back to article Healthcare: Look anywhere you like for answers, just not the US

A few weeks back I pointed out that the US has the second largest social welfare system in the world. This produced a certain amount of pushback (journalistic speak for me whining to El Ed that you commentards are shouting at me) over the fact that a good part of that is the woeful healthcare system in said US. So, as the New …

  1. OzBob

    So remind me again

    Why can't we tax fat bastards more than thin people, to cover their medical expenses?

    1. Any mouse Cow turd

      Re: So remind me again

      While we're at it, why don't we also tax those who exercise to cover physio and sports injuries too.

      1. Charles 9

        Re: So remind me again

        Sports injuries are one reason why top-class athletes get paid well. Athletes run the risk of overexerting and injuring themselves: both acutely (torn ACL) and chronically (concussions). Once they're too beat up to continue, what they earned in their career may be needed to help maintain themselves in later years. As for injuries during their career, that's usually paid by their team as an investment in returns at ticket booths and media contracts.

        When it comes to non-athletes, one should consider that physical therapy in the like can result in a return for the government by returning an injured person back into the workforce (thus the tax rolls) and so on, not to mention knock-on effect if the individual is a breadwinner.

        1. Anonymous Coward
          Anonymous Coward

          @Charles 9

          No, sports injuries have nothing to do with why top athletes get paid so well. It is gate revenue and TV money. In the days before TV, it was gate revenue. Look at what top class athletes get paid in sports that people have little interest in watching on TV or attending in person.

          Are women's professional basketball players any less likely to be injured than men's? Probably not, but they sure don't get paid millions to play like the men do. That's entirely due to the fact that no one wants to watch them on TV, and few want to attend the games. In other countries substitute football for basketball and the same is undoubtedly true (assuming there even is the rough equivalent of Premiere league for women)

      2. Yet Another Anonymous coward Silver badge

        Re: So remind me again

        >why don't we also tax those who exercise to cover physio and sports injuries too.

        Did BUPA coverage for our small company once.

        I mentioned we should be a cheap good risk, all young fit hunks.

        On the contrary we were the highest payment band the rep explained rather frankly - we have to cover expensive physio for all your rugby and skiing accidents while we dump middle aged managers with heart attacks on the NHS

      3. OzBob

        Re: So remind me again

        Sports injuries are by definition, "accidents". No-one accidentally and consistently shovels more calories into their gob than they exert.

        1. Nigel 11

          Re: So remind me again

          Sports injuries are by definition, "accidents"

          Hardly. The joint damage caused by traumas (Football, Rugby ...) or repetitive strain (Running, Tennis ...) is an entirely predictable consequence of the nature of the sports.

          And probably very expensive to the NHS, since the consequences are likely to be early onset of arthritis needing rest-of-life treatment, but not an earlier death.

          Nevertheless, I'd defend both the principle of equity, and the right to play sports (along with the right to overeat, to not play sports, to inhale tobacco smoke in private, etc. etc.)

    2. Charles 9

      Re: So remind me again

      Because anorexia and emaciation (among other things) have problems of their own separate from obesity. Furthermore, one would think the obese would purchase and consume more goods, thus they DO pay more in associated taxes.

      For some reason, Americans are VERY averse to specifically taxing vices. If foods were taxed based on its value to a healthy person, this could at least allow for some degree of correction, both in terms of reconsideration and in terms of increased revenues to handle increased catastrophic care.

      1. chivo243 Silver badge

        Re: So remind me again

        @Charles 9

        I know that vices are pretty heavily taxed. In my home state they are called "SinTaxes" Alcohol, tobacco, Firearms and gentlemen's clubs are some that come to mind, as well as the amount of tax on petrol/benezine/gasoline. VAT varies from state to state, even counties and cities get their fingers in the till for things such as food and medicine. I know that states that have legalized Cannabis, are heavily taxing it.

        I live in a different country now, and feel no place is perfect. In the end, you trade one set of issues for another set of issues.

        I agree that health care systems should work for the patient. How that is financed is up to the beancounters in the government.

        I should stop now before the question of government and privacy comes into the argument...

        Getting my coat.

        1. Katie Saucey

          Re: So remind me again

          SinTaxes Alcohol, tobacco

          As a Canadian living a 20 minutes drive from a prosperous indian reserve, I feel lucky to be able to avoid those taxes. My carton of smokes costs me only 12$CAN, as opposed to north of 90$CAN in town, and the bottle of whiskey is about half price (though I'm pretty sure this is an illegal sale here in Ontario). That aside I'm quite sure I've already contributed enough though various ridiculous taxes and fees to fund a lung or liver replacement, should the need arise to use our great public waiting healthcare system here in the great white north.

    3. Tim Worstal

      Re: So remind me again

      Well, in a medical care system that provides life long care fat people actually save the system money. The obese (and smokers and topers) die younger and the savings from a reduced number of years of health care are greater than the treatment costs of their being fat puffing boozers.

      A strange but true fact that. And this is true purely on health care costs, without even considering any extra taxes that might be paid by various of these habits.

      1. joed

        Re: So remind me again

        I'd take a different view on this one. While it's true that the system has to provide care for healthy(ier) individual for longer, one has to consider the expense and/or complexity of the care provided to a patient with a condition resulted from obesity, smoking etc. Just to start with a simple example - did you try lifting a 400#+ blob of helpless flesh onto/off the bed?

        Also, while no politicians would mention this, every citizen is just a taxable entity. The state makes some initial investment (basic education etc) and the longer we live the greater ROI for the state (as long as we're not subject to some chronic - often obesity or smoking related - disease). In the end state always wins.

        As far as I'm concerned I agree with calling US healthcare a clusterf... And the only result of so called Obamacare is that now we're forced to fund profits of insurance companies while having no expectations of getting anything in return (especially that having spent your limited funds on the premiums you may not have noting left for egregious co-pays). Same applies to retirements funds that are great way to prop WS indexes and brokers but not a prudent way to save for an average person.

      2. Mark 85

        @Worstal - you're slightly off there.

        One of the biggest factors on the health care clustertruck that is the USA is "political correctness".

        Obesity is a "disability" thrust upon it's victims, right? Smoking is "self-inflicted". Yet, one of our former board members (health insurance company), as a doctor and an actuarial, tried repeatedly to point out that smokers should NOT be penalized. They maybe should be encouraged. They smoke, they get cancer or something equally bad and die. Money wise from the insurance company... a winner. Obese people tend to get diabetes and heart issues with drugs, surgeries, recoveries, more of the same over and over (even transplants) until they die... a money loser.

        In the offices, the smokers were constantly badgered by... the fat ones. Yet they were worst insurance risk for health care. As a smoker, I'll take my cigs and stogies and face my doom. It's far better than heart surgeries, amputations starting at toes and nibbling upwards, kidney transplants, etc. until the end.

        1. DocJames

          Re: @Worstal - you're slightly off there.

          amputations starting at toes and nibbling upwards are usually caused by too many cigs and stogies. Just FYI.

          Non diabetic never smokers tend not to get peripheral vascular disease, and traumatic amputation is rarely progressive or age dependent.

          Much the same applies to "heart surgeries", by which I assume you mean coronary artery bypass grafting - try to guess the 2 biggest modifiable risk factors. (Alright, age is the biggest unmodifiable risk iirc.)

          And renal transplants? I'd prefer one to dialysis or death, the other options available if a transplant is offered. They tend not to get offered to the frail elderly.

          So you're basing your choices on erroneous information. They remain, however, your choices.

          (Icon: my personal choice)

    4. Naughtyhorse

      Re: So remind me again

      We do

      vat on cheesburgers

  2. Elmer Phud


    When it is a model purely to sell yet another form of insurance, other than a hearty bank account where does 'health' come in to it?

    1. Tom 7

      Re: Heathcare?

      I had a close relative who ran a $20Mpa medical business - best insurance available. Had to bring his wife back to the UK for treatment when their insurance ran out.

      1. Naughtyhorse

        Re: Heathcare?

        Had to bring his wife back to the UK for treatment when their insurance ran out.

        back taxes or fuck off :-)

  3. Charles 9

    I have one critical question about the Singapore scenario. Could what they do be realistically possible in a country that isn't a tiny little speck in Southeast Asia? Can geography snag this plan? Or perhaps cultural makeup or history (this is one thing that snags the Americans; the Red Scare has made many older Americans afraid of the S-word, and the can-do self-sufficient attitude from WW2 preceding didn't help matters. There are people who would willingly tell an infirm person, "Go somewhere and DIE" and do so with a clear moral conscience.

    1. Tim Worstal

      Good question

      And one to which there's no very good answer.

      Unless, well, what if we just accept that 2.5 million people or whatever is the right size for an efficient health care system? Meaning that one trying to voer 65 million (the NHS) or 300 million (the US) needs to be broken down into smaller and more efficient units?

      I don't say that's correct, only that it's a possible implication of Singapore being efficient just because it is a small system.

      1. Neil Barnes Silver badge

        Re: Good question

        Though if two and a half million is the right size for a health system, there's nothing to stop a country being carved up into as many chunks that size as are needful. Of course that leads to cries of 'postcode lottery' closely followed by 'well, move, then...' but in concept there's a certain amount of sense there. There's also room for competition between the blocks...

        With a smaller population to preserve, maybe you have significantly less middle management.

        But on the other hand, wasn't that the intent of the NHS Trusts that no-one, least of all the NHS, seems able to understand?

      2. John Sager

        Re: Good question

        Better to risk-pool the insurance over 60M rather than 2.5M people. The drawback there is that us healthy southerners are subsidising Glaswegians with 3rd world mortality rates, before they do croak (sorry about the Scotist stereotyping). Perhaps we just live with that for the greater good.

        1. Skoorb

          Re: Good question

          Well, sort of. You might be subsidising people in Newcastle, but the NHS is now a devolved matter, so the NHS in Scotland, Wales, NI and England are totally separate. They don't even have NHS numbers in Scotland and in NI it's all run by Social Services!

        2. Steven Jones

          Re: Good question

          @John Sager

          People dying early and quickly are actually rather subsidising everybody else. The biggest cost is the treatment of long term chronic diseases, and particularly of the elderly. It is said that type II diabetes is a problem, not so much because it kills, but because it kills very slowly but involves huge expense over time dealing with all the related chronic diseases. That's just the medical costs. Add in pensions, welfare, free bus travel, heating allowances and so on and it gets worse. The deficit is largely down to us all living longer.

          So those Glaswegians expiring early of heart attacks, lung cancer and stabbings are good value. Well, if you're an accountant (and we all know bean counters have no compassion).

        3. Fungus Bob

          Re: mortality rates

          "subsidising Glaswegians with 3rd world mortality rates"

          No the mortality rate is the same all over the planet - one out of every one people dies.

        4. Tim Worstal

          Re: Good question

          Could be. Although a lot of the US doesn't think so. Most large US companies are actually self-insuring. They use an insurance company to run the system but they're actually carrying the risk themselves (ie, there's no insurance fund backing up the health care payments, just company revenues). You'll note from the piece itself that I'm not exactly a fan of the US system. But as far as risk pools go 50k, 100k people seems to be large enough if companies of that size are self-insuring.

          That doesn't mean that health care provision makes sense on such a scale. You'd never be able to support the more advanced (and rare) treatments on such a scale. But as a risk pool it does seem to work for some value of "work".

      3. Ugotta B. Kiddingme

        @ Worstal - Re: Good question

        The problem with breaking any US system into smaller/efficient units is portability - both of coverage and patient.

        At one level, the US is a single jurisdiction. However, there is a second level with 50 separate jurisdictions - each with their own ideas/laws/etc. However, there are no restrictions on movement between these sub-jurisdictions. It's a simple matter for me to drive or fly to another state and my health coverage needs to work there as well. If we break down the health system into smaller units, cross-unit coverage between jurisdictions will be just as problematic as it is today between private insurers.

        Example: Outpatient Procedure X costs me $200 if I use an "in network" provider. Once my annual deductible is met, my "out of pocket" portion of that is 10%. If, however, I use an "out of network" provider either by choice or because I am across the country on vacation/assignment, that procedure now costs $500. Furthermore, because I am "out of network", my portion of that is now 30% - double whammy.

        Any designed segmentation of the US system into smaller and more efficient units must also take the above example into consideration. It could work, but must be done very carefully. Given that politicians and for-profit people will be involved, you can be certain they will get it wrong. Very VERY wrong. The ACA ("Obamacare") is a shining example of exactly HOW wrong they can be. All politics aside, the intent of the ACA was laudable, but the execution ultimately made a flawed system even worse.

      4. Tom 13

        Re: broken down into smaller and more efficient units?

        You've already cited the counter-example: Vermont

        1. John 62

          Re: broken down into smaller and more efficient units?

          1) Read the article: Vermont set up monopolies for each district, which Singapore did not.

          2) Vermont has a population one quarter the size of Singapore's.

    2. Kunari

      Even if geography and cultural issues wouldn't sink it, the special interests who are making bank-loads-of-cash would.

    3. JLV
      Thumb Up

      @Charles 9

      Nailed it!

      Not to mention that Singapore, especially while Lee Sr was at the helm, was not very democratic at all. It is however technocratic-ally competent and has low corruption ratings. Less pork, special interests and campaign contributions driving those decisions, as well as the capacity to take a hard-headed approach to health management, rather than appealing to voter fears and emotions*.

      So, aside from the small size, this is the dream type of government you'd want to design a good health care system, if they do start out with good intentions. Not entirely surprising they ended up with top tier results. And this aspect needs to be considered if you want to emulate their health care.

      This is not an endorsement of Singapore in any way, shape or form. I dislike their nanny state, morality police mentality and lack of truly competitive government. But their results in this instance brings to mind Churchill's quip about democracy as well as the philosopher king ideas of ancient Greece.

      * college buddy of mine, a doctor, was Facebooking his aversion to Obamacare by playing up the "funds for granny will be cut by Washington" card.

    4. streaky

      No it only works because it's a rich city-state with wealth based in international trade rather than actually having to work where all the kids are healthy and well educated. Give them a healthy dose of obesity and scale it up to 250 million people and it'll collapse pretty catastrophically.

  4. Efros


    When I came to the US, about 14 years ago, the thing that struck me most with my dealings with the healthcare system is the arcane and convoluted billing system. You can and will receive bills for procedures/consultations anywhere up to a year after the event, you are also given no clues as to whether your insurance has paid this bill already or not. I also discovered that you can study for an associates degree in Medical Billing, now that fact there should tell us all something.

    1. WylieCoyoteUK

      Re: Billing

      And the bill can be changed after it has been issued.

      A few examples: (CBA to find sources at the moment, but they should be easy enough to find similar stuff)

      Guy has a few stitches after an accident, bill $200. After they find out he has insurance, bill magically triples, but is still not high enough for his insurance to pay out.

      Woman is hit by another vehicle, hers is written off,

      Hospital bill suddenly doubles when they try to claim some of her payment from the car insurance.

      1. Yet Another Anonymous coward Silver badge

        Re: Billing

        The billing inefficiency and overhead is stunning.

        I worked for an IVY league university with a fantastic insurance plan, I went for a medical at the university hospital and for the next two years received bills for $0.00, demands to pay $0.00, refunds of $0.00, statements for $0.00 and so on. A colleague broke a wrist went to the same place and received a bill for $200 because a 2nd doctor not covered by the plan had also looked at the x-ray.

    2. Anonymous Coward
      Anonymous Coward

      Re: Billing

      Had occasion to claim on travel insurance 9 months ago. Have a wonderful collection of debt collector notices received on a monthly basis ever since.(over 100 pages and growing) Tried explaining to the billers, etc that they should talk to the insurer, who accepted liability,but who was refusing to pay the outrageous bills (£8K/day for a hospital bed!). Supplied all the insurance and address info to all and sundry, rapidly came to the conclusion none of them could read and none have a email address! Now just send the bills back to whoever sent them. I can understand the insurers unwillingness to be ripped off, but 9 months for billers to not agree claims seems strange. The insurer told me that this was normal negotiating practice when dealing with US hospitals and wrote to confirm that I had no outstanding liability. The irony is that the insurer is American. The UK end of the insurance company settled my part of the claim within 4 weeks of receiving the paperwork. Having since talked to Americans, they can't understand the billing system either. I gather it's now about $15K/yr for health insurance per employee in small businesses (<100 people) with a lot of extra charges which the employee has to meet.

      1. Efros

        Re: Billing

        My insurance premium for myself and my wife with 85% coverage and a $2000 deductible is $1600 per month. That is a significant percentage of my salary and is the largest bill I pay on a monthly basis.

        1. JEDIDIAH

          Re: Billing

          What you are complaining about is numeracy fail. Unless you are planning on milking the system, get a plan with a higher deductible. Then take the premium savings and put it into a savings a count. Put it into Health Savings Account if you can. Then not worry about how high your deductible is.

          If you don't have some sort of expensive chronic condition, there's no reason for a low deductible.

  5. Anonymous Coward
    Anonymous Coward


    It is a major mistake to consider the NHS as a single, monolithic entity. The NHS is actually comprised of the following trusts:-

    211 clinical commissioning groups (including 198 now authorised without conditions)

    160 acute trusts (including 102 foundation trusts)

    56 mental health trusts (including 41 foundation trusts)

    34 community providers (16 NHS trusts, 2 foundation trusts and 16 social enterprises)

    10 ambulance trusts (including 5 foundation trusts)

    c.8,000 GP practices (all for profit, private businesses which just bill the NHS for services rendered on a pre agreed pricing list)

    c2300 hospitals in the UK (many of which are actually their own trusts)

    So as a low figure there are 400 NHS's in the UK, all of which offer different services, operate to different standards of care (as seen in the occasional disaster which makes the news such as Mid Staffordshire) and you may be able to get certain drugs (new, and more or less experiential drugs) in the NHS in one trust, but not another. It is not for nothing that it is called a postcode lottery.

    This is because of the historical legacy of how the NHS was created, which was pretty much simply as a billing structure to pay the existing private businesses providing healthcare. Most people would consider their GP as being one of the finest parts of the NHS.

    Yet having worked in the NHS, I can tell you that as every GP practice in the country is it's own private business the NHS proper doesn't consider GP's to be part of the NHS and refuses GP's access to post jobs on the site etc.

    Each of the 453 trusts mentioned earlier have their own management structures, their own staff and their own IT, HR etc.

    There would be truly colossal efficiency savings to be made simply by forcing every trust within a county to use the same HR & IT staff and systems. At the moment the duplication in functions is truely staggering, and that's simply within the NHS and not accounting for the fact that the local council have their own set of staff for IT/HR staff....

    1. Chris Miller


      Didn't they try the 'single IT system for the NHS' and ended up pissing away several billion before calling a halt to the clusterfuck (to borrow Tim's favourite expression)?

      1. Paul Crawford Silver badge

        Re: @Chris Miller

        You are right.

        However, the goal of a single and effective IT and management system across the NHS is a good idea, but government organisations (and a lot of private industry) seem to be useless and properly specifying and developing such a system, and the contract inevitably go to the usual suspects who seem worse at software development than a room full of 2nd year comp sci students.

        The answer? I don't know, but I guess that having a small group work with a couple of NHS trusts to prototype something, get proper feedback from those actually using it (not those who fear it, or those paying for it) and then pay more to scale & deploy it when proven would be a good start.

        1. Chris Miller

          Re: @Chris Miller

          Your suggestion is extremely sensible, and therefore it will never happen.

        2. Devil's Kitchen

          Re: @Chris Miller

          There is certainly a problem in specifying software systems (traditional companies tend to think that software/UX/UI designers are nowhere as valuable as software developers), but there are other problems.

          1) Public sector organisations change their requirements a hell of a lot, and this tends to set projects back or leads to shoddy development. And, of course, whilst government "standards" are extant, trusts interpret these in different ways.

          2) There are considerable problems associated with the fact that you are dealing with people's most intimate data. The requirement for fine-grained permissions systems mean that these things are a nightmare to design, to code, to set up, and to keep efficient. Compulsory encryption means that, e.g. searching is insanely complicated (and permissions further complicate what results you can return, which also complicates pagination, etc. etc.).

          3) All of this kind of software needs to be deployed on the NHS's N3 Virtual Private Network, which is very difficult for any supplier to access, and requires "hard" point-to-point lines to any servers which are deployed on it (which very few suppliers provide)—resulting, for instance, of yearly server rental costs of £8k+ per server. Aside from the server costs, all of these measures mean that deployment and maintenance is incredibly expensive compared to a lot of software.

          4) Software security is expensive—very expensive. You generally do not want to deploy an Open Source system (the access to uncompiled code means flaws are far too easily exploited, their code review processes too lax, e.g. WordPress (constantly), Drupal's recent issue, Heartbleed SSL, and the ability to seek redress too problematic), which means proprietary systems. This means a huge investment in design and programming, but also in QA, penetration tests, URL whitelisting, measures against XSS, SQL injection, encryption algorithms, etc.

          Interestingly, however, the Scottish NHS got their version of "the Spine" up and running in about 4 years and for a few tens of millions, by using a centralised data-centre and "dumb" terminals. The NHS in England, however, did not: part of the huge expense was on replacement hardware and the setting up of the aforementioned N3 Network.

          Which merely emphasises another problem: how poor the public sector is at procurement.

          P.S. As a small company, we sometimes employ CompSci graduates: many of them can barely programme a toaster, unfortunately.

          1. Jamie Jones Silver badge

            Re: @Chris Miller

            "You generally do not want to deploy an Open Source system (the access to uncompiled code means flaws are far too easily exploited, their code review processes too lax,"

            Apples and oranges.

            Your examples refer to software that is free, and used widely. That the code is exploitable is because of lax programming standards, not source visibility.

            There are many peer-tested secure open sourced projects (often paid for, but open to allow external auditing)

            How has 'security by obscurity' helped those guys and gals down at Redmond?

        3. Tom 13

          Re: across the NHS is a good idea

          Are you sure?

          There are some assumptions that go into that which I'm not sure are true. I understand there was recently a huge program to redo medical billing codes. I'm not sure if it was limited to the US, or if this was a coordinated worldwide effort. The new system is so complex it includes a code for a surfer suffering an acid burn in the ocean (okay, I hope I'm making that up but I'm told it is possible such a code exists). The new system was intended to correct a problem with the current system where unlike injuries were being thrown into the same vague billing code and throwing off calculations for what it should cost to fix a condition, (for example: broken arm, simple fracture with no complications). The end result is something that takes at least a year to learn and is actually likely to create more miscoding because they've increased the code complexity by 5 orders of magnitude. I expect this is but one of the problems you'd have in creating a system for 10 million people let alone the numbers you need for the UK or the US.

          Even your simplifying suggestion is likely to run amok as soon as you get outside the initial small group suggested. While all groups will need some similar data, most data needed by one group will be different from another. Yes, I know, that's what databases are supposed to do. But much of what they have dealt with is probably actually fairly simple compared to medical information. Which means the best approximation you'll manage is to be able to standardize within a group and then have some sort of universal data exchange to send it to another group.

          I've been told one of the Intel QC gurus was once asked if he stayed up nights worrying about how to test the billions of gates on their CPUs. He answered, "No, I worry about testing the exponentially greater combinations in which they can be triggered." I expect his issues were small compared to a universal record system for healthcare.

    2. Tom 7


      But most of the diversification into different units has been done as part of the tory* 'cost savings' - ie actual increase in costs. These things are not instigated from within the NHS - even their managers couldn't think up such Machiavellian monsters if inefficiency.


      1. Anonymous Coward
        Anonymous Coward


        No, it wasn't. It really wasn't. I worked in the NHS while it had hundreds of trusts under the labour government, which of course brings up the biggest problem with the NHS.

        Making any changes to it is a political matter and utterly uninformed idiots will argue that it's political party X's fault, despite the problems having provably existed for 50+ years and individual trusts like mid staffs managing to kill many times more people than every serial killer in the 20th century combined.

        And people defend it anyway, despite this being utterly indefensible. And as a result of such political patronage, it's unthinkable to charge people with criminal negligence or murder when it is appropriate.

  6. Chris Miller

    Competition and choice

    A couple of years ago my brother had what turned out to be a (fortunately, relatively minor) heart attack. The ambulance was there almost before his wife put the phone down (it was a Sunday morning) and the crew correctly diagnosed the problem. "Where would you like us to take you?" was their question. He lives roughly equidistant between three hospitals. He knew absolutely nothing about how good they were at treating cardiac problems (and nor, it appears, did the ambulance crew), but getting to hospital A involved a short section of M25, visitor parking at hospital B was widely known to be terrible, so he opted for C. He was lucky, and it turned out that they'd just had a major refit of their Cardiology Dept, had all the latest kit and fixed him up a treat, but we did end up wondering what the point of patient choice was.

    1. Richard Ball

      Re: Competition and choice

      Every time I hear of Choice in the NHS I just hear Blair in Monkey Dust talking about "Education, Education, Education".

      It is tribal short-term politics and nothing more.

      1. Neil Barnes Silver badge

        Re: Competition and choice

        @Richard Ball

        A few years ago I piled into the ground in a flying accident which left me with a fine selection of broken ribs and vertebrae and sundry internal injuries; I was picked up by a helicopter (a charity I have supported generously before and especially since) and transported to hospital where I received not only the immediate care required but also subsequent emergency surgery during the recovery.

        At no time did anyone ask me where I wanted to go, or which surgeon I preferred: I was offered care, not choice, and that was exactly what I needed.

        Choice for a patient in an emergency situation should be restricted to the judgement of the physician: which hospital has the best facility vs which hospital is nearest. I shouldn't *need* to choose.

        1. Richard Ball

          Re: Competition and choice

          @Nail Barnes


          Glad you were put back together and it worked out OK.

    2. Yet Another Anonymous coward Silver badge

      Re: Competition and choice

      There's an app for that .....


      Re: Competition and choice

      Sometimes a patient already has a relationship with a particular hospital. That hospital might also be closer to your GP or one of your specialists. Although EMTs should have good feel for "what's best for the patient" in the absence of any stated preference.

  7. AndrewA

    very interesting article - not quite right with singapore

    Very thought provoking. I live in Singapore with a Singaporean wife and extended family. You are right about the assurance aspect (with the caveat that the mandated saving plan is strictly limited in which procesures are covered, how much can be spent on any given procedure and how much spent every year).

    However health care is means tested. Even the poorest have a significant co-pay which limits access. One ICU visit completely cleared the savings of my mother in law and then some. The middle classes have little subsidy and need insurance or self-fund. In hospital relatives are required to guarantee the patient's bill before admission.

    Not quite the paradise suggested in the article.

  8. James 51

    My post seems to have been eaten by gremlins so second time's a charm.

    The problem with quoting spending by GDP without mentioning the absolute amount spent or average spending for patient/procedure is that a place that is twice as rich could spend half the amount of GDP on something but still be spending the same absolute amount. I doubt that Singapore is twice as rich as the UK but it would be interesting to have that information too.

    Edit: If labour and drugs cost half the amount in Singapore that would account for a lot too.

    And as someone else has touched upon, the smaller size of the system probably makes it easier to mange. It would be interesting to know what the writer thinks of the reorganisations of the NHS and the desired v actual impact.

    1. Tim Worstal

      Numbers, % of GDP and actual expenditure (PPP, so adjusting for price differences) are here:

      Singapore is low in expenditure as well as %ge.

      1. Steven Jones

        Healthcare Triage's summary

        This is Healthcare Triage's take on the Singapore system (they have an excellent series on various national health care systems). Despite the videos all being produced in the US (largely by doctors), they aren't too impressed with their own system.

        One thing to note is that the Singapore system has a huge amount of state intervention in order to minimise costs. They tried open market supply, but found that competition was increasingly through expensive technology and then changed the system to stop it. In effect, avoiding the way the US went.

        So this is a long way from being a free market system. The Singapore government is pragmatic if it is anything, but I can't imagine the system of co-pays and enforced medical saving being accepted in the UK. In effect, Singaporeans are forced down a route of compulsory saving for any number of things that are at least partly covered by state welfare systems in most Western European nations. (Of course it helps that income tax is so much lower). The whole philosophy appears to be to minimise state exposure to welfare costs through enforced savings and incentivising citizens to not make demands on the state.

  9. captain veg Silver badge


    The quality of care in France may well be good (I haven't had much cause to find out), but the inefficiencies of a fragmented system are obvious. Every French family has at least one set of crutches in the loft because when someone breaks a leg -- and, since everyone goes skiing here, that's not uncommon -- they are obliged to buy their own set. The purchase is reimbursed, but the crutches remain the property of the breakee, who pretty soon has no further use for them. The total lack of any kind of connectedness between the various medical agencies also means that individuals are responsible for keeping their own medical records and carting them around with them when visiting the various practitioners. X-ray images are pretty unwieldy things to carry on a bus, I can tell you.


    1. jason 7

      Re: France

      Sounds a better way to do it to be honest.

      I know several people here in the UK that were issued new crutches, braces etc. that were marvels of stainless steel and engineering and must cost quite a lot of money.

      None of this stuff was internal, just external use kit.

      When they were finished using them they asked about returning them.

      "Oh we don't them back!" was the hospital's reply.

      1. Tim Soldiers

        Re: France

        We don't want them back, since the risks of being sued (should the device fail) would then be borne by the hospital, rather than the manufacturer.

        NHS Buyer

    2. Anonymous Coward
      Anonymous Coward

      Re: France

      The big difference between the French system and the NHS is that in France you are expected to take responsibility whereas the British system is the nanny system where nanny knows best - regardless.

      The fact that you keep your own medical records in France is an advantage - you can select which doctor you want and go where you want, something that might just be catching on in the UK at last. Also here we pay to see the GP, and get it back later, which does mean that most people that go to see a doctor do, actually, have something wrong with them which leads to very short waiting times (the longest I have had to wait in A&E was 12 minutes).

      1. Zog_but_not_the_first

        Re: France

        "The fact that you keep your own medical records in France is an advantage "

        An excellent idea, although perhaps not for everyone. It might go a long was to getting around some of the IT bottlenecks.

        1. Paul Crawford Silver badge

          Re: France

          Keeping your own records sounds like a good idea, until they are needed in an emergency or the person finds they have lost them (or electronic copy is deleted, corrupted, HDD failed etc).

          What we need ideally are central records that can only be accessed by staff treating you, and that you can see an audit of access if you want. And not being available otherwise, except as anonymous data for research.

          1. Yet Another Anonymous coward Silver badge

            Re: France

            Let us know when you have solved that particular computer science problem.

            A lot of people in banking, the military, security, etc would like to know how you did it.

            ps a password isn't the solution

        2. Peter Jacobs

          Re: France

          "An excellent idea, although perhaps not for everyone. It might go a long was to getting around some of the IT bottlenecks"

          Tricky for those of us with complex chronic conditions. My wife's records have been known to cause back injuries...

      2. captain veg Silver badge

        Re: France

        > Also here we pay to see the GP, and get it back later, which does mean that most people that go to see a doctor do, actually, have something wrong with them

        By "here", do you mean France? If so then the "something wrong with them" that you mention is almost entirely hypochondria. Honestly, your average French person will go urgently to the doctor because of a sniffly nose in winter (which they will insist on calling "rhinitis"), and won't leave without a prescription.


        1. Charles 9

          Re: France

          "If so then the "something wrong with them" that you mention is almost entirely hypochondria."

          What about the other way around? I thought one of the reasons some medical establishments suggest seeing a doctor on a periodic basis regardless of symptoms was to find those dangerous conditions that are best caught in the asymptomatic phase (because by the time symptoms actually appear, it may be much harder to treat--or even too late).

          1. captain veg Silver badge

            Re: France

            They already have that one covered. All employees in France are obliged to undergo a medical examination every two years at the expense of their employer. This is a make-work scheme for a cohort of médecins du travail who do nothing else -- certainly not general practice -- and would be otherwise unemployable.


    3. JLV

      Re: France

      When I still lived in France, in the early 90'd, we were treated to a stunning example of those inefficiencies.

      There had been a world-wide public healthcare provider conference. Which the French delegation had totally dominated in terms of numbers. 350 odd attendees, compared to a few dozen at most for other countries.

      French health care is organized at a "Departement" level (think State/Province) and France has 95 of those. Every single Departement sent several staff.

      Of course, the fact that the conference was in Bali had nothing whatsoever to do with this diligence.

  10. poopypants

    Anecdotal, so obviously not important

    A few years ago I had open heart surgery. Lots of procedures, lots of specialist care, lots of in hospital bed occupancy. The total cost to me was under $6,000. If I hadn't had cheap hospital cover it would have cost nothing, but I would have been put on a (shortish) waiting list.

    That's how we do things in Australia, and I have no complaints.

    1. Anonymous Coward
      Anonymous Coward

      Re: Anecdotal, so obviously not important

      Chap I met was feeling a bit poorly a few years ago, lay down and woke up four days later with a new heart. He was in his mid-twenties, rare but not unheard of apparently. As I remember it there was a team of god knows how many and more than a million quid spent on him. Total cost to him? Zero.

      That's how we do things in blighty, and long may it continue.

  11. Zog_but_not_the_first


    It's a big topic. No easy answers from me, I'm afraid, but for what they're worth, a few thoughts (in no particular order).

    I still regard the concept and formation of the NHS as one of our species' greatest achievements. If a rich developed society can't find resources for issues like health (and education) there's something badly wrong.

    My personal and second-hand (family and friends) experience of the service is good; sometimes excellent, although the inner circle of Hell that is A&E is something best forgotten.

    The US system is very good, while the money lasts, but thereafter it gets grim, as related by a seriously-ill friend who was told she was now "off plan" and her treatment had to be stopped.

    Some small countries seem to have a well-sorted system - Singapore, subject to the above comments and one I know better, Finland. Perhaps their setups don't scale well.

    The fragmented nature of the NHS must have a major impact on its efficiency. Waste through duplication, and the failure to access patient records consistently. Imagine how good the service could be if this could be tackled.

    The role of GP and consultant staff has always troubled me. I find it hard to swallow the notion of these professionals working for the NHS and running private consulting businesses at the same time. That can't be right, can it? Decades after Nye Bevan "stuffing their mouths with gold" it's still going on.

    An NHS manager (they're not all bad) told me they have restructuring plans ready for deployment when all the opposing senior medical staff are dead!

    Unfortunately, I don't trust politicians of any hue to get this sorted, given their inherent short-termism and propensity for "influence". What to do?

    Postscript. When will people stop repeating the lie that surprisingly we've all suddenly started to live longer and that this is the cause of so many problems (healthcare, pensions etc.). Actuarial calculations have been updated routinely to reflect gradual changes in life expectancy but the corresponding action required to deal with this has simply been put off, or ignored.

    1. jason 7

      Re: Thoughts

      The big problem for the NHS is mainly inefficiency on the clerical side.

      People can't make booking for when it's best for them. They advise the clerical person they will be on holiday for the first week of June and two weeks later when they get their appointment letter through it says...yes, it's the first week of June. Go back to Start.

      The GP will say "You need to see biomechanics!" The person will try to book with biomechanics but will be pushed to chiropody due to the biomechanics list being too long (they only have one specialist). Person goes to see the chiropodist to be told they should see biomechanics and have to start the booking process again. Finally goes to see biomechanic and they don't have enough time to do the job properly so it just gets worse and more expensive over time. Person resorts to going private instead.

      Many cases where treatment A is the best course of action but the patient for some reason has to go through treatments B, C and D due to the clerical dept's insistence/ineptitude before finally having to go back to treatment A.

      In most cases the treatment is okay, it's the total clusterf**k of actually getting to that point that's the problem. Most non-medical people in the NHS just aren't smart enough for what's required.

      1. Skoorb

        Re: Thoughts

        That's not the clerical staff, but the (relatively) new idea of "Referral Management". File on 4 have an interesting episode on it. Broadly speaking, if you have a dodgy knee your referral will be "managed" to see if the cheaper physiotherapy will do enough to make you happy and only if that fails will you be passed up to an expensive Orthopedic surgeon. It is possible to get around this by the referral meeting criteria to not go to physiotherapy, but GPs tend not to push for that in most cases.

        A good example is when a provider gets a set amount (say £400 million) to provide all Musculoskeletal services, so they have an incentive to not let people to to surgery, as they lose money. Saves the NHS money (improves efficiency), but may annoy some patients. Have a listen to the File on 4 episode, it's really interesting.

      2. AndrueC Silver badge

        Re: Thoughts

        The big problem for the NHS is mainly inefficiency on the clerical side.

        A couple of years back my optician referred me to my GP and I spent two years having regular appointments to see a specialist for monitoring. The appointments consisted of half an hour for an eye test and half an hour to discuss the results. So they'd book me in for an hour. When the confirmation came (and the reminder nearer the time) I'd get two letters, one for the first half hour, another for the second half hour. Something of a waste of postage methinks :-/

        Thankfully nothing was found to be wrong. Well..sorta. I still didn't do very well on their visual field test but the consultant's view was that since the machines claimed I was half blind and couldn't read and since we spent ten minutes comparing golf stories he thought the machines were wrong. His parting comment was "If it's not bothering you, it doesn't bother me."

  12. Jason Hindle

    I've been saying this for years

    And I'm now saying it as a fully de-anonymised card carrying member of the Labour Party (not sure why - I can't stand a single one of the parties, at the moment). We need NHS 2.0. We need to be looking at France, Germany and Singapore, and seeing what works for them, and determining what will work for Blighty. The problem? I reckon plenty of the politicians have been thinking what I've been thinking. And I'll bet the same for a good few clinicians. The problem is going to be the cost of burning NHS 1.0 (or migrating from NHS 1.0 to NHS 2.0). In IT terms alone, it will be the cluster ---- from hell, with all the usual snouts in the trough. In other words we have structural issues, within the fabric of government, that must be solved first.

  13. Boris the Cockroach Silver badge
    IT Angle

    If you

    want a decent comparision between the NHS and US healthcare, you should try the little exercise the ward did while we was recovering from heart surgery.

    Decided to see what the cost to us would have been in the US had we had no insurance (and what it would be if we did)

    My scans, tests and bypass surgery would have come to about £130 000, for a fellow inmates heart valve, it would have been about £140 000

    In both cases it would have left us bankrupt and homeless, if we'd had insurance, depending on the insurance, we could have had £6000 to pay before the insurance co took up the rest.

    But then if we had been an insurance company sending 10 heart patients a month to a hospital, we could have got the ops done for a lot less (60% was a figure looked at.. but the insurance co would have listed it at full price)

    And heres the real kicker, neither of us would get any new insurance for heart conditions because it was a pre -existing condition, we would be stuck with our original insurers for ever.(until the insurer went bust... or if it was job related .. your employer went bust)

    Be perfectly honest... would you like the US system?

    1. Justin Clements

      Re: If you

      Why would you have no insurance though? Why would you be putting your car payment before your health?

      1. Yet Another Anonymous coward Silver badge

        Re: If you

        >Why would you have no insurance though?

        You lost your job, you changed job and the new scheme doesn't kick in for 6months, you started working for yourself, your new employer's insurance won't cover you because you had a cold as a child so everything that involves breathing is a pre-existing condition.

        Or just paperwork, you become unemployed and file form xyz123 for free coverage but you have to pay the first month's premium of $N000 dollars and will be refunded - but you pay it late and so have no coverage for that 6month billing period but you don't know this.

        Or you just see a doctor that was in your insurance scheme when the list was published but has since dropped out and you get a $20,000 bill - it's your responsibility to check that every medical professional you see during your treatment is a member of your specific insurance plan.

      2. Anonymous Coward
        Anonymous Coward

        Re: If you

        Many hard working people in the U.S. can not afford health insurance. A basic policy that doesn't cover much except for major surgery, cost $500+ per month. If you must chose between being able to get to your work place via car or not having a job, then you do what you must do when there is only so much money to go around. Many people are under paid in the U.S. for their labor compared to other countries.

        It's a disgrace the U.S. could not implement a decent healthcare program instead of a social hand out to those who refuse to work. Every person who has insurance is paying for those who refuse to work. The U.S. even itemizes the tax on healthcare insurance that they charge consumers every month to support the deadbeats. It's incredible the waste and mismanagement.

        1. Anonymous Coward
          Anonymous Coward

          Re: If you

          And that's exactly how they want it. No amount of political will short of a full-blown revolution (complete with civil war) will overturn this bottom-heavy cart. And the odds are no one would survive such a scenario enough to put the place back together.

          And everyone else is wise enough to not take any newcomers without something special to bring to the table.

      3. Boris the Cockroach Silver badge

        Re: If you

        Why would you have no insurance?

        SImple, your insurance is tied to your job, lose your job through whatever means and you lose the insurance.

        I have a dear friend in the northwest US who got treated for breast cancer under her employers insurance, her job went down the swanee with about 35 other jobs when her employer went under, which meant finding another insurerer.

        But she had a legacy of the treatment for breast cancer... so no insururer will cover her for that condition, they'll cover her for a broken leg sure... but with the pre-existing condition... no chance.

        That single reason is enough to convince me that no matter how flawed and stupid our NHS system is (and yes it could do with improvements) , it is 100 times better than the US model and that the US model of healthcare should never be attempted in the UK.

        1. JEDIDIAH

          Re: If you

          I don't like saying nice things about Obamacare but it did eliminate that "pre-existing condition" problem.

          Based on what some people have said regarding referrals to specialists, I am not sure we have it so bad on this side of the pond. (even with the warts)

    2. Jason Hindle

      Re: The US system - my experience

      While on business in Texas, I had the worst flu I've ever had, and needed to get hold of a blue inhaler. Since our travel medical insurance is for nasty stuff, I was told to pay for it and expense it. I visited a place called an Emergency Room. As far as I can tell, by the way, Emergency Room is a brand name for what is the rough equivalent of a GP Practice/Polyclinic. Emergency Room has a Hummer converted to ambulance (coolest looking ambulance I've seen). Financially, it broke down as:

      - $200, just to see a Doctor

      - But this includes mandatory blood pressure and diabetes tests

      - For paying cash (well, Amex), he wrote the prescription for free

      - I then went to the pharmacy counter, at the local supermarket, handed over the prescription and paid the full cost of the drugs.

      Back at the office, an American colleague told me about her experience of giving birth in Australia. They'd just paid for all the medical services associated with having a baby, and couldn't believe how cheap it was compared to back home.

      In the US, I think the Medical Industrial Complex takes everyone for a ride.

      1. JEDIDIAH

        Re: The US system - my experience

        A place called "emergency room" is just as the name implies. It's for emergencies. If you weren't really having an emergency, you really didn't belong there. Hospitals are a big part of the problem in American healthcare .They are robber barons posing as non-profits. ER visits are a cash cow and you and your insurance are going to get milked.

        There are drop in clinics in the US that are much more appropriate for non-emergencies.

        Still, a lot of people go to the ER when it's really not at all appropriate.

  14. Gray

    Kick the can down the road ...

    The great clusterf*ck that is US healthcare primarily depends on putting the problem on somebody else's back.

    The new Affordable Care Act (affectionately known as 'Obamacare') hugely depends on federal subsidies for poor enrollees via Medicaid. States enrolled in the program currently see little increased burden as these subsidies cushion the impact on the state medicaid share. These subsidies will end, however, and the huge cost shift will impose a crushing burden on states already struggling with massive budget problems. At that point, the ACA system will implode.

    Much sooner, however, is the anticipated attack by a newly empowered Republican majority in Congress (House and Senate) which carries a self-perceived mandate to eviscerate or repeal the ACA. Some pundits have bravely suggested that the Republicans dare not attack a program that for the first time ever hints at equitable health care for all Americans, but that remains to be seen. The Republicans are engaged in an internal power struggle reminiscent of the Night of the Long Knives. The ACA is a prime target.

    Long term, the US voter refuses to accept any plan that smacks of Socialism, and Congress ensures that no plan will exclude the multitudinous private insurance industry or impose cost negotiations on pharmaceutical corporations.

    In short, any plan to reform health care or curb steadily soaring costs in the US is stillborn upon delivery.

    1. BornToWin

      Re: Kick the can down the road ...

      You got that right!

    2. Charles 9

      Re: Kick the can down the road ...

      "The Republicans are engaged in an internal power struggle reminiscent of the Night of the Long Knives. The ACA is a prime target."

      There's a big stumbling block, though: the Democratic president with the power to veto any legislation they pass up to him. Odds are anything that de-powers the ACA will turn even a must-pass bill into a must-veto, and the Republicans don't have enough hands to override his veto.

  15. Brandon 2


    Healthcare is not something that should be planned by the state. It's a service, just like any other, and should be appropriately regulated, but left alone. Some people have Ferraris; I don't; it's not fair; but that doesn't mean the government should step in. Some people can afford the best care in the world; I can't; it's not fair... well... you get my libertarian drift...

    1. Yet Another Anonymous coward Silver badge

      Re: planned?

      Same with the police, I have to pay for the police that arrest me for drunk driving - that's government gone mad. Why can't I contract out arresting me to ther cheapest least effective private supplier available ?

  16. jason 7

    I don't get the mentality of the US healthcare consumers.

    I was staying in Oregon a few years ago and some of the locals were asking me about life in the UK.

    "You have the NHS over there? What's that all about?"

    I just explained that through a manageable level of taxation I was eligible for free healthcare, so if I had to have open heart surgery it would all be done free of charge etc. etc.

    "Wow!" they said. "We have to pay over $7000 a year for the pair of us!"

    You think if it's that expensive then why are so many Americans against paying for something like the NHS through taxation? Surely it would have been far less than $7000 a year out of their pocket?

    Just sounds a bit of a mess.

    Plus I've never considered such things as the NHS as socialist or communist (daft). I just think it's a basic requirement for a country to consider itself civilised in this day and age.

    1. Yet Another Anonymous coward Silver badge

      Re: I don't get the mentality of the US healthcare consumers.

      That's a bargain - we are paying nearly $2500/month for the family coverage of our single US based salesdroid.

    2. david 12 Silver badge

      Re: I don't get the mentality of the US healthcare consumers.

      I just explained that through a manageable level of taxation I was eligible for free healthcare, so if I had to have open heart surgery it would all be done free of charge etc. etc....

      You think if it's that expensive then why are so many Americans against paying for something like the NHS through taxation?

      Historically, the NHS was very poor at paying for heart surgery, compared to any other 1st world country, including the USA. Heart failure was on the list of "we just let you die" disorders.

      It's unfair to judge the NHS just by Heart Surgery -- it was very good at things like broken arms -- and it is particularly unfair to judge the NHS by the health care they offered 40 years ago, but since you ask: the NHS had a reputation problem, and it hasn't entirely lived that down.

      There is also a fairness/equity argument that wasn't addressed in this article. It is absolutely critical to any analysis that you understand that the NHS was unfair and inequatable by American standards. Difficult for UK citizens to get their head around the fact that Americans really do take equity and fairness seriously, when the culture is so different. Two countries seperated by a common language etc etc. The current American argument about American health care is that it is so unfair and inequatable that perhaps even other systems are no worse, but don't let that confuse you about why they didn't adopt the NHS on the UK model.

    3. Anonymous Coward
      Anonymous Coward

      Re: I don't get the mentality of the US healthcare consumers.

      It's simple. Many Americans don't trust the State. Period.

      The only reasons the police and fire departments are state-run is because in the 19th century, private firms became protection rackets ("Shame what might happen to your house, eh?"). By the time the idea came around to medicine, there were already fears of rationing and big-government inefficiency, to the point they'll take private firm inefficiency over big government inefficiency. Besides, under US law, emergency rooms can't turn anyone one (that was passed in the mid-80's to prevent the "inhumane" practice of turning the suddenly-ill away from emergency rooms in a day when charity hospitals were overstretched and shutting their doors—IOW, it became the emergency room or death, and anyone who chose the latter would've been railed in the news).

    4. Tim Worstal

      Re: I don't get the mentality of the US healthcare consumers.

      From memory, so don't take this as gospel, NHS spending per head of population is some $3,500 a year. So $7,000 vfor a couple ain't that different really.

      1. AndrueC Silver badge

        Re: I don't get the mentality of the US healthcare consumers.

        From memory, so don't take this as gospel, NHS spending per head of population is some $3,500 a year. So $7,000 vfor a couple ain't that different really.

        That was more or less the conclusion me and my ex-US colleagues came to when we compared life on both sides of the Atlantic. From a purely financial point of view it seemed about equal. There seemed to be only three significant differences:

        * A lot of what they bought was bigger or 'better' in some other way. Housing being an obvious example although I was told that on the Eastern seaboard the difference isn't quite as extreme with land scarcity being an issue there.

        * They get more choice. They don't have to lose a chunk of their income to pay for health care if they don't want. Possibly it's a Hosbon's choice but choice is usually a Good Thing(TM).

        * In the UK if you're one of life's losers life is a bit naff but you're usually healthy and can get by. In the US if you're one of life's losers life is hell. We reckoned that it was a lot easier to become a loser in the US if things went wrong. That is to say that the my US colleagues were a lot more scared about how they'd cope if they lost their jobs than we were.

    5. Tom 13

      Re: Surely it would have been far less than $7000 a year out of their pocket?

      No, it wouldn't. That $7000/yr is via the most efficient means known. If it went through the politicians it would at at least another 20% for the federal staff to manage it, plus another 10% for the lobbyists arguing all sides of the legislation. And the side effects?

      Oh wait that's right we just did this and we still don't know what all the side effects will be. What we do know is most people's cost of insurance has gone up at least 10% and in many cases doubled while not insuring a single extra person. Oh sure they note all the people they've signed up, but not all the people who've lost insurance because of it.

      There are a lot of correctable problems with US healthcare.

      1. Because it involves health and everyone puts the value of health at infinity the cost of malpractice lawsuits is way too high. Yes, truly guilty should be punished, but malpractice suits ain't doing that. That's just another insurance racket on top of the medical one.

      2. There is not interstate competition. Tim noted Vermont which is the worst case, but other states have similar issues.

      3. Insurance being tied to your job as a result of FDR's socialist policies. Yes, I said it. And 0bamacare didn't correct that.

      4. Lastly, and yes I know this will stick in British craws, but here it is: the US is the leading country in researching diseases, finding cures, and supporting everybody else's health care systems. Sure it only cost 10 cents to manufacture the drug, but it costs billions to develop it, plus all the failed trials that lead to the one that worked. So forcing pharmaceutical companies to lower prices because NHS or whatever other agency is buying in bulk doesn't equitably spread the cost of finding the cure.

    6. jason 7

      Re: I don't get the mentality of the US healthcare consumers.

      may I just point out that $7000 figure was for the year 2002.

      I would assume its now considerably more.


      Re: I don't get the mentality of the US healthcare consumers.

      Without an actual number your kinds of claims are meaningless. You (and everyone else) are taxed at some rate that's not disclosed. That has to compare against what we pay out of pocket. With no data whatsoever, it's pretty hard to actually make that comparison.

      Americans probably have more to spend either way. They just choose to ignore the possibility of a future calamity (of any sort).

      Someone mentioned the idea of non-free health services needing to compete with fine dining (and other luxuries). People would rather pay for a pedicure than a doctor. If you think this would be a problem in the UK. Magnify it by 10x across the pond.

      1. Neil Barnes Silver badge

        Re: I don't get the mentality of the US healthcare consumers.

        According to the NHS, who ought to know since they're spending it, the cost per capita last year was £1,912 (call it $2900):

  17. Anonymous Coward
    Anonymous Coward

    Let me explain the why the US healthcare system is this way

    Since Tim and many of you non-US people seem to think it is astonishing that we've arrived at a system that falls short in so many ways.

    Politicians aren't stupid, they know it could be fixed and cost less, but they know where their bread is buttered. Where do you think that massive 18% of GDP goes? What happens to the US economy if we were able to rip it out and replace it with Singapore's system that requires only 1/4 as much GDP? Millions would lose their jobs, pensions and retirement accounts would be devastated, the economy would be thrown into a massive recession! OK, maybe not, since it would undoubtedly take many years to make the transition so the pain would be spread out over a long enough time the economy could probably absorb it, but it would still be a massive economic dislocation to the millions and millions of people who are involved in some way in that 18% of GDP.

    As well, I don't think we could really get down to 4.5% like Singapore, because while the US does waste a lot of money, much of the world's basic research into new drugs and new medical procedures takes place here. Well, the ones that will end up expensive so there's a good return on all the money that is spent bringing them to market. Singapore doesn't have to bear that cost, but if the US wasn't doing it because we got down to 4.5% like they did, some of the new drugs and surgical advances originating in the US would not be available for anyone.

    1. DanceMan

      Re: Let me explain

      Where did that vaccine for ebola come from? Canada, with "gov't" healthcare. Mind you it was bought by a US company, flipped for a massive profit, and is now being developed by a large US pharma.

      But you're absolutely correct that there is a huge component of the US economy sustained on shuffling paper for healthcare and resistant to a change that would spend that money on doctors and nurses instead to provide medical care for everyone.

    2. Gray

      Re: Let me explain ...

      As for the saving grace that US Big Pharma brings us a cornucopia of miracles through research ... it has been proven repeatedly that Big Pharma spends far more on product advertising and physician promotions than it does on research.

      And just this past month when Pres. Obama forgave Cuba for not submitting to US demands to overthrow their government and submit, suddenly a Cuban-developed treatment that reduces diabetic-related amputions by 70% became available to the U.S. Apparently US Big Pharma was not interested ... too little $$ return for the effort.

      1. Anonymous Coward
        Anonymous Coward

        Re: Let me explain ...

        Don't misunderstand, I'm not saying that Big Pharma in the US isn't wildly inefficient, but it does come through with some stuff that the world probably wouldn't have without it.

        At least for market niches where there is a 'need' felt by people with lots of money. i.e., don't look to them to cure diseases that only affect the third world - there's no money in that for them!

        1. Charles 9

          Re: Let me explain ...

          But that's also part of the problem. Big Pharma is only interested in repeat business, so they'll never research CURES...only treatment regimens that cost a fortune AND have to be bought every so often or you DIE. When was the last time a long-term solution like a permanent vaccine was developed?

          1. JEDIDIAH

            Re: Let me explain ...

            I will happily take a treatment that keeps me alive. Perhaps someone else that is more altruistic will develop a permanent treatment while I am waiting.

  18. Anonymous Coward
    Anonymous Coward

    A different model....

    Kaiser Permanente is a different model in the US. Except for drugs it is a closed system: insurance, hospitals, doctors, labs, pharmacies (who have to purchase drugs externally) all part of one system.

    This 'solves' a number of problems of the open-market system, specifically the pay-for-procedure incentive for doctors and hospitals to order up things 'just because'. It also provides incentives for 'the system' to foster health among the membership.

    Also; the largest non-governmental EHR system in the world; 9+ million members, all health records computerized (most available to you online).

    Signed: A guy paid to keep the systems up.


    1. Charles 9

      Re: A different model....

      A lot of the "just because" is due to the risk of medical malpractice suits. Thus the term "defensive medicine." How does Kaiser work around that problem, which can often result by accident?

      1. Anonymous Coward
        Anonymous Coward

        Re: A different model....

        You must agree to an arbitration clause when you become a member, I believe. Takes the ambulance chasers out of the equation while still allowing for some independent review.

        You can (and people do) argue the deck may be stacked in arbitration, but this is one solution to the over-proceduring/lawsuit problem.

        1. Charles 9

          Re: A different model....

          But can anyone argue that the arbitration clause is unenforceable due to the idea a non-government contract cannot take fundamental rights (like the right to sue for damages) away?

          1. Irony Deficient

            Re: A different model …

            Charles 9, if the contract is voluntarily signed without coercion, then why should it be unenforceable? The right to sue would be given away by the signer rather than taken away from him. Compare such a contract to, say, a non-disclosure agreement; what is a NDA but a voluntarily signed contract that limits another fundamental right, one’s freedom of speech?

            1. Charles 9

              Re: A different model …

              But if the NDA covers up a criminal act and you reveal this to law enforcement, you cannot be held liable for breaking the NDA (indeed, using the NDA to cover up the idea you didn't blab could get you a rap for aiding and abetting). Remember, no one is above the law. Furthermore, some rights are inaliable and cannot be taken away by any instrument except the government itself. I'm pretty sure one of them one of them is the redressing of grievances: particularly if said grievance is an illegal act (and acts of medical malpractice, which can result in permanent or even fatal injuries, can easily cross into criminal negligence).

              1. Irony Deficient

                Re: A different model …

                Charles 9, where was it argued that someone is above the law? What does a NDA being used to cover up a criminal act have to do with the comparison of a NDA to a contract for mandatory arbitration? Again, you’re using the phrase “taken away” to describe something which in this comparison is being given away; please note that “taken away” ≠ “given away”.

            2. auburnman

              Re: A different model …

              In theory, Fundamental rights cannot be signed away, full stop. In practice there are grey areas like the ones mentioned above. The key is with these clauses being in civil contracts, all the other party has on you is - potentially - breach of contract if you sue without the agreed arbitration or break an NDA.

              In the example of suing before going to arbitration, assuming you have a semi-valid sounding grievance a decent lawyer could argue this shows the other party has breached the contract first and you have no reason or obligation to honour a contract when the other side isn't holding up their end*.

              Queue the legal Merry-go-round.

              *However this means time & cost to construct the argument on sound legal footing & opens up more options for counter-attack in the courtroom, so you could equally argue it still serves well as a deterrent.

        2. Anonymous Coward
          Anonymous Coward

          Re: A different model....

          "You must agree to an arbitration clause when you become a member, I believe. Takes the ambulance chasers out of the equation while still allowing for some independent review."

          Surely there is another, more efficient way to take the more blatant ambulance chasers out of the equation: if a "no win, no fee" arrangement applies between the plaintiffs and their representatives, a "no win" results in plaintiff and representatives jointly/severally liable for defendant's costs. The ambulance chasers have to share in the losses if they don't win, as well as any gains if they do.

          1. Anonymous Coward
            Anonymous Coward

            Re: A different model....

            The problem is worse than that.

            You get a bereaved wife with young children whose husband died during surgery on the stand and any decent attorney can convince the jury the surgeon and the 'rich' hospital he/she worked for must be punished.

            Regardless of the facts, people are human and 'sympathy verdicts' are not uncommon.

            An arbitrator.... maybe not so much.

  19. Graham Marsden

    @Tim Worstal

    An article you've written that I can agree with, thank you!

    But perhaps you could convince Nigel "I think we are going to have to move to an insurance-based system of healthcare" Farage of this...?

    1. david 12 Silver badge

      Re: @Tim Worstal

      An article on a complex subject, but unfortunately long, discursive, cheap, and poorly assembled. Would have done better at half the length or twice the content. 7 out of 10.

    2. Anonymous Coward
      Anonymous Coward

      Re: @Tim Worstal

      You missed an important section from your smear campaign; Farage’s remarks, were made in September 2012..

      "Frankly, I would feel more comfortable that my money would return value if I was able to do that through the market place of an insurance company than just us trustingly giving £100bn a year to central government and expecting them to organise the healthcare service from cradle to grave for us."

      More recently - Key points pulled from a 2014 BBC article regarding UKIPs health policy;

      UKIP, opposes the inclusion of health services in a trade deal between the European Union and the US. Fighting the inclusion of the NHS in the deal - the Transatlantic Trade and Investment Partnership (known as TTIP).

      UKIP also opposes the Private Finance Initiative (PFI), a financial process that has been used since the 1990s by the Treasury to build, run and manage some hospital buildings

      But UKIP has one very distinctive policy: a major change to the NHS "plumbing".

      The party would abolish Monitor, England's main hospital finance regulator, and the Care Quality Commission (CQC), which regulates hospital care quality. These roles would be taken up by local health boards run by clinicians

      1. Tim Worstal

        Re: @Tim Worstal

        What smear campaign? And what in buggery does Farage have to do with this? Sure, I'm a suporter of UKIP. And?

        Does a journo who supports the Labour Party have to defend everything Milipede says? A Tory can only discuss health care within the confines of whatever Cameron has been saying this week?


        1. Anonymous Coward
          Anonymous Coward

          Re: @Tim Worstal

          Mr Worstal,

          to continue your list: a little over a year ago, I was seriously ill and was lucky enough to have exceptional care at Lewisham Hospital in South East London. For anyone who knows local healthcare issues, Lewisham Hosp was threatened with significant changes (although not closure) following Whitehall-mandated changes that were partially because of the huge losses run up by PFI at a Woolwich hospital The local, and some parts of the national press, reported extensively the successes of the "Save Lewisham Hospital" campaign.

          What I do not recall hearing mentioned anywhere is that locally people were stopped in the street - happened several times to me, and more to others that i know - and simultaneously asked to Save the NHS, Save Lewisham Hospital and take Socialist Worker; any refusal to take Socialist Worker was criticised as not caring about the NHS or local hospitals, and the suggestion that the Blair/Brown era PFI at Woolwich that ran up debts had happened under a left-of-centre government was, I was told, a "f*cking lie".

          As long as one political faction claims exclusive moral rights over healthcare, it will never be free of idiocy. As long as newspapers / media reports cover up or simply fail to report those attitudes, it will continue.

  20. ElectricRook

    it's all about shaking the money tree

    The congress critters are the root of the evil here. They create the noncompetitive insurance environment, massive regulations at the request of the equipment manufacturers causing providers to have to constantly upgrade perfectly acceptable equipment and facilities in the name of safety which cannot be questioned about whether the cost or benefit is reasonable. The litigation lawyers are in bed with the congress critters in the tort game sucking down up to half of the maternity dollars in some places (Las Vegas). The malpractice insurance industry is onboard too catching their piece of the action. The psychologists jumped on board declaring that health insurance needs to cover counseling and drug treatment . . . suddenly we noticed that there was a dead camel under the pile of sticks.

    The root cause seems to be that the lawyers can legislate from the court with out consequence of the cost, and once a law is in place it cannot be repealed especially if it has health or safety in the name.

  21. A Long Fellow

    Health as a profit center

    I've lived in all the systems mentioned above _except_ France, and I must say that the US model is genuinely striking. Only in that country do we have the situation where the optimum economic situation is that everybody should be _just well enough_ to go to work, but not actually healthy.

    In most countries, the optimum economic condition is one in which people are healthy until the moment that they die; in the US, the government/corps generate the largest amount of revenue by keeping everybody moderately ill until they run out of money.

  22. FelixReg

    Suspicious numbers

    Am I the only one suspicious of those percent-of-GDP numbers repeated endlessly in discussions like this?

    In some cases, I'd guess the numbers come from the fox guarding the hen house. Sorta like Soviet economic growth numbers. In the US case, I'd guess the numbers are maximized because someone thinks the real numbers are "too high", whatever the real numbers may be.

    And "life expectancy" numbers for different modern-world areas? They look like statistical bobble.

  23. FelixReg

    Cost maximizing in the real world

    Remember, as Tim has pointed out, the US system is mostly a one-payer system, Medicare. Dying old folks. You could slash overall costs by pulling the plug on anyone who matches some approximate pattern of "gonna die soon". Easy enough to stop life expectancy numbers shining a light on what you're doing.

    And the US system is a cost-maximizing system. Is that true of other places, too?

    Why cost maximizing? Maybe because it would be uncaring, mean and inhumane to not provide the very best to ourselves and any other people with whom we feel charitable. So spend more, get more.

    Which provides measurable proof the US system is the best in the world. Four times better than Singapore! :)

    In the US some systemic lies are exposed to all. Several people have commented about US medical billing. These caustic comments don't even scratch the surface. A US medical bill can be assumed to be an arbitrary number, often wrong by any measure and on many levels.

    The question is whether closed, single-payer systems hide such things. Comments here seem to indicate such is the case. Do UK people generally know that they have "rationed" health care, subject to budgetary and other oddities? Here is a thought of why people in the UK like the NHS despite the things commented on in discussions like this. Same reason "Jaws" was scary and "Earthquake" was not. No. Not the director or general quality of the movie. :) No, it's that sharks eat you. Alone. Just you. But we're all in an earthquake together. Secure. Warm. Cared for.

    In the US you know you're on our own. Alone. You must count your fingers after shaking hands with any part of the medical system. That's not pleasant knowledge. It's not like we're talking about a competitive system, here. They are completely safe from you, legislated, like banks and phone companies.

  24. Anonymous Coward
    Anonymous Coward

    A broken system

    In the U.S. everyone in the medical health care pipeline is raking in the bucks be it the doctors, hospitals, pharmacies, etc. and consumers are paying through the arse for it all. Here's a little gem that many people in the U.S. do not know. If you have health care insurance, what the doctor, hospital or pharmacy receive in payment is MUCH lower than what these entities receive from a person without health insurance. In other words if you're too poor to afford health insurance you pay MUCH more for the same services, drugs, etc. than what the insurance company normally pays for these services.

    As an example I recently had some standard blood work lab test at the local hospital. The insurance company paid the lab ~$65. for the few simple tests. Had I no insurance, I would have been billed $549 for the same tests. How does that make any sense - especially when in most cases the service providers get paid at the time they provide the service - if you have no health insurance? The doctors, hospitals, etc. get paid within a week of filing their claim with the insurance company.

    Here's another gem and the root issue to the health care problems in the U.S. If I were an illegal alien in the U.S. and I went to the Emergency room of a hospital for care - (which as noted is a substitute for many to actually having a family doctor), I'd pay ZERO for all services - because I am an ILLEGAL alien in the U.S. and I'd get the same services as someone paying dearly for the services. The U.S. currently has at least 20+ million illegal aliens who are bleeding the social services system dry. The amazing part is the illegals actually believe they are entitled to all of the social services - for free when they never contributed a dime and are technically criminals, illegally living in the U.S.

    Anyone who doesn't understand the magnitude of the issue is either braindead or in deep denial. The corrupt politicians pushed through the disgraceful affordable health care act - which is not affordable at all, so that they could be re-elected and so that Obama would have a legacy of corruption, aka helping the ghetto rats expand their free lunch. If you actually talk to people who now have health insurance as a result of the AHCA, they will tell you they pay more and get less than before they were forced to accept this inferior health care system. Those who can't afford the new AHCA coverage - because they refuse to work even though they are able, they get it for FREE and that is why those who actually work for a living are paying more and getting less health care than previously. It's an outrageous abuse of power by the criminals in DC.

    1. Anonymous Coward
      Anonymous Coward

      Re: A broken system

      pretty much this.

      People often lavish praise upon Mexican dentists for being so inexpensive, but what they fail to realize is much of the difference in cost is less "outside of the US system" and more "you paid in cash".

      A dentist here in the States, fully certified, fancy office, lots of Yelp reviews, will do a procedure for at *least* a third less if in cash than billed to any insurance you might have. Sometimes less than half.

      My case: Wife and I went in for tooth cleaning to a place that took my work insurance. Cost to get the wife's crowns? over $3K with $500 out of pocket. Went to another dentist, one recommended by a co-worker, better online reviews, nicer office, paid cash, $800 TOTAL.

      Now in my area all sorts of "clinics" are popping up, dental and medical, like 7-11's in the 80's. In strip mall and shopping centers, all new and online, started building the beginning of 2014. All advertising taking ACA, all ready to rake off their cut of the action.

      I wonder how long until the Fed demands "lawyer insurance" and we'll get mall stop lawyers like that guy on the Simpsons everywhere.

      1. JEDIDIAH

        Re: A broken system

        There are "cash-only" medical clinics popping up in the US too. Their cash prices are more in line with the "insurance discount" prices or sometimes even lower. Taking insurance and "medical billing" out of the equation greatly simplifies things.

        THIS is why Americans are skeptical of Big Government run healthcare. We have Medicare and Medicaid which are both kind of disasters already.

  25. codejunky Silver badge

    In the UK

    Unfortunately health is a political football in the UK instead of a realistic problem that people want to deal with. Labour cries that tories will dismantle it, tories cry that labour is throwing away unaffordable amounts of money and libs are rarely realistic anyway.

    When you occasionally get past that the debate always falls on 'private bad NHS good.... Ug' using the US as the only example of anything not NHS which leads me to believe some people cannot handle more than a boolean choice.

    If you get past that the talk is about funding which often falls on 'take money from the rich because they can afford it, anything else is bad'. Again the boolean choice problem but also assigns blame to an undefinable group ('rich').

    The best system is the one that not only performs well but we can also live with. Unfortunately we dont seem to have a system that covers either option, but moaning about it makes us happy.

    1. Charles 9

      Re: In the UK

      Not a football (kind irrelevant). A hot potato. And it's like that in the US, too. It's one reason Medicare and Medicaid are regarded as third rails (as in touch it and kiss your career goodbye). It doesn't help that seniors are historically the most active voting bloc (and growing).

      So you end up in a no-win situation. Something has to be done, but too much is sunk into the status quo to let anything be changed much. And since medicine is an existential business (because we values our lives more than anything), it's also too emotional a topic to discuss rationally. Anyone who tries gets a loved one thrown into the mix. That's how it was with the ACA debate ("The Enemy is going to leave your Grandma to DIE!" is not far from actual ads plastered during the debate). A system everyone can live with simply does not exist. We'd have an easier time trying to find an absolute universal truth.

    2. Anonymous Coward
      Anonymous Coward

      Re: In the UK

      agreed I'm fed up of hearing the Labour party say the Tories are destroying the NHS (they're saying it again now) we hear it time and time again. There is already a massive amount of private involvement within the NHS, in terms of actual healthcare (think dentistry a huge amount of private work) and other areas such as cleaning, catering, laundry, etc. The NHS needs to stick with providing core health services, and I don't care how this is done I don't give a feck as long as its FREE at the point of delivery.

  26. nobody2

    Demographics matter

    I know nothing about Singapore and its health system but I do know that frail elderly people account for the lion's share of NHS costs. It's easy to look after a young healthy population.

    A useful comparison is the Elderly Dependency Ratio. This is the ratio of the elderly population (ages 65+) per 100 people of working age (ages 15-64). The UK's is 27.6% and Singapore's is almost half at 14.5%. This will make a vast difference to healthcare costs.

    (source: CIA World Factbook)

  27. Jagged

    Hate seeing that £30,000 figure quoted anywhere, since its never been made in any official capacity.

    Plus whenever its mentioned, they never say that American Insurance firms are said to use a surprisingly similar number ($50k)

  28. Bob Dole (tm)

    Excellent article. Well written and a pleasure to read.

  29. Anonymous Coward
    Anonymous Coward


    the author concludes, "... the US could have it as good as they do for everyone, instead of just the majority, at a quarter of the price. The power of thinking about things, eh?"

    Not going to happen. Today, it is all about "I'm in charge, this is what I want to do," "First, we maximize profits," "We can provide services to 70% of the population and still make alot of money. Let someone else figure out what to do with the other 30%"...

  30. DaveDaveDave

    Singapore Slings and Arrows

    Tim, we go over this every time you mention Singapore: their figures are simply made-up. The reality is that 80%+ of their population has no access to the public healthcare system at all, so it's massively inequitable. It's also, once you factor the proportion of the population actually being treated, no more efficient than the US.

  31. Ken Knowles

    Options in the US

    This article fails to address the HMO / PPO options in the US. The HMO option works more like the NHS but gives the consumer less elective options. As an ex Brit I find this much easier to work with than using a PPO. The other bad thing I found with PPO was the continuation of care between health care providers leaves something to be desired


      Re: Options in the US

      The HMO option typically has a significantly smaller network due to lower reimbursement rates.

      The better doctors are likely not available on the HMO option.

  32. Anonymous Coward
    Anonymous Coward

    as an "insider"

    I found this article to be very accurate. It surprised me how much the politicians in charge, and the "decision makers" absolutely REFUSED to do anything that worked with what healthcare systems we already had in place-for example, any suggestion that enhanced coverage be built off of preexisting State (for example MediCAL for California) infrastructure-which already had relatively streamlined systems for intake, qualification, and payment-and a surprisingly effective oversight system to keep costs under control. It was already used to handling large amounts of individuals and had a network of actual healthcare providers accepting it.

    Any suggestion to expand this to handle increased load and the new qualifications was met with heavy resistance from the Democratic Party and the Union. As in, accusations of "right wing extremist!" and worse being thrown. Note there was no change in who would qualify, but running it at a proven, State level system that could already scale instead of a brand new, central Federal, lumbering bureaucratic infrastructure from scratch.

    As it was, for months, the only way anyone in California could meet the Federally mandated deadline and get their coverage was through an expansion to MediCAL that worked until the Fed finally got something resembling workable out to the public.

    Now keep in mind, the Fed was all about health *insurance* and not about health *care*. Propaganda aside, the two are NOT the same. A new system with new billing and new rules that many practitioners were not (and still not) ready for does no one a service, while again our stopgap state run systems actually got health *care* to clients who needed actual treatment.

    People can play politics all they want, but the US system has not actually provided *care* but lined the pockets of *insurance* companies and brokers, while still leaving the State systems to actually help people. State systems often act as a "middleman" getting funding from the Fed, and all the inefficiency, waste and fraud possibility (as well as TONS of actual honest mistakes) this enables.

    We in America were already "doing it right" for the "poor", all we needed to do was expand it to handle everyone else. Instead it became a political wealth transfer-the Political/Insurance Complex. I suspect eventually it'll fail back to the State systems, if the politicos benefitting from the charliefoxtrot will allow it to do so, before it really becomes the monster the Other Party claims it is.

  33. Anonymous Coward
    Anonymous Coward

    Skin in the game

    You write, "Over on the provision side we want patients to be exposed to prices on routine care, so that they do indeed buck up providers, but not on extreme or emergency care." What evidence do you have that patients are any savvier consumers of medical care than they are of bridge design? Or that patients' having skin in the game has a salubrious effect on optimal provision of treatment (the appropriate type and amount), value for money, provider prices, or aggregate healthcare costs? Real-world evidence -- the Rand study of cherrypicked healthy young working families notwithstanding -- strongly suggests it doesn't and that expert monopsonist bargainers and outfits like NICE do a far better job on all of these counts.

    You're on the money with calling US healthcare a clusterf*ck, but it's so much more: it's one of the biggest protection/extortion rackets on the planet. Take the percentage of GDP the US spends on "healthcare" (18%), subtract the percentage of GDP the second most medically expensive tier of countries (Switzerland, France) spend on actual healthcare (12%), apply it to the US GDP ($16.8 trillion), and you get *a trillion dollars a year* that's being lost to skimming, administrative featherbedding, and price-gouging. And that's not even taking into account that the second-tier countries provide actual healthcare to virtually *all* of their citizens and get generally better overall outcomes. The fact that the skimmers, featherbedders, and price-gougers can buy Congress, the White House, state legislatures, and the commercial news media for barely a penny on on the dollar -- through campaign contributions and revolving-door payoffs for the first three, by leveraging their commercial advertising expenditures for the last -- does not bode well for the prospect of genuine substantive reform.

    Finally, you missed a great recent example of the US system's weakness at "assurance": the US's first Ebola fatality, Thomas Eric Duncan, who was "treated and streeted" at a Dallas hospital ER (A&E) without so much as a blood test. Federal law requires hospitals that accept Medicare -- the US public insurance program for senior citizens -- to treat anyone who shows up at their emergency rooms without regard to ability to pay. It does not, however, guarantee that the hospitals will get paid. As a result, when a patient is uninsured and not visibly well to do, the care provided is usually minimal and sometimes only nominal. In Thomas Eric Duncan's case, it was Tylenol and a recommendation to get plenty of rest and drink plenty of fluids ... and he was sent out into the community with Ebola. You see, if the hospital had done a blood test and preliminary quarantine, they might have been saddled with a collection loss...


      Re: Skin in the game

      Duncan presented as a flu patient. NO ONE gets a blood test for the flu over here. People like to talk about US doctors going crazy with the testing but I've never heard of anyone ever getting a blood test for the flu. X-ray perhaps. Strep culture perhaps. But no bloody blood test.

      Not that they would have been looking for the Ebola to begin with. (That was kind of the problem)

      It's easy to second guess with the perfect knowledge of hindsight. Not quite so easy in real time.

      ...and fluid replacement is a key part of Ebola treatment.

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