side effects of socialized health care

Great Debates
141

Governments of countries with public-funded healthcare systems usually negociate the price of the drugs sold. So, the reasonning is that since pharmaceutical companies make more money on the american market by selling their drugs at a higher price, the research is funded mostly by the american consummer.

However, this is limited by the fact that a company could always choose not to lower the cost of their drugs, and that the healthcare authorities couldn’t just refuse that a drug which is proven to be efficient could be sold.

So, to clear up this issue, it would be necessary to understand quite well the dynamics of the system, and why the pharmaceutical companies accept to lower their prices. In develloping countries, it’s easy to understand : either the price will be lowered, either it won’t be sold at all because people can’t afford it. In industrialized countries which can afford them and with a population which wouldn’t accept that an useful drug couldn’t be available, the reasons why it work this way I don’t really grasp.

142

Thank you for restating this so well.

I’m not really sure this is true. Authorities could in fact refuse to allow the selling of a drug. Especially if their efficacy approval system was closely tied to their price regulation system.

I agree entirely that the whole thing is outlandishly complex. I fail to grasp most of it most of the time. :wink:

One problem with this assertion, is that the private healthcare increases in cost in countries with universal coverage. Look at British again. Private healthcare is only for the rich (this is certainly a generalization).

Well, as has been pointed out many times, we do spend a lot more per patient than other countries. While I agree that there are inefficiencies which account for some of this, they do not account for nearly all of it. The rest simply has to be additional medical services.

I agree that there does not seem to be any great difference in life expectancy. However, I think this has much more to do with the fact that the healthcare system of any society has less to do with life expectancy than we might like. Lifestyle and other societal habbits have much more to do with it.

I always like to ask the question: “What is the most profound medical breakthrough in the western world in the last 2 centruies?” My answer: “Sewers. They have done more to decrease the death rates than any other medical advance.” Somehow, I don’t think expenditures for sewers ever makes it into an analysis of the difference in life expectancies. :wink:

I must object to the characterization of capitalism as a lottery system. Suggest that resources are not allocated by need if you must, but this alone does not mean that capitalism is inherently random.

I should note, that the free market is not very free in this industry. I should also note that the life expectancy numbers bandied about in this thread show that the American system is not exactly wretched either.

There, you’ve made me use two arguments I find distastful. Are you happy? :wink:

143

*something of a “reductio”, don’t you think? We have a system of some federal government intervention (medicaid) administered state to state, some county patchwork interventions (ie, yourt coverage varies with the vagaries of location) a variety of excresencse on an employment based deliverty system that evolved with no particular reason other than the circumvention of wage controls …

**american health outcomes suck.

144

Not necessarily. Besides the administrative costs and the lawsuits/insurance costs (which by the way are rising here too, in particular for obstetricians, who have seen their insurance premium raised by up to 200% last year), the higher price of drugs, the higher income of physicians, the profit margin of the private hospitals, etc… may play a significant part too.

We would need a breakdown of the overall cost of healthcare in various countries in order to make a valid comparison. Assuming that such figures are actually available. And also informations about the relative cost of the same medical acts in these countries. So, we would know if there are actually more medical acts in the US, and if these acts are more costly and why.

145

Just thought about it, but also what are these medical acts, exactly? I would assume there are vastly more breast implants placed in the US, for instance, since it seems to be a relatively widespread practice, while it’s not very common over here. If these are included in the healthcare costs, it could also distort the picture.

146

This is an outstanding point. I had not thought of this difference. The numbers used to show national expenditures on healthcare do not seem likely to diferentiat well between cosmetic surgeries and other medical procedures.

As to your other note, I agree that we would need a breakdown to know for sure. But the earlier estimates of profits of 20% or so, do not seem to jive with the idea that we spend up to twice as much on medical care. It seems we would have to find quite a price difference to explain that gap. I do not, however, deny that higher prices for doctor services and drugs contribute to this spending difference. I am not claiming that the whole gap is explainable by additional medical procedures.

147

clairobscur, did you read the OECD report cited on page two, and the breakdown per capita earlier here on page three about this? Is that what you’re looking for?

148

We had an interesting discussion about price regulation and subsidizing of drugs around the world. Apparently there are many different methods in place. The thread was: “Does less restricted drug pricing in the US subsidize the rest of the world?”, at

149

:slight_smile:

I agree. This has turned out to be one of the most enjoyable threads I’ve participated in.

Now, on to page 4 …

150

Yes, and this goes to the heart of the matter. I would like to emphasize something I posted earlier. If we look at the amount of dollars spent per capita, as I posted a cite on (on page three of this thread), and factor in Sam’s NYT cite that 45% of health care spending in the US is public spending, then we get the following:

Total per capita: (roughly) $5.000 / 45% = $2.250 per capita in public spending in the US

The OECD’s report’s average for 2001 was $2.100 per capita in total spending for western countries. In other words, the USG is using the same or more in public spending per capita alone, than other western countries are using on their entire national health care programs. Then there is private spending by americans on top of that.

Which again leads me to ask the same question I’ve asked a couple of times in this thread already: Are there any reliable data out there outlining where all the health dollars in the US go? Not a snippet here and a snippet there, but some sort of summary somewhere?

I know there’s lots of information in the Agency for Health Care Research and Quality’s database (including cost per specific treatment diveded into commercial, Medicare, etc), at http://hcup.ahrq.gov/HCUPnet.asp, but I haven’t had time to dig into the information yet. Anyone?

151

Well, I’m back :slight_smile:

I don’t think that problems with a certain kind of cancer in a certain country at a certain time says much about the quality of national health care, or private health care for that matter. Just as I don’t think that your story about the woman that had to wait 4 months (??) before they put that piece of her skull back into her head means much. There are always horror stories and there always will be.

As for the impact of guns on life expectancy. It’s a valid point, but without any cites I’m tempted to disregard it. I could counter your argument with high suicide rates. And you can point out that the US has the highest overall fire death rate of all industrialized countries. Among american teenagers, the three leading causes of death are unintentional injuries, homicide, and suicide. Of course all of these things have an impact, but is the impact significant? We need better numbers to determine that.

Just providing some information here:

In the sort of national health care system we got (it’s two tier) the following applies to those who are part of the system:

  • Ordinary doctors are in private practice. When I visit such a doctor, there’s a co-payment (no paperwork), and the doctor sends a bill to the goverment for the rest (standardized paperwork). Besides prescribing medication, doctors also issue requisitions for diagnosis, or refer the patient to a specialist. Note, I can’t visit a specialist inside the system without a requisition from a doctor whose also inside the system.

  • Specialist are also in private practice. They specialize in treatments (like physio, minor surgery) and diagnosis (like x-ray, blood testing, neural even). Note: public hospitals have identical services, but the bulk of these services (at least in the cities) are carried out by specialists in private sector. When I visits a specialist there’s a co-payment similar to doctor payments, the rest of the bill is sent to the goverment.

  • Hospials are, very roughly, 98% public, 2% private business. They handle surgery, or pretty much anything really.

Demand & Supply:
For ordinary doctors and specialists, demand is set by the market by clients. The government can adjust supply by putting more money into public education or raise the fixed price for consultations. There are also a few public county doctors, and the county administration can raise salaries for these.

Hospitals, while state owned, are now run pretty much like companies. There’s a fixed price for every treatment, and the hospital administration has to keep cost down to go break even (which is their goal). What this means is that the hospital at the beginning of a fiscal year has a projected budget (derived from the national budget). This budget outlines the expected number of patients and treatments to be carried out. However, hospitals are also required by law to provided treatment for most illnesses, and may receive more patients than they anticipated. In that case, they request more money, which btw could involve discussions about cutting costs. As for the number of doctors and nurses employed, the hospital administration employs the people they feel they need, and it’s not uncommon to hire from abroad if supply is scarce.

The anticipated demand of health services for hospitals is measured based on historical data of demand (both emergency patients and ordinary patients), and on data about last year’s wating lists (which only includes ordinary patients). A waiting list is simply the number of people who has a case which has not been closed, which doesn’t mean that they are necessarily waiting at home for treatment (more about this in a later post). According to the latest data, the waiting list is about 8% of the capacity, meaning that if there are 100 beds (all occupied), there are 8 people waiting for a bed.

Note: All this is in my home country (Norway), and I can guarantee you it’s not the same all over.

Excellent counterargument. I think we can conclude that life expectancy is not useful to measure health care quality. Some interesting numbers could be:

  • the number of doctors per 100.000
  • the number of nurses per 100.000
  • the number of hospital beds per 100.000
  • the capacity versus order reserve (waiting lists) ratio
  • the percentage of the population seeking treatment for certain diseases
  • the sucess rate of treatment for certain diseases
  • net cost per patient

I’m currently processing some data about time elapsed between request and diagnoses, and between diagnosis and treatment, for certain diseases. Look for a follow up post

I have read many times - over many years - about patients (for instance cancer patients), who are are not treated because they don’t have insurance. I know about Medicare and Medicaid, though I don’t know enough about them. I have heard that there are roughly 15 million americans covered by the government through public programs, but I’ve also heard that 45 million americans don’t have any coverage at all. Can you tell me more about this?

152

…in the USA, doctors and medical personnel have to carry enormously expensive malpractice insurance. There are 1 million practicing lawyers in the US and they are hungry! Some medical specialists like neurosurgeons have to spend >$100,000 per year on insurance!
What i would like to know…if the state takes over medical care (assigns your doctor, etc.) does that mean that the state can be sued for malpractice?
High rates of lawsuits and malpractice insurance are a major factor in health care costs in the US. of course, the ABA says there is no such problem…it is all because insurance companies make BAD investments@ :smack:

153

Agreed. That was just a suggestion of a possible place to start.

Also, agreed.

Your system sounds almost identical to ours. I would also call our system a two tier system. Most hospitals are not for profit. Meanwhile most doctors are in private practice. I do have a couple question. What sort of incentives motivate hospitals to keep costs down. You suggested that breaking even is their goal, what happens if they do not?

Those are excellent options. I also noted a study which claimed to measure the disability rate of people over 65. Perhaps numbers showing disability rates amongst various age groups could be used to show how well healthcare systems deal with disabilities.

One report I looked at mentioned offhad that 39 million are covered by medicare (which is supposed to cover retirees). Apperently Medicaid covers about 14% of the population under 65. Is that another 30 million or so? If I remember correctly, Medicare covers anyone who worked for 10 years with medicare coverage and is over 65 (if your spouse worked, you qualify too). Medicaid is supposed to be for poor people who cannot afford insurance. It varies from state to state, but I think covers people who ear about 66% of the poverty level (around $20,000 per year).

This cite (Warning pdf) contains a lot of information about the uninsured.

(From page 7) The number of Americans without medical insurance was 43.3 million in 2002. 36% (15.8 mil)of these were poor people (those with incomes below the poverty level which is $29,000 yearly). Another 28% (12.1 mil) were those with incomes twice the poverty level. 24% (10.4 mil) came from families with incomes at 2-4 times poverty level. and the last 12%(5.2 mil) are people at 4 times or more of the poverty level. I did not see where the document broke down the number of people in this who qualify for medicaid. It is generally about 2/3rds of the poverty level. So, some of those in the first group should qualify.

I asked clairobscur about this, so I should ask you. You mention a copay. Can you give me an idea how big they are? What happens to those who cannot afford this? And, of course, do you have any idea how many such people there are?

clairobscur, did I ask you if you could find out how many people cannot affort to pay upfront for medical coverage?

I understand that such numbers of people would be pretty small.
This is an old money article which talks about how much America spends on healthcare and were. It is not comprehensive. In fact it is really just a quick article.

I hope you find this information useful.

154

Well, you can make fun of this claim. But, more convincing would be if you backed up your claims about the high rates of lawsuits and the idea that bad investments aren’t an issue. Here is an Ohio group that provides some info on the subject:

155

Pervert asked for more specific info about waiting lists in national health care system, so I’ve done some digging.

First of all, I’ve discovered that waiting lists are not such a clear cut case as they seem to be:

[ul]
[li] Waiting lists include both patients waiting for consultation or treatment, AND patients who has received consultation or treatment, but whose case is still open (for example pending final diagnosis)[/li]
[li] Waiting lists do not include patients classified as “emergency care” (giving birth, broken bone, appendicitious, heart attack). According to one hospital, this amounted to 41% of all admissions at the hospital; (numbers from the source: 17774 out of 43349. In total, 280.000 patients were served in that hospital that year, so emergency care amounted to 6.3% of total number of patients).[/li]
[li] Waiting lists appear as a little longer than they really are because some patients reschedule appointments for a later date, while other patients are too weak and are rescheduled for later.[/li]
[li] And finally, waiting lists are not lists of patients, but lists of tasks. About 4% of the patients had multiple requests in the system.[/li][/ul]

A good method to analyse waitings lists (which are essentially order reserves) is as percentage of total capacity. Currently, the size of waiting lists in Norway is at 8% of the capacity in the system.
Further, to understand waiting lists one should understand the process behind an ordinary case. As an example, let’s look at a requisition for an MRI scan sent directly to the hospital by the doctor (NOTE: the patient can also take the requisition and make arrangements her/himself, cutting down wait time to a week):

  1. The doctor refers the patient to an MRI. At the hospital the case is screened by medical personnel, who prioritize important cases. Time: One week (longer in clearly unimportant cases)
  2. The patient has a right to receive notice about scheduled appointment some time ahead. Currently 2 weeks notice is given.
  3. Hospital personnel reviews the MRI images. Time: One week
  4. Possible step: The patients is recalled for a sum up consultation. At least 2 more weeks (notice time ++).

So, the process in a typical unimportant MRI case, handled by the hospital, would normally take at least 4-6 weeks, and during all this time the patient is on a “waiting list”. It’s only when a case goes beyond this that there is actually “waiting” or delays in the system.

Now, on to the juicy stuff. Pervert asked for delays between diagnosis and treatment by oncologists. By “treatment by oncologists” I gather he means cancer surgery. As I suspected, this was not as simple as it seemed, because there are many types of cancer, several types of treatments, and some cancer patients are further along than others.

Last year the Norwegian government launched a public database, available on the web, which consists of 87 common consultation and treatment indicators and 9 quality indicators. The patient can pull a nationwide list of clinics offering a certain treatment, including updated lists of expected wait time, listed per treatment per clinic. Wating periods are even diveded into examination/consultation, daycare bed treatment, and admission (overnight stays).

The 9 quality indicators represent 4 patient satisfaction indicators about service and treatment, as well as 5 other indicators, including percentage of people who got an infection at a certain clinic and average number of days in bed after surgery, listed per clinic.

There’s quite a lot of data available, even though the database is less than a year old. However, cancer surgery does not seem to be one of the 87 indicators currently in the database (but see end of post). So I just pulled some random data. The following is average wait time in weeks for a few examinations and treatments:

Note on my format:
“0 - 0 - 2”, means weeks to wait are 0, 0 and 2 at clinic 1, 2 and 3, respectively
“8x <= 4w”, means 8 clinics with equal to or less than 4 weeks to wait, etc

Chemotherapy:
Total listed: 6 clinics
Simple care: Wait time: 0 - 1 - 2 - 3 - 3 - 3
Daycare bed: Wait time: 0 - 2 - 3 - 14
Overnight stay: Wait time: 0 - 1 - 1 - 3 - 3 -

Heart, bypass surgery:
Total listed: 6 clinics
Simple care: Wait time: -
Daycare bed: Wait time: -
Overnight stay: Wait time: 1 - 1 - 1 - 4 - 4 - 8

Lungs, unspecified:
Total listed: 50 clinics
Simple care: Wait time: 8x <= 4w, 17x <= 8w, 36x <= 12w, 14x >= 13w
Daycare bed: Wait time: 1 - 2 - 2 - 3 - 12
Overnight stay: Wait time: 0 - 0 - 0 - 0 - 1 - 1 - 2 - 3 - 3 - 4 - 4 - 9 - 12 - 12

Gastroskopi, examination:
Total listed: 59 clinics
Simple care: Wait time: 5x <= 4w, 35x <= 8w, 50x <= 12w, 9x >= 13w
Daycare bed: Wait time: 20
Overnight stay: Wait time: 0 - 4

Cruciate Ligament:
Total listed: 50 clinics
Simple care: Wait time: 4x <= 4w, 13x <= 8w, 32x <= 12w, 18x >= 13w
Daycare bed: Wait time: 3 - 6 - 8 - 10 - 10 - 12 - 12 - 12 - 20
Overnight stay: Wait time: too many to list

Kidney disease, unspecified:
Total listed: 36 clinics
Simple care: Wait time: 6x <= 4w, 15x <= 8w, 30x <= 12w, 6x >= 13w
Daycare bed: Wait time: 4 - 4 - 8 - 12 - 12 - 16
Overnight stay: Wait time: 3 - 4 - 4 - 4 - 6 - 6 - 8 - 9 - 12 - 24 - 26

MRI, standard scan:
Total listed: 48 clinics
Simple care: Wait time: 16x <= 2w, 32x <= 4w, 42x <= 8w, 6x >= 9w
Daycare bed: Wait time: 0 - 0 - 1
Overnight stay: Wait time: 0 - 0 - 1 - 1 - 1 - 1

Enjoy!

In addition to the above, I’ve also been able to finds some data about treatment of cancer mammae (breast cancer) and cancer coli (colon cancer) in Norway. According to two studies the average wait time upon receiving an external requisition to surgery is done, is 28-30 days.

You draw your own conclusions.

156

Just to be clear: When I talk about UHC, I do not mean that one’s doctor is assigned. This is one of the major things I hate about some insurance plans I’ve had.

This is how I would work it: Instead of an employee’s share of insurance premiums being deducted from his paycheque, there would be a Universal Health Care Contribution; just like Social Security. This tax (yes, tax!) would be used to pay the insurance premium instead. Unemployed people would not pay this tax, of course; if they’re unemployed, there is no paycheque to deduct it from. However, they would still be covered my UHC.

People would not be assigned a doctor or dentist. They would go to the doctor of their choosing, just as they do when they have better private insurance (and which seemed to be more common 20 years ago). The patient would present his Social Security number, or other form of identification that would show who they are in order for the administrators to count their beans and so that their treatment can be tracked so as to provide better health care. Some people don’t have ID. For example, homeless people might not have ID. No matter. People without ID are still human beings.

“Oh!” the naysayers will say, “Then everyone will go to the most exclusive doctor in town! They’ll all want to be treated at Cedars Sinai!” I don’t belive this is true. For one thing, with more government oversight and less focus on the bottom line, hospitals would be in danger of government sanctions if their health care is not sufficient. And as I said earlier, most people would not simply go to the doctor because it’s “free” or because they feel it would be a fun outing. When I had insurance I almost never went to the doctor. No reason to change under UHC!

What would change is that people would not have to live in fear of illness because of lack of coverage. People’s lives would not be in danger just because their job went to India or their company otherwised downsized them onto the streets.

This country was founded because people objected to paying their fair share of taxes. We’ve done quite well since then, so perhaps it was the right thing to do at the time. Today, the right thing to do is to take care of the citizens that make this one of the more desireable countries in which to live.

157

[QUOTE=ralph124c
What i would like to know…if the state takes over medical care (assigns your doctor, etc.) does that mean that the state can be sued for malpractice?
:[/QUOTE]

There’s no reason to expect that the state would assign you a doctor.
But concerning your question, I doubt it would change a thing. It’s mostly a cultural issue, IMO. You can sue your private practitionner or your public hospital for malpractice here too, but apparently there’s way less such lawsuits (though one might assume there’s as much cases of actual malpractice), and courts award much less damages. I also heard about lawyers wandering around hospitals in the USA, and trying to convince people to sue. I don’t know if it’s a caricature or an actual fact, but it’s unheard of here, for instance.

But as I wrote above, it becomes a growing concern here too (not only in the medical field, by the way…people seem to be much more eager to find someone who’s responsible for what happened…for instance, France is divided in 30 000 or so “communes”-roughly former parishes- headed by a mayor, which means that in many little places, the mayor is a regular guy who has to some spare time left and some interest in doing something part-time for his little community. In the recent years, following a significant increase of lawsuits on teneous basis against the mayors, the number of willing candidates in little places has significantly dropped).

So it could be, unfortunately, that we’re heading to the same lawsuits/insurance problems than in the USA, on the long run. I noted in a previous post that practitionner’s insurance had significantly risen recently, in particular in some medical fields. And barring an overall change of attitude regarding lawsuits generally speaking in the US, I can only assume that a public healthcare system wouldn’t result in less money being spent on insurances. Possibly even more, if we assume there will be more medical acts.

158

Yes, you can sue the government for malpractice at a public hospital, but you will not receive the kind of compensation you would in the US. It’s typically between $100.000 and $1.000.000. I think the biggest payout ever has been around $1.500.000 (and it’s tax free if I’m not completely mistaken, and the lawyer don’t take anything of compensation, he’s normally paid as a public defender or the government would have to cover his bill). You can sue doctors in private practice as well, so I would reckon many of them has insurance. It’s not commom to sue doctors though.

159

Thank you very much for an excellent post. Outstanding. It is much appreciated.

Let me say that I agree entirely that the existance of a “waiting list” is almost useless in determing the effectivness of a nation’s healthcare system. I agree entirely that the case is much more complicated than that.

Yea, this is pretty much a characture. We have a term for it, it is called “ambulance chaser”. Although that usually refers to a lawyer who seeks out accident victims in search of someone who wants to sue whoever caused the accident. It can apply to lawyers who look for people who want to sue their doctors.

Malpractice is a significatn contributor to the increase in health costs. I recall a study which claimed that something like 7% of the increase in medical costs in the last decade or so can be attributed to malpractice lawsuits.

So, what sort of options would people have? Would all employers be required to make these witholdings? Would all workers be required to participate? At what rate do you think it would be necessary? During the transition phase, how much of the health insurance premiums would be withheld? Some companies now simply pay all of the costs for their employers. An expense they can deduct from their taxes. How much of this employer contribution would you want to collect? How would you offset the tax deductions to the businesses?

That’s a lot of questions, Johnny L.A.. I hope it does not look like a pile on or anything. I’m turly just asking.

160

As far as medical care? The same as the insured have now. The same as citizens of other countries like France and Sweden have.

Are all employers required to withhold Social Security taxes? Yes, all employers would be required to withhold UHC tax.

Again, the UHC tax would be deducted just like any other required deduction.

Any specific rate I could come up with would be meaningless. However, I think that an amount equal to the current amount that is being withheld to pay the premiums on current private insurance sounds like a good starting point. This way, the tax would be transparent to the employee.

There is a story about how Sweden went from driving on the left side of the road to the right side. A date and time were announced, and it simply changed. I think the transition to UHC could be done the same way. One week, the premiums would be paid by the employer to the insurance company, and the next week it would go to the UHC Administration.

Now the question is this: What happens to the insurance companies when they lose all of this revenue? Tough question. One way I can think of would be this: UHC would mandate standards similar to the ones in, say, France. Each insurance company would be required to pay for the services mandated by UHC. In return, the government would pay the premiums out of the funds collected from UHC Withholding. People would be free to buy additional insurance directly from the insurance companies, if they feel they need it. Eventually the companies that give good value for the premiums paid on private policies would survive. Those that did not, would not. Over time the UHC Administration would “cut out the middle man” and provide the standardised care to all out of the tax they collect. Now, what could insurance companies offer that UHC doesn’t? I don’t know. Better to ask one of the European Dopers who live in countries that have UHC and private insurance.

I’m not a tax expert, but I doubt that an employer that pays $1 million per year to cover their employees deduct $1 million from the taxes they owe. Instead, they deduct $1 million from their gross to come up with their taxable income. It’s true that reducing taxable income reduces the amount of taxes paid.

Let’s take an extremely simple example. I own a company that makes widgets, and my taxes are 30%. In this simple model, my income after deducting all costs except health insurance is $1 million. Now let’s say I pay $1 million in health care expenses. My net income after all deductions is zero. 30% of zero is zero. No taxes. But let’s say that I’m no longer paying my employees health care premiums because we now have UHC. Suddenly my net is $1 million. Now I have to pay $300,000 in taxes. After taxes, I’m left with $700,000.

That’s extremely simple, and as we all know taxes are much more involved than that. But it seems to me that being taxed on money not given away might not be such a bad thing.