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For a brief moment, my heart leapt with joy…

A few days after the recent election, whilst walking down the street near Chelsea & Westminster Hospital, I noticed this sticker & my heart leapt with joy. With enormous regret, I had just voted Tory as I live in what was the most marginal Labour seat in the UK (20 vote Labour majority), and it did indeed turn blue by a narrow margin (150 vote Tory majority). Suddenly I did not feel so bad about voting ‘Conservative’.

But upon closer examination, I realised that far from being a Conservative sticker, it was without doubt propaganda designed to produce the opposite reaction to the one I experienced. Not hard to understand the thinking, as to people who produced this sticker, it was inconceivable that anyone actually wanted to see the NHS privatised. Indeed, I do not either, I want to see it abolished completely, but I would settle for genuine privatisation 😉

35 comments to For a brief moment, my heart leapt with joy…

  • Snorri Godhi

    I’d prefer privatization… especially if the proceeds are used to pay off some of the public debt.
    But i suppose that the line about abolishing the NHS altogether was not meant seriously.

    I had just voted Tory as I live in what was the most marginal Labour seat in the UK (20 vote Labour majority)

    What was the margin in the most marginal Tory seat?

  • William O. B'Livion

    From what I understand about the efficiency of the NHS privatization is functionally abolition.

  • Peter Barrett

    Slowly and inevitably our overfunded, overmanned and increasingly inefficient health service will increase its use of private facilities, resources and services. This development was berated below (Jan 8th, a quote from Jessica Arnold, who is described as “associate director of primary care for NHS Bromley clinical commissioning group”).

    This will not be the complete reorganisation the author and many others including myself would prefer (I assume that is what “genuine privatisation” refers to), but it might be a start.

  • Lee Moore

    Yes, but no.

    There are, obviously, many more sensible health systems around the world than the NHS, which do not suffer from the religious dogma of “free at the point of use.”

    Nevertheless, because the need for health care is very unequally distributed, and because ill health is correlated with poverty, nothing seriously resembling a free market health system is likely to work to the satisaction of more than about 5% of voters. Consequently, in this galaxy, the state is always going to have its muddy foot right in the works. Insurance is part of any sensible solution, but it is far from a panacea, what with agency problems, and pre-existing conditions, some of which date from fertilisation. We could do a lot better than the NHS, but a free market in health care is never going to fly.

    On the other hand, that other great bulwark of socialist welfarism – state education – is perfect for privatisation. There’s nothing at all about the technology or logistics of schooling (or education generally) that requires state provision, and only about 20% of parents need a subsidy. There are no serious economies of scale – no doubt a school corporation running 20 schools may have some scale advantages over a single school, but there’s no reason to believe that running a thousand schools gives you any advantage over running fifty. As for modern technology, e-lessons and so on, there are no barriers to entry at all.
    Even if you don’t want to privatise school finance, privatising the actual provision of schooling should be a doddle with voucers. And with vouchers you can privatise bit by bit, without having to go nuclear.

    If you want to privatise something, forget about health. Do schools.

  • Chester Draws

    E-learning doesn’t work. Humans need the human touch, even as adults. A very conscientious adult can make it work, sometimes.

    The chance children will work when not directly attended is close to zero.

    We’ve had distance learning via correspondence schools for ages. They don’t work very well, even if the parents are invested.

    The dreams of distance learning taking over will remain that — dreams.

    An that the ideal that computer programs will be able to replicate human teaching in the next couple of decades is hopelessly optimistic. Even Maths teaching is proving intractable.

  • mickc

    But surely the NHS was “privatised” from the start? Are doctors not self employed, rather than employees? Is this not “contracting out”?

  • Doctors have a contract with the NHS, so that really not mean the NHS is ‘privatised’.

  • APL

    Frequently the Continential system, particually the French system is held up as THE model of ‘how things should be done’.

    Yet, on the chyron of yesterdays pablum television news:- “Protests over working conditions at French hospitals have intensified after 1,200 medical staff threatened to quit their administrative duties in an attempt to force the government back to the negotiating table.”

    Not everything is rosie in the fifth Republic.

    PdH: “Doctors have a contract with the NHS, so that really not mean the NHS is ‘privatised’”

    The general practitioner service is largely and has been since the NHS was instituted. GPs knew what their own self interest was at the time, and they are still pretty shrewd now.

  • Patrick

    Any health system requires thinking about who:
    1. Pays
    2. Regulates
    3. Delivers
    The beef with the NHS is all about 3 and its Stalinist monopoly uselessness. Private delivery via a competitive market is clearly going to give much better value for money. The religion aspect of the NHS is mostly around 1 (free at point of use principle). I’d like to see the NHS become a thing that controls payment and regulation but doesn’t actually deliver medical outcomes.

  • Slowly and inevitably our overfunded, overmanned and increasingly inefficient health service will increase its use of private facilities, (Peter Barrett, January 15, 2020 at 7:59 pm).

    Will return to the increased use of private services it practiced before Blair (see this discussion, specifically point (1), paragraph two) and then perhaps increase further.

    If you want to privatise something, forget about health. Do schools. (Lee Moore, January 15, 2020 at 9:05 pm)

    +1 as the more productive place to start (a) in general, and (b) given the current government’s manifesto.

    nothing seriously resembling a free market health system is likely to work to the satisfaction of more than about 5% of voters.

    I think that’s a sizeable underestimate – especially once we have ‘done schools’. 🙂

    There are, obviously, many more sensible health systems around the world than the NHS

    Swiss health care providers are wholly private. The government requires health insurance and taxes it (not very much) and the sum raised by that tax funds emergency and other treatment for those who cannot pay. Each of the 7000-or-so Swiss communes is aware that it will pick up the tab from this fund for aliens who cannot pay, so, to protect their own indigent, are swift to check that foreign residents are insured or can otherwise fund their health care – and have a generally stern attitude towards any immigrants who cannot meet this requirement.

    In some ways (not in others), the Swiss system is less private than the US before Obamacare, but it might be a goal on the horizon for evolving the NHS. In the UK, the task of converting dependent voters to insured voters is not IMHO impossible but Lee is right that school vouchers are far easier.

  • Assuming Perry is right, and those stickers are black propaganda against the Tories (whose election speeches about the NHS must have annoyed “only safe with us” Labour speakers), then a quite separate issue is how one fights such black propaganda.

    And a separate issue again is how one speaks of “black propaganda” in the US. In the country where one cannot ask for black coffee without clarifying, the expression “black propaganda” is presumably wide open to being misunderstood. Obviously it’s a form of fake news, but it’s a very specific form and merits a specific term. What is the American English for “black propaganda” (and for “grey propaganda” and “white propaganda”)?

  • Surellin

    Do I recall Jeremy saying that if Boris won the Americans would buy up the NHS? Just thought I’d tell you that we have all the packing crates assembled and we’ll be over shortly. 🙂

  • bobby b

    “What is the American English for “black propaganda” (and for “grey propaganda” and “white propaganda”)?”

    I’ve never heard the phrase, but “Black propaganda” would be a “false flag operation” here, I think.

  • Fraser Orr

    @Patrick
    I’d like to see the NHS become a thing that controls payment and regulation but doesn’t actually deliver medical outcomes.

    But controlling payment and regulation are also a huge amount of the cost of a healthcare system, and my cost I don’t only mean in money, but in mortality and morbidity. If there is no accountability for cost then healthcare is massively over used, which leads to rationing, which leads to misallocation. And regulation costs millions of lives from opportunity cost from delayed approvals and overly cautious bans.

    Here in the US President Trump has tried to fix some of these things. For example, “the right to try” is the right to use an experimental medication if you are terminally ill. Boy did that piss of the FDA. Better to let people die if they don’t fill out form 789/a sub para 17.5 in triplicate. He has also, so far unsuccessfully, tried to require hospitals to publish their prices. My god, you’d think he had proposed that all hospitals include a brothel. How can you have a free market healthcare system without that most fundamental mechanism of free markets — the price?

    The FDA is one of the most egregious examples of this. The history is complicated, but basically in the 60s the FDA was doing their usual bureaucratic thing and delayed the approval of thalidomide. Of course we all know what happened. Thalidomide is an effective anti-emetic (prevents you from vomiting) which was unfortunately something that pregnant women in the first trimester do a lot. And it turned out that the drug causes damage to the fetus during development. About ten thousand kids were born with horrible birth defects until some doctors in Australia put two and two together, raised the alarm and the substance was put on hold. In the meanwhile, the bumbling bureaucrats at the FDA were so busy filling in their rooms full of paperwork, thalidomide didn’t get approved in the US. And so they claimed this as proof of a big win for their organization, in a — a stopped clock is right twice a day — kind of a way.

    And they have leveraged that victory to install the most pessimistic and restrictive standards of drug regulation in the world. And that is not without consequences. They delayed the release of the drug tPA for about twenty years (I forget the details). This drug is an emergency treatment for people having a stroke, and if administered within a few hours of the event improve survival rates something in the order of 50%. By comparing the effective use the tPA in other countries where it was legal and the USA where it was illegal due to delays at the FDA, it has been estimated that the delay caused the deaths of about 800,000 people. And that is one drug only. tPA is now legal in the USA and is the standard of care for acute stroke. So it may very well save your life one day. If it does, be thankful that the bureaucrats are not still dithering.

    Of course there is a downside to overly optimistic regulation. This too has been examined. In 2007 Zheng Xiaoyu the head of the Chinese equivalent of the FDA, The State Food and Drug Administration, was executed (yup, the literally strapped him to a table and, ironically, injected drugs into his system to terminate his life) because he had been accepting bribes from Chinese drug companies to approve their products. He approved, personally, approximately 150,000 drugs for use in mainland China. How many deaths were caused by his negligence? Of course it is hard to say, but the only ones that were traced were the use of a Chinese drug for the flu, which caused 4,000 deaths in Mexico.

    (I apologize I am citing all this from memory. I dug into this a lot a while ago but couldn’t find my data.)

    So regulation causes death and lack of regulation causes death, and from what I can see it is disproportionately against state regulation. What we really need is to allow people to use whatever drugs they wish, and to have a competitive system for regulation. Let your doctor advise you on what is safe and appropriate.

    As to paying for medical care. The fundamental problem is not so much the price mechanism but the fact that medical care is so darned expensive. And that is largely to do with the monopolistic, regulated, crony capitalism, guild restricted rules associated with medical care.

    To give an example — I was in hospital for one reason or another and got talking to one of the nurses. He was going to catheterize a patient (fortunately not me) for urine collection. So they stick this needle up the urethra (ouch….) and then attach it to a plastic tube which leads into a collection bag. He told me that the plastic tube and bag (both non sterile) were charged out at $300 each. I could plainly buy the equivalent at Home Depot for about 50 cents. So when I say that I think medical costs are about 10-100 times as high as they would be without all this government intervention, you can see that as an example. To say that medical care is overpriced is like saying that Imelda Marcos liked shoes.

    Here in the USA a decent family medical insurance policy costs about $20,000 a year. If it were a tenth of that, $2,000 a year or about $180 a month, then it simply would not be a matter for political discussion. If the only cars that were allowed on the road were Rolls Royces then most people would either be walking or demanding that the government provide them Rolls Royces for free. Rolls Royces are, after all, a human right.

    OK, I have rambled on enough.

  • TMLutas

    I think it would be a bit presumptuous for an American to do it but I’m sure that starting a privatization endowment to enable the NHS to serve the nation would improve the political chances of it happening. Voluntary fraternity is better than forced fraternity. With cryptocurrency being incredibly cheap to transfer and maintain, you might consider that as an option.

    I am considering how to do such things in the US. Does anybody know someone who would be willing to manage the funds as a side gig until they grow large enough to fund a paid manager?

  • John B

    1. The NHS has no business value. It is entirely a cost centre, not a revenue and profit generator. Aside its assets, property and second hand medical equipment, it is not possible to value it in order either to establish an acquisition price, or initial offering share price. Consequently no investor would touch it since they cannot see what the return on their investment would be.

    It is a clear indication of the self-delusion of most of the population, many politicians that they imagine the NHS could be privatised.

    2. The remedy is to remove its protected status as a State run monopoly. This can easily be done by allowing people to opt out of contributing to the NHS in order to use the money to buy private insurance. This would make provision and insurance in a competitive free market viable, and the NHS would have to compete (for the first time) on quality of service and price.

  • Andy Dan

    A friend of mine recently had spinal stenosis surgery at a private hospital. The pain was so bad, he was happy to pay £8000 for the operation done by the same surgeon as it would be on the NHS, but only having to wait 2 months instead of 18 months..(or longer, because they can’t say). All was well until a week later he developed an infection in the wound. (It can’t be determined whether this infection can be blamed on treatment at the private hospital). This caused a sudden acute condition of course.
    From there on he was taken into an NHS hospital where he had another operation to open the wound, was treated with intravenous antibiotics in hospital over a period of a couple of weeks and released all okay.
    Now, unless you can explain to me (and people even thicker) how a private system is going to give my friend the overall service he received over this period, I can’t see how you’re going to convince people to go over to a privatised system. I’m not making a case for socialised medicine, I just want to know the details of how it would work, from picking up an acutely ill patient to dealing with complications.

  • bobby b

    “Now, unless you can explain to me (and people even thicker) how a private system is going to give my friend the overall service he received over this period, I can’t see how you’re going to convince people to go over to a privatised system. “

    Here in the US, it’s mostly all private. They handle such scenarios every day. I guess I don’t understand your question. Why wouldn’t a privatized system be able to handle this? (And why couldn’t the first, private, hospital handle the infection in the first place?)

  • Fraser Orr

    @Andy Dan
    Now, unless you can explain to me (and people even thicker) how a private system is going to give my friend the overall service he received over this period, I can’t see how you’re going to convince people to go over to a privatised system.

    It isn’t complicated at all. Your friend had two medical issues:
    1. Spinal stenosis
    2. A post operative infection.

    He needed both treated and so he weighed the pros and cons of his options. For the spinal stenosis the cost was a long wait in pain or $8000, he chose the latter. For the second the options were pay some other amount of money for immediate IV antibiotics, or pay nothing for basically the same treatment at the NHS. His choices were both perfectly logical. I’m sure he could have had is infection treated privately too, but it would have cost him money and he can get essentially the same service for free at the NHS. (Because they can’t put you on a waiting list for post operative infections.)

    I don’t understand all the bleating about the US privatizing the NHS. I mean most of the stuff in a hospital, whether medical machines, drugs or medical techniques were invented and made in the USA already. So what exactly are they concerned with? If it is to be anything it is that Trump might tear down the barriers between the two countries to allow American medical consumers to buy these things in Britain, causing a price equalization, which would mean the prices in the NHS which are massively subsidized by the American medical consumer may well become actually fair for a change.

    Fun fact, most likely the surgeon who performed that spinal stenosis likely used a piece of software that my team and I wrote for monitoring the integrity of the nerves. Another fun fact? $8000 is a bargain. It’d cost ten times that in a US hospital. Hell the IV antibiotics with a few overnights at the hospital could have come close to $8k.

  • Julie near Chicago

    Adding to bobby’s point, nobody, but nobody, bats 1000. The question here is whether the tea leaves say that private hospitals in the UK would mess up even more than the NHS does.

    We in the Provinces hear lots of horror stories, and I’ve even seen some discussed on this very board.

  • The question here is whether the tea leaves say that private hospitals in the UK would mess up even more than the NHS does.

    There are some private hospitals in the UK.

  • Julie near Chicago

    Noted, Perry. There would have to be at least one for the story to even be true — that much I figured out all by myself. *Pats self on back, thus breaking shoulder*

    Nevertheless, thanks for making the point. I admit to getting the impression that you folks don’t have private hospitals.

  • There are some private hospitals in the UK. (Perry de Havilland (London), January 18, 2020 at 2:41 am)

    There are indeed. Their ratio of doctors and nurses to administrators is better than that of the NHS. Their record of not giving people infections is better than that of the NHS. I’ve seen one study saying their utilisation of costly equipment is better than the NHS – i.e. less down-time when the item is not being used (this surprised me, since they must await paying patients while the NHS can just treat anyone who wants it).

    Thus I’m unsure what John B (January 17, 2020 at 3:34 pm)’s point 2 about ending the NHS monopoly. You can have all your hospital health care private in the UK today, just as you can have your children educated privately if you pay, despite there being a state school system.

  • Thus I’m unsure what John B (January 17, 2020 at 3:34 pm)’s point 2 about ending the NHS monopoly. (Niall Kilmartin, January 18, 2020 at 10:01 am)

    My thought as well as my grammar was inadequate here. I think John B’s proposal is not too far from some distant equivalent of the voucher system of schools – that people be allowed to opt out of paying for some NHS-proportion of tax which they can use to buy their health care.

    This is not a million miles from my own ideas on the subject. The insurance aspect of health care, where individual needs are far more unpredictable than a child’s education, add many complexities but I think them solvable (and will not witter on about them over this busy weekend). It will take a long time to replace the state’s promise to pay (out of future tax revenue) with actual insurance held by actual people.

  • Paul Marks

    Perry – first, congratulations again on the win in your constituency.

    On health – the great (and I think hopeless difficulty) is the lack of a free market health system anywhere. Most people do not know that many of the hospitals taken over in 1948 were free (charitable) or had free wards – or they think that these hospitals and wards were terrible (an insult to the poor), and nor do most people know that some 80% of the “working class” were already members of Friendly Societies (mutual aid societies covering health and old age) as far back as 1911 – the obsession of the British establishment (both Liberal Party and Conservative Party) with copying Germany (which President “Teddy” Roosevelt also wished to copy) stopped a voluntary system that already covered 80% of the Working Class in 1911 developing further to cover 100%.

    We both know that the situation in the United States has been horribly more and more distorted (over decades) by endless government subsidies and regulations – but to most people the American situation is “capitalist healthcare” and they know they could NOT afford it.

    People point at France, Germany and so on – but actually taxation pays the vast bulk of the bill in these countries as well. Indeed the state is expanding its control in France, Germany and so on.

    “And your solution Paul?” – I have no solution. Without a country with a real free market healthcare system to point to, one is just talking theory – and most ordinary people are not interested in theory.

    The present government will spend a lot more money on the National Health Service – but most people will NOT believe that it is spending more money. After all most people do not understand that the NHS has had rising (rising – not falling) amounts of money spent upon it for more than 40 years. There have been no “Tory cuts” – but people think there have been.

    So in 2024 (the next General Election) the Labour Party will be able to point to the poor state of medical care and will blame “Tory cuts” (even though there will have been none) – and when Labour come to power (after all it will be “their turn”) they will throw even more money at the system – and it still will not work.

    But (and it is a big BUT) there will still be no real free market alternative to point to. And the “insurance” based systems of the United States, France and Germany have NOT controlled health care costs – quite the contrary.

    Oddly enough Mexico, of all places, used to offer reasonable private health care at a price most (not all – but most) people could afford. But then a “Conservative” President (President Fox – the same man who did the massively corrupt private-public housing scam) came in and set up “free health care for all”.

    It is a promise that seems good – Governor Long did the same in Louisiana back in the 1930s (before the NHS was created in 1948) and the Soviet Union got there in the 1920s.

    There are government hospitals in the United State (and not just in Louisiana) and in Russia – and such systems have been around a long time.

    Most people do not think they work very well – but they are free, and that does matter. What people want is to be able (without ever higher “insurance” costs) to know that they can get healthcare when they need it, without then getting a big bill. And the American situation fills most people with dread.

  • Fraser Orr

    @Paul Marks
    And the American situation fills most people with dread.
    This is an extremely cogent analysis Paul, thanks. However, the American situation should fill people with dread. Fall down and break your leg and they put you on an ambulance? It can cost thousands of dollars to drive you a few blocks, and then you have to spend months fighting a faceless bureaucracy to try to get them to pay.

    But how much does that ambulance ride cost? They give you an aspirin in hospital, how much does that cost? A nurse takes your blood pressure and temp, how much does that cost? Nobody knows. Even the hospital probably doesn’t know. For sure you don’t know. It is a literal nightmare, and for those in a weakened condition they often have to literally chose between physical and financial health.

    So, living here I see very much the attraction of an NHS type system, it is an attractive illusion. What we, as libertarians have to do is emphasize the point you make that America does not have a free market health care system. Nothing even close. My god the President recently put forward an initiative the require all hospitals to publish their prices. The reaction was so strong you’d think he had demanded that all neurosurgeons must be zombies.

    You can argue over what “capitalist” means in the context of an industry for which there are good arguments for some degree of regulation. But you can be sure that any system that does not publish its prices is not “capitalist” or “Free market”. Price is one of the most fundamental feature of a free market, competitive system.

    For the first time in fifty years we have a president that might actually do things to fix this. However, it does not seem to be his priority, and the alternatives from the other side are literally, (and I mean “literally” literally) insane.

  • Ben David

    Not quite sure why commenters on a libertarian/conservative website are so baffled by overpriced hospital services. Even the US “free market” for medicine is:
    1. Highly regulated
    2. Funded indirectly, with government bureaucracies and other 3rd parties inserting themselves between consumer and provider.
    3. Operating under constant threat of expensive lawsuits.

    This is enough to explain the crazy pricing of some services.

  • Paul Marks

    Fraser Orr – I think that President Trump means well (and that is radical change in my position on the man – compared with what I thought in 2016), but I still think he is not a “details man” not a POLICY man.

    A President Ted Cruz might (might) have been able to explain the case for free market health care reform in the United States (the present health situation in the United States is an utter mess – we agree there), but I do not think that President Trump will.

    Let us hope that I am WRONG – after all I have already (as I mention above) had to radically revise my view of Donald J. Trump since 2016.

  • Paul Marks

    It is well known that the internet companies are pushing Pete Buttigieg (an empty suit that “Woke” Big Business can control for the SJW cause) for President – but like many other people I suspect that the SENATE is the real target of the left this year.

    Even if President Trump is reelected he can do nothing without the Senate – not appoint judges, nothing.

    Certainly free market HEALTH CARE REFORM will be impossible with the Democrats controlling either chamber of Congress (so the House must be retaken – and decent Speaker is needed), but the Senate is the more important chamber – by far.

    Google and the other internet companies delivered the House to the Democrats in 2018, in 2020 the target is the Senate.

    And President Trump just sits there – allowing Google to rig search results and the other internet companies to play their dirty tricks (see the academic work of Dr Richard Epstein, a life long Democrat, on this).

    The internet companies see CALIFORNIA (with its high taxes, high government spending and endless regulations) as the model for all of the United States.

    We live in a bizarre age – perhaps the most dangerous enemies of capitalism are capitalists (Google and others).

  • Snorri Godhi

    We live in a bizarre age – perhaps the most dangerous enemies of capitalism are capitalists (Google and others).

    A better way of putting it would be:
    Perhaps the most dangerous enemies of the free market (today) are capitalists.

    Which is not bizarre, and has occurred in other ages.

  • Fraser Orr

    @Paul Marks
    A President Ted Cruz might (might) have been able to explain the case for free market health care reform in the United States (the present health situation in the United States is an utter mess – we agree there), but I do not think that President Trump will.

    I think there are some ideas floating out there that he may well pick up on, and in fact a couple he has picked up on. This is a poltically challenging thing for sure. For example:

    1. Allow consumers to buy their drugs from overseas pharmacies. (There has been considerable discussion about allowing State governments to do this, so it isn’t a huge step to doing so for consumers.)
    2. Forcing hospitals to actually publish their prices.
    3. Allowing consumers to buy health insurance across state lines. (How this works is unclear yet, for example, if I am in Illinois and I buy insurance in Georgia, does that Georgia insurance have to meet all the ridiculous, overloaded garbage that is required in a policy sold in Illinois? I’m not exactly sure how Illinois would regulate that, and in fact the much abused interstate commerce clause could well be used to make it illegal for them to do so.)
    4. Changing tax laws to improve the horribly messy health savings account rules.
    5. Changing the tax laws so that individual health insurance purchasers had the same tax benefits as corporate tax purchasers.
    6. One he has already done, but is mired in the courts — requiring all immigrants to have healthcare coverage. (As an immigrant here I can tell you that one of the core principles of Immigration law in the US is to prevent immigrants becoming a burden on the public purse, so I am utterly shocked that this hasn’t always been the case.)

    These are all small and readily achievable healthcare changes that together could make a huge difference.

    If he was bold he could also get the lawsuit thing under control. For example, he could pass a tax law that made any contingent fees to lawyers taxable up to 90%, though per hour fees not. Or extent the “right to try” to everyone, not just people at death’s door, or make FDA an advisory rather than a regulatory body.

    That is a start. Truthfully most solutions for the medical care crisis have to take place at the state level rather than the federal level, and so one of the primary goals of the federal government should be to get out the way (such as points 1 and 3) to allow the States to be “laboratories of democracy.”

    Imagine if, for example, Nevada saw an opportunity to raise a bunch more tax revenue by liberalizing their medical laws, and to make it a destination for lower cost medical care? I’d much rather do that than go to Thailand. But the commoditization and fungibility of the states’ medical laws come often from the top down through centralized, standardized control.

    It is a standard “If I Were King” mistake for anyone to think that there is one big thing that can fix medical care in the USA. Rather the solution is small achievable changes that will kill of the choke points that makes our present system the primary cause of bankruptcy in the USA.

  • bobby b

    Fraser Orr January 21, 2020 at 9:29 pm;

    Let me address your suggestions from the point of view of someone who worked insurance coverage litigation across all 50 states for a decade.

    “1. Allow consumers to buy their drugs from overseas pharmacies.” Let’s be clear what we’d be doing with this one. Drug companies would alter their pricing strategies and begin pricing drugs in the rest of the world higher very quickly. We’re currently subsidizing drug prices in other nations, in a very haphazard way. There’s no reason (except for the negotiating strength of Canada’s provincial buying programs) why we should be subsidizing Canada, but we also subsidize Mexico, the Caribbean, much of South America, Africa . . . We would likely just find another way to deliver those subsidies, out of our own pockets again. We’d equalize prices with Canada, but that’s not a huge amount. I think the savings here would be smaller than expected.

    “2. Forcing hospitals to actually publish their prices.” For what? Aspirin? MRI scans? You can usually get those prices. For appendectomies? New knees? Much harder. Ask a lawyer to publish a price list for “divorce”, and they’ll laugh, because each one is different. Each operation and procedure in a hospital is also different. Docs have different expertise, and so charge differing hourly rates. You might bleed more than I do, and use up more time and supplies. I don’t think we gain as much with this as you might think. We’d do better to mandate that pricing be the same for insured and uninsured billing.

    “3. Allowing consumers to buy health insurance across state lines.” Good luck with this one. “Insurance Commissioner” in many states is a very powerful, patronage-loaded position, and the power of the post comes from regulating the huge amount of money spent on and by insurers. In many states, this position is right up there with Governor in terms of power and money and influence.

    “4. Changing tax laws to improve the horribly messy health savings account rules.” Do we still even have these? Didn’t Obamacare kill them off? If they’re still available (I used to use these years ago), then they’re probably not too badly set up. (These were my go-to plan, along with ridiculously-high-deductible catastrophic coverage.)

    “6. One he has already done, but is mired in the courts — requiring all immigrants to have healthcare coverage.” Not that much of a dollar impact, in the overall scheme.

    “If he was bold he could also get the lawsuit thing under control. For example, he could pass a tax law that made any contingent fees to lawyers taxable up to 90%, though per hour fees not.” As someone who spent a lot of time trying to minimize insurer payouts, this is wrong. There’s no reason to boost the defense lawyers over the PI lawyers. I could see statutory caps on awards – nobody should get $245 million for fake Roundup injuries, or $200 million for fake silicone injuries – but handicapping meritorious cases by limiting what plaintiff lawyers can charge is unfair. There are a LOT of meritorious PI cases out there – people do injure others every day – and arbitrarily cutting off their justice would be a poor way to save money.

    We’re only going to save money on health care in the US if we make a social decision to stop trying to rescue premature and very ill babies, and stop trying to extend the life of people over 65. That’s where the bulk of our overcharge comes from. Other countries have already made those decisions, which is why they’re cheaper overall.

  • Fraser Orr

    @bobby b
    Drug companies would alter their pricing strategies and begin pricing drugs in the rest of the world higher very quickly. We’re currently subsidizing drug prices in other nations, in a very haphazard way.

    I’m sure you are right about increased costs elsewhere. The model for drug pricing worldwide is to use national boundaries to price discriminate, and then to screw over American consumers because they have less negotiating power than large national organizations. Which means as you correctly point out American consumers MASSIVELY subsidize the drug prices world wide. The success of this strategy is the wall of separation of pricing at national borders. Tear that down and prices equalize, and we stop subsidizing the NHS who look down their noses snootily at us about our terrible healthcare system, while reaching their hands in our back pocket to pay part of the cost of their system.
    The biggest risk to this strategy is that these other countries like Britain and Canada would make it illegal to export drugs to the USA. And that is a risk that has to be handled in trade negitiations. Britain right now is scared of “Trump privatizing the NHS”, which is kind of code for “Trump wants to take away the massive subsidies the NHS has been getting from the American drug consumers”.

    I think the savings here would be smaller than expected.

    I don’t know what the savings would be exactly, but this I can assure you, my friend, who is a type 1 diabetic, who could get her insulin from Mexico for $40 a month rather than $1000 a month from CVS would have her life quite significantly improved.

    2. Forcing hospitals to actually publish their prices.” For what? Aspirin? MRI scans? You can usually get those prices.

    Really? When I take my car to the garage for a new clutch he will tell me how much it will cost. Is he always right? No, sometimes when he is in there he finds the brakes need fixed, or whatever. And sometimes the price is fixed irrespective of the extra cost by the hospital having a fund the manage the variability (insurance, that is to say.) When my son broke his laptop for the third time I was very glad of the $200 insurance I bought. It was a fixed price and they absorbed the variable cost into their risk pool.

    Which is to say, people solve this problem all the time. (And FWIW, my divorce lawyer did give me a price, with the understanding that confounding factors might make an adjustment necessary, just like my car mechanic.)

    “3. Allowing consumers to buy health insurance across state lines.” Good luck with this one.

    Maybe, but if anyone can make that one fly it is Trump.

    “6. One he has already done, but is mired in the courts — requiring all immigrants to have healthcare coverage.” Not that much of a dollar impact, in the overall scheme.

    The cost of indigent and unpaid medical bills is hugely impactful on the overall cost. Along the same lines, one of the really toxic elements in the medical billing system is Medicare and Medicaid. I discussed this at length with my doctor. He inherited his practice from his father and so had a lot of older people on Medicare. He felt a loyalty and obligation to them, but told me they mostly cost him money. Why? Because he said Medicare (and even worse Medicaid) always pays their bills six months late, and always pays only 60% of what is due. Who makes up the difference? People like me with private insurance. (BTW this doctor, due to the massive complications and regulatory burden that can with Obamacare had to eventually give up the whole “my practice” idea, and got vacuumed up into a massive medical group as an employee.)

    I have in my life encountered a few medical companies that refused government money like Medicaid and Medicare. Without exception their service was excellent, their prices reasonable, and, over time competition drove their prices down and service quality up.

    but handicapping meritorious cases by limiting what plaintiff lawyers can charge is unfair. There are a LOT of meritorious PI cases out there – people do injure others every day – and arbitrarily cutting off their justice would be a poor way to save money.

    I don’t think the tax approach is best. What is best is loser pays. However, that is a matter for the states. The federal government can control the tax code though and use its influence here. As I said, I am not suggesting for a moment that plaintiff lawyers should not be paid, what I am saying is that they should be paid in a manner that does not encourage ridiculous behavior. The case that particularly sticks in my mind is regarding a product called Airborne. It is basically a soluble, fizzy vitamin C tablet. The makers made the mistake of suggesting on the packaging that it might reduce the incidence of cold and flu, which, of course, had not been evaluated by the FDA. So with ambulance chasers tripping over their tongues, they got together a class action, sued the company, won a judgement of $28 million of which they kept 40%, and the rest was in a fund so that anyone who had bought it, and had a receipt, could get a couple of dollars back (limit 2.) And of course, a spunky little start up company was destroyed in the process.

    I remember watching Erin Brokovitch, the movie, where everyone was getting all “Hooray for the little guy”, and I was flabbergasted. Right there in the movie itself, Julie Roberts says that the lawyers got 40% of the settlement “plus costs”. Meaning that the lawyer drove off in his new Ferrari while the kid with terminal cancer got something like $20,000. I mean they said it right there in the movie.

    No doubt there are many meritorious cases, and a good mechanism to allow the resource strapped plantiff to get his day in court is necessary, but the system is so grossly abused and so utterly destructive that, to me, the suffering caused by it outweighs the suffering it alleviates.

    We’re only going to save money on health care in the US if we make a social decision to stop trying to rescue premature and very ill babies, and stop trying to extend the life of people over 65. That’s where the bulk of our overcharge comes from. Other countries have already made those decisions, which is why they’re cheaper overall.

    Which other countries? Are you saying Britain and Germany and Canada don’t give adequate healthcare to premature babies or the elderly? I don’t think that is the case at all. And for what it is worth, it is a while before I hit 65, but I would appreciate it if the medical establishment would do all they could to extend my life, thankyouverymuch.

    If what you say is right then why is it that an appendectomy with no complications for the same demographic of person can cost $50,000 one place and $150,000 another in he same city. And why is it that that same operation probably costs less than $10,000 in Britain or Mexico. Premature babies and old people don’t often get appendectomies. And why is it that, if you get an ambulance ride to the ER to get that appendectomy, it’ll add $5,000 to your bill?

    Premature babies and end of life care are both perfect examples of what insurance SHOULD be for. In the first case a high cost at very low risk, spreading the cost out over a very large risk pool, and in the second case an accumulation of value over a lifetime of payments.

    I’m afraid I’m not a fan of your proposed death panels.

  • I would appreciate it if the medical establishment would do all they could to extend my life, thankyouverymuch. (Fraser Orr, January 22, 2020 at 3:19 am)

    Well yes, wouldn’t we all – if someone else were paying!

    How much of your own money will you spend on geometrically or exponentially more costly statistical increments? How little will your leave your children in order to pay for these increments? What is the amount you would pay to increase your statistical length of life by a week. Would you pay twice that to extend the statistical probability for another day? Ten times more again to add yet one more statistical hour?

    It’s rather like leading a healthy lifestyle with lots of exercise. Perhaps, in the hour before death, many people wish they had done more in that line – even those who did indeed do some – but 30 or 50 years earlier it somehow seems too much like work. And even the most prudent set a limit on how much money they deprive themselves of in the present to spend on a future that will probably (but not certainly) come.

  • Fraser Orr

    Niall Kilmartin
    Well yes, wouldn’t we all – if someone else were paying!

    And if that someone else were paying due to a contractual obligation he had to me to do so in recompense for fifty years of receiving insurance premiums then I’d expect them to do so. The problem here is the fact that “the public” is paying and so they are doing you a favor even giving you a band aid. It is no longer a contractual obligation but a gift from a man in a grey suit, demanding that you give thanks to the gracious kindness of your government.

    So if “the public” is paying then “the public” has the right to pull the plug.

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