Wednesday, August 19, 2009

Danny's take on the healthcare debate

A fascinating article in today's Times from Danny Finkelstein. Here is a quote:

The debate about American reform begins with the American system. The debate about British reform begins with the NHS. Voters in both countries fear what they stand to lose more than they look forward to what they stand to gain. Since they fear losing different things — in the US case, for instance, they fear loss of choice and control, while in the UK we fear losing universality — the debates in the two countries will always be different.

The US will never create the NHS and the UK will not adopt the American system because we are starting in different places.

The only meeting point is that we face a common crisis. Available treatments now outstrip our ability (never mind our willingness) to pay for them. In the US this is experienced as a crisis of cost, with health inflation rampant. In the UK it is experienced as a crisis of provision, with the State refusing to finance life-saving procedures.

Health care has just got too expensive.

The World Health Organisation records that in 2006, Americans spent $6,719 per head while Britons spent $2,815. One result of this disparity is the startling fact that the US Government spends more on healthcare per head of population than the UK Government does ($3,076 in the US compared with $2,457 in the UK).

This is the point that I have been trying to get across for a long time. The US already has a taxpayer-funded health service - Medicare, Medicaid, Provision for children, the VA, the NIH, the CDC, medical insurance for government employees, tax breaks for companies. Compared to the NHS, they just don't get value for money.

Meanwhile, in the UK — how do we decide how much of our income to spend on treatment and how do we cope with the fact that, while every person has a different answer to this question, we all still feel that everyone should get a good standard of care.

The truth is that as the very clever Enoch Powell once said, medical care will always cost more than we can afford, and just as we buy Fords rather than Rolls Royces, we have to cut our cloth according to our means. The NHS is predicated on getting value for money. It is reasonable that the public provision of health care should be rationed. There are plenty of conditions that could be done a few weeks later quite safely - I heard of someone who had a cataract operated on privately because the NHS appointment given was too soon to fit in with their arrangements at home. If we have to make a choice between someone waiting an extra two weeks for their hip to be done and someone getting a drug for their breast cancer that gives a 20% chance of their living an extra year, I would always choose the latter. But suppose the choice were between an extra six months wait in pain and a 1% chance of living an extra year? There is always a position of equipoise where choosing is invidious, and the choice that different individuals make will be scattered over a large area - people wouldn't even make the same choice themselves every day.

In a socialized system where the community clubs together to provide for a need, individual choices will always be different. Imagine a poor community joins together to buy a car for communal use. There will be days when more than one person needs the car at exactly the same time; how do you resolve such issues? But 2 cars? Possible but then suppose that three people need the car at exactly the same time. Eventually you reach a point where no more cars can be paid for and the demand exceeds the supply. In a free market the price goes up, but we are not dealing with a free market. For a market to operate there must always be the possibility of someone going bankrupt and their being an unlimited supply of good to sell if the price is high enough. The market in health care is constrained by a limit on the number of physicians and the impossibility of allowing a major provider to fail.

HMOs were an attempt at rationing in the US and very unpopular they were, but the fact is that not everybody in the world can have the best health care. There are scare stories from both sides of the Atlantic where both systems fail individuals.
Doctors dislike giving individuals less than the best. But I guess car salesmen would prefer that their customers drove out of the showroom in a brand new Mercedes. At the moment we are giving away clunkers on both sides of the Atlantic to some poor individuals; we should at least attempt to provide Toyotas.


Dissenter said...

Excellent, balanced view Terry. I have tried to express something similar on a video I just posted on youtube referring to the recent BMJ item on inadequate provision of cancer radiotherapy service in the NHS.

Probably both we in Britain and the Americans could learn a bit from each other and both move closer to the mixed provision systems which seem to work very well in mainland Europe. But you are right we will never be able to do everything for everyone, just as we can't all have Rolls Royces or consume lobster and Champagne every day. we must be realistic about rationing.

Psalm 90 is very apposite here

'..the years of our life are three score and ten, or perchance by reason of strength four score, and then we fly teach us O Lord to number our days so that we might get a heart of wisdom.'

kind regards

Burke said...

Doctor Hamblin writes,

"In a socialized system where the community clubs together to provide for a need,..."

I'm sorry, but this is not what socialism of any kind is. People don't just get together to provide a need. What happens is that those with the ability to provide for themselves are forced to provide for others.

Which is the main reason health care becomes so expensive.

And where does it lead to?

We have the answer in another news report from Canada today:

"Dix said a Vancouver Coastal Health Authority document shows it is considering chopping more than 6,000 surgeries in an effort to make up for a dramatic budgetary shortfall that could reach $200 million.

"'This hasn’t been announced by the health authority … but these cuts are coming,' Dix said, citing figures gleaned from a leaked executive summary of "proposed VCH surgical reductions.'"

Further down in the article:

"Dr. Brian Brodie, president of the BC Medical Association, called the proposed surgical cuts 'a nightmare.'

"'Why would you begin your cost-cutting measures on medically necessary surgery? I just can’t think of a worse place," Brodie said."

The lesson is obvious. You can't have the prosperity and productivity of capitalism without capitalism.

As Margaret Thatcher said, in socialist societies, sooner or later you run out of other people's money to spend.

Anonymous said...

I certainly don't pretend to have the answers and remain sensitive to all sides of the issue, but I can assure everyone in the US that the "cost" of healthcare to individuals will be higher than they could ever imagine if and when the US government provides "free" healthcare...A plan which those in our Congress have and will continue to make themselves exempt from. (because as in Orwell's Animal Farm...some animals are "more equal" than others).


Burke said...

Dr. Hamblin,

I would be interested in your view of the reasons for and events surrounding the recent release of the Lockerbie bomber. The news story linked below suggests that it was part of an oil deal with Libya, although the Brits deny it.

From afar, it appears that Great Britain is compromising its security and the security of its allies because of its economic problems--economic problems caused largely by its decades-long slide into socialism.

Many believe that the former Soviet Union collapsed because it could not feed its huge military with its socialistic economy.

So, I find myself wondering: If socialistic nations cannot feed themselves and be responsible about their own security, how can anyone expect them to produce a high-quality health care system?

Terry Hamblin said...

I am disgusted by it. It was not within the gift of the United Kingdom, though. Scotland has a devolved government and Scottish law is different from English law.

Gordon Brown's Labor party is in opposition in Scotland and the Scottish Labor party has spoken out against the release. It would be strange indeed if the Scottish National Party did something at the behest of the UK government, which it opposes.

However, I think Mandelson is a slimy liar, so if he is denying it, it may well be true. The release has caused as much controversy here as it has in the US.

Anonymous said...

One reason costs are higher in the US, and outcome inferior, compared to other societies is partially explained by 'diversity' and geography.

The US is a huge country, with large portions sparsely populated. Native Americans sometimes live tens of miles from the nearest health care facility. It just stands to reason that a heart attack patient in London is going to get more prompt care than someone 50 miles from the nearest ambulance.

The US also has large population of non-English speaking, often illegal residence. The may be reluctant to get health checkups. A heart attack (with the often overweight hispanic patient) can't be prevented if the patient doesn't get screened.

Plus, the calculations don't factor in quality of life.

For example, rituxan isn't covered by the NHS or in Canada for CLL. Rituxan has certainly meant a better (and longer) quality of life for me.

As for the HMOs, I was a member of Kaiser for many years, and I was satisfied by the care offered. When I was diagnosed with CLL. Being a rare disease, I knew I wanted to be in a clinical trial. Kaiser didn't offer any. So I moved my insurance.

The whole key to health care 'reform' is to sit down and go through the 'problems' one by one. Don't try to jam it down our throats in two months. That's the mark of someone trying to hide something. That is the over one trillion dollar cost, coming on top of a seriously over-spending US government.

Terry Hamblin said...

[For example, rituxan isn't covered by the NHS or in Canada for CLL]

Not true now. The NHS does allow rituximab for CLL since the German CLL8 trial results became available. Until, that trial there was no available evidence that rituximab was an advantage in CLL. The FDA actually complained about the off-label use of rituximab in America for CLL. To those familiar with FCR it was pretty obvious that it was better than FC, but nobody produced any evidence. Doctors got FCR paid for under the fiction that CLL was a type of NHL even though the trial of rituximab in NHL only showed a 13% response rate in CLL. I don't blame NICE for the delay in the UK, I blame the pharmaceutical companies for not setting up a trial years earlier.

Burke said...

Dr. Hamblin,

I have a couple of questions on this subject, ones you seem particularly well qualified to answer, if you don't mind.

How good would the state of medical care be in the UK and in other socialistic health care systems without the advances in health care that came from the United States?

Are socialistic governments outside the U.S. paying the same thing for medicines and medical equipment that private citizens and companies pay here? Or are we in the U.S. effectively subsidizing the socialistic systems?

(For example, they have price controls on drugs in Canada, I understand, which means that U.S. citizens are paying more for drugs developed here than Canadians are, effectively subsidizing them.)

Terry Hamblin said...

How good would health care in the US be without the advances from the UK like antibiotics and monoclonal antibodies? The scientific advances in medicine are not just the result of research in the US, but they occur all round the world. In CLL for example the IGVH gene separation into two types came from the UK, the separation by chromosomes came from Germany, ZAP-70 was a collaboration between the UK and NIH, Chlorambucil came from the UK, fludarabine from the US, the development of rituximab from the UK, the US and Switzerland. Bendamustine comes from East Germany. The idea that America subsidises the rest of the world is ludicrous. 50% of useful drugs come from America and 14% from the UK. America is roughly 6 times as big a Britain, so if America was punching its weight it would have pharmaceutical industry 6 times as large rather than less than 4 times as large.

Burke said...

A nation of a little over 300 million produces 50% of the drugs in a world with over 6 billion people? Last I heard, the US was spending about the same on its military as the rest of the world altogether, protecting most of the free world and much of the unfree world--doing much more than "punching its weight" there, I would say, and getting very little appreciation for it mostly.

What's the explanation for that?

How can such a tiny portion of the world's population be so much more productive than the rest of it?

And, I don't mean to seem like I'm pounding the UK, but we keep getting pounded over here with stories like this:

(I know I'm probably sounding critical, doc, but I don't mean it that way. Really, I have traveled very little and learn a lot from you and others on the Internet. Your comment about Scotland being so socialistic, for e.g., was quite interesting. I had no idea.)

Terry Hamblin said...

The Daily Mail is a bit of a rag. It exagerates anti-NHS stories for political purposes. Yes there are babies born in corridors, but this is rare (like babies born in taxis) and often the fault of the parents rather than the hospital. WE also read horror stories about the American system. I would no more believe the Daily Mail than I would believe Michael Moore. They deal in polemic not evidence.

Terry Hamblin said...

By the way, I admire most things about America, especially the American revolution which almost uniquely demonstrated that you don't have to give up religion to be free. I do object to Americans misappropriating the achievements of others and the lies about history told by Hollywood. America has enough to be proud of without needing to exaggerate.

Burke said...

America's Revolutionary religion:

Not many "evangelicals" over here admit it, though.

Burke said...

The Daily Mail is still at it:

Burke said...

Doc, this is pretty damning, and it doesn't come from the Daily Mail:

It sounds a lot like the kind of thing you were writing right after you retired.

Terry Hamblin said...

But the Telegraph also has an agenda. Britain's answer to Fox News. I think this is about the Liverpool pathway for dying patients, which has been adopted world wide. Some retired doctors are complaining about the thinking being taken out of medicine, reducing it to box-ticking. I agree with that concern and have complained about it before on this blog. However, it is even more rife in America where unless the right boxes are ticked they get sued.

I have read the letters from American doctors who have seen a simple stage 0 CLL patient for the first time. They are full of extraneous detail that has no relevance to the disease, because every box has to be ticked - and all that detail costs money. A five page letter looks impressive, but s simple "This patient has stage 0 CLL" is all that is needed in most cases. We really don't know the color of grandmother's bedsocks!