacemaker, but a formula that positively forbids it to her – removes it from the market. Gives her a ration book without a pacemaker ticket. And says only ration book tickets may purchase health care items. McArdle might come back and say she actually meant the other thing, that some piece of legislation might merely not promise a pacemaker. But hell, most legislation doesn’t do that. Practically everything congress has ever done doesn’t give granny a pacemaker (usually because it isn’t about healthcare at all). We don’t say it follows that almost all acts of congress are attempts to ration pacemakers. That’s a crazy way to use the word ‘ration’.

And yet here is Megan McArdle, complaining about people overusing the word ‘ration’. It’s a funny old world, I say.

{ 100 comments }

1

Dan 08.11.09 at 10:24 am

What possible motive could legislators have to force people not to top up their own healthcare on the private market to the degree that they deem prudent?

I don’t know what the motives were, but I think cases like Linda O’Boyle here in the UK somewhat undermine your short-cut to an impossibility proof.

http://www.timesonline.co.uk/tol/life_and_style/health/article4040146.ece

“A woman dying of cancer was denied free National Health Service treatment in her final months because she had paid privately for a drug to try to prolong her life.

Linda O’Boyle was told that as she had paid for private treatment she was banned from free NHS care. “

2

john b 08.11.09 at 10:30 am

@1, only if you’re a lying right-wing hack. O’Boyle paid for the (unapproved) drug privately, but was seeking to get NHS doctors to administer it and monitor her whilst she was being treated with it. That isn’t in any sense analogous to the situation John’s describing.

3

john b 08.11.09 at 10:32 am

(similarly, I’ve bought myself an awesome new prosthetic robot hand with built in lasers that can vaporise a man at ten paces, but those statist bastards at the NHS are refusing to attach it.)

4

yabonn 08.11.09 at 11:07 am

Maybe the correct model for what goes on in wingnut gnomic brains on this is :

1 : Government
2 : …
3 : Rationing!

5

Henri Vieuxtemps 08.11.09 at 11:10 am

Ummm, of course you can go and buy that pacemaker yourself, with your own money, but that’s still rationing within the plan. So, I think (contra McArdle) that it’s fair to say that there is rationing in the current system and there would be rationing in a public plan as well. Not that anything is wrong with that, every program has its limits.

6

John Holbo 08.11.09 at 11:30 am

“So, I think (contra McArdle) that it’s fair to say that there is rationing in the current system and there would be rationing in a public plan as well. Not that anything is wrong with that, every program has its limits.”

It all depends on what you want to mean by ‘rationing’. As you say, everything has limits. Supporters of the plan use ‘rationing’ to signal that they aren’t just ‘and a pony’ idiots. But what the other side hears is ‘scarcity’. Of health care. Not enough machines and doctors. Imagine a world in which you’ve got money but you can’t buy health care because it’s all been used up. (Like wartime London in which you can’t buy an egg even if you’ve got a pocket full of coins.) This actually does SOUND potentially worse, so it’s a bad frame.

7

LizardBreath 08.11.09 at 11:30 am

Rationing is the wrong word for it, but I think Megan’s successfully pointing at a group of people who would get less care in a single-payer system. Picture a pretty good public plan, and a middle-class person who doesn’t have much money in the bank, but now has a gold-plated health-care plan. That person probably won’t buy additional insurance on top of a public plan, because they don’t have the money for it and the public plan is pretty good. If they get some disease for which there is a dubiously effective and wildly expensive end of life treatment, I’d believe both that it would be likely that a public plan wouldn’t pay for it and the private insurance they have now would, and that they won’t have the resources to just pay for it (rather than have it paid for by insurance) when they want it. That class of people will perceive some treatments as being withheld by a public plan that they would have received under a private plan.

If that’s who she’s talking about, I think it’s clear that it’s not a significant problem. People who didn’t have gold-plated insurance are better off with the public plan; people who can pay for the treatment they want can still pay for whatever they like. The problem is limited to a leveling of inequality (mostly leveling up, but in this one situation leveling down) between people who now have no or lousy insurance and people who now have great insurance, but can’t afford to pay for their own healthcare outside their current employer-paid insurance. I can’t see that as something to worry a great deal about.

8

Chris E 08.11.09 at 11:31 am

I don’t see the point in responding – she has repeatedly proven she has a weak grasp on economics – in spite of boasts to the contrary back in her ‘Jane Galt’ days.

9

John Meredith 08.11.09 at 11:35 am

“@1, only if you’re a lying right-wing hack.”

Not really. If you remember the Boyle case led to a massive scandal which has since forced the NHS to change its policy of refusing treatment to people who top up with private medecine. They could hardl; have reformed the polcy if there had not been such a policy to begin with:

http://www.guardian.co.uk/politics/2008/nov/04/nhs-health-cancer-topup-treatment

10

John Meredith 08.11.09 at 11:37 am

“Like wartime London in which you can’t buy an egg even if you’ve got a pocket full of coins.) “

You could always buy eggs, of course, just not at the government price.

11

hardindr 08.11.09 at 11:55 am

Bob Somerby wrote about this a little while ago, albiet in a slightly different context http://www.dailyhowler.com/dh061909.shtml .

12

tps12 08.11.09 at 12:09 pm

If they get some disease for which there is a dubiously effective and wildly expensive end of life treatment, I’d believe both that it would be likely that a public plan wouldn’t pay for it and the private insurance they have now would

I think “dubiously effective and wildly expensive” treatments are exactly the sorts of things that most private insurance plans tend not to cover.

13

John Holbo 08.11.09 at 12:11 pm

“You could always buy eggs, of course, just not at the government price.”

And it was technically illegal to do so – right? – even if everyone did a bit of black market on the side?

14

John Protevi 08.11.09 at 12:18 pm

an awesome new prosthetic robot hand with built in lasers that can vaporise a man at ten paces

Your ideas intrigue me, and I would like to subscribe to your newsletter.

15

rea 08.11.09 at 12:24 pm

If they get some disease for which there is a dubiously effective and wildly expensive end of life treatment, I’d believe both that it would be likely that a public plan wouldn’t pay for it and the private insurance they have now would

Private insuer? Pay for expensive treaments? Ha, ha, ha!

http://www.sunjournal.com/node/101075

16

John Meredith 08.11.09 at 12:28 pm

“And it was technically illegal to do so – right?”

Oh yes, although everybody really did seem to be doing it. I think eggs only came off the ration in 1953, and then only because the natives were gettinmg mightily restless.

17

Zamfir 08.11.09 at 12:36 pm

Coming from one of those socialist hell holes, I am suprised how easily people say “but of course you can always buy more on top, if you want to”.

Over here, a two-tier health care system with better care for people who pay extra is considered American Practices, something even right-wing parties stay quiet about in fear of losing votes.

The general fear, and very justified too in my opinion, is that in a situation where the middle classes have their own more expensive health care system, funding for the universal part will decline year over year, as no one with power or influence actually depends on the universal system.

We have the same problem with private schooling: if the leading classes don’t have their kids in public schools, you can’t rely on them to keep the public system working well. Vocational training suffers from this problem all over the world.

18

Dan 08.11.09 at 12:36 pm

john b,

Isn’t it ironic that your accusation that I am a “lying right-wing hack” is itself based on a material misreading of the facts? It’s not that Linda O’Boyle wanted the NHS doctors to administer her privately bought drugs; it’s that the moment she spent a penny on health-care outside the NHS her already ongoing free treatment (including a chemotherapy drug she was receiving) was withdrawn.

So when Holbo asks (rhetorically) “[w]hat possible motive could legislators have to force people not to top up their own healthcare on the private market to the degree that they deem prudent?” my answer is, who can say what their motive is, but that notwithstanding, it sure as hell can happen.

19

Zamfir 08.11.09 at 12:37 pm

Coming from one of those soc1alist hell holes, I am suprised how easily people say “but of course you can always buy more on top, if you want to”.

Over here, a two-tier health care system with better care for people who pay extra is considered American Practices, something even right-wing parties stay quiet about in fear of losing votes.

The general fear, and very justified too in my opinion, is that in a situation where the middle classes have their own more expensive health care system, funding for the universal part will decline year over year, as no one with power or influence actually depends on the universal system.

We have the same problem with private schooling: if the leading classes don’t have their kids in public schools, you can’t rely on them to keep the public system working well. Vocational training suffers from this problem all over the world.

resubmitted without the offensive term

20

John Meredith 08.11.09 at 12:39 pm

“my answer is, who can say what their motive is2

In the case of the NHS, the motive was explicit: to prevent the existence of a ‘two-tier’ health service, with people on adjacent beds having widely different hopes for survival because of their personal wealth. The reforms mean that there will now be a two-tier NHS. Whether this is socially sustainable remains to be seen but already the government has been forced to raise the drug spend threshold to contain the problem.

21

John Meredith 08.11.09 at 12:41 pm

Which socialist hell hole do you come from Zamfir? The French one seems to do OK with a pretty explicitly multi-tier approach.

22

Henri Vieuxtemps 08.11.09 at 12:48 pm

Somerby’s link in 11 is interesting. Apparently he believes that “rationing” is the codeword for “currently uninsured people will clog the system and we’ll have to wait in line”.

23

belle le triste 08.11.09 at 12:48 pm

(my mum’s parents — who were quite calvinist — proudly insisted they never once broke the rationing rules, or even bent them: i am inclined to believe this; certainly i would be surprised and a bit saddened to discover otherwise)

24

John Meredith 08.11.09 at 12:51 pm

I am sure there were upright people like that Belle, but they seem to be in the minority if the WW2 memoirists are any guide. I can’t imagine abiding by rules like that myself.

25

dsquared 08.11.09 at 12:52 pm

Picture a pretty good public plan, and a middle-class person who doesn’t have much money in the bank, but now has a gold-plated health-care plan.

wouldn’t this middle-class person still have her private health-care plan (full disclosure; I currently have a gold-plated private health-care plan) under a universal health insurance scheme? And if not, then isn’t it quite obvious that the implicit wage cut is doing all the bad work here?

26

chris y 08.11.09 at 12:57 pm

Dan @17. If I were a doctor, administering a somewhat dangerous course of medication (chemotherapy for advanced cancers always carries an appreciable risk) according to a recognised protocol, and my patient insisted against my advice on additionally taking a course of another drug whose interaction with the first was not well known (it not yet being generally approved for use), I might well be reluctant to continue my treatment as a matter of simple ethics, quite regardless of how either treatment was to be paid for. I don’t think you can blame the NHS for that.

27

John Meredith 08.11.09 at 1:04 pm

“and my patient insisted against my advice on additionally taking a course of another drug whose interaction with the first was not well known “

I think the medical advice was that she would benfit from the top up treatemnet. Besides, the NHS policy was not concerned with medical benfit but with social equality.

28

John Meredith 08.11.09 at 1:04 pm

hell hole

29

ejh 08.11.09 at 1:13 pm

in a situation where the middle classes have their own more expensive health care system, funding for the universal part will decline year over year, as no one with power or influence actually depends on the universal system.

Also see “public transport”.

30

JoB 08.11.09 at 1:29 pm

What Zamfir-18 said, but then again, I’m coming from another socialist hel-hol.

And what of it: if the capacity is limited then, for a given number of users, there will be limits for users. The winner is the one that manages the situation best (and rich Belgians continue support public health care precisely because it enables them to receive advanced treatments that would not even get developed if only the mega-rich were interested in them (by the way, some Russian magnate had himself treated in Belgium for his burn wounds!)).

One of the more immoral things one can do is use up valuable doctor time to get something that does not even improve one’s own life.

31

ajay 08.11.09 at 1:30 pm

then isn’t it quite obvious that the implicit wage cut is doing all the bad work here?

Quite. The step that LB omits in her example is the one where, after decent but not gold-plated public health care becomes available, our middle-class person’s employer unilaterally, and without compensating her, cancels her gold-plated private health care plan, thus leaving her with nothing but the public health care scheme.

This might well happen in reality – some employers never miss a chance to screw their employees – but it wouldn’t be legal. It’s analogous to LB coming up with an argument against public transport along the lines of: “Some people would be well off. What about someone who, right now, has a nice company car, but, if we introduced public transport, would have to get to work by bus?” To which the answer is “well, hang on, where did her company car disappear to all of a sudden?”

The O’Boyle case is a real “hard cases make bad laws” one, but let’s be clear here: there’s nothing stopping a UK citizen from having private health care insurance. The O’Boyle case was about a sort of pick and mix approach to medicine: that you get to choose your own drugs and get your free NHS care as well. The view at the time was, well, it’s either NHS or private, not both – this is still to an extent the case, as anyone who wants to buy private care will still have to go and receive it in a private hospital, not in an NHS one, as far as I understand it.

32

John Meredith 08.11.09 at 1:40 pm

“this is still to an extent the case, as anyone who wants to buy private care will still have to go and receive it in a private hospital, not in an NHS one, as far as I understand it.”

No, it is still possible to receive private care administered in NHS hospitals by NHS consultants.

33

JoB 08.11.09 at 1:42 pm

(re-post without the most offensively spelled word in the universe)

What Zamfir-18 said, but then again, I’m coming from another soc1alist hel-hol.

And what of it: if the capacity is limited then, for a given number of users, there will be limits for users. The winner is the one that manages the situation best (and rich Belgians continue support public health care precisely because it enables them to receive advanced treatments that would not even get developed if only the mega-rich were interested in them (by the way, some Russian magnate had himself treated in Belgium for his burn wounds!)).

One of the more immoral things one can do is use up valuable doctor time to get something that does not even improve one’s own life.

34

ajay 08.11.09 at 1:49 pm

29: Are you sure? This is from the Guardian’s report of the decision on November 4 last year:

“But [health minister Alan Johnson] denied categorically the government was presiding over a dilution of the founding principles of the NHS, which promises healthcare for all, free at the point of delivery. Any patient who wants to pay for drugs the NHS does not provide must get their course of treatment privately, not in an NHS ward where fellow sufferers cannot raise enough money.”

35

chris y 08.11.09 at 2:00 pm

Do the non-Brits here understand that private health insurance in the commonest perquisite offered to middle grad and senior employees by British companies? And that there is a reason for this?

36

JoB 08.11.09 at 2:03 pm

I realize that people in the US should rather look for continental European healthcare examples rather than for Anglo-Saxon ones, is that what you mean?

37

Donald A. Coffin 08.11.09 at 2:04 pm

“But the scarce item in the healthcare case isn’t healthcare, it’s money.”

Spoken like a philosopher, not like an economist.

Scarcity comes from the fact that we have limited real resources, so our ability to produce (anythng) is limited. The implication of scarcity is that, if our economy is operating (more or less) at full employment, we can’t produce more (for example) health care without (a) producing less of something else or (b) acquiring more resources or (c) generating productivity-increasing technical changes.

For economists, production of health care is subject to scarcity, because it requires real resources to produce. That does not mean that the amount of (and quality of) health care we’re producing is optimal, just that it’s not free–not in a money sense, but in the sense that producing more requires more real resources.

Money isn’t scarce, or not in any practical sense. Producing more computer database entries is essentially a resource-free activity.

38

LizardBreath 08.11.09 at 2:08 pm

The step that LB omits in her example is the one where, after decent but not gold-plated public health care becomes available, our middle-class person’s employer unilaterally, and without compensating her, cancels her gold-plated private health care plan, thus leaving her with nothing but the public health care scheme.

Huh. To make my affiliation clear, I think single payer health care is an excellent idea, and I’m hoping for it, and I don’t think the issue I’m pointing out is significant, just that it looks to me like the only category of people likely to ‘lose’ anything at all in the transition, so if Megan’s talking about anything, that’s it.

That said, I’d expect ” our middle-class person’s employer unilaterally, [and without compensating her], cancels her gold-plated private health care plan,” to happen either immediately or pretty soon for most middle class people if there were a reasonable public plan. Salaries might go up in response to the drop in expenses, but I’d be surprised if employers kept providing insurance except for a few highly compensated employees who get unusual benefits.

I could be wrong, it just doesn’t seem as if the difference between public health care and private insurance would be worth the cost to most employees ex ante, which might leave some people feeling deprived when they want the sort of treatment that would fall into that gap.

39

ajay 08.11.09 at 2:08 pm

32: really? I would have thought it was a pension.

40

LizardBreath 08.11.09 at 2:13 pm

And I hadn’t seen 32 before my last — in fact I hadn’t known that. How does it generally work — if you have private insurance you get private care from the ground up, so you don’t have to interact with the NHS, or does it kick in only for treatments that the NHS won’t provide?

41

christian h. 08.11.09 at 2:14 pm

Well I think Somerby has got it right. What the McArdles of this world realize – correctly – is that a single payer system would end their current privileged access to health care. Right now, if I (with a silver-plated insurance) want an appointment, I get it much faster than the guy with the bare-bones HMO, while the uninsured don’t even get to see him or her. Under a reasonable single-payer system, one should hope any doctor who accepts single-payer patients at all (and most will have to do so) will have to treat all equally. This will result in less convenience for the currently privileged.

Now I happen to think that’s a very reasonable price to pay, but some might disagree, and call it “rationing”.

42

Richard J 08.11.09 at 2:15 pm

I’ve had it since my first job, and never had much cause to use it, TBH. The exclusions and limitations in cover rarely make it worth your while…

That said, it’s only a couple of hundred quid on the P11D at the end of the year, so the associated tax is easily bearable.

43

Chris 08.11.09 at 2:17 pm

@18: In America, our right wing considers two-tier systems a feature, not a bug. Despite, or perhaps because of, the fact that the “poor people” tier may deteriorate in quality. After all, if they only worked harder to become more productive they could afford to get out of it.

The fact that hard work isn’t very economically productive when you got a lousy education is lost on them. They have a Green Lantern view of economic success: if you’re not rich, the *only* possible explanation is that you’re not trying hard enough or doing something wrong. (This is, in fact, the logical consequence of the view that you can do anything if you try hard enough: the only things you can’t do are the ones you don’t try hard enough at. I’d say this is about a third-grade view of the relationship between will and achievement, but some third-graders probably know better.)

44

Matt McGrattan 08.11.09 at 2:20 pm

re: 37

You can opt to go private for lots of elective treatment, or because you want the non-elective treatment done more quickly or in a different way from the way the NHS would standardly provide it. If you are getting a cataract operation done through a private insurer the NHS is still going to treat you if you get run down by a bus. The NHS still provides care for the conditions you aren’t having treated privately.

Also, private health providers don’t usually do the serious stuff anyway. The NHS still handles the vast majority of the core treatment for serious illness.

45

Richard J 08.11.09 at 2:22 pm

so the associated tax is easily bearable.

To explain – PHI is a taxable benefit in kind – there’s no exclusion that I’m aware of. There’s three main significant tax breaks in the UK these days – pensions, child care and, um, bikes to work.

46

chris y 08.11.09 at 2:30 pm

32: really? I would have thought it was a pension.

Pensions are usually provided for all employees or none; BUPA is for the “elite”.

LB, “if you have private insurance you get private care from the ground up, so you don’t have to interact with the NHS, or does it kick in only for treatments that the NHS won’t provide?”. Depends on how generous the plan is, innit? Usually it’s a top up. There are cheaper top up schemes for the masses which are widely used to pay for things like dentistry, which is effectively not available on the NHS, and quite expensive even when it is.

47

Chris Williams 08.11.09 at 2:33 pm

Yr middle-management largely get private insurance so they don’t have to get their trousers off in the same room as Teh Pooor. The actual medical treatment they get is usually the same, from the same people. It happens a couple of weeks earlier and they stay in a different wing of the hospital, is all.

Anecdotal evidence suggests that, perhaps outside one or two places in London, if you are very ill in the UK, the best place to be is in an NHS hospital, rather than a private one.

When comparing the UK and the US healthcare systems, always refer to the percentage of GDP spent on each. There’s a slight difference.

48

Omega Centauri 08.11.09 at 2:34 pm

zamfir: You make the case as it would be seen by someone who already has a universal plan. Over here, the concern is that there is no well defined minimum care, and that even middle class people can be thrown out of the top tier -for example by having their illness declared as pre-existing. They are both real fears, but how muck likely damage per capita is probable varies.

For instance, as a middle class American with an employer paid for plan any rational assessment of policy induced medical treatment risk, would rate the danger of denial of care due to loss of private insurance (say I get fired), as a much greater danger than a lowering of quality that might happen by being put onto a public plan. So even as someone in the upper tier, I should be concerned with the quality of the lower tier -as I have no quarantee that in the future myself, or my kids may fall into it.
But, politically the upper tier can be made to fear having the government select their level of service, so keeping the optional upper tier available is probably a political neccesity.

49

matthew kuzma 08.11.09 at 2:45 pm

Congratulations. Up until this very moment I wasn’t giving the “destroying competition” argument any serious thought, but it seems to me from your smashing of McArdle’s use of “rationing”, that she can only be making a logical leap from the presumption that the public option will kill the competition. Because if you assume the public option, by competing unfairly, will drive out all other options, then McArdle’s take on rationing actually makes any kind of sense.

As I said, I had been dismissing the idea of the public option killing the competition, because in my experience it takes more than one good product to constitute monopolistic business practices, regardless of how good or how cheap it is. Even if apples are free some people will still want a burger. But is there something I’m missing? Is it reasonable to be worried that the public option will eventually become the only option, at least for all but the top 10%?

50

SamChevre 08.11.09 at 3:12 pm

I think you’re looking in the wrong place, but LizardBreath is on the right track.

It’s not the privately employed; it’s the elderly. Currently, Medicare is very generous in what it will cover. One of the plausible and reasonable ways of coming up with the money to get universal coverage is to reduce that cover somewhat–to European levels, say.

51

Steve LaBonne 08.11.09 at 3:13 pm

Is it reasonable to be worried that the public option will eventually become the only option, at least for all but the top 10%?

Worried?? That’s what a lot of us HOPE for. But never fear, if the public option even survives into the final bill it will be crippled in various ways to make sure this doesn’t happen. After all, maintaining the profits of greedy, murderous insurance companies is a paramount goal of good public policy. At least, it is when your political system is fueled by an elaborate system of legalized bribery.

52

JoB 08.11.09 at 3:17 pm

45 – but you’re thinking there is useful competition between insurance companies, quod non if you just compare the cost of healthcare in the US with respect to publicly insured countries. It is clear that useful competition is between providers of health care: doctors, hospitals, .. and it is perfectly possible to have a system in which the insurance is public and the providers private (in fact this is the case over here).

42- if it’s insurance getting you more comfortable single-tenant rooms basically, that’s not core to healthcare

53

john b 08.11.09 at 3:34 pm

Pensions are usually provided for all employees or none; BUPA is for the “elite”.

Not IMX. The large professional services partnership I’ve worked for provided pensions for employees above ‘manager’ grade, and BUPA-or-equivalent for all employees at any grade. The mid-sized listed media company I’ve worked for provided both pensions and BUPA for senior managers only. And the mid-sized privately held media company I’ve worked provided neither for anyone.

Do the non-Brits here understand that private health insurance in the commonest perquisite offered to middle grad and senior employees by British companies? And that there is a reason for this?

There is a reason, or rather a two-fold reason, but it’s got nothing to do with people being desperate to escape the clutches of the NHS:

1) it provides a small degree of fake reassurance, in the unlikely-but-tabloid-stoked event that NHS treatment isn’t good enough or carries a massive waiting list

2) it costs the employer next-to-nothing, because most people barely ever use it, because the NHS is nearly always good enough and doesn’t carry a massive waiting list. Proof of this can be seen by anyone who’s been ‘generously’ gifted private medical insurance by their employer, through the simple means of looking at their end-of-year tax statement.

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Chris Dornan 08.11.09 at 3:38 pm

John I think I picked you up on the first paragraph, the rest following very clearly. I think you are clarifying an important distinction that has become somewhat confused in the healthcare debate.

McArdle is bright if a bit stubborn and I think you will find that she will take your point while changing her line of attack.

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john b 08.11.09 at 3:41 pm

Oh, and:

I think the medical advice was that she would benfit from the top up treatemnet.

Private doctor: “you would benefit from having this extremely expensive drug, whose manufacturers have coincidentally taken me out for a very nice day at the races, administered in our also extremely expensive private hospital”.

Independent statisticians who actually know what they’re talking about: “this drug is not B/CA effective”.

This is why the NHS is a Good Thing.

Besides, the NHS policy was not concerned with medical benfit but with social equality.

Some of both, I’d say. The NHS happily (or at least, “without massive chargebacks”) and frequently provides emergency and intensive care treatment to people whose private surgery has gone wrong. If it were solely driven by social equality, it would tell them to get lost and let the private hospital fix it.

This view has a certain appeal from an equity point-of-view, but would be a little harsh to put into practice given that private hospitals are far inferior to the NHS at emergency and intensive treatment.

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Richard J 08.11.09 at 3:48 pm

What John B said, basically. I happen to have my end of year summary of benefits – my premium was £478.61 for a non-smoking man in his early 30s, so it’s not exactly an expensive perk…

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John Meredith 08.11.09 at 4:05 pm

“Private doctor: “you would benefit from having this extremely expensive drug, whose manufacturers have coincidentally taken me out for a very nice day at the races, administered in our also extremely expensive private hospital”.”

No, as I understand it, she was advised by her NHS consultant that the drug was likely to prolong her life but that he was forbidden to prescribe it.

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John Meredith 08.11.09 at 4:08 pm

“Some of both, I’d say.”

No, you have misunderstaood. The policy on withdrawing treatment from people who take privately bought top-up tretements was entirely in place for sioccial equity reasons, which is why is was abandioned. The NHS would hardly abandon a policy in place to protect patients’ health.

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Uncle Kvetch 08.11.09 at 4:10 pm

This is why the NHS is a Good Thing.

At least until the government-run death panel decides you’ve outlived your usefulness–but what then?

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Richard J 08.11.09 at 4:23 pm

but what then?

It’s a lovely ceremony. You take your gran down to Bettys for a final Fat Rascal and pot of Darjeeling, then you all make your tear-stricken goodbyes, before finally putting on the raincoats and pulling out your cricket bats.

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john b 08.11.09 at 4:30 pm

The NHS would hardly abandon a policy in place to protect patients’ health.

Rubbish. Most of the ‘patient choice’ agenda is precisely about allowing people’s fetish for choice to interfere with best health outcomes. See also the NHS’s willingness to bow to community wishes on hospital closures, even though large centralised sites consistently demonstrate the best patient outcomes.

@54 haha, FTW!

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b9n10t 08.11.09 at 4:33 pm

#54

Hah! The NHS and NICE should start posting a death exchange that records an evolving, vacillating number of $ representing resources newly available from the death squads.

Doctor: “Looks like we had a smashing weekend, what with everybody’s mum and dad wanting to bow out after that brilliant football match. Seems we’re a go for the baboon heart. Brilliant!”

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antirealist 08.11.09 at 5:24 pm

Independent statisticians who actually know what they’re talking about: “this drug is not B/CA effective”.

Curiously enough, those “independent statisticians” concluded in June this year that Cetuximab does work after all.

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ajay 08.11.09 at 5:24 pm

It’s a lovely ceremony. You take your gran down to Bettys for a final Fat Rascal and pot of Darjeeling, then you all make your tear-stricken goodbyes, before finally putting on the raincoats and pulling out your cricket bats.

Sorry to nitpick, Richard, but actually that applies to Yorkshire only. Oxfordshire pensioners deemed economically unviable are offered a draught of hemlock, before their bodies are set adrift down the Cherwell on a blazing funeral punt. In Newcastle, the panel only decides on a shortlist of useless grannies, who are then compelled to fight to the death with axes in the Tynederdrome, the winner receiving an extra five years of life before returning to defend her title. The panel in Glasgow is still in a trial stage: it’s running into practical difficulties, as it’s not clear that, once a Glaswegian has survived seventy years of the Glasgow diet and lifestyle, there is any way of killing him at all.

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ajay 08.11.09 at 5:26 pm

51: NHS consultants do an awful lot of private work on the side, as a rule.

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Katherine 08.11.09 at 5:48 pm

That said, it’s only a couple of hundred quid on the P11D at the end of the year, so the associated tax is easily bearable.

My partner cancelled his gold-plated, employer provided private insurance (and he’s not high management – not even management, in fact) because the tax he had to pay on the benefit (since he is a higher rate tax payer) was ridiculous.

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Mitchell Rowe 08.11.09 at 6:48 pm

The fact that private plans in the UK must charge such low prices is proof that most people are happy with the NHS. Otherwise the private companies could get away with charging much, much more.

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less is better 08.11.09 at 8:05 pm

In the 1970s I was taking economics classes at night to work on a masters in economics.
The instructor had a PhD in economics. I talked to her one night about why she was teaching at a community college. She told me she actually worked as a realtor and this was just a job to patch her through until she could make a living selling real estate.

I was sort of stunned, but she explained that she had worked in Indonesia for either the World Bank or some other huge institution. Full study of the known facts. The final report neither mentioned the graft or corruption of the elites nor did it mention that at least 40 per cent of all international trade came “across the beaches.” Then she told me that economics was a total waste of time. Made sense, quit school and went to work pouring concrete in Aspen and Vail.

Every time anyone mentions free trade or any of that horseshit, I think about just how much the Congress and the Senate make in bribes, sweetheart deals, “tuition waived education” at the major universities and even where their children go to school in Washington, DC, also, the number of people that I have met in my lifetime that are strictly dealing blackmarket.

ANY economist that pretends to know a damn thing about economics is a damn liar and should have their degrees invalidated. Hell, chiropractors probably have a better concept of money than the “experts.”

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Phil 08.11.09 at 8:39 pm

let’s be clear here: there’s nothing stopping a UK citizen from having private health care insurance

…and nothing to stop a UK citizen who has health insurance using the NHS. Whatever the O’Boyle case was about, it certainly isn’t the case (Dan @17) that the shutters come down “the moment [one spends] a penny on health-care outside the NHS”.

If you’ve got a non-urgent condition, you can wait a while before you get to see a specialist; NHS hospital wards are quite hard to confuse with hotel rooms. But that’s about it for the debit side, as far as I’m concerned. Private healthcare provides a padded service which is rationed by price: if you want immediate treatment for a condition that isn’t getting any worse, if you want the doctor giving you a check-up to run all the tests instead of the ones [s]he believes to be necessary, or if you want any stay in hospital to be a pleasant and relaxing experience, then you’ll need to pay or have someone pay for you. But most people, most of the time, don’t want those things badly enough to pay for them. On the other hand, if you’ve got something life-threatening or urgent, a private clinic will generally hand you back over to the NHS anyway.

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Phil 08.11.09 at 8:40 pm

Can I just point out that the proper name for a medical professional who concentrates on a single field, and is referred to as an authority in that field, is ‘spezialist’. HTH.

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rea 08.11.09 at 8:59 pm

the proper name for a medical professional who concentrates on a single field, and is referred to as an authority in that field, is ‘spezialist’.

In what language?

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john b 08.11.09 at 9:02 pm

@57, but they hadn’t at the time, and therefore the decision was the correct one to make when it was made. See: “haha, that Newton was such a fuckwit for not discovering special relativity”.

@60, depends on your definition of ‘ridiculous’. If you’re on gbp37.5k, and suddenly you’re being taxed gbp300 for gbp700′s worth of superturbo-medical insurance you have no intention of using but that’s deemed as ‘income’, then yup, I can see his logic. But it’s an order of magnitude below US costs.

@61, indeed, that was my point above

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Erin McD 08.11.09 at 9:19 pm

The base argument seems to be that rationing can only exist in a finite zero-sum system, whereby any increase to one comes at a loss to another. Empirically at any given moment healthcare in the United States is indeed finite: one could, with sufficient time and resources, actually count up each and every doctor/hour or equipment/hour available. But two features of the system seem relevant make this seeming finite system into much less of a zero sum system. First, it is vast and complex, which enables a lot of load sharing geographically within a single time frame. Second, while there are certainly forms of emergency treatment with narrow time windows, many kinds of health care have large and flexible treatment windows, which similarly allows for load sharing across time. Here I’m thinking of load sharing as the ability to shift resources and needs around in time and space when one part of the system is over-loaded (scarcity). These features alone give the system a fair amount of flexibility that practically reduce the apparent finite nature of the system. more importantly, it is a dynamic system, adjusting over time to changes in demands. I believe this is true even of many state-run health care systems, but all the more true of a system where the production of health care is in the market economy (but part of the payment of health care becomes state run).

This gets us a far way from rationing and scarcity. And it hasnt yet even engaged the idea that changes towards universal coverage should affect logics in favor of preventative care, which should reduce the overall per person burden on the health care system by shifting from costly and time consuming emergency treatment to less costly (in time and money) preventative measures. University settings are a fascinating microcosm of this argument, because they already mandate universal coverage of all their members, and are also disproportionately likely to offer preventative care (particularly with respect to contageous illness where there are high positive externalities of preventative care).

@18 I think you raise an interesting point with respect to funding and support for political programs and the broadness of participation. Certainly there is a wide and growing support in social science literature on the welfare state that suggests that universal programs are more sustainable over the long run because they enjoy the patronage and support of middle class citizens. I believe a case often cited as an exemplar in this regard is Denmark.

@23 I believe the argument was that the person would voluntarily choose to discontinue their gold plated program because they did not see its continuing relative worth to them, because the government program was “good enough” and they were tight on cash. And then some disaster comes along where (theoretically) they would have been better off keeping their gold plated plan. But this logic is all a bit too big brother for my taste.

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Phil 08.11.09 at 9:24 pm

rea – in the international language of DamnStuckInModeration*Again*!

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sg 08.11.09 at 9:59 pm

Funny how the US right is so hellbent on using the NHS – the most underfunded and the oldest of the public health systems, with the worst outcomes in the country with the greatest inequality – rather than any of the systems developed afterwards, which learnt from its mistakes.

Also funny how all this discussion of top-ups ignores the fact that many US private health insurers would apply the same rules. If O’Boyle had a side effect from that drug what are the chances she’d have been covered for the treatment by her private insurer in the US?

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sg 08.11.09 at 10:01 pm

Also it’s worth noting that the system the UK had before the NHS was widely accepted as bankrupt and failing, and had to be fixed. I bet we won’t find the US right singing the praises of Britain’s pre-war private system, with its workhouse-style charity hospitals for the poor. There is so much more to the NHS’s good and bad points than just its public payment mechanism.

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Cian 08.11.09 at 10:25 pm

Its not just that the NHS is underfunded, but also that senior doctors have an outrageous control over the system, which was part of the deal made at the NHS’s founding. We have a system that (though its improving significantly) benefits doctors over patients.

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john b 08.11.09 at 10:44 pm

@66, apart from “most underfunded” and “worst outcomes”, spot on. Oh, wait, that’s not very impressive, is it?

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antirealist 08.11.09 at 11:46 pm

@57, but they hadn’t at the time, and therefore the decision was the correct one to make when it was made. See: “haha, that Newton was such a fuckwit for not discovering special relativity”.

The effectiveness of Cetuximab was well understood at the time on the basis of multiple clinical trials, which is precisely why O’Boyle’s consultant recommended it. The “independent” statisticians of NICE – who performed no clinical trials – were only concerned about its cost-effectiveness, which is fine if you are trying to work out what the NHS should spend its money on. However, those considerations are clearly irrelevant to the issue of whether someone should be allowed to spend their own money on a particular treatment. That is a purely ideological/political question.

In this thread you’ve cynically implied that the physician’s motive for recommending Cetuximab was purely financial, and that he/she had been effectively bribed to do so by the drug manufacturer, even though there was strong clinical evidence of the drug’s efficacy, and it had already been approved in other jurisdictions, including Scotland. You’ve told us that the “independent statisticians who actually know what they’re talking about” had given the thumbs down to the drug, though in fact NICE hadn’t actually made a decision about it at the time, and now they do support the use of the drug within the NHS for cases like O’Boyle’s. You seem to be remarkably lacking in cynicism about the “independence” of NICE’s statisticians.

I’ve worked as a physician in the UK and Canada for nearly 30 years, and never once within the private sector. I’m a passionate supporter of “socialized” health care, but I cannot see how it’s possible to have a comprehensive single-payer system without some form of evidence-based, cost-effectiveness informed “rationing”.

Linda O’Boyle’s tragic predicament perfectly exemplifies a specific concern of many Americans about universal healthcare. Although this failing has already been corrected in the UK, you seem determined to defend it, in the face of all the facts, to which you seem to be completely indifferent. Perhaps you are equally indifferent to the healthcare needs of ordinary Americans – they’re foreigners after all – but you’re just playing in to the hands of the opponents of guaranteed minimum healthcare in the US.

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John Holbo 08.11.09 at 11:56 pm

Sorry for all the comments stuck in moderation. I just turned them on. As you were.

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john b 08.12.09 at 12:02 am

NICE’s decision to recommend Cetuximab was based on the final results of the CRYSTALa study, which weren’t published until April 2009 and which were substantially better *in terms of clinical effectiveness against metastatic colorectal cancer* than anything that had previously been published. It’s likely (not certain, but likely) that without CRYSTALa, NICE wouldn’t have reversed its earlier decision (note: decision, not lack of decision) to not recommend it.

O’Boyle’s physician might have heard about CRYSTALa, or he might have merely experienced the enormous marketing push that all drug companies, Merck Serono included, give to drugs for which the clinical data is less-than-settled (leaking early trial results, talking up anecdotes, the usual drill).

And yes – the fact that the NICE statisticians don’t meet patients (=> emotional reactions that mess with your judgement, exaggerating false hopes) or drug reps (=> the obvious), whilst being at least as qualified on the stats side as physicians, does indeed make me less sceptical about their decisions.

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antirealist 08.12.09 at 12:34 am

The FDA approved Cetuximab in 2004. The CRYSTAL data showing its efficacy were presented in 2007. People don’t stop dying while papers are being peer-reviewed.

You still have not explained (1) Why it is morally defensible to deny people the right to spend their own money on a last-ditch treatment, the efficacy of which has not been accepted by the state, within the context of a single-payer system, and (2) Why statisticians who are paid by the state can be cheerfully assumed to be independent of the interests of their employer.

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nick s 08.12.09 at 6:05 am

McArdle is bright if a bit stubborn

Now that’s a claim where evidence is scant indeed. I’d go with “silly, shallow, and destined to go far as a result.”

Anecdotal evidence suggests that, perhaps outside one or two places in London, if you are very ill in the UK, the best place to be is in an NHS hospital, rather than a private one.

I’m pretty sure that there’s more than anecdotal evidence on the proportion of NHS and private operations that go wrong and have to be dealt with by NHS A&E. (Anyway, there’s a thorough document on the NHS or MiniHealth website now about how the new public/private guidelines are implemented.)

The fact that private plans in the UK must charge such low prices is proof that most people are happy with the NHS.

Not sure it’s “proof”, so much as there appears to be relatively consistent pricing for supplementary or premium-based healthcare payments across a number of systems, which. For individual cover, French and Dutch supplementary premiums are around €100/mo, most Australian premiums seem to hover around AUS$100, and so on. There are regulations on premium increases, but the recurrence of that “100 local currency units” mark signals to me a market where you’re hitting psychological resistance and possibly heading into medical tourism territory.

Cold comfort for Americans who regularly get to choose between plans with four-figure premiums.

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Ceri B. 08.12.09 at 6:13 am

Here’s what pisses me off.

Say that everything allegedly awful about Susan Boyle’s situation is true. Grant it all. Nonetheless, nobody’s offering up any suggestion at all that her plight is common. How many times a year does anyone in the UK run into her kind of conflicted situation?

Because over here in the US, nearly 50 million of us don’t have any insurance at all, and an unknown but large fraction of the rest have coverage they can’t count on. It’s expensive, and prone to being revoked when real needs do arise, and recourse is slim.

To me, these arguments sound like saying that because some people are hit and killed by meteorites, nobody should be allowed to fly in planes.

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sg 08.12.09 at 7:45 am

antirealist, the situation with Linda O’Boyle and top-ups was spelled out clearly at the time it happened and in this thread: she can have standard chemo or she can go private for experimental chemo. In the UK her choice of chemo was considered experimental so she had to go private. Her PCT cocked up its interpretation of the rules, and told her that if she went private with her chemo she would have to take the whole regime (experimental + non-experimental) private, which her own husband admits was a PCT-specific mistake.

This is an unsurprising piece of British incompetence, it has nothing to do with the general failings of health care systems. Try getting a dentist in Britain who does root canals on the NHS – it’s difficult, because every PCT has its own interpretation of the funding rules and of how vigorously they should prosecute them.

The NHS was the only modern public health system that had the top-up rule, which was introduced because of the ideal “free at the point of care, based on clinical need rather than ability to pay”. There’s no reason it has to be implemented in an American system, as indeed it isn’t in Australia, France etc. So why the fuss?

Also, your attack on NICE is really nasty. Every system has rationing, including even the best-run private ones, and the British method simply makes it clear how they will do it. Do you think that US private systems don’t have their own threshold over which they do all they can to deny payment? Australia has the PBAC, which tells drug companies what the government will pay and doesn’t subsidize drugs which it can’t negotiate a good price for, I’m sure every other system has a method too. The difference is that the private system in the US has an ad hoc system for refusing treatment after the fact which is brutal and bankrupts people.

If anyone has a better way of containing health care costs while giving everyone a pony, I’d love to see it. Until then it’s simply a question of whether the method is transparent and rigorous, as in Oz and the UK, or arbitrary and brutal, as in most private systems.

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dsquared 08.12.09 at 8:35 am

The effectiveness of Cetuximab was well understood at the time on the basis of multiple clinical trials

No this isn’t true. At the time of the 2006 NICE overview, there was, to quote from the report, “no trials that compared cetuximab with current standard comparators”. Since the NHS is (obviously) interested in the relative effectiveness of new therapies compared to what it is currently doing, this was the relevant case.

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Cian 08.12.09 at 9:11 am

82: The FDA approved Cetuximab in 2004.

For a doctor that has allegedly worked for the NHS you seem remarkably confused about the process.

NICE and the FDA are two completely different things. Cetuximab was approved for use in the UK, otherwise she wouldn’t have been able to take it privately.

When NICE made the original decision there was no evidence to prove that CRYSTAL was better than the existing (and cheaper) alternatives. Plenty of people thought that it was better, but then plenty of people think that crystals can cure cancer. So what?

The CRYSTAL data showing its efficacy were presented in 2007. People don’t stop dying while papers are being peer-reviewed.

Uh-huh. And plenty of papers fail to peer-review process, or have to be substantially revised. Or did you think it was some kind of rubber stamping exercise?

If it had turned out that in 2009 a paper was published showing that Cetuximab was in fact WORSE than the alternatives, what then? Doctors who had prescribed Cetuximab would, according to your somewhat hysterical logic, have been killing some of their patients.

One of the many failings of the US system is that not only are more expensive drugs often prescribed when cheaper alternatives are available; but often more expensive drugs with worse outcomes are prescribed. Most doctors (as you seem to be demonstrating on this thread) are not very good at reviewing medical data. Having a central body of experts carrying out this important task is very useful, though obviously drug companies would disagree.

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Zamfir 08.12.09 at 9:36 am

Nick S says: French and Dutch supplementary premiums are around €100/mo

Just a nitpick, but this isn’t true for the Dutch case. All Dutch people are privately insured, and the 100/month is for the standard coverage, not premium. On top of the 100 a fixed portion of your income is also send to the insurance company of your choice. This is usually the larger part of the premium.

The 100 is basically a trick to remind people that they are actually paying for healthcare, and it gives insurance companies something to compete on. They are not allowed to offer a different coverage from the standard, nor to change the percentage of your income part of the premium, but a very efficient company can lower the 100 to say 90, and a company with pleasant help desks etc might be able to charge a bit more than 100. It’s mostly cosmetics.

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ajay 08.12.09 at 10:06 am

And no one seems to be addressing the point that this wonderful Cetuximab stuff did not, in the end, make very much difference to the case. O’Boyle was diagnosed with bowel cancer by the NHS in December 2006 and the NHS treated her until September 2007, when they told her that, unfortunately, there was nothing else they could do. She asked if they could pay for Cetuximab, and they told her that the NHS wouldn’t cover it. So she paid to go on to Cetuximab privately, and five months later she died.
It’s not like the NHS denied her life-saving drugs.

90

john b 08.12.09 at 10:12 am

dsquared, Cian – yup, this. To be approved for marketing (whether by the FDA or the EU), a drug has to be demonstrably more effective than placebo. It doesn’t have to be demonstrably more effective than the current gold standard treatment.

That’s probably the wrong criterion, and in practice NICE is much more about ensuring proven effectiveness than rationing on cost basis alone (its cost assessments are more generous than I’d use if I were in charge: £30k per QALY is higher than GDP per capita of £22k, which doesn’t seem to make sense).

The sporadic “NICE beancounters made my mum die” stories are much more about PR storms kicked up by the drug industry with the help of (understandably) statistically ignorant lifestyle journalists, and often (less understandably) statistically ignorant doctors, concerning drugs that are not proven more effective than the leading NICE-approved therapy, than they are about real cost-saving trade-offs.

(background: worked for one of the biggest pharma marketing research consultancies, then for a strategy consultancy that due diligenced pharma M&A. Or “Not A Hippy”, if you prefer.)

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john b 08.12.09 at 10:20 am

@ajay 89, even Merck Serono don’t pretend that cetuximab [mild nitpick: cetuximab is the generic name and is written with a small C, Erbitux is the brand name and is written with a capital E] has much more effect than prolonging the last few months of life.

The question of whether it’d be better to have five months of terrible suffering and false hope, or a couple of months as many self-administered opiates as you like (no maximum cutoff) whilst being well cared for by hospice nurses, is possibly not one that NICE should be answering for people, and is what the wingnuts fear about this kind of B/CA analysis. Which is why it isn’t one that NICE answers for people and isn’t covered by this kind of B/CA analysis.

(although for me, it’d be B all the damn way, and if I ran the world I’d be sorely tempted to cut down on aggregate misery *and* healthcare spending by making B the only funded option…)

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JoB 08.12.09 at 12:12 pm

john, right on! It’s mystifying how they keep the majority of the population convinced that the pope has it right on life being sacred, even if it’s terminally painful.

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Chris 08.12.09 at 3:25 pm

@91: But then you really *would* be a one-man death panel. I would probably decide for myself the same way you would decide for yourself, but I’m not very comfortable with either of us deciding for others.

Even the false hope is a kind of psychological opiate. I like to think that I would refuse it myself, but I haven’t been put to that test, and even if I had, that doesn’t necessarily give me the right to refuse false hope to others. I do find people who sell false hope for a profit rather disgusting, but if other people find their “product” useful, maybe I shouldn’t come between them.

(Similar remarks apply to that even bigger false hope, the afterlife.)

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engels 08.12.09 at 3:32 pm

I do find people who sell false hope for a profit rather disgusting, but if other people find their “product” useful, maybe I shouldn’t come between them.

Free Bernie Madoff!

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john b 08.12.09 at 3:33 pm

@93, agreed – that’s why I dismissed it before even raising it. There are a lot of things that I Would Do If I Ran The World that I wouldn’t *actually* do in the unlikely event that I were to find myself in charge of the world.

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Stuart 08.12.09 at 5:03 pm

I am sure there were upright people like that Belle, but they seem to be in the minority if the WW2 memoirists are any guide. I can’t imagine abiding by rules like that myself.

So you would have happily contributed to poor people starving due to shortages so you can feast as you are rich, and just because their is a war on it shouldn’t require you to make any real sacrifices?

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Chris 08.12.09 at 6:22 pm

@95: But then they’re things that you wouldn’t do if you ran the world, so isn’t it a little confusing to describe them as things that you would do if you ran the world? At least, it confused me.

@94: Good point. People who buy false hope aren’t exactly making an informed decision, are they?

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john b 08.12.09 at 10:19 pm

@Chris, I’m assuming that most people have a bit of a fantasy “if I ran the world I’d do X to eliminate stupid things Y and Z” set of beliefs going on, which shape their ludicrously over-high expectations of political representatives and which, if actually put in charge of the world, they’d be more circumspect about. But I may be over-generalising from my personal standpoint.

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Danielle Day 08.13.09 at 7:12 pm

What i want to know is, how does anyone in the “Star Trek” world pay for anything. They seem to have abandoned the idea of currency (no one could fit a wallet into those skinny uniforms anyway). I was struck by this idea while watching one of the franchise movies. Not unlike Dilbert’s garbage man or Hogwarts’ Hagrid, the groundskeeper is the “Wise Sage” of Starfleet Academy. But how did this happen? Do they pay the guy? If not, why hang out like some low-rent Mr. Chips? How much does Kirk Make? McCoy? Do they assign “life jobs” like “Futurama”? Is everything in their world rationed and assigned? If so, they all seem content, if not happy— just like Denmark.

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engels 08.19.09 at 11:50 pm

From the Financial-Times-columnist-who-is-not-usually-regarded-as-a-party-line-Communist Philip Stephens:

Beneath the transatlantic waves lies an awkward truth; one that politicians of all shapes and sizes – conservative and progressive, European and American – would prefer not to discuss. Healthcare is rationed everywhere.

Some countries, of course, choose to spend more on health than others, just as they set different priorities for education or defence. Some prefer direct state provision, others more plural arrangements – compare France’s devolved not-for-profit insurance with Britain’s monolithic NHS. But all the models, the American included, share one characteristic. They ration access, while pretending otherwise. In Britain, the state imposes the limits; in the US the market does much the same job. What separates them are questions of efficiency and equity.

The NHS stands condemned by US President Barack Obama’s opponents as an instrument of state-sponsored euthanasia. Its socialised medicine, Americans are asked to believe, would have deprived, on grounds of age, Senator Edward Kennedy of treatment for a brain tumour.

Such charges are palpable nonsense, serving only to unite British politicians in defence of the distinctly imperfect NHS. [...]

European criticism of the US model tends to focus on its inequities – the 40m-plus uninsured Americans denied access to anything but emergency care. The more startling fact is the truly enormous cost.

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