We are developing the social individualist meta-context for the future. From the very serious to the extremely frivolous... lets see what is on the mind of the Samizdata people.

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Samizdata quote of the day

This is a country in which dogs can get a hip replacement in under a week and in which humans can wait two to three years.

– Dr Brian Day, of Vancouver, explaining what happens if you make private health care illegal, but leave private veterinary clinics alone. (It’s a shame about the picture of Dr Day and Fidel Castro though).

53 comments to Samizdata quote of the day

  • Maybe there’s a hidden benefit to calling your elderly relative an “old goat.”

  • It’s obvious. Veterinary care must be nationalized.

  • Nick M

    The nationalization of veterinary medicine… At last a cause to unite cats and dogs! Animals of the world unite! I can see it now, the bourgoise pets and the proletarian farm animals marching shoulder to shoulder together… until. I think I’ll write a best selling story along these lines.

    Oh, bugger! It’s been done.

  • jimmmy

    this site keeps close tabs on the failures of socialized medecine as well as academic bias in american uni’s. they have made documentaries on said subjects, and update their blog frequently.

  • Verity

    I don’t think the British need any additional information on the failure of socialised medicine as, now the USSR’s gone, we are the prime example of it.

  • Pete_London

    Canada’s private health-care system is called ‘America’.

    – Mark Steyn

  • Verity

    Pete_London/Mark Steyn – V good!

  • permanent expat

    Didn’t the late Pontiff also have a photosession with Fidel? Or am I wrong. Mark Steyn, as usual, tells it how it is.
    Veterinary medicine is expensive everywhere I know but folk are prepared to care for their livestock & pets, spending hard earned cash so to do. That is absolutely right & there are few gainsayers. The name of this phenomenom is PERSONAL RESPONSIBILITY.
    In Human medicine……….I need not go on.

  • Verity

    Yes, permanent expat – when people want something, they consider how much they want it and decide whether they want to pay for it. If someone’s feeling off-colour, they’ll pay to go to a doctor and they’ll pay for the medication he prescribes.

  • Dave

    But what about people with long term medical conditions? they will probably not be able to afford insurance, what will happen to them?

  • Verity

    Dave – they should have thought of that before. And there are always, in other countries, charity hospitals that will treat people free.

    Even the fact that you posed the question is rather unpleasant. The notion that somehow I am responsible for people with “long term” conditions. Why are those people themselves not responsible?

  • permanent expat

    Dave: I really do appreciate the point you raise but it doesn’t alter the truth. Free lunches are not on the menu. Many years ago, my wife & I took out horrendously expensive private medical insurance because we were intelligent enough to know that drugs & good treatment are just that, expensive. My late wife became, unfortunately, one of those to whom you allude. She received the optimum care & treatment available during the remainder of her life. It would have been very different had we not had the foresight & knowledge that, in the final analysis, you get what you pay for. It was our responsibility to ensure that we got the best. Now, as a pensioner, I still pay a premium that hurts a bit… but it is MY lunch.

  • Nick M

    I regard healthcare as one of the things which possibly is best provided at least partially by the state. It doesn’t work too well in the UK, but then the US system (with its different, but equally myriad, bureacracy) doesn’t work too great. Other EU countries manage though. All I care about is the best possible healthcare system with the greatest effiency. I’m an avowed anti-bureaucrat.

    People in pain don’t care about ideology.

  • permanent expat

    NickM:………..neither do they care about theory. State health care is, in theory, a wonderful idea. The trouble is that all goodies have a price, ESPECIALLY state goodies for reasons it is superfluous to go into. The list of “in theorys” is endless…..Communism, Christianity….to name but two. What happens in practice is the yardstick & if, as you say, you are an avowed anti-bureaucrat you will know that, eventually, “in theory” means jobs for the boys(read: parasites)

  • Nick M

    permanent expat,
    Everything costs. Private insurance can cost a lot more. I lost you a bit towards the end. Your point was?

  • permanent expat

    NickM: Of course private insurance costs more, and yes, premiums increase from time to time….but you do get that for which you are paying & the goods are delivered in quicktime. The few times I have had to go to hospital have never been more than a three day wait maximum.
    The point is that if you are prepared only to pay the bare state minimum to keep your ONLY worldly body in good nick………it’s your choice. You may be lucky or have inherited cast-iron genes. Esentially you are gambling wih a very precious commodity of which unforseen circumstances may relieve you. I have never been a gambling man, especially in health matters. I feel myself to be in credit & don’t have to visit “Theodore Dalrymple” Krankenhäuser. After you have passed 50+ the possibility of later illness is, rightly, a constant factor in one’s thinking and, should I become an incompetent wrinklie, I have prepaid the prescence of someone to look after me until it’time to go. To keep an open mind on this subject is accompanied by the danger that one’s brains might fall out.

  • Nick M

    permanenet expat,
    Not my point. What I’m bothered about is how efficient the whole system is.
    I’d rather the money was spent on drugs and doctors than insurance companies and administrators arguing the toss as to what is covered.

  • Nick M

    permanent expat,
    Sorry for the farcical mispelling.

  • ResidentAlien

    Having experienced both UK and US systems the UK’s is better, although I think a free market is the best solution.

    The US system is absolutely not a free market. For complexity and volume of rules it would give the EU a run for its money any day.

    To give just one example of the ridiculous way the US system works…. I lost my job recently and was entitled to COBRA (COntinuation of Benefit Rights Act – I think) benefits. This means that for two months after leaving my employer I can elect to continue paying premiums and receiving benefits under my old employer’s scheme. So, if I don’t get sick during those two months I can just decide not to bother paying the premiums, on the other hand if I do get sick and my treatment costs more than the premiums I can just pay my premiums and send the bill to the insurance company – post dated insurance! No wonder premiums are so high.

    Total health care spending as % of GDP is roughly double in the US what it is in the UK – I fail to see what Americans are getting in return for those bilions of extra dollars. And don’t tell me that we have choice, the insurance companies through a myriad of “network agreements”, “prefered provider organisations” and the like do a very good job of telling us which doctors to see.

    The government should get out of healthcare and leave consumers, insurance companies and providers to get on with it. I predict that we would see a blossoming of new insurance forms, a fall in costs and a lot of laid-off health bureaucrats.

  • Dave

    Nick, those same people exist within the NHS also, arguing over who gets what.

  • Verity

    NickM – I don’t understand your point. “I’d rather the money was spent on drugs and doctors than insurance companies and administrators arguing the toss as to what is covered.”

    This is an extremely confused, not to say idiotic statement. Drugs and doctors bought by whom? Companies – what companies? – and administrators – NHS administrators, who are legion?

    I sincerely cannot work my way through your confusion.

    Are you trying to say you want the taxpayers to pay for drugs and doctors and operations and follow-up care for people they don’t know? Why would they want to do that? Why not care for their own families through private health insurance?

    Why would I want to pay for an ambulance plus attendants plus emergency care plus a possible operation plus a bed to recover in plus life support for some shit gangstarapper who’s been shot? Or some moron who was driving at 100 mph and hit a tree on a bend? In my view, that’s crazy. Why would we want to save a shallow gene pool?

    I don’t know what you’re trying to say here, except it sounds rather self-righteous and lefty.

    In person, I may care for other people. State-enforced? No. Don’t give a monkey’s. If people die, they die.

  • Dave

    Verity, thanks for your thoughtful response. But I was not trying to suggest anyone is forced to pay for anyone else. I was asking a question about medical insurance since not everyone can get that at a responsible price if they have a serious long term health condition.

    “Why are those people themselves not responsible?”

    I don’t know, perhaps they were born with a genetic condition, perhaps their parents were drug addicts, etc. Should the child be condemned if the parents couldn’t be bothered to do the right things, and perhaps get prebirth insurance for the child.

    I’m all for the freemarket and small government but I don’t want to live in a world where people are thrown on the scrapheap without even having a chance.

  • Ron

    Out of interest, what is stopping someone desperate from having their hip replaced by a vet?

  • guy herbert

    A quibble: The story cited quotes Canada’s leading private hospital. What’s the relevance of the reference to making private healthcare illegal? (And where apart from Cuba, is it the case?)

  • guy herbert

    Sorry, I just re-read the cited story more carefully. That’s a legal position so preposterous that I failed to understand it the first time.

    I’d be interested to know how Canada treats alternative therapists and over-the-counter drugs in that case. Is it permissable to charge for waving a crystal at someone with a serious disease, but not to examine and treat them using real medical knowledge? Why can a supermarket sell you aspirin, if they also use it in state hospitals?

  • So if British health care goes to the dogs, that would be an improvement.

  • rosignol

    Verity, thanks for your thoughtful response. But I was not trying to suggest anyone is forced to pay for anyone else. I was asking a question about medical insurance since not everyone can get that at a responsible price if they have a serious long term health condition.

    There are people in this world who’s greatest contribution to society is being an example of what not to do. I happen to think that the best way to deal with such people is to let them get on with darwinating themselves with a minimum of state interference.

    As far as the rest of your comment is concerned, I am confused by your use of the word ‘responsible’ in that context. Responsible to who? Responsible for what?

  • Verity

    Ron – actually, that’s not a bad idea. Vets have to be extremely clever. The systems of dogs and cats are quite different and they have to know both. They have to know birds and lizards, too. And ferrets. And sometimes cows (who have seven stomachs) and horses. So they have to know how to operate on all these animals, and also what drugs to prescribe and in what amounts. And how much anaesthetic to give. The knowledge they have to have to practice their profession is mind-boggling.

  • The difference between vetinary care and human health care is that very few people are willing to give their wife or child a euthanasia needle if it’s going to cost $100,000 to get them fixed.

    It’s a much easier decision if it’s just a dog.

  • permanent expat

    With utmost respect, is it possible that Dave wrote “responsible price” when he meant “reasonable price”?
    …………and what, as Prof. Joad might have said, do you mean by reasonable? In view of the fact that my life or limb may depend on efficient, timely, …and yes, expensive medical treatment… I do not begrudge the premium my (carefully sought-out) provider gives.
    It is not a fair world; nor will it ever be. There are those for whom, through no fault of their own, including perhaps the wrong choice of parents, state or charitable care is the only option. I am personally & perforce contributing to the care which these unfortunate people receive. No quarrel with that as long as my money is used to treat the patient rather than to provide State tenure to hordes of bureaucrats. It is coincident that one can add to the a/m crack-addicts, drunken hooligans, slut baby-mothers etc.

  • Part of the problem with State health is the violence to staff. If people appreciated what they got ‘for free’ and ‘their right’, they would think twice. They would also think twice about using it if there was some charge involved.

    Cut up rough in a private clinic and find yourself barred. Should happen in the NHS.

    The State should provide A&E, precisely the part that private schemes do not.

  • permanent expat

    TimC: That’s what “you” voted for. That is the system “you” chose. Those are the conditions that “you” are seemingly prepared to accept. The tragedy is that “you” have Rights but have forgotten Responsibilities. The Septic Isle is in the hands of PC Yahoos (non-Internet variety!) and “you” can either chuck them out…….or get out.
    Perhaps, as a first step, fewer bureaucrats in hospitals; their number being replaced with a bunch of no-nonsense heavies & a “growing-up” cell in the basement where the unruly, injured or not, could have time to ponder the mysteries of Attitude.

  • Dave

    Ofcourse people who have made bad life choices such as smoking and drinking too much, drugs etc, should have to pay higher rate of insurance. Thats not what I’m talking about.

    What about for example a child who develops cancer through no fault of his own (he wasn’t smoking or playing with x-ray machines etc), the parents were not good and didn’t pay medical insurance.
    Without the NHS what happens to that child ?

    You don’t try to help him because its his parents fault for not having insurance? that may be true but sounds kind of heartless.
    I am not advocating the state take money from people to fund others health, I am just asking what happens to those most vulnerable in this libertarian solution.
    I don’t think relying on charity is going to fill people with much confidence.

  • Rob Read


    the state is a transfer mechansim. Because of parental irresponsibility you plan to fine people who were moral?

    think about what you are saying…

    Just make it illegal to create a child you cannot afford to look after.

  • HJHJ

    I think there is a bit of confusion here . “State provided” medical care (it isn’t ‘healthcare’ by the way) is the worst of all possible worlds. This is because not only does it remove consumer choice, it makes the providers immune from the need to satisfy you – producer interest. Hence the ballooning salaries in the NHS, cushy retirment options, falling productivity and the worst outcomes in most areas in Europe.

    State guaranteed medical care is different – the state doesn’t have to be the provider – in fact, it can encourage competing providers to achieve better value, avoid producer interest and give an element of consumer choice. This is better but still has several drawbacks as it means that the state decides what treatments will be paid for and it forces all taxpayers to pay for its choices. It also has to decide, in the absence of free market spending choice, how much of national income should be spent on medical care relative to spending on other things.

    European systems generally blend government guaranteed schemes with insurance and allow more consumer choice without leaving anyone uncovered. These tend to be better because of this choice and because they constrain producer interest. However, purists, like Verity, will point to the fact that they are not fully down to personal choice, responsibility and payment, but I think most of the public think they strike a reasonable, albeit far from faultless, compromise.

    The US system has its merits but the medical professson there knows all about protecting producer interests through a regulatory system and hence it is incredibly expensive.

    I’d certainly like to see more medical tourism – a bit of globalisation in medical care would do wonders to improve standards, choice and decrease costs.

    Last, but not least, the sooner we realise that for most people, most of the time, the primary determinants of health are not down to medics, the better it will be for our health.

  • “Just make it illegal to create a child you cannot afford to look after.”

    Right, because allowing the government to dictate who may and may not have children is perfectly acceptable, whereas allowing the government to steal money to pay for health care is not.

    Looks like somebody wants to bring back eugenics.

  • Bartkid

    >a country in which dogs can get a hip replacement in under a week and in which humans can wait two to three years.

    Betcha the number of humans wanting a hip replacement is at least couple of magnitude more than the number of dog-owners willing to pay to get Fido a new hip.

    Keep in mind that the US pays 2x what Canada does for health and one out of seven American have NO health coverage whatsoever.

    I would have no problem with paying 2x the taxes going to healthcare IF AT THE SAME TIME PRICE CHANGES FOR PRESCRIPTIONS WERE HELD TO INFLATION OR LESS.

    If a company invested 100% of the R&D to find a new drug, fine, they get the copyright protection for X number of years. But any companies cherrypicking from government findings shouldn’t get that protection. If you claim “let the invisible hand of the free market decide” then no monopoly protection for you.

  • Verity

    Actually, HJHJ, I’m not such a purist that I can’t see that the French system works. (It consistently comes in at a draw with the US as top medical care provider in the world.) When you live in France, you do get a lot of control over your own care. I think I’ve written before, that if you need an X-ray (or any other specialist service), your doctor will write you a prescription. You are free to take that prescription to any diagnostic lab you have heard your friends praise.

    So laboratories try to give good service and nice facilities to get your business. Instead of waiting on tenterhooks for a week or however long it takes for your results to come back to your GP, in France, the lab has someone right there to explain them to you. With an X-ray, they develop the film while you are getting dressed, then a technician immediately takes you in to see your films and explain them to you. He then pops them into an envelope and hands them to you. They’re yours. To take back to your doctor or to any other doctor.

    There is a tremendous amount of freedom of choice in France, and a tremendous amount of competition for your business. Diagnostic labs are spotlessly clean, they try not to keep you waiting for your appointment, the staff is friendly. They want you to speak well of them to your friends and family. The patient in France has a lot of control. I must say, it is managed highly intelligently.

    “Just make it illegal to create a child you cannot afford to look after.” Obviously, the writer didn’t really mean this, but, Ken Hagler, the statement clearly has absolutely nothing to do with eugenics. Calm down.

    I agree with HJHJ – medical tourism, excellent! Shop around! Currently, India is your best bet for excellence in medical care for around 1/3 the cost of going private in Britain, and in some instances, the NHS will even pay your plane fare and for your treatment. Even if it doesn’t, it’s affordable for most, and it’s immediate. Thailand, too, except the facility in English isn’t as good. And everyone trusts Indian doctors and dentists from their own experience.

  • llamas

    Bartkid wrote:

    ‘Keep in mind that the US pays 2x what Canada does for health and one out of seven American have NO health coverage whatsoever.’

    Untrue, on several levels.

    This refers to the (in)famous ’40 million Americans’ claim, which has been widely debunked already. It’s already been well-established that the data do not support this blanket claim, and the claim also ignores publicly-funded health programmes such as Medicare and Medicaid.

    A truer statement might be

    ‘Up to one in seven Americans may not always have continuous, private medical insurance.’

    Which is not quite the same thing.



  • Kenj Hagler – I think the enormous majority of Samizdata readers are sufficiently educated to understand the concept of eugenics. Rethink your link.

  • “already understand”, I should have said.

  • HJHJ

    Verity: I’d say that the French system is better than that of the US as it’s cheaper, largely because it is less beholden to producer interests. It does, however, still lack effective mechanisms to control spending caused by over-provision and unrestricted demand, especially in areas such as drugs. In particular, it puts too great a burden on employers, with unfortunate consequences for employment.

    Most western systems do too little to encourage personal responsibility and to a large extent this suits the medics as it increases the amount of work they have available. If they were honest, they’d be telling most people that their own behaviour is the prime determinant of health.

  • Verity

    HJHJ – I wouldn’t argue with anything you’ve written. A slight quibble only: why do you say it puts a burden on employers? What have employers got to do with it? Everyone pays their national insurance contribution; end of story.

    The French system is just terribly well organised. A have an elderly friend in my village and she hurt her hip too badly to drive, so her doctor wrote her a prescription for a taxi.

    The problem is, it’s so efficient and easy to get treatment in France that, of course, everyone avails themselves of it at the drop of a hat. Doctors have been ordered to stop writing drug prescriptions with such merry abandon. A friend of mine’s husband is a doctor and a government inspector dropped in on him unexpectedly to question him. They track how much of any drug any one doctor is prescribing through the computerised records of the pharmacies.

    I don’t approve of the NHS, but as long as it’s there, why can’t it be run with the intelligence and efficiency of the French system … oh, never mind.

  • The US has several different health care systems. The insurance system for honest, hard-working people is the best in the world, and the fairest. The government-run systems – Medicare, Medicaid, ER-care – have the fatal flaw that they are supported by the honest hard workers, not by those who use them. And they don’t provide the best level of care. I won’t get into the disaster that is the Food and Drug Administration and the other bureaucracies and the tort system that impose generally unnecessary and intrusive burdens on all the systems.

  • HJHJ

    Verity: My understanding of the French system is that there are direct taxes, or NI (same thing really) levied on employers to pay for it. So it adds to the cost of employment (and hence reduces employment).

    Yes, the French system supplies very well and (as I said above and as you have observed) its main fault is that it gives consumers insufficient individual incentive to reduce demand.

  • JEM

    In terms of actual outcome, measured at the national level in terms of life expectancy, etc., the results for all West European, North American (not Mexico) Japanese, and Australasian ( call that “western”) health systems are so close together as to make the small differences that do exist not statistically significant.

    See: http://www.who.int/healthinfo/statistics/whostat2005_mortality_en.pdf

    No-one has yet devised a health care system that treats everyone as rapidly, as effectively, and as cheaply as people might wish. I don’t think anyone ever will.

    The fundamental problem is that, in principle, there is potentially infinite demand chasing finite resources. So demand has to be rationed: that cannot be avoided. The only question is, how? Broadly, there are just two ways. One is by price, the other is by queuing.

    All western health care systems use one or the other of these, or a hybrid of the two. (In fact, none is 100% one extreme or the other.) The US system tends towards using price — but not entirely; we have Medicare, etc., for example. The UK system tends towards using queuing, but not entirely; about 15% (and growing) of UK health care is carried out privately, meaning you can buy your way to the head of the queue in effect. I did not know until I found this thread that private health had been illegal in Canada. That makes the Canadian system much more severely rationing-based than the UK NHS.

    The European system, most commonly described as French but also used in Germany, Italy, Holland, etc., is more evenly placed between the two extremes than either the US, Canada or the UK. And based upon the evidence of ‘customer satisfaction’ it seems to deliver the most acceptable results. Patients are treated swiftly and effectively, and treatment costs very little at the time. Also, insurance premiums are much less than in the US and coverage is universal and unlimited (for chronic diseases, for example).

    The portion of the national income spent on health in these European countries is typically about two-thirds of what the US spends. Canada seems to spend about the same as the Europeans, and the UK after long lagging behind, is now amost at average European spending levels.

    So what, exactly, does the US get for spending half as much again as everyone else?

    Objectively, not a lot. As mentioned at the beginning, the actual national health outcome is about the same. The biggest difference is the lack of proper universal coverage on the one hand (although I know there are charity hospitals, but that’s very much a second-best solution) and ‘express’ treatment for the rich (although it does nothing to extend their lifespans on average)

    So what is my conclusion?

    (1) In terms of bang-per-buck, the US system is the worst around.

    (2) The UK system, so long as it remains a bit cheaper than its European neighbors, gives the best value, bang-per-buck.

    (3) The best all-round system is found in France, or maybe Germany.

    It would pay us all, in the US, the UK, or Canada, to learn from Europe, at least on this matter.

    By the way: the reason humans can’t be treated by vets is that that any vet who did this would be guilty of common assault. A vet is not licensed to treat humans.

  • Verity

    A vet is not licensed to treat humans.

    My god, why would they want to be?

    Our pets don’t write angry letters about their treatment (not just because they can’t write, but because their treatment is actually first rate – being private). A vet gets to keep his patients in a portable cage until he’s ready to operate. He gets to put them back in their little cage when he’s done.

  • JEM

    I know a few hospital staff who might think keeping human patients — especially the ones who arrive drunk, etc., on Friday or Satuday nights — in little cages would be a good idea…

    …and if the treatment didn’t work, well just like at the vets, the patient could always be put to sleep.


    More seriously, it’s still a zero-sum game as, yes, (private) vets are excellent, but most animals get no treatment at all — and that’s never the animal’s fault, by the way. So the average health outcome is probably far worse than for humans under any national medical system.

  • ATM

    What does the US get for its increaded expenditures? Better care for premature infants is one thing, including heroic efforts for infants who would often be allowed to die right after birth in European medical systems.

  • JEM

    What does the US get for its increaded expenditures? Better care for premature infants is one thing, including heroic efforts for infants who would often be allowed to die right after birth in European medical systems.

    Sorry, but no it does not. European (including UK) health outcome statistics show this aspect of care is just as good as in the US. There is really no getting away from it: the US system is about 50% more expense, but there is nothing to show for that extra spending in terms of better health.

    That is not to say there are not individual cases where a particular disease is better treated in this hospital than that, but that is true all over all western medical systems, not just in terms of US versus the rest. Bottom line, these individual cases make no difference to the overall national outcomes.

    Also, if I was uninsured for unlimited cover for chronic illness and, say, diabetic, the worst possible place to live would be the US. There are many, many more uninsured diabetics than premature babies in America. And that’s just one example.

  • llamas

    Verity wrote:

    ‘A vet is not licensed to treat humans.

    My god, why would they want to be?

    Our pets don’t write angry letters about their treatment (not just because they can’t write, but because their treatment is actually first rate – being private). A vet gets to keep his patients in a portable cage until he’s ready to operate. He gets to put them back in their little cage when he’s done.’

    And, don’t forget – as my vet always reminds me – a vet can shoot his/her mistakes in the head and haul the remains to the fenceline for someone else to clean up.

    Joking aside – more than one large-animal vet that I know will work on humans. Many medications that are prescribed to humans are also available in a veterinary version, usually at far lower cost. And many vets have far more skill at closing wounds with minimal scarring – horse owners demand it. If you go to the ER with a serious flesh wound, you’ll get stapled shut and to hell with how it looks. A good vet will break out the needles and silk. Vets also have the use of a great range of anaesthetics, sometimes far more than MD’s do. And – large-animal vets sometimes develop a fine skill at dealing with their patients – as MD’s would if an unhappy patient could and would bury a steel shoe in their skulls when they did it wrong.



  • permanet expat,

    Why should I leave my country? I did not vote for the NHS or the ongoing funding expansion without restructuring. I did not vote for this nonsensical NeuArbeit government. To leave is just another form of abdication.

  • Paul Marks

    This may have already been said on the comments, but it is the case that the Cuban health system is even worse than the Canadian.

    Without influence (the “aristocracy of pull” as Rand put it) or unofficial cash payments (bribes) Cubans do not tend to get much medical care.

    As for the N.H.S. – thousands of people die waiting for treatment. And many of those who do get treatment get very poor treatment (mapractice suit style treatment by American standards) – for example people may be given inferior medical drugs (or no meds at all), because the powers that be (such as N.I.C.E. – straight out of C.S. Lewis nightmare, I wonder if they knew when they named it) have not approved it.

    I am well aware that the F.D.A. has delayed drugs and caused thousands of deaths by so doing. And that its regulations make the development of new medicines vastly more expensive than it would otherwise be.

    However, it does not ban medicines from the major hospitals in the nation on cost grounds.