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.
Samizdata, derived from Samizdat /n. - a system of clandestine publication of banned literature in the USSR [Russ.,= self-publishing house]
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Samizdata quote of the day – sell the NHS for scrap! The Americans are gaining healthy life years while we are losing them.
Hmm, that is interesting, no? Thus the UK requires more red in tooth and claw capitalism, more neoliberalism, obviously. Sell the NHS for scrap and go private!
And, well, but that’s not quite how American health care works, not for those over 65. That’s Medicare. Which is paid for by the government. But not supplied by the government. Which is a reasonable guide to what the problem is with the NHS. Tax paid health care is fine. It’s government supplied that is not.
At which point we gain our prescription – sell the NHS for scrap and have more neoliberalism. We’ll gain longer and healthier retirements by doing so.
– Tim Worstall
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Who Are We? The Samizdata people are a bunch of sinister and heavily armed globalist illuminati who seek to infect the entire world with the values of personal liberty and several property. Amongst our many crimes is a sense of humour and the intermittent use of British spelling.
We are also a varied group made up of social individualists, classical liberals, whigs, libertarians, extropians, futurists, ‘Porcupines’, Karl Popper fetishists, recovering neo-conservatives, crazed Ayn Rand worshipers, over-caffeinated Virginia Postrel devotees, witty Frédéric Bastiat wannabes, cypherpunks, minarchists, kritarchists and wild-eyed anarcho-capitalists from Britain, North America, Australia and Europe.
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I would hazard a guess that the scrap value of the NHS is extremely negative. Ie we’d have to pay a stupendous amount of money to get someone to take it off our hands. If you could find a taker, which I doubt, because who would be that stupid?
Just to be pedantic: From the day of my first job to the day I retired, I paid in about 3% of my gross pay to the government as the Medicare tax. Now that I’m 70, it provides a base of payment for my healthcare needs. But I wouldn’t say that it was paid for by government.
(BTW, that’s also my outlook on Social Security, towards which I paid during that same half-century 12%+ of my gross pay to the government. Yes, I know they spent it as soon as I sent it in, but I still see that as a different system than welfare.)
And the estimable Tim Worstall also neglects to mention that Medicare, while it certainly is funded out of taxes, is actually significantly-controlled by the government. Yes, the providers are not government employees, but they might-as-well-be, since the government decides what Medicare will pay for, and what it will not. He who pays the piper, and all that. Just like with the NHS, many Medicare recipients choose to buy additional private insurance to fill the gaps in what Medicare will pay for.
llater,
llamas
An interesting idea. The only problem is that any British politician who suggested it would be committing instant career suicide, although I suspect that British attitudes to the NHS might – just might – be shifting.
Ultimately, I don’t think there’s any solution to healthcare costs. Medical advances produce new – and costly – treatments which people invariably want because, despite what they might say to the contrary, just about everyone wants to live for as long as possible.
And yet there are more healthcare provision options in other countries, so we are not restricted to just the American option. It seems perverse that we don’t consider the French insurance based system, particularly when it is said to be much better.
Indeed, DJ. The Swiss, French, Dutch, even Spanish systems are better than the NHS & are hybrid, with a much larger private element than the dismal NHS
It’s an odd thing about discussions of the NHS. Any criticism of the current system is always met with the same response: Would you rather we had the American system? It’s like conditioned response behaviour. I can’t remember a single time when the critic of the NHS pointed out that other health care systems are available.
American life expectancy is falling (not rising), and American health care has been horribly mutated by endless government subsidies (there has been an explosion of government spending in the United States – going as far back as 1965) and endless regulations.
I am no fan of the NHS (quite the opposite) and I am very much on the side of Tim Worstall – but I wish he would not write quite like this. The American health care “system”, saturated with government spending and endless regulations, should not be copied.
As for health care generally in the Western world – the relationship between the individual patient and their doctor has broken down (perhaps, perhaps, because doctors are no longer paid directly by the individual patient) – this was shown, horribly shown, during Covid – where most doctors (most – certainly NOT all) did little to save the lives of their patients – in spite of Covid, if-caught-early, being a treatable illness. They were more concerned with their standing with various bodies (government, corporate and “professional”) than in saving the lives of their patients.
Think about that – it is truly awful, it betrays everything the practice of medicine stands for.
“Tax paid health care is fine.”
It really isn’t. The state is no more competent as a customer than it is as a provider.
“American life expectancy is falling (not rising)”
Not according to the CDC. Where are you getting your information?
It did fall a bit between 2014 and 2017 and then again during the Wuhan Flu panic from 2019 to 2022, but since then it’s been on the rise again.
I agree with the remainder of your comment though. The US health care “system” is hardly something to be emulated. Better than purely socialized health care to be sure, but still heavily regulated by the government and highly inefficient as a result.
My first thought after reading the OP (from Tim Worstall) was basically what Jim said.
Except… Then I thought “scrap”. Now by definition that means breaking for parts and yeah there are somethings of worth. What is rotten to the core is the control.
From recent personal experience within my family if I was to point out the eternal singular failing is that the NHS is massively bad at communicating either to patients or within itself.
I am well aware that is a very specific managerial fail and not necessarily a critique of the concept of the NHS. I thought I’d mention it though rather than just chime in with the usual “keep government out”.
Other than that I agree the NHS is conceptually wrong but I thought I’d add something specific.
And two more points…
At the end of my street is a large doctors surgery (6 Drs, 5 nurses) and they don’t do cervical smear tests. Instead you have to go to a clinic which from here (which is hardly the sticks) you have to go to a clinic which is quite a way off and VERY difficult to get to from here without a car. Fortunately my wife does have a car but lots of people don’t. Free at the point of delivery – if you can get there! This applies to all gynaecological services around here.
Not unrelated is that the NhS currently currently spends more on settling malpractice litigation concerning childbirth than it does on maternity services. I am not making that up. You’d probably be better off giving birth in a stable in Judea 2000 years ago. At least you might be seen by three wise men.
That single final fact is shocking. In almost any other circumstance (without the Government Magic Money Tree) that would be utterly unsustainable. But instead let’s just jail Lucy Letby. All her fault.
I nominate Patrick for QOTD…
“The state is no more competent as a customer than it is as a provider.”
About that horrid American healthcare system:
My dad’s 93, failing health, COPD, macular degen, bad hip, all sorts of issues.
I have taken him to a local hospital emergency room five times this year. An ambulance has taken him twice. He sees five different docs regularly for his various ailments.
He has Medicare, and one of the normal “advantage” private plans that lower his deductibles.
In our horrid system:
– We call and get non-emergency appointments within a few days;
– Emergency care is always available, with a wait time of about an hour when it’s busy;
– His eight different prescription meds are ready and waiting at the local pharmacy as he runs out, for no cost to him;
– The bills that he has generated have hit about $270,000 this year. His portion of those bills has been about $500.
Honestly, not too horrid of a system. And no one goes without care because they’re broke. The hospitals eat those bills, and never turn anyone away.
Where, you ask, does Paul get his information? Take a guess.
I had a cascading series of dire health emergencies three years ago. I’m almost fully recovered but I am still undergoing follow-up care. It has all (or mostly) been paid for by Medicare. And the care I received, in whatever form, has been excellent. Prescription costs, getting appointments? No problem, no complaints.
Paul doesn’t know what he’s talking about. As, I’ve discovered (when he writes about various issues peculiar to America), is often the case.
To build on what bobby b. observes, I have to say that Medicare, while it has its faults, is far-better administered than most private health insurance. I was never so happy as the day that mrs llamas (who has some ongoing health issues) was able to transition to Medicare plus a supplement policy, and we were finally mostly-free of the constant, low-level administrative “sludge” that typifies most private health insurance. The constant calls to quibble about payments, the baffling and illogical rules about coverage, the strange interactions with the tax code, all of this was a constant stone in our shoes. Medicare has (to this point) been blessedly-free of all of this. My medical needs are blessedly-few, but even my relatively-straightforward issues have been much-easier to deal with under Medicare than under private insurance. And – maybe we are just incredibly-fortunate in our local facilities – but if you rock up at A&E in our local hospital, you’re going to begin being treated in less than 15 minutes, and if you’re leaking blood, they’ll start treating you before they even know who you are. Ask me how I know this . . . . .
I’m inclined to cut Paul Marks some slack here, because I’m going to guess that he gets most of his information about US healthcare from UK media sources. From my own, repeated experience, UK media outlets are systemically-incapable of telling the truth about the US healthcare system, and will happily report the most-outrageous falsehoods as gospel. I have seen this on UK TV, in UK newspapers, on UK websites, and countless times had it repeated to me in-person, so it’s not the odd mistake or oversight – it’s systemic and deliberate.
llater,
llamas
llamas,
A huge amount of the UK media (and much of the populace) thinks the entire US population are obese, uncultured, gun-slinging religious mentalists. I have spent quite a bit of time in the USA and… er… no. But hey! I put my boots on the ground and did things like actually talk to Americans. I know it is a radically old-skool way to find out about a place but it worked for me!
Anyway, I’m curious, why did you use the term “A&E” and not “ER”?
NickM wrote;
” . . .why did you use the term “A&E” and not “ER”?”
Even after almost 50 years in the US, I still unconsciously revert to the spelling and expressions of my youth in the UK. It confuses mrs llamas to no end, but she does like that I can explain the arcana in Downton Abbey and Doc Martin.
llater,
llamas
@bobby b
Honestly, not too horrid of a system. And no one goes without care because they’re broke. The hospitals eat those bills, and never turn anyone away.
Your point is well taken, though it is actually paying medical consumers that pay those unpaid bills not hospitals. I actually talked to my insurance about this because I have heard horror stories about ambulance costs. They told me that on average ten out of every eleven ambulance rides is not paid for by the rider. Which is to say the shmuck who does pay his bill actually pays eleven times as much as he is due. It is also undoubtedly the case that American ERs are often packed to the gills with illegal immigrants seeking minor medical care because they can’t go to a real doctor. When your ER costs $1000 per visit, and people are going to get some free Advil samples or to stitch up a minor laceration, something is dramatically wrong.
And this free rider problem is a major contributor to America’s medical cost problem, and it isn’t just Americans. In truth the rest of the world, including the NHS, is a free rider on the American medical consumer. You see this most clearly with drugs because of their unusual cost structure (the NRE is the vast majority of the cost, the marginal cost is tiny.) So the drug companies have to decide how to distribute that NRE, and, for various reasons, it is almost all put on the shoulder of the American medical consumer. So that is right, the NHS is not only crap, but it is crap despite the fact that it is massively subsidized by the Americans whom you all like to laugh at for our supposedly crap medical care system.
FWIW, one very simple way to reduce the cost of medical care in the United States, especially drugs and medical devices, is to tear down the customs barriers that prevent us from buying abroad. If you are an insulin dependent diabetic it is a disgrace that you have to pay $250 a vial, when exactly the same vial is available in Mexico for $10. What a profit opportunity, right? Get a refrigerated truck, drive down to Mexico and buy out their supply, and drive back here and sell it at twice the cost, where local diabetics get an 80% reduction in medication cost. But you can’t, because it is illegal.
If Trump could do something quickly to fix the horrendous cost of drugs in the United States, which he could do by simply by stating and enforcing by EO that we will no longer collect duties or prevent the importation of foreign drugs, prices would crash and people would love him. But Trump is really rather more a “put up tariffs” than “tear down tariffs” kind of a guy.
But to your point, I have a dear friend in Glasgow who has chronic extremely painful gallstones, though not a medical emergency. If he went private he could get his gallbladder out next week (as could I were I suffering the same affliction.) On the NHS they will try to fit him in in about eleven months. I’m friends with a pretty prominent cardiac surgeon who I was talking to about this. He told me he went to a conference in Britain and talked to some of their top cardiac surgeons. They told him that the NHS has a budget for cardiac operations and once the budget is expended they can’t do surgery any more. So, or so he tells me, it is pretty common for cardiac surgeons in Britain to take December and a fair bit of November off because there is no money to pay for their surgeries. I don’t know if that is true, but it is what he told me.
I’d like to talk about the dramatic impact of AI and robotics on all of this, but I guess you guys are sick of me spouting off about that stuff. But let’s just say it is overwhelmingly huge.
I repeat my previous comment – I do not need to be “cut any slack” because what I typed was correct. Especially about costs.
Massive government intervention, subsidies and regulations, has been a disaster in the United States.
@llamas
I was never so happy as the day that mrs llamas (who has some ongoing health issues) was able to transition to Medicare plus a supplement policy, and we were finally mostly-free of the constant, low-level administrative “sludge” that typifies most private health insurance.
Firstly I am very glad for you that your wife is getting such great care, and I wish her good health, and wellness.
But I think it is important to understand the truth about Medicare. If you talk to doctors and medical administrators, which I have done a lot both through my personal friendships and my professional work, they will tell you that Medicare is a nightmare, especially since Obamacare. Why? For three reasons: first of all they don’t pay their bills, second they pay their bills VERY late and third it is a byzantine administrative disaster. What they tell me is that Medicare typically only pays 50% of the bill, they typically pay their bills at least 6 months late and the administration (and this isn’t just Medicare is is ALL medical insurance companies since Obamacare) is so insanely complex they often have to hire more administrators than clinical staff to keep up. Moreover, the clinical staff have a gigantic extra burden of dealing with insurance, especially Medicare that takes them away from their clinical practice.
Now of course Medicare might be good for the consumers, which is to say the voters, but it is largely a big blame shifting game. You don’t have all that administrative sludge because they forced doctors to hire armies of administrators and then hit the tax payer up with the bill. They took 3% of your paycheck all your life and promised you great care, but when it came time to deliver they had stolen and spent all this money buying votes for themselves, so they used the power of government to shift the blame and steal from someone else to pay for what you already paid for. And then had the audacity to claim that medical companies and medical providers were greedy capitalists seeking your ruin.
If you ask most doctors they will tell you they make a significant loss on every Medicare patient treated (and don’t even get me started on Medicaid), most doctors would prefer to drop Medicare patients but often do not out of ethical obligation rather than out of a desire to make their practice successful. My personal PCP (GP for you Brits) inherited his practice from his father and between the two of them had built it up into a successful business providing a valuable service to the community. However, because he inherited it a large number of his patients are on Medicare (apparently he is good at keeping people alive❤) and so this thriving independent business got hammered with unbelievable administrative burdens, especially with Obamacare too, and he had to hire dozens of administrators, so that more than half of his staff were non medical. Eventually it got so burdensome that he had to sell out to the large medical conglomerate that dominates this area, an be reduced to a mere employee, after decades of building his business. And despite that he still works most evenings and weekends to keep up with the “sludge” of administrative work. This FWIW is why people who hate “big business” while advocating for more regulation don’t understand the deep relationship between the two.
All of this means that Medicare is a vampire on the rest of the medical insurance system. Now of course we have all contributed massively to Medicare and the government has an absolute obligation to provide what we have paid for (even though instead of investing and saving the money we paid it they in fact stole it and used it to buy votes for themselves), which is why the idea the the US national debt is 40 trillion dollars is simply not true — that is our bond debt, our unfunded liabilities are at least three times that.
And while several people have painted a rosy picture of medical care in the United States, and to be clear, if you have good health insurance and live in a nice part of town, American medical care is unbeatable, but what they did not mention is that medical bills can be utterly destructive to people’s lives. The vast majority of bankruptcies in the United States are due to medical bills, and is becoming more and more common for parents to be unable to leave any inheritance to their children because end of life care, especially residential care, sucks up the last few drops of blood you have been able to accumulate over a lifetime.
American medical care is stuck half way between a fully private system and a fully government system, and it takes the worst aspects of both. Certainly if you can afford it, there is incomparable medical care available here, but many Americans live with a Sword of Damocles hanging over their head waiting for a life destroying medical bill to bring them complete ruination.
And to be clear, those of you on Medicare who are getting good care — you absolutely deserve it because you paid for it. But what is going on to make that happen under the surface is the horrific corruption, malfeasance, fecklessness and Machiavellian blame shifting that you’d expect from our civil service and politicians.
And I don’t get my facts from the British media, I get my facts from American medical consumers and the medical staff who provide it.
The idea that I get my information about the United States, on medical costs or anything else, from the media – is false.
I am sorry that Tim Worstall has chosen to write nonsense about the United States – implying that there is a free market health care system there, but it is NOT my fault that he wrote nonsense.
And, no, life expectancy has not been doing well in the United States – so it is not just a matter of exploding costs, due to subsidies and regulations.
As for the NHS – I have not discussed it in this thread, because there is no point in discussing it – it is a horrible mess and throwing ever more money at it has solved nothing.
By the way – it was not the first such system in the world, in reality it is a copy of the Soviet system created in the 1920s.
Fraser Orr – thank you for your kind wishes.
What you say about the issues with Medicare is likely largely-true, but I will counter it by observing that these issues (while undeniably troublesome) bear much harder on individual providers than on corporate systems and those working in them. I also know several medical providers who observe that, while Medicare is slow to pay, and pays lower rates for services than they would like to be paid, they are still happy to serve Medicare patients and wecome them into their system. Medicare may be slow, but it is reliable/predictable, and dealing with Medicare, while it may be burdensome, does at least have the advantage that you’re only dealing with one large payer instead of 36 smaller ones. A large healthcare system can adjust its billing systems to optimize for Medicare’s quirks, and has the resources to absorb the built-in payment delays. These issues would be much-more significant for a small practice or an individual provider.
Incidentally, I can’t be bothered to chase down the comment that claimed that a vial.of insulin costs the patient $250 in the US. I’ll merely note that this is staggeringly-untrue, and invite readers to research this for themselves.
llater,
llamas
Oh, and – Fraser Orr wrote:
“The vast majority of bankruptcies in the United States are due to medical bills . . . .”
and while this a story often-repeated by the likes of Elizabeth Warren and Bernie Sanders, there doesn’t seem to be much data (rather than anecdote) to back it up. I wouldn’t normally cite Snopes as a reliable source, but gien their well-known and obvious liberal bias, if even they cast serious doubt on this claim, you can be sure that there is a lot more to the story than this simplistic claim.
The basis of the claim seems to go back to a study in which 60-something % of people filing personal bankruptcy stated that serious medical bills were a part of their obligations. This was then re-cast as “showing” that 60-something % of bankruptcies were “due to” or “caused by” medical debt. A deeper dive by economists at the University if Maine found that medical debt was the principal obligation in about 14% of personal bankruptcies, and was virtually-never the only significant obligation.
Just another “fact” about the US health funding system that everybody “knows”, that just ain’t so.
llater,
llamas
https://www.snopes.com/fact-check/643000-bankruptcies-in-the-u-s-every-year-due-to-medical-bills/
A. Was just about to type about the bankruptcy myth – the Pocahontas claim. But llamas beat me to it.
B. Fraser Orr: yes, Medicare is a tough admin nut to crack. That’s why so many get the add-on “Advantage” policies from private providers, that work in conjunction with Medicare.
You sign up for an Advantage policy with a private insurer, and Medicare sends the amount of money to them that is attributable to one insured. I have a Blue Cross Advantage policy, as do my parents.
What this means is, Blue Cross then takes over the entire admin and payment role that the government otherwise handles. You work within their stable of providers, and it is seamless for the user. Docs get paid faster, so they love it.
And the best part is, Blue Cross (and the other private insurers) know they can do this admin job far more efficiently than the gov can, and so when Medicare pays over to them the monthly $$ that Medicare books as the payment for the coverage, Blue Cross does the job better, for less money, and makes a profit.
And – this is important – the Advantage policies are frequently FREE to us patients. I pay zero dollars for this Advantage policy. My parents pay about $50/month.
So we’ve found a great blend of public/private here.
@llamas I don’t want to get into dueling studies since I think “studies” are pretty bogus in Internet discussions, but despite what the loathsome Snopes might say there are certainly studies which say the opposite: “In surveys conducted by researchers with the Consumer Bankruptcy Project in 20015 and 2007,6 a majority of recently bankrupt debtors implicated medical bills or illness-related work loss as causes of their bankruptcy, findings that President Obama used to argue for passage of the Affordable Care Act (ACA).”
I’ll grant you that says something a bit different to what I said, but it shows we are in the right ballpark at least.
Regarding insulin, my source for the number is from a few type 1 diabetics I know, however, it looks like the government passed a new law limiting the cost of insulin to $35 a month which I suppose from the point of view of the end user this is good. But why $35? Why not $15? Why not free? Why not a lot more for rich people than poor people? IT is just an arbitrary measure to deal with one politically visible thing rather than solving at the root cause of the problem. It is really part of the whole problem with medical care and its payment: the one solution they don’t seem to want to try is competition.
It is also worth noting that things are getting noticably worse on the payment front. I was talking a couple of weeks ago to the HR dept of a large employer, they were telling me they dropped one of their insurance options because premiums went up 60%! And the other three they carry, premiums only went up 25% of which the employer absorbed about 1/3. So no bonuses or raises for anybody this year, I guess.
FWIW, I find it a bit weird trying to convince you, of all people, that a government run, centralized system is a problem for something as important as medical care, though obviously this is a situation of critical importance in your personal life. But I think the real issue with American medical care is that it is caught between a private system and a government system and takes the worst aspects of both. We would be better off if we had one or the other, but now we have the worst of both worlds.
However, maybe temporary band aids (if you’ll excuse the pun) might be the best for now since the whole business is about to be turned upside down via robotics and AI. It worries me because it is trapped in this government bureaucracy that does not deal well with innovation and rapid change. And most likely a lot of people will die as a result. Hopefully I won’t be one of them.
No one should present the medical “system” of the United States, with its endless government spending and endless regulations (which have massively inflated costs – and undermined the personal relationship between most patients and their doctor), as something to be copied. What Tim Worstall wrote was silly – he got carried away by rhetoric. One might as well support the, utterly demented, government backed “student loan” system in the United States – which has led to an explosion of tuition costs.
As for the United Kingdom – the only positive thing that can be said is that, unlike Canada, private medical care (i.e. patients paying for their medical care directly) is NOT illegal here.