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A Tale of Two Prostates - Elizabeth Unexplained
Lots of data but no answers
A Tale of Two Prostates
It seems that with all the talk about health care reform recently a lot of people are bringing up the option of a single payer system, and often they do so with the assumption that it will save a lot of money and solve a lot of problems. While I would agree that our health care system has some serious problems, I am also pretty convinced, based on what I know of other single-payer systems, that such a system would at the very least create as many problems as it solves. To illustrate this, I have a little anecdote I like to call A Tale of Two Prostates.

It was the best of times, the very best of times as far as my Dad was concerned. I am referring to the nine years Dad spent in the army. That’s where he met John. They both joined the 5th Royal Tank Regiment at the same time, left and the same time, and have been good friends ever since. Dad and John have a lot in common: they’re from similar backgrounds and have similar habits and lifestyles. The big difference is that Dad moved to New York when he left the army and John stayed in Yorkshire.

Several years ago Dad noticed that he needed to use the bathroom a little too frequently, a condition not uncommon in men or a certain age. He had health insurance through Mom’s employer, went to a doctor, and the problem was diagnosed and treated right away, long before his enlarged prostate could do anything nasty like turn cancerous. As far as we know that was the end of that, and Dad’s in pretty good health for a guy his age.

A couple of years ago John was diagnosed with prostate cancer. I don’t have the whole story, but I gather he’d been having symptoms for some time before that. John is a retired fireman, and his health service is the British NHS. I’ve no idea why he didn’t get it diagnosed and treated before it was cancerous, though since numerous British friends and relations have reported that getting care through the NHS is at the very least annoying I imagine that may have had something to do with it. The scandalous part is that he was diagnosed with cancer in October and did not receive treatment until April. Cancer has this nasty tendency to spread, a six month delay for a patient with cancer can be fatal. In John’s case he had a heart murmur, something he’d had since he was a young man, but before they would operate he had to see a cardiologist, which took a couple of months to set up, and then he had to see his oncologist again, which was another couple of months, and then he had to wait another couple of months for the surgery. By the time he actually got the surgery it was a very major operation, and he’s probably lucky to be alive.

This is just one story, but the thing is, stories like this are extremely common when it comes to the British NHS. My boss at my previous company was from Scotland, and told me that most people in the UK these days who have good jobs get private health insurance because the NHS is such a nightmare. I certainly have issues with the way health insurance works in this country, but my Dad is alive and well which counts for a lot. That’s not something I want to give up, and thus I do not want the US to move to a single payer system. The British NHS certainly isn’t the only single payer system with these issues, I’ve heard horror stories of waiting a month for an MRI for an injured knee in Canada. I think the Republicans are shooting themselves in the foot when they talk about death panels instead of real life tales of woe from other countries. People won’t die in this country because some organized panel decided that they aren’t worth treating; that’s giving the government far too much credit. If we move to a single payer system they very well might die because a receptionist insists that they just can’t fit you in any sooner, sorry. That’s what has happened with other single payer systems, and so I have every reason to believe that sooner or later it would happen here if we went to a single payer system.
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izmirian From: izmirian Date: October 8th, 2009 12:59 am (UTC) (Link)
Well, I was going to say that there is no chance of getting a single-payer health system in the US anytime soon, though then I realized that we already have one in the form of Medicare. Although I don't know the details of the British NHS, I would guess that the waiting periods are due to efforts to cut costs and not specifically the single payer health system. My mother-in-law has used Medicare very extensively in the past few years and I haven't heard of any delays or limitations on her care. Of course sooner or later the US is going to have to work harder at constraining healthcare costs ...
greyautumnrain From: greyautumnrain Date: October 8th, 2009 01:55 am (UTC) (Link)
Yes, I believe it's the case that part of the problem with the NHS is with cost cutting measures, and it's sheer size relative to the population. They basically cover everyone except the top income brackets. I think that caps on doctor's salaries may be part of the effect. I've had my fertility doctor come in on her day off to do a procedure for me so I wouldn't miss a cycle, I doubt she'd be quite as quick to do that sort of thing if she weren't well compensated.

I agree that healthcare costs in this country are a problem. I don't have a solution, I just don't think people should hold single payer up as the answer to our problems because it comes with it's own set of issue.
psychohist From: psychohist Date: October 8th, 2009 02:18 am (UTC) (Link)
We actually have another single payer system: the VA. I can personally vouch for the fact that the VA health care system has many of the same faults as the UK NHS. Monopolies have little incentive to provide good service.

Medicare is only kind of a single payer system, because much of the care is provided by people who are paid from multiple payers. That said, my mother's treatment for her chronic conditions appear to be somewhat distorted by what medicare will and will not pay for.
izmirian From: izmirian Date: October 8th, 2009 06:58 am (UTC) (Link)
I'm not in favor of a national health service, just a national health insurance program. As you say, monopolies have little incentive to provide good service. Our medical group seems to be working fairly hard to innovate and make the patients happy. There are lots of medical groups and individual doctors who compete for patients. The insurance industry is different though. In fact it is already pretty close to a monopoly in many states so going to a single payer health insurance system wouldn't be as much of an issue.

psychohist From: psychohist Date: October 8th, 2009 03:11 pm (UTC) (Link)
There are a lot of different flavors of "national health insurance program", with different faults, and in a few cases, strengths.

The VA is a single provider service: the government provides all the care. This is the strongest form of monopoly, and in my opinion provides the worst care. I'm guessing this is what you mean when you say "a national health service".

The UK NHS, despite the name, isn't single provider; it's single payer, and it's the form Elizabeth is complaining about. The government sets the prices for the services, but at least sometimes, you get service at privately run clinics.

Medicare isn't really single payer, as I said; while it is a monopoly payer for older people, it works in a competitive service market. One of the big differences is that medicare can and does set prices based on a survey of actual competitive prices, rather than by government fiat. That's probably why medicare is not as bad as the UK NHS, but it can't happen in a true single payer system, since there are no competitively set prices to provide a benchmark.

Then there is the Massachusetts system, which is basically a mandatory health insurance system with private payers. I like the Massachusetts system and I think it's better than what most of the U.S. has. One of the reasons I'm against the national systems thus far proposed for the U.S. is that it would preempt the Massachusetts system - for example, some of the coverages currently allowed or required in Massachusetts would probably be lost, and things would probably be made more difficult for the self employed.

Can you give a source for health insurance being a monopoly "in many states"? It's not in any state I'm familiar with, which is many of the high population states like Massachusetts, California, and many rust belt states, but I suppose it might be in some low population states. I doubt that situation applies to a large fraction of the U.S. population, even if it does apply to a lot of low population states.

The current system does have a related failing: while there are lots of insurance companies in Massachusetts, for example, the actual user of the services often has no choice because it may be a monopoly across an employer. As a result, you can get some of the disadvantages of a single payer system, or at least a system like medicare: while individual services have prices that are competitively set, the overall program of health care is set up for the short or medium term benefit of the employer, rather than for the long term benefit of the insured. This often results in the insurance companies selecting solutions that will push problems off to the next insurance company a few years down the line, rather than the best solution for the person's lifetime.

The reason it works this way is that insurance is usually only tax deductible if you get it from an employer, and not if you get it yourself. That's what really needs to be fixed in the U.S. - and I believe is fixed in some European systems.

Unfortunately, all the current proposals for a national U.S. system also preserve this fault of tying insurance to the employer or some other third party rather than to the individual.
treptoplax From: treptoplax Date: October 8th, 2009 02:26 am (UTC) (Link)
that the waiting periods are due to efforts to cut costs and not specifically the single payer health system

You could spend essentially infinite money on healthcare. If you're not pricing, you're rationing (waiting lines being a sort of back-door rationing; or alternative curreny pricing, if you prefer).

In short, I think in any single-payer system you get either explicit rationing or this sort of semi-systematic discouragment to get consumption down to resource availablity.
izmirian From: izmirian Date: October 8th, 2009 07:07 am (UTC) (Link)
I agree with your last sentence, but it's not like we don't have all kinds of strange implicit rationing/discouragement in our current system. One of the worst kinds of rationing in our current system is where you get sick, lose your job because you can't work, and then lose your health insurance because no longer have an employer.
psychohist From: psychohist Date: October 8th, 2009 03:17 pm (UTC) (Link)
"One of the worst kinds of rationing in our current system is where you get sick, lose your job because you can't work, and then lose your health insurance because no longer have an employer."

Agreed. This is another symptom of tying health insurance to the employer, rather than to the individual. COBRA benefits cover short periods of unemployment, but they need to be indefinite rather than limited in time, and they need to be tax deductible.
kirisutogomen From: kirisutogomen Date: October 8th, 2009 02:12 pm (UTC) (Link)
I would guess that the waiting periods are due to efforts to cut costs and not specifically the single payer health system.

Actually, these are the same thing. One might say "The bread shortages in the Soviet Union weren't due to the government setting grain prices, they were due to efforts to cut food costs."

The entire reason why it's a bad idea to let the government set prices is because the government sucks at setting prices. They'll always get them wrong, and inevitably there will be excess demand or excess supply, i.e., shortages or surpluses. Controlling costs is a really good idea, but markets are much better at controlling costs efficiently. Attempting to control them by fiat, just declaring them lower, completely ignoring the reasons why they were so high in the first place, just screws things up even worse.

I think we all agree that the current system for setting prices is pretty lousy. But single-payer systems actually manage to isolate and enhance the aspects of our current system that make it so bad.
izmirian From: izmirian Date: October 9th, 2009 06:18 pm (UTC) (Link)
Look, I'm not going to argue that governments can price things more effectively than truly competitive markets, but there are plenty of cases where the government does a fine job. Sometimes government assigned pricing is preferred because the markets aren't really competitive and sometimes it's because there are other benefits that outweigh the pricing issues.

Our water supply is priced and run by the government. Our electricity is more or less priced by the government but technically run by a private company (which was bailed out by the government). Some of our bridges and roads are priced by the government and others are priced privately. Sometimes these services become deregulated and sometimes they become re-regulated and it's not like it's a big deal. I would argue that health insurance would be similar. Yes, there will be "rationing" if you want to call it that, but our roads are "rationed" all the time (think traffic jams) and privatizing all of the roads is generally not proposed as the solution.

The military is also run by the government and the wages in the military are set by the government. In this case we actually have some information about the market price for a soldier since lots of security contractors were hired in Iraq. My impression is that they generally make several times more money than the soldiers. And yet the Department of Defense ignores this and sets the wages for a soldier through some different mechanism. And certainly they periodically have to adjust this value if they aren't able to recruit enough soldiers. The same would be true for adjusting the reimbursement rates if there weren't enough doctors. I wouldn't propose this if there weren't huge problems with their current health care system, but there are.
sorceror From: sorceror Date: October 8th, 2009 02:24 pm (UTC) (Link)
Most Western countries have both public and private insurance. The problem with Canada is that we don't permit private insurance for procedures that are covered by public insurance. That doesn't actually prevent rich people from getting better or more timely care -- they can always go to the US -- but it does set the bar for 'rich' higher.

The waiting times can indeed be pretty terrible, *especially* for something judged to be non-life-threatening. If you need a hip replacement, for example, you may be doomed to live in pain for several years, because that isn't seen as a direct or immediate threat to your life.

Both countries have a relatively low doctor-to-population ratio, which also explains many of the problems.
nicola314159 From: nicola314159 Date: October 8th, 2009 10:36 pm (UTC) (Link)
This tale doesn't really hold up unless you also tell the story of the third prostate, belonging to your father's friend Bob, who lived in the US and had no health insurance at all. How would his experience have gone?

The NHS in the UK, and Medicare in Australia (and presumably in Canada although I have no firsthand knowledge), are not designed to replace health insurance completely. Rather, they are there as a safety net to provide a level of healthcare for all citizens. There is always the option to go private, either by paying out of your own pocket (which still would cost much less than in the US) or by taking out private health insurance of your own. But the point is, no one has to go without.

In Australia, where I now live, everyone with an income over a certain level is encouraged (via tax breaks if you do, and minor tax penalties if you don't) to take out their own private hospital cover in order to reduce the load on Medicare. A family can take out basic hospital cover for less than $100 per month. I have the top level of cover which covers all hospital visits, any ambulance, all maternity including full cover of infertility and IVF treatments, plus a payment for dental, physiotherapy, osteopathy, even alternative therapies like acupuncture and dieticians.

Having said that my husband recently had a very nasty cycling accident requiring ambulance, 8 hours in the ER, MRIs and CT scans, and we didn't see a single bill. It was all covered by Medicare.

In the case of your father's friend John, it was truly unfortunate that he had to wait that long for treatment. Usually illnesses are prioritised by severity and I have firsthand knowledge of people who went to their doctor one week with symptoms and were being treated for their cancer the next. John should also have been treated faster, and probably would have if he'd questioned and pushed it. Unfortunately the Brits are notoriously bad at questioning authority and pushing for themselves (I should know, I am one.) They are also very bad at going to the doctor when they first have symptoms, which we don't know whether John did or not, and which could have made all the difference.

Finally you can blame the waits in treatment times on the NHS needing to save money, but as other commenters have said, however big their budget it is finite and they do need to prioritise, hence knee scans taking longer. Your private health insurance will protect profits by haggling over whether items are covered and raising premiums. That's not really an option for the NHS.

The NHS in particular does have its faults, but after living under it for a total of 18 years of my life I would much rather live somewhere that had it or some form, than under the American system.
psychohist From: psychohist Date: October 8th, 2009 11:38 pm (UTC) (Link)
The present U.S. system does have a safety net as well - it's called medicaid.

Until recently, the UK didn't permit private insurance, so it wasn't just a safety net - it was intended to be the primary source of care for everyone. I think permitting private insurance might have been a "new labor" thing that came in with Blair, though I could be wrong on the exact timing. It was basically a recognition of how badly the NHS was failing.

I believe it's also supplemental to NHS, as opposed to what you're describing for Australia, where you're allowed to purchase a private partial replacement for your version of NHS.

What's being proposed for the U.S. is different, and I'm sure you'd be just as unhappy under that system as you would be under the present system. In particular, it's extremely unlikely to cover IVF.
nicola314159 From: nicola314159 Date: October 8th, 2009 11:52 pm (UTC) (Link)
Until recently, the UK didn't permit private insurance, so it wasn't just a safety net - it was intended to be the primary source of care for everyone. I think permitting private insurance might have been a "new labor" thing that came in with Blair, though I could be wrong on the exact timing. It was basically a recognition of how badly the NHS was failing.

I'll have to take your word for the private health insurance thing in the UK but when I was a child in the UK in the seventies, we definitely could go private for a number of things.

I believe it's also supplemental to NHS, as opposed to what you're describing for Australia, where you're allowed to purchase a private partial replacement for your version of NHS.

Sorry, I don't think I understand the difference here. The private health insurance here is also supplemental to the NHS/Medicare. It's not a replacement.

In particular, it's extremely unlikely to cover IVF.

I wouldn't expect the public health care system to cover IVF. Here my private health insurance does it all, as I said. I only mentioned it as I know that a lot of health insurers in the US won't cover it even in the current system but here it's standard, and another good thing about a non-US system.
sorceror From: sorceror Date: October 9th, 2009 03:59 pm (UTC) (Link)
In Canada, the government is the only payer for most health care. I have private insurance for dentistry & optical care, but if I get a cold I have to present my provincial card at the local public care center and wait in line for treatment. If (God forbid) I were to get cancer, I'd have to get treatment through the public system -- that, or cash in my RRSP and hop across the border for more timely treatment.

Canada's position on this is an aberration, though. The vast majority of western countries do at least *permit* private insurance for those who can afford it, as in your examples with the UK and Australia.
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