Nobody likes to be called a dummy by a dummy.

Health Care practices in various countries

Here in the US, if you are poor and don't have insurance coverage and you get cancer, you die. Cancer therapy runs in the hundreds of thousands of dollars. Hospitals are required to treat emergency room patients with no money, but they aren't required to keep you after they stitch up your wound. Nor are they required to fix what's wrong with you if you can't pay.

Is this the normal way things are? Is it the same way in other countries? If you don't have coverage and you get sick, you're just out of luck?
Permalink Wondering 
August 13th, 2005
Is this *really* the case in the US? On the one hand, I always hear these fuzzy "the poor are left to die" stories; on the other hand I know my wife's grandmother received good care, though "poor", my sister-in-law had heart and liver transplants on welfare (heart transplant was ten years ago - she's still alive and well), my aunt received massive medical care post-stroke and heart attack....

However, this is purely anecdotal, and I do in fact find it hard to believe everyone who is impoverished receives this level of care. Are there any statistics on people who die for lack of readily available medical care? (i.e. they could have lived, but were denied care for lack of money)

I expect to be horrified by the answer, but would like to know the objective truth.

Philo
Permalink Philo 
August 13th, 2005
Is it possible that in each case you mention, Medicaire or Medicaid paid for the treatments?
Permalink Wondering 
August 13th, 2005
I'd expect the major effect of a pay as you go health system would be a reduction in preventative health care, if it costs you money to go see your general practitioner and you don't have the money then you obviously don't go.

I've had any number of friends and acquaintences not go to the doctor because they didn't want or couldn't spend the money.

The result of an insurance paid health care system, which is what all well employed americans live within is fine until the insurance runs out, or the the job is lost. Costs are relatively higher because hospitals optimise their billing to charge every possible cent. One of the deplorable results of the New Labour's introduction of the internal market in the NHS is that our hospitals are also getting into the same game.
Permalink Simon Lucy 
August 13th, 2005
I believe that most health insurance in the US is tied to the relationship between an employer and an employee. While it's oft ignored, this limits fair trade and market value of the workforce, and basically puts the fearful into servitude. While we don't have it to that degree here in Canada, we do have something similar by way of "benefits", largely dental and prescription coverage, which is one of those things that keeps people at a job they otherwise would leave. Similarly the old school pension was setup for this sort of lack of workforce mobility (at least at the employees discretion).
Permalink Dennis Forbes 
August 13th, 2005
mmm...my Dad remembers my Nan saving to visit the Doctor* which is as far as I'm concerned an obscenity. Fortunately any party openly advocating such a system in Britain would be committing political suicide.

*This would have been before 1948.
Permalink a cynic writes... 
August 13th, 2005
here in NZ they have a public health care system and an entirely optional private health care system.

everyone is entitled to public health care...wait lists are long, so the only way to get *quick* care is to be nearly dead so you get bumped up the list.
if you want fast, comfortable service you are better to use private health care, but if you cannot afford that you *will* be treated for free through the public health syste, (eventually)

kids are treated very quickly and effectively through the public health system.

its actually a bloody good system, and a very big reason why I wont be returning to the US in a hurry. the other is a very cheap and good education system.

The other thing that keeps the costs way down here is the lack of an ability to sue, people give that up in exchange for ACC...accident compensation.

the longer Ive been away from the US the more broken the system over there looks to me, when I first came here I was sceptical but more and more the US approach just seems insane in hindsight.
Permalink Jesus H Christ 
August 13th, 2005
Count your blessings. I mean you people are lucky people. Sincerely.
Permalink Another poster... 
August 13th, 2005
"Count your blessings. I mean you people are lucky people."

Lucky? Neither Canada, the US, or New Zealand had native Healthcare Trees that dispense healthcare. Instead it's a result of work and good government (which is the work of the people).
Permalink Dennis Forbes 
August 13th, 2005
"Lucky? Neither Canada, the US, or New Zealand had native Healthcare Trees that dispense healthcare. Instead it's a result of work and good government (which is the work of the people)."

Exactly... and when the government declares health care a HUMAN RIGHT, they effectively claim possession over someone elses' labor without regard to the price.

For example, if the US government said "Bug Tracking Software is a HUMAN RIGHT!" how much would Joel be allowed to charge? As Eric and Joel point out in their pricing article, no matter HOW much they charge, someone will complain... so effectively, they cannot charge anything but still have to provide the same level of support.

If healthcare is a HUMAN RIGHT, then it should be equally applicable when you live alone on a desert island as when you live in downtown NYC.
Permalink KC 
August 13th, 2005
Ummm, that was gibberish.
Permalink Simon Lucy 
August 13th, 2005
How about if they declare treatment free at the point of need a public good and pay accordingly?
Permalink a cynic writes... 
August 13th, 2005
Don't forget the cost of pharmecuticals - The Australian Pharmaceutical Benefits Scheme (PBS) is just holding its own against the Free Trade policy and a knockkneed government in thrall.

This is one shining demonstration of a social good that big pharma wants to bury.
Permalink trollop 
August 13th, 2005
I could never spell that word.
Permalink trollop 
August 13th, 2005
"and pay accordingly"

What's "accordingly"? What's "accordingly" in order to offset the required twelve years of post-graduate education?

And how do you set up the system to get rid of bad doctors? After all, the administrators are going to have metrics on number of patients seen and wait times - cashing out a doc will really hurt those numbers. So he kills a few people - it's not like they can sue the government.

And haven't you noticed that every socialized medical system in the world has a private medical system as well? (Unless they legislate it away). Doesn't that tell you that the socialized medicine isn't filling the need?

I still think teaching hospitals and public service medical paybacks are better solutions. The current problems are lack of funding for teaching hospitals (we could probably fix that overnight with what Hillary spent just investigating national healthcare), and people bailing on their public practice obligations (throwing a few in jail will fix that very quickly)

Philo
Permalink Philo 
August 13th, 2005
> I could never spell that word.
http://spellbound.sourceforge.net/ for FF.
http://www.iespell.com/ for IE.
Permalink PNII 
August 13th, 2005
The private medical system in this country was originally allowed to exist as a cherry to induce doctors to sign up for the NHS originally in 1948.

It's kept going largely by doctors who are mostly paid by the NHS there are a few private only doctors but they're barely noticeable.

Virtually all of the private procedures are covered by medical insurance which runs at about (depending on all the usual personal circumstances) £120 per annum for the whole family. Again by far the majority of those procedures are elective, even the first attempt at infertility treatment is covered on the NHS now.

The NHS is funded by taxation (apart from when a private case is passed to the NHS, which does happen), the relative levels of taxation are at similar or even lower levels than industrialised states in the US, like NY and Calif. In other words you could have a public health system free at the point of use for all for no more than the personal expenditure and taxation paid at the moment.
Permalink Simon Lucy 
August 13th, 2005
>> And haven't you noticed that every socialized medical system in the world has a private medical system as well? (Unless they legislate it away). Doesn't that tell you that the socialized medicine isn't filling the need?

Of course it's not, that's not the point. The idea, whether you agree with it or not, is that by having one level of service for all citizens, that level of service will be 1) equitable, and 2) minimally acceptable. The underlying worry in a two (or more) tiered health system is that the people in power (i.e. - with money) will not sufficiently support the lower tier.

There are good arguments to made all over the place as to whether this approach is warranted, but the tendency for those who can afford superior care to not really support a reasonable level of care for those who cannot afford it is pretty hard to dispute. Of course, I know ?off is up to the challenge.
Permalink Mongo 
August 13th, 2005
Comparing their life expectancy with the dollars per capita spent on health would seem to indicate that the Japanese have the most value-for-money health system. It seems to be a combination of compulsory private insurance for those who can afford it and publicly-funded insurance for those who can't.
Permalink Mick 
August 13th, 2005
Thanks for the feedback. It sounds like other countries are the same for our cancer patient. Even with the national health systems, he'd be waiting in the queue, which would allow his cancer to progress until it was untreatable. So, throughout the world, only those with private insurance or lots of cash get treated for cancer. I guess also the over 65 crowd in the US since it gets covered under Medicaire.

I ask since I have a well-under-65 friend who has cancer and no insurance, so he's just dying and not being treated.

I had a over-65 relative die last year. Treatment was bad and late - everything was about getting the most billing possible, and in the end the bill came to around 1.5 million, of which his widow was responsible for the 20% co-pay under medicaire, which came to $300,000, that required she sell her home and assets and move in with her daughter.
Permalink Wondering 
August 13th, 2005
The major needs that state provision doesn't cover is the comfort of the accomodation and avoiding queues. You could draw a comparison with the various grades of air travel.
Permalink a cynic writes... 
August 13th, 2005
>> Thanks for the feedback. It sounds like other countries are the same for our cancer patient.

No. No. NO!

Canada. Not gonna happen.

You may have to wait for a while for knee surgery, no one's going to wait for cancer treatment.
Permalink Mongo 
August 13th, 2005
Also, you're not going to lose your house and go bankrupt paying for required medical care.
Permalink Mongo 
August 13th, 2005
It's unlikely that cancer would become untreatable - any sane queuing system works on the basis of need rather than "first come-first served". What we do have is what's referred to as a "postcode lottery" as the NHS is decentralised - so provision does vary.

The real question is whether the administrative overhead of a well run insurance industry is less than that of government. This is unclear despite the political dogma of both left and right.
Permalink a cynic writes... 
August 13th, 2005
> I believe that most health insurance in the US is tied to the relationship between an employer and an employee.

Two more factoids I believe about this kind of private health insurance in the States:

* Each insurance company (a.k.a. "HMO") has an associated chain of hospitals and doctors ... so the HMO dictates which doctors and hospitals you may visit ... if you change jobs and consequently change insurance companies then you consequently change doctors

* HMOs, together with your employer, decide what the insurance policy will and won't cover ... for example, the insurance premiums to cover the cost of mental illness and/or addictions in the employee and/or the employee's family members might be high, and 'they' may decide that your insurance policy won't cover this.
Permalink Christopher Wells 
August 13th, 2005
>> The real question is whether the administrative overhead of a well run insurance industry is less than that of government. This is unclear despite the political dogma of both left and right.

That's interesting. I haven't looked into this seriously, but every credible reference I can remember seeing shows that US system costs a lot more per capita than any comparable socialized system. In fact, I can't really recall any claim otherwise outside of political discourse. Could you point to some credible arguments showing the other side of this?
Permalink Mongo 
August 13th, 2005
Not in Germany either.

My wife was diagnosed with had breast cancer a couple of years ago and was treated immediately and efficiently with the best drugs available here.

She has the compulsory health insurance that all Germans have, and, as far as I know, was treated no differently than any other woman. Having said that, she may have received especially good treatment because of her youth - most breast cancer patients are much older than her.
Permalink Mick 
August 13th, 2005
"The underlying worry in a two (or more) tiered health system is that the people in power (i.e. - with money) will not sufficiently support the lower tier."

Thanks, Mongo, that is one of the most profound statements I've ever seen regarding social programs.

And Chris, the argument keeps being made that it's important to "keep your own doctor". Personally, I don't understand this. In private care, in a free market, isn't it more important to seek quality care at a reasonable price? How does "keeping your own doctor" have any value at all in that model?

The HMO's try to control costs by getting a pool of people to belong to the HMO, and maintaining a pool of doctors and specialists to serve them. Even insurance companies have a pool of doctors who are willing to provide service for the insurance company set rate.

As far as I can tell, the only difference between having private industry manage this situation, and having the U.S. Government manage this situation, is that private industry has the insurance companies acting as a profit-making middle-man between the doctor and the patient.
Permalink AllanL5 
August 13th, 2005
Mongo - I wasn't actually thinking of America. As Mick said Germany has a compulsory insurance scheme as do other countries. They seem well run and I'm not sure that they are more expensive than getting civil servants to administer it.

In the event that America chooses to reform their heath system and ensure a service free at the point of need, I think they are far more likely to do so through a process of regulated compulsory insurance. In the final analysis it is fact of being free at the point of need that's important.

One other thing - the impression I get is that America relies far more on specialists and far less on local general practice. I have no idea how this translates into results.
Permalink a cynic writes... 
August 13th, 2005
Somehow I thought you'd have a reasonable explanation. Ok, thanks for the clarification.
Permalink Mongo 
August 13th, 2005
Choice is entirely illusory most of the time but when it comes to medicine it is always an illusion. You don't choose the 'best' doctor because you have no real notion of what that means.
Permalink Simon Lucy 
August 13th, 2005
"Costs are relatively higher because hospitals optimise their billing to charge every possible cent. One of the deplorable results of the New Labour's introduction of the internal market in the NHS is that our hospitals are also getting into the same game."

I don't have information to dispute your point Simon, but I don't follow the logic. Isn't the idea of an internal market that those who provide the services most efficiently (i.e. at lower cost) are the ones who get the business? Surely increasing the billing by charging every penny would make those service providers less cost competitive?
Permalink Ian Boys 
August 13th, 2005
Insurance schemes, whether the German or the American variety, cost about 30% more than comparable all paid by the state systems.

What is putting pressure on 'socialist' healthcare systems is geriatric care, rather than medical needs - though progress in medical science may force doctors to make decisions they have not been asked to before in developing countries.
Permalink Stephen Jones 
August 13th, 2005
> And Chris, the argument keeps being made that it's important to "keep your own doctor". Personally, I don't understand this.

Well I pointed it out for two reasons:

* Because I once heard a [untrue] criticism of 'socialized medicine': that "the government chooses your doctor for you": which isn't true that I know of [in Canada] but which, ironically, *is* true of the American private insurance-funded system.

* Because my mum lived in the States for 15-odd years and 2 or 3 employers, and so was subject to that phenomenon, and mentioned it to me.

As for whether it's *important*, it must be more or less important sometimes:

* Sometimes it's not important: for my personal 'general practioner' needs for example, I have chosen to register at the family practice clinic of my local teaching hospital ... so 'my' doctor changes from year to year (I'm typically seen by one of the interns/residents) ... but at least I get to keep the same hospital that I like and trust, the one hospital keeps my medical records ... and, crucially, *my* needs are uncomplicated, i.e. I'm chronically healthy.

* If on the other hand I were being treated for any long and complicated illness, especially if I were being treated by a doctor whom I liked and trusted, then I might very well prefer to *not* be required by a change in HMO/billing to skip from one doctor to another.

> In private care, in a free market, isn't it more important to seek quality care at a reasonable price?

I suppose it is; I don't know. In our system, the services I receive are already 'free' -- I see no price for *me* to try to minimize ... to improve the quality/price ratio, all *I* can do is try to improve quality ... and allowing me to choose any doctor helps me to do that. It's up to the government to keep the overall prices reasonable.

> How does "keeping your own doctor" have any value at all in that model?

You can choose any doctor, more or less [and not just that subset of doctors with whom the HMO that your employer chose has negotiated a deal] ... and if you find a doctor that you like then you can keep him ... that helps, surely, to improve the quality of care.
Permalink Christopher Wells 
August 13th, 2005
> Could you point to some credible arguments showing the other side of this?

Assuming it's true that cost per capita is quite a bit higher in the U.S., the debatable part of the question would then be *why* ...

* Private insurance leads to higher administrative overhead?

* Private insurance leads to inefficiently used resources, e.g. 'spare' capacity?

* Labour and materials are more expensive in the States?

* Ambulance-chasing lawsuits have increased the cost of practicing medicine, either directly or because doctors have become too 'defensive' (ordering unecessary and expensive diagnostic procedures)?

* The overall quality of care is higher?

* ... ?
Permalink Christopher Wells 
August 13th, 2005
> Also, you're not going to lose your house and go bankrupt paying for required medical care.

Well, you might: if you're seriously ill then perhaps you're unable to work, and on top of *that* the cost of certain *prescriptions* can be ruinous ... but it's true that it's not the most *common* cause of bankruptcy.
Permalink Christopher Wells 
August 13th, 2005
"You may have to wait for a while for knee surgery,"

This is not necessarily a good thing. I developed a problem with my knee.

NHS route; referal to ortho surgeon (three months), wait for MRI scan (six months), schedule surgery (three months).

Private route; (which fortunately I had funding for) referal to surgeon (three weeks), wait for MRI scan (a week), discover I have osteonecrosis destroying my knee joint after breaking it. Whisk me in for surgery before it got serious serious. As it was I ended up in physio for several years and needed more surgery.

The NHS route apparently would have ended up with my knee joint having to be removed because by the time they'd found out it was urgent it would be too late.

The private route cost about 2 grand in claims. Can you imagine how much the NHS would have ended up spending by trying to take longer about? Knee replacements every ten years for the rest of my life isn't a cheaper option.

This is one of those "stitch in time saves nine" things.

I do wonder how many people die needlessly because whatever they have is curable but not obviously urgent.
Permalink Katie Lucas 
August 13th, 2005
"Isn't the idea of an internal market that those who provide the services most efficiently (i.e. at lower cost) are the ones who get the business?"

Yes, but the problem is that while the hospitals are businesses, they're also effectively monopolies.

If I'm going to be referred to a hospital I get the options of going to a hospital run by Cov & Warwickshire NHS Trust or... er... buggering off.

My GP can't say "Oh, hang on Heartlands is cheaper, we'll send you there".

Nor can I get the money value of whatever Cov&Warks is charging and use that plus some of my own money to go to BUPA.
Permalink Katie Lucas 
August 13th, 2005
>> I do wonder how many people die needlessly because whatever they have is curable but not obviously urgent.

Or even just have irreparable harm, yeah. This is a good point, and is a big problem.

I was just pointing out, though, that the egregious, obvious stuff will get dealt with in a reasonable time frame.

In Canada, for exaple, we don;t have socialized dental, not even for children. So poor kids sometimes don't get proper preventative care, with predictable results.

Short sighted and mean spirited, all in one.
Permalink Mongo 
August 13th, 2005
Health care, even the superior kind offered by places like Canada, carries odd problems. It appears that any serious profession, backed up by an organization with control over its practitioners' education, should be deeply scrutinized for monopolizing/cartelizing some body of information. I've heard the AMA and Bar Associations do quite a bit to limit the supply of practitioners, and I'm sure there's some fruitful investigation into the matter lying around.

As Adam Smith explained, "People of the same trade seldom meet together, even for merriment and diversion, but the conversation ends in a conspiracy against the public, or in some contrivance to raise prices."

(I am aware of the commonly given reason for the existence of these professional organizations, that bad things will happen if they're "tinkered" with by consumers of their services, etc. There's no doubt some truth to that; I'm certainly not saying they should be eliminated. But like anything else, thoughtfully and sharply scrutinized.)
Permalink Tayssir John Gabbour 
August 13th, 2005
I found this to be rather funny.

Another way to cut medical costs: Split your pills
http://www.latimes.com/features/health/la-he-pillsplit8aug08,0,5169585.story?coll=la-home-health

Quit yer whining.
Permalink Silence Dogood 
August 13th, 2005
In US, say, you have cancer and you don't have coverage - you die anyone telling you otherwise is a fucking moron. In Canada, if you have cancer, you die in the long waiting period to get the treatment - unless you have enough money to go to US/Europe/India to go to private clinic.

You're fucked either ways.

In Europe things are heck of a lot different. In my experience Holland and Germany have the best healtcare systems in the world. Still wondering why the fuck I left my home country.
Permalink Dan Denman 
August 13th, 2005
Well, I forgot to mention ... Sweden and Finland have really really good healthcare too.
Permalink Dan Denman 
August 13th, 2005
"but it's true that it's not the most *common* cause of bankruptcy."

Actually, I am fairly sure that in the US, medical bankruptcy is overwhelmingly the most common cause of bankruptcy. And also that of those who were driven to bankruptcy for medical reasons, most actually had insurance.
Permalink Wondering 
August 14th, 2005
Travellers' health insurance is always advisable. Expect to pay higher premiums if travelling to the US where medical evacuation costs can be $100,000's if hospitalised.

So I can see that a local in the US with insufficient cover may well be bankrupted.

Australia tolerates private hospitals, which can be quite large businesses. They take the easy profitable work such as uncomplicated obstetrics and elective joint replacements leaving to the state the chronic care and cases requiring expensive equipment and those who won't or can't pay. Lifethreatening conditions jump the queue, you will probably die of treated rather than untreated cancer if you go state, but you'll wait bloody ages for a new hip and a lifetime to see a dentist.

Medical fees are either paid by the state (bulk-billed) or paid privately and reimbursed by insurance. I mentioned prescriptions earlier.

The system is under considerable strain from an aging population and drug costs coupled with increased professional insurance premiums due to litigation and underwriters' price hikes.
Permalink trollop 
August 14th, 2005
Approximately, how many Americans (in percentage) are having the health insurance coverage? I said, you all are blessed, because, situation here in India can be termed as worst.
Permalink Another poster... 
August 14th, 2005
Heartlands might be an alternative you could ask for within the direct contract provision between GPs and Trusts but avoid Good Hope Hospital (also known locally as Abandon Hope) at all costs.
Permalink Simon Lucy 
August 14th, 2005
Hey, I was born in Good Hope Hospital!

We always called it "No Hope Hospital" though. It does offer a spectacular view of the neighbouring cemetery from the higher windows.
Permalink Mick 
August 14th, 2005
Simon, which question did you just answer? Reading back up the thread I can't find any context.
Permalink Ian Boys 
August 14th, 2005
It wasn't really a question, just a comment to something Katie Lucas said.
Permalink Simon Lucy 
August 14th, 2005
Another,

I have read that 50 million of the 250 million people here have no insurance of any kind, so that's about 20%. I don't know any breakdown as far as how many oy those covered are covered in such a way that a serious illness wouldn't bankrupt them. As I understand it, very few people have 'full' coverage and most plans try to exclude as much as possible, such as any preexisting conditions.
Permalink Wondering 
August 14th, 2005
"As I understand it, very few people have 'full' coverage and most plans try to exclude as much as possible, such as any preexisting conditions."

This is what seems insane to me - we live in a society now where people change employers frequently. Often your health coverage is tied to your job. So what happens when you grow a big cancerous lump but fail to notice it, and then you switch jobs (and thus health plans) and they declare that the lump is at least two years old, or what have you?
Permalink Dennis Forbes 
August 15th, 2005
<Dennis Forbes>So what happens when you grow a big cancerous lump but fail to notice it, and then you switch jobs (and thus health plans) and they declare that the lump is at least two years old, or what have you? </Dennis Forbes>

You're fucked, is what you are, unless you take the insurance company to court, which takes years, and by the time you "win" your case, you're probably not alive to reap the benefits.

The insurance companies seem to put most of their time and energy into figuring out ingenious ways to deny coverage to their policyholders who have spent large chunks of their disposable income paying for those policies. If the companies focused instead on sensibly holding down costs while maximizing patient access to health care, we'd be a lot better off ... but it's easier for them to make a profit by denying coverage.
Permalink Dana (formerly Blue State Bitch) 
August 15th, 2005
My uncle is moving from the USA to Ireland partly because of the difficulties of getting good ongoing healthcare for his son. America has the best healthcare in the world if you get very ill, very infrequently. It is extremely poor for ongoing or chronic conditions.
Permalink Colm O'Connor 
August 15th, 2005

This topic was orginally posted to the off-topic forum of the
Joel on Software discussion board.

Other topics: August, 2005 Other topics: August, 2005 Recent topics Recent topics