"YIKES". Marginal Revolution points to a problem in Britain's National Health service. Patients have been paying extra for treatments not covered by the NHS, while still getting the majority of their treatment on the government's dime. Now the NHS is cracking down.
"Patients “cannot, in one episode of treatment, be treated on the N.H.S. and then allowed, as part of the same episode and the same treatment, to pay money for more drugs,” the health secretary, Alan Johnson, told Parliament."
The article is about an important problem for public health systems: politically, they find it very hard to tolerate any inequality of access to treatment, but even harder to finance all the treatment people might demand, or to forbid rich people to take life-saving actions. But it hints at another problem for Europe's health care systems. It strikes me that for a long time Europe managed to keep its health care costs down because patients had relatively little information. Governments therefore found it fairly easy to set the standard course of treatment using some sort of crude cost-benefit analysis. But differences in systems, plus the internet, mean that cancer patients now know there is an Avastin--and you will have hell to pay if you deny it to them. Browbeating the pharmas will not generate enough savings to finesse this trend.
Beurocracies, both healthcare and otherwise, retain a secret weapon: access.
If people demanding Avastin find that their waits for scans and treatments jump from 6 weeks to 6 months, sooner or alter they'll get the hint - or die. That may very well be what happened in the case in question.
And as long as elites and media gatekeepers beleive that 'protecting the system' is more important than the lives of individual patients this will continue.
Of course, sooner or later they system will mess-up and not give the proper person the 'bump up the que' that elites demand as their price for keeping quiet & protecting the system. Then they blow the lid of the story.
Which may also be what happened in this case.
Megan writes,
"It strikes me that for a long time Europe managed to keep its health care costs down because patients had relatively little information."
It isn't that patients had little information, it is that the EU has actually banned advertising for pharmaceuticals. Europeans cannot actually find out if there are new treatments for their illnesses. They have to rely on whatever the government doctors tell them. There is a information blackout.
For more, read here: http://www.juandemariana.org/article/842/ignorant/our/own/good/
Great post, Megan. If only there were a way to get your colleague Matt Yglesias to read it.
Megan,
That's a very good point.
What a woefully ignorant post and responses. Speaking as a Brit with private health care, this is an old problem, and an impossible one to remove. There is no health care system or insurance policy that can guarantee all treatments will be paid for. The option should always exist for people to pay over and above the national standard. If you believe in choice, then the only question is how best to resolve the problematic cases, and that will always be a matter of ongoing debate.
There is no way to "finesse" a healthcare discussion of this nature. The pharmas are not "browbeaten". And adults able to have an intelligent conversation about a serious matter will largely prevent having "hell to pay". Those who are unhappy with the decision will either have to find a way to pay themselves, or simply have to life with the fact that life isn't always fair. I doubt you would like an "I deserve to get something for free" attitude anyway.
There is not an information blackout, although the internet is improving people's self-research. But the fundamental lid on costs is not ignorance, but universal health care. We treat good health as an individual right which requires an intelligent approach to the funding and provision of health services. Cost per head is far cheaper simply for taking out most of the profit motive and the transaction costs from agents such as insurance companies.
The lack of advertising does seem to prevent the national hypochondria and malpractice insurance that blights the US as well.
Perhaps the US will eventually realise that letting your chlidren be hurt or even die simply because of the circumstances of their birth is immoral. Of course, the practical argument is that universal healthcare is far more cost effective for the individual.
It's unusual for the US to be both immoral and stupid with money, I have to say.
More mishegas from Megan. If the Brits don't like their health care system, they have the option of voting it out. Ditto with the Dutch, the French, the Germans, et al. I haven't read anything suggesting that the rest of the world wants our health care system. When I do, I'll pay attention to what Megan has to say.
Jon wrote: The option should always exist for people to pay over and above the national standard.
Well then...maybe if you had bothered to actually read the article, you would have seen that this was exactly what the person in question wanted, and saved yourself the rest of that stupid blustering. To review: she had breast cancer that had mestasticized, and wanted to pay $120,000 for Avastin treatments on her own. She had raised $20k in gifts and was about to sell her house in order to get the other $100k, when the NHS stepped in and said, either you accept what you're given, or you pay for everything out of pocket.
Quoting from the article:
Meanwhile:
Jon wrote: We treat good health as an individual right
No, you don't. You claim equal access to healthcare as a right, even if the enforcement of equality requires playing whack-a-mole with the exceptional cases.
"Those who are unhappy with the decision will either have to find a way to pay themselves, or simply have to life with the fact that life isn't always fair."
If people could "live with the fact that life isn't always fair." Why have the NHS?
And " taking out most of the profit motive and the transaction costs" yeh, because that worked so well for British Leyland.
The NHS - the Lucas Electronics of Healthcare...
Agree about information flow affecting cost. I think the same thing happens in Japan because the doctor-patient relationship is much more directive in nature there. The doctors tells the patient what to do and the patient generally complies without question. It will be interesting to see if that changes as more Japanese gain access to medical information over the internet.
Jon, this nice lady--Debbie Hirst-- is going to be hurt or even die because she was born in the UK. Do you mean to attack that, or defend it?
If the Brits don't like their health care system, they have the option of voting it out. Ditto with the Dutch, the French, the Germans, et al. I haven't read anything suggesting that the rest of the world wants our health care system.
The Brits, the Canadians and the French are clearly moving in the direction of private funding, as their public systems struggle to meet the demand for the constant stream of new and improved health care products and services created by the medical-industrial complex. The internet is making the residents of these countries increasingly aware of what they are missing by relying on their government-run systems. And it's only going to get worse.
Mixner, where have you read that Great Britain, Candada, and France are moving in the direction of private health care funding? Have you read stories in Canadian or European newspapers suggesting that anybody wants our so-called health care system? What political parties back privatizing health care? What are your sources?
There's a simple way to summarize this story: The British are treating health care the same way Americans are treating primary and secondary education.
Stan:
http://books.google.com/books?id=c_Krw_hWYdMC&pg=PA249&lpg=PA249&dq=france+supplemental+insurance&source=web&ots=yXLiPo3-8_&sig=IiIjB954FNiD_Hfc1FmVWYG-_tA
In France most people buy supplemental insurance to pay for what the government will not. As costs in France continue to rise there is more and more pressure to push costs on to the supplemental insurance system.
jmo's post shows what a sensible health system the French have. It provides competent medical care for everybody and allows those with enough money to buy optional extras. Contrast that with what we have here.
From a Brit. 1. For a start the NHS is unique in Europe with continental systems involving mixtures of insurance and state subsidy. 2. it's not just the EU that has banned pharma ads, Britain has banned them for decades. 3. the debate in Britain is always about priorities. There will never be enough money so hard but clinical choices have to be made. 4. it is not the government that restricts drug use but the expert advisory panel NICE (National Institute for Clinical Excellence) which advises the local health care Trusts about the cost effectiveness of treatments. 5. The truth is there is no British backlash to the NHS. Any party who suggested privatising the NHS would be politically dead in seconds. The issue is that local health care Trusts set different priorities based on the needs of the population they cover. It's called by the tabloids the postcode lottery. All drugs are available to health care trusts despite the advise of NICE. NHS access to drugs depends on the Trust in your area. So far from forcing equality (except for point 6 below) there are many nuanced differences in the NHS depending on locality 6. the details concerning the lady in question is not a British issue or a problem for public health systems but a party political one in that the governing Labour party have always been about forcing everyone to the same standard even if the standard is much lower. That isn't the case with the opposition Conservative party who are far more interested in personal freedom and responsibility.
I've only been treated for very minor conditions in Japan and France, so I've had little exposure to foreign healthcare. In each of her healthcare posts I'm amazed at the difference in descriptions of reality across the ideological and geographic spectrum.
It is clearly very difficult to describe any healthcare system from both high and ground-level views.
Stan remarks that Europeans can vote for a different healthcare system - so can we, and true to a point. Both private and public healthcare systems become highly entrenched interests, don't they? And voters also divide into groups that are favored/disfavored by the status quo. Try reforming social security or medicare!
This, of course, is the rub, isn't it? To get actual equality in healthcare, you must actually cap the care that is received by all, whether they can pay for it or not.
In Canada, it was actually illegal to get care from the medical industry by paying more than the provincial government paid. These sorts of restrictions are fundamentally immoral, but are the natural results to be expected when goods and services are rationed by government fiat.
Unless the fount of medical progress can be effectively plugged up in the United States, European countries will have an increasingly difficult choice in these matters- either except greater inequality in care, pay even more for more equal care, or start restricting even more the choices available to everyone. The NHS is choosing option 3 in this case.
"European countries will have an increasingly difficult choice in these matters- either except greater inequality in care, pay even more for more equal care, or start restricting even more the choices available to everyone."
It seems like most European countries don't care if there is inequality in care, because most allow the purchase of supplemental insurance. The idea is that everybody is entitled to some basic level of care and anything above and beyond that is your responsibility. Not saying they are all like this, but "universal health insurance" certainly does not mean a British type system.
"universal health insurance" certainly does not mean a British type system.
But it doesn't rule it out either. I think a French-style system might be reasonable, but a British-style system would be horrible.
Many "universal health care" advocates in the US are somewhat fuzzy about what they are actually proposing, but (IME) the ones who are the loudest are in favor of the British-style single payer system. Since they're the loudest, whenever I hear "universal health care" I assume (sometimes incorrectly) that they're talking about a British-style system.
"Jon wrote: The option should always exist for people to pay over and above the national standard.
Well then...maybe if you had bothered to actually read the article, you would have seen that this was exactly what the person in question wanted,"-anony-mouse
That isn't quite right. Cancer treatments involve a lot of integrated processes - surgery, radiation, chemo - they can't necessarily be delivered seperately. The drug she wanted would need to have been administered by the NHS. It's one thing to pay money for extra health care from a private supplier, but she essentially wanted to pay a third party to get better health care from the NHS. That would completely contradict what the NHS was set up to do.
Jordan T,
I never wrote it meant that you had to have a British type system.
Yes, you can have supplementary insurance in many European countries, but the "basic level" of care will have to rise (along with its relative costs) with the advance of medical science, or inequality will grow.
The British system is not as unique as you are implying, however. Faced with the growing inequality, the NHS seems to have decided that if you pursue supplementary care, then you must divest yourself of the “right” to consume the public service altogether for your illness. Every public/private system faces this dilemma of constraining public costs in the face of advancing levels of care, especially the US where such advances are almost always available first.
So far, I have not seen anyone here give a reasoned defense of the NHS’s decision in this case- only denials that it has any broader significance. Why was it improper for this patient to supplement her care privately?
"to finesse this trend": bugger me, what's that in English?
According to SG," Many "universal health care" advocates in the US are somewhat fuzzy about what they are actually proposing, but (IME) the ones who are the loudest are in favor of the British-style single payer system."
In fact, the British system is not single payer. Neither is the Spanish, or the American Veterans Administration system, or the system used by our armed forces. In these systems all health care providers work for the government, and there is no need for health insurance. The French and the Canadians do have single payer systems. In these countries and in the American Medicare system, doctors and nurses are private, but the insurance is owned or controlled by the government. The health system proposed by Senators Clinton and Obama (and earlier by Governor Romney of Massachusetts) is different. Its main feature is a subsidy paid to people who don't receive job related medical benefits and who purchase medical insurance on their own.
I don't blame SG for being confused about this. The press is not concerned by things like medical insurance. It devotes its attention to important topics, like whether John McCain had an affair with a lobbyist or whether Michelle Obama dissed America.
Njorl wrote: That isn't quite right. Cancer treatments involve a lot of integrated processes - surgery, radiation, chemo - they can't necessarily be delivered seperately. The drug she wanted would need to have been administered by the NHS. It's one thing to pay money for extra health care from a private supplier, but she essentially wanted to pay a third party to get better health care from the NHS. That would completely contradict what the NHS was set up to do.
Two problems with this refutation:
1. This kind of thing has reportedly been going on for a while, but this woman in particular was singled out for a letter-of-the-law application. A cynic might say it was solely because her case was becoming sufficiently known as to make the NHS look bad.
2. The regulatory decision that lead to this was premised around the idea that "the rich" will get disproportionate benefits. Did it not occur to the empty suit who made this statement that the only difference as a result of this decision is that now only the very-rich will get "disproprtionate benefits", since only they will be able to afford the luxury of paying for the entire cost of expensive healthcare outside of the system?
In any case, Jon was plainly misrepresenting the situation as an opportunity to sneer at the Yanks. "Good health" is not be treated as a "right" by any system that operates on this perverted logic.
Stan,
Mixner, where have you read that Great Britain, Candada, and France are moving in the direction of private health care funding? Have you read stories in Canadian or European newspapers suggesting that anybody wants our so-called health care system? What political parties back privatizing health care? What are your sources?
Media reports, academic papers, government statistics. That sort of thing. In Canada, for example, there is no doubt that the role of private funding and provision of health care is increasing. Canadians are paying for private services to avoid the long waits that are widespread in the public system (Medicare). The landmark Chaoulli ruling by the Canadian Supreme Court struck down Quebec's ban on private health care. The Canadian Medical Association predicted that the ruling could lead to "the end of Medicare as we know it."
The French public health care system is going bankrupt. It's been running a deficit every year for the past 22 years.
But differences in systems, plus the internet, mean that cancer patients now know there is an Avastin--and you will have hell to pay if you deny it to them. Browbeating the pharmas will not generate enough savings to finesse this trend.
Interestingly enough, there's a related WSJ editorial page article on Avastin today. Seems that the FDA, while having approved it for other cancers, hasn't approved it for metastasized breast cancer. It seems that, once the patient is diagnosed, Avastin increases t_healthy, the amount of time before the cancer spreads further and healthy becomes significantly worse. However, it decreases t_sick; once it spreads, the patient dies quicker. The FDA regulatory process mostly cares about mortality rates and t_total = t_healthy + t_sick. Avastin most likely increases t_total by a small amount, but current small studies have not shown an effect large enough to be considered significant.
Of course, off-label prescriptions are common enough in the US. My insurance company will even pay for them. (Though I have an HSA high-deductible plan.)
Every few days I read the English language version of Der Spiegel and a number of British papers. I see no tendency for Germany or Great Britain to adopt an American style system, and I have a strong feeling that any party proposing such a change would lose in a landslide. Konrad Adenauer wouldn't have thought of it, and even the saintly Margaret Thatcher did not attempt privatization of the National Health. And I have no idea what Mixner means when he says that the French public health system is going bankrupt. Governments and governmental organizations don't go bankrupt when they run a deficit. As Cheney said, Ronald Reagan taught us that deficits don't matter.
Stan,
I see no tendency for Germany or Great Britain to adopt an American style system, and I have a strong feeling that any party proposing such a change would lose in a landslide.
I don't see anyone suggesting that either of those nations, or any nation with a health care system currently dominated by public funding, is likely to simply replace it wholesale with a privately funded one. Rather, the role of private funding will probably continue to rise gradually over time, as the public system finds it increasingly difficult to pay for all the new and improved tests and drugs and surgeries that people demand. Inequality in health care will likely also rise as the role of private funding grows.
When you talk about health care in the UK vs the US, keep in mind that the NHS is funded by the taxes paid by big UK pharmas such as Glaxo Smith Kline, defence industry giants such as BAE System, and Energy giants such as BP on profits from US sales.
In other words, the US taxpayer is partly funding the UK universal health care system.
If that doesn't make you feel sick in the stomach, you don't need health care; you're already dead.
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