In all healthcare systems some form of rationing occurs since there aren’t enough resources to provide the best care to everyone. A system that rations care based on ability to pay or on wether or not your employer is generous is immoral. It is also immoral to profit off of denying someone care. Tough decisions have to be made and financially rewarding a company by denying care is despicable.
> A system that rations care based on ability to pay... is immoral.
You lost me there. What makes it immoral? Money is an asset allocation tool, so why is it morally wrong to use it for medicine the same way we do for food and housing?
Genuine question. I have a hard time understanding what sets medicine apart from everything else when people think healthcare should be universally free, but not food, water, clothing, housing, etc. especially considering those other things are more directly necessary for survival.
The demand price curve is different. If housing gets more expensive you could (although) difficult move into a smaller apartment, or different region. (Similiar with food up to a certain amount). This allows the market to find the best/right price by supply and demand. (I think this is called inelastic demand)
If you have cancer though than basicall the market cannot find a price, and it would tend towards to: 'give me all you have'.
> If you have cancer though than basicall the market cannot find a price, and it would tend towards to: 'give me all you have'.
Yes it can... there is more than one oncologist in the world. Competition exists.
As for if youre talking about the chemo drugs, you don't have to use the latest-and-greatest on-patent treatment. There are now decades of drugs that are off patent. They may not be as good, but then again, it is your life so many choose to pay for the new better ones. If it was illegal to pay more for better drugs than they would never exist (and don't talk to me about government funding; not a single socialized medicine country has innovated any drug of value in the past 50 years, and yes, they do steal from us in the USA by taking our IP and not paying for it).
Medical prices being inelastic (to the extent they are) has much more to do with medicare/medicaid/FDA regulations, govt & insurance allowable reimbursement rate lists, and costly govt requirements to even participate in a govt funded plan (like electronic medical records).
Proof? Services not typically covered, like plastic surgery or cosmetic dermatology. Clearly listed and even advertised prices for their services, openly discussed up front.
But if the govt reimbursement rate for an annual checkup is $x, why would anyone need to list that price up front, or have reason to ever charge any less?
Your last comment is the reason for the massive gap between list price versus net price in the US system.
The US has a rule about “usual & customary price”. That’s a legal definition and providers can’t charge any customer more than that.
If you’re looking to price discriminate, you set your U&C price as high as possible, maybe 2-5x what you’d accept. That way if you find a customer willing to pay 4X, you’re not running afoul of the law.
For everyone else, you negotiate a much more reasonable net price, typically through insurance.
The people who get screwed in the end are ones without insurance. They get billed the imaginary number nobody ever intended anyone to pay.
> The demand price curve is different. If housing gets more expensive you could (although) difficult move into a smaller apartment, or different region. (Similiar with food up to a certain amount). This allows the market to find the best/right price by supply and demand. (I think this is called inelastic demand)
Changing housing situations is exactly as easy as changing hospitals and emergency rooms no? Since the latter are mostly decided by where you live. In fact, most mid to large cities feature many hospitals near any given residence, so it is actually easier. I would also point out that the demand curve for housing, energy and food are far more inelastic than for medicine.
> If you have cancer though than basicall the market cannot find a price, and it would tend towards to: 'give me all you have'.
Why couldn't the market find a price? Cancer actually seems like the worse example possible. The people I've known who've been diagnosed with cancer have shopped around for care from many different hospitals. It would seem that cancer would be the perfect candidate for market forces to lower prices since a diagnosis generally affords a bit of time to find and decide on treatment options. Even in the extreme case of 'you have months to live' people tend to spend a few weeks collecting different opinions.
You're choices are: die, or pay whatever cost is associated. its not a choice that can be negotiated. markets don't deal with this situation well. changing hospitals don't change the baseline costs for providing health care in a significant manner for there to be competition nor are many hospitals in a competitive market (often there is only one hospital for an entire rural region).
that's before even getting into pharma. which can charge millions of dollars for life saving/changing drugs for single course treatments. hell take a look at what happened with epipens. there is no protection against profiteering via nebulous 'markets' when your choices are 'purchase or die'.
> You're choices are: die, or pay whatever cost is associated. its not a choice that can be negotiated
This account, or at least should account, for a very small minority of interactions with healthcare facilities. Saying that's why the whole market is defunct is recklessly reductionist.
> markets don't deal with this situation well.
They don't deal with it at all. Imagine if some people needed bread or they'd die, would that change the price on the shelf? No, because the bread didn't get there because of that niche market, it got there because most people eat it. It is the same with healthcare. If a hospital exists because people routinely visit the doctor, some people needing their life saved isn't going to suddenly change prices.
> that's before even getting into pharma. which can charge millions of dollars for life saving/changing drugs for single course treatments. hell take a look at what happened with epipens. there is no protection against profiteering via nebulous 'markets' when your choices are 'purchase or die'.
Totally agree. The issue there is regulation and how we allow companies to be a position of no competition. If the government stepped in and payed those prices for you, it wouldn't solve the problem.
I don't think it's inconsistent. The people who advocate for free healthcare would probably also advocate for other parts of a social safety net, like food banks, food stamp programs, free access to water, temporary housing for the homeless and programs to get them to permanent homes, etc.
And indeed the US has many such services, though they are often overwhelmed, or performed through a complex set of nonprofits combining govt funds with donor money as best they can to provide good support. Sometimes they are overwhelmed specifically because of externalities related to the for-profit insurance healthcare system. The high and often unpredictable cost of any medical situation, means people with tight budgets become sicker before getting care, if they ever get it, leading to a higher percentage of bad outcomes, up to and including job loss and homelessness for the individual, and knock-on effects for the rest of their family. This puts extra pressure on the parts of the support system that do exist - those already mentioned, and, of course, the police, who end up getting called to many situations that could have been prevented by the people involved having better services to begin with, to meet their health, food, and housing needs.
> don't think it's inconsistent. The people who advocate for free healthcare would probably also advocate for other parts of a social safety net, like food banks, food stamp programs, free access to water, temporary housing for the homeless and programs to get them to permanent homes, etc.
Isn't it though? "This thing should be free for everyone all the time" is a lot different than "we should help people out a little if they're down on their luck". Temporary housing, food banks, etc are the latter, and I'm all for the same with medicine. The fact that food and housing are subject to markets makes it easier for organizations to carry out such missions, which is one of the barriers you mention in your second paragraph when you talk about the complexities of dealing with insurance companies.
People don't consume healthcare "all the time" the same way they do food, housing, water. Preventive healthcare is cheaper/less work than treating illnesses that have gotten more serious, leading to less total consumption of healthcare (and those other downstream resources impacted by people avoiding preventive care). Also "Free healthcare available to all" doesn't preclude a private market. The Govt Healthcare is not always timely, may not cover treatments people want, or cover certain elective surgeries. Some people will always choose to participate in a private insurance market that provides value above a baseline govt health plan.
You can't pitch ways of increasing demand as a fix for a supply shortage. You're just shuffling around how who gets what is decided. Why is a government agent deciding any more ethical than your bank account?
And creating a public market necessarily diminishes the private, driving up costs, as purchasers are now competing with government for the same supply.
Of course healthcare isn’t and can’t be free. Unless by free you mean free at the point of usage. I support government provided healthcare and government runs off of tax revenue. Denying a person cancer treatment for no other reason than because they can’t pay $x at the point of usage is an immoral system. An analogous situation occurs with federal courts. Those who can’t afford filing fees have those fees waived and those that can pay them do so. This is done because the court system recognizes that access to the court system based on the ability to pay at the point of usage is a bad system.
That's a bad comparison. The filing fee is small compared medical treatment, and it's in support of the government itself. The cost of doing that for people is tiny and doesn't really take away from anyone else.
Medicine is a scarce resource at this point, and, generally speaking, giving care to X often means Y won't get it. The fundamental problem with medical care is supply, lowering barriers for demand isn't a solution to that.
The analogy is apt since it was an example of the idea that some people, thankfully, are aware that some services should not have their availability based on ability to pay at the point of usage. In the U.S. system denials of care by insurance companies are not done so another person can get said care. They are done to increase profit margins and profiting from denying someone care is immoral.
> The analogy is apt since it was an example of the idea that some people, thankfully, are aware that some services should not have their availability based on ability to pay at the point of usage
That last bit is exactly what we're in disagreement about, and I haven't seen a good case for it yet.
> In the U.S. system denials of care by insurance companies are not done so another person can get said care
True.
> They are done to increase profit margins
Indirectly, sure. Its a business where money out must be less than money in.
> and profiting from denying someone care is immoral.
Again, this is the disagreement, and I'm not really seeing a good argument for that being the case. Some people should be denied care. I don't see why performing a necessary function shouldn't be profitable, especially when it's beneficial to everyone in times of scarcity, like now.
In countries with public healthcare it’s still based on ability to pay. You pay out of pocket and cut the queue, have decent time allotment with the doctor, get best medication available without money-saving algorithms etc.
In Canada private health clinics can not legally provide care that is covered by the Canada Health Act.
EDIT: After further reading it appears that private health care is a murky area in some provinces. My above stated belief appears to be wrong at least in terms of how things actually work there. Here is my view. Private medical care should be banned.
Here in backwater Europe we had no private medicine for a long time. The outcome was massive healthcare black market. Semi-official price list you've to pay to nurses/doctors/etc to „premium“ care.
On top of that, official medical staff wages were crap. People were forced either work for peanuts (IMO nurses and doctors jobs are damn hard and they have to be paid well), take money under table or... emigrate.
Now we have mixed system and it's definitely better than it was before. Doctors gets paid well. Elite doctors tend to work 2-3 days in private clinics and then 2-3 days in public hospitals so you can still get hold of them for free. Those who have an inch for premium services can pay local&legal, so local economy wins.
Do they? I was under impression that all US politicians aside from Sanders support current system.
Anyway… I think both systems are very similar in the end. Rich (or even middle class) gets great service in premium facilities. Average folks get OK service with some downsides, likely paying out of pocket in various ways. The only difference may be poor people coverage which is subsidized by upper tier payers. Who themselves may never use public service and go to premium only.
Also, another major difference may be the big expensive procedures. Aside from the 1%, people would do the procedure in public hospital because it’s crazy expensive otherwise. But everything else leading up to it and recovery after it more likely to happen in premium market since it’s much more affordable.
It's because a lot of times the doctors know it isn't going to work on the outset. A number of generics don't work exactly the same. You're punishing the patient and questioning the expert simply for the fact that the insurance company (or the government in the case of geriatrics) might save a few dollars.
Part of the issue is that insurance companies often “reset” this process. I know a friend with really hyper specific health conditions that requires a fairly expensive, experimental treatment. They need this because they’ve tried everything already. But sometimes the insurance company seems to forget that they already tried everything, and refuses to pay and tries to get them to go through it all over again, a process which destroys their ability to function and leaves them seriously disabled for months at a time.
This also happens if the employer switches insurance.
So no it isn’t as innocent not as simple as saving costs for generics. This makes sense for the first time the patient seeks treatment. This doesn’t make sense if the patient already has a treatment plan that works and the insurance company decides they want to do the whole pony show again, fucking in peoples life for months.
Speaking of genetics, screening for the genetic profile of variable liver enzymes for known mutations and their associated drug interactions could actually save on the shotgun approach to dispensing medicines.
The problem is, you won't be able to hammer down the health of the patient to the lowest cost option, only the most effective.
My bad. You are correct. I misspoke. What I meant to say that at times generics (and similar drugs, but not generics) won't work as well as the original drug. Not always, but sometimes they just aren't effective in certain circumstances. The doctor may know this, but can't immediately prescribe what is effective in the name of "saving money"
> Generics are well known to be effective, and exceptions are unusual.
A [relatively] well known exception is anticonvulsants. My younger brother paid for that with his life. I hope the FDA figures out how to properly evaluate generic equivalence.
It can also just be a matter of convenience. When I was first put on testosterone I was prescribed AndroGel, which is a gel you out on once daily. It costs $400 a month. Insurance gave a bit of hassle but with my test numbers they acquiesced.
They shouldn’t have, though. Injections (what I’m on now) work better. They’re easier to maintain the correct dose, you don’t have to worry about getting it on your partner/kids, you only take it once every week or two…and it’s maybe $20 a month.
That’s not just a few dollars saved. There are probably hundreds of thousands of men out there that take it. I see there’s a generic gel now but it still costs anywhere from $60-$150 a month.
Thousands of dollars per patient times many different patients and drugs quickly adds up to a substantial proportion of all healthcare spending. Countries with universal healthcare have specific programs in place to move people over to generic drugs for exactly this reason, or at least the UK does - along with policies that intentionally give people less effective treatments if the better ones are a lot more expensive. It's one of the ways they stop costs from ballooning as much as they have in the USA.
No, sorry “the doctor knows it won’t work” is complete BS.
We don’t spend 100x on a drug because a doctor “has a feeling”.
The insurance requirements are typically quite limited for 1st line failures. Doctor just needs to prescribe then 2 weeks later attest that it didn’t work.
Seems reasonable to save the healthcare system thousands of dollars when tens of dollars would do?
Which doctors know? Insurers have doctors too, that's why they have these rules. What do the doctors treating the patient know that the insurers don't know or are refusing to acknowledge?
Well at least in Europe pharmacists always tell you about generics, that they are cheaper and work the same. Not sure who is spreading misinformation here.
Maybe you're talking about different medicines that people are using (like different insulins), the generics use the same formula as the original.