I don't wish to be snarky, but you are aware that the NHS as an institution has existed since the late 1940's and has been working reasonably well for a long time? An institution does not become beloved by the public for failing to provide a good standard of care for a long enough time that people become used to it doing so.
So when you say:
> It never had a great track record to begin with.
Are you talking about government institutions in general or the NHS? I maybe wrong, but I suspect you're speaking of US institutions which are an entirely different dynamic to UK and European ones.
If you are speaking of the NHS, then please outline how it doesn't have a great track record commensurate with its lifespan.
>An institution does not become beloved by the public for failing to provide a good standard of care for a long enough time that people become used to it doing so.
Here's how you do it: you pump unsustainable amounts of money into the service over time. This allows you to offer a great service until in the future you can't pump enough money into it anymore. But that's a problem for the future generations. Those future generations were funding the previous generations all the while, but won't get the same benefits themselves.
An ever increasing percentage of GDP is being poured into the UK's NHS. At some point it's going to be too costly and the young generation at that time will have to pay for it, but won't get the same level of service themselves when they're older. They will be the ones left holding the bag.
I don't think there's a politically viable solution to this though. The problem with this model is that you're effectively borrowing from future generations, but the system takes so long to reach actual unsustainability that people will grow up with the feeling that the system is great.
Is £2,647 per adult per year an unsustainable amount? How much is is OK to spend on the military? On roads? On tax breaks for energy companies?
Don't forget healthcare isn't about you, it is about society and if you don't care about society just think of it instead as having healthy employees and customers, who aren't ruined if they fall ill, and therefore have cash to spend...
What's a better system then? Because it certainly isn't privatization. And correct me if I'm wrong, but I'm assuming that's what you're arguing for.
>you pump unsustainable amounts of money into the service over time. This allows you to offer a great service until in the future you can't pump enough money into it anymore.
This is how every growth based juggernaut business works as well. Quality of service always goes down to continue growth of profits, especially after you've crushed the competition.
IMO, healthcare of the public should not be a profitable business. Or the business will always find ways to squeeze their customers who simply need care for the health.
It's not so much the profit that matters, in principle. But profitability does provide some constraint and guide to resource allocation that a public institution is still grappling with how best to do. Private institutions can go under and be replaced more easily. Again, not perfect, but you never see the same creative destruction in government institutions.
I think general survey results are probably a poor metric to use in evaluating the success of a healthcare institution. Sure, at any point in time, most people should be able to get what they need, but the serious cases, or anything out of the ordinary, is a much smaller percentage of cases for any given year. Anecdotes of waiting lists and the rationing of care (e.g. delaying services to the start of the next fiscal year when new money gets distributed) have been notorious for years now. This dissatisfaction only reveals itself over time, where it personally affects a greater swathe of the people. The pandemic accerlated this, but it shows how ultimately unsustainable it is.
Healhchare is tricky, because treatments are not one-size-fits-all. Large institutions are rigidly setup to deliver a product, a product that is ever changing, as new treatments are always being refined and added. When it was created it was set up to deliver products that were new 50 years ago, but the structure is inherently slow to evolve. But the private health insurance in UK does not have these problems. More effort could be made at growing the economy in such a way that rising incomes allow people to purchase the private health insurance. It's not an immediate answer for many, but it definitely beats throwing more money at a bureaucracy that cannot adapt.
Isn't it possible that demographics have changed enough that funding requirements have changed enough that the 1940s-2000 or so system is no longer viable?
I know the demographics in the US has vastly changed some cost models over that time, making some earlier social program hit major funding problems through no evil from govt actors.
The demographics have changed, but they take that into account in terms of how they handle and manage care.
There's a lot of thinking and work that goes on to cover working out the changing needs of your population that has to be handled by any well managed healthcare service.
In the NHS specifically I am aware that they also have change management procedures that exist to try and understand how to provide continuous improvement as needs and situation change.
That's not to say things are perfect, by any stretch of the imagination. For example the NHS still has a big blindspot when it comes to tech. Most people aren't willing to take the effective pay-cut of being a techie and working in the NHS, a lot of people inside the service don't really respect people with tech skills and there's still a bit of a holdover of not paying much for anyone that isn't a doctor.
That's not to say the situation remains static, some doctors for example are slowly accumulating tech skills as a result, so what will probably happen is that success for a tech person in the NHS is going to require a prerequisite medical degree, at least in the near term.
Which though I don't think it's the best strategy, I can't also argue it's a terrible one to expect people who provide tech services into the NHS have a reasonably high level of domain knowledge.
This is a large institution with a substantial mandate, we should expect to pay a reasonable amount proportional to what it provides us. The fact that it's substantially cheaper than other healthcare services while still providing a very high quality of care leads me to believe that it's doing a pretty good job meeting that mandate.
So I don't think blindly questioning it without taking such things into account is helpful, nor do I think that pointing to costs as being "too high" are helpful without considering what is happening and why they are being paid for in the first place. Chesterton's fence and all that, it's not enough to just cut costs, you have to ask what doing so gains you. There are too many social programs which we cut because "spending less is good" without asking if the spending actually gives us a positive return as a society.
One common complaint from doctors (at least, in the U.S.) is the need to hover over a laptop all the time that takes time away from talking to the patient. A big problem as I've heard of a number of doctors retiring early because they don't feel as though they are even treating patients anymore, they are slaves to a console. (And these are not old doctors nearing retirement anyway.)
Personally, I think we've become a little too tech obsessed in thinking every problem can be solved with IT. Digitizing records only feeds a surveillance state anyway and can be dangerous (for other, obvious, reasons).
Well, doctors are mainly hovering over a laptop to justify their treatment plan to insurance companies anyway. They were not implemented because someone thought they would improve quality of care.
They have actively worked at crippling it. Now that it’s crippled they tell you.. oh but surely the government can’t fix it, we need private enterprises to fix it!
You walked right into it.
What makes you think private business are capable of delivering something cheaper than what the government can do? The most expensive health care in the world is private.
To be honest I'd be ok with private healthcare if they had to also obey the same constraints as public healthcare.
IE they had to provide care to everyone at a reasonable price.
I'm deeply suspicious of healthcare that gets to exclude people for cost reasons.
I too can provide great healthcare if everyone is mandated to pay me for my services and I get to exclude those I treat, that's a great business, the healthy pay and I exclude the sick, what wonderful pure profit business!
The insurance model bothers me for that reason, they really shouldn't be allowed to exclude anyone, if they're taking on the business of healthcare, then that's that, they are providing a utility service, which means they supply to everyone and they make money by spreading the cost between everyone.
There are nuances to that, but practically that's the goal they should aspire to, but unfortunately that model isn't the most profitable.
I mean take a look at the original US health insurance that existed:
> The first plan guaranteed teachers 21 days of hospital care for $6 a year, and was later extended to other employee groups in Dallas, and then nationally
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That insurance model worked, it just happened to get outcompeted by entities who were willing to undercut them by aiming to capture only the most healthy people, which is in effect a tragedy of the commons.
Which is a real problem in my book, I'd be fascinated to see what innovations a private company could come up with under that model. We might have missed out on a whole slew of interesting ideas if we kept going down that route, which would still have been a pretty profitable business and would have been a great success for those who do believe that the private space can do healthcare better.
As it stands I don't believe the current private model meets that criteria as it fails at the first hurdle of being a health care service, it doesn't care about health.
So it seems like the choices are bad private care, good public care and bad public care. So yea, I'm leaning to the good public care.
Exactly. Why would it be cheaper or better to run healthcare as a for-profit business? If you have to take a profit, then by definition there's less funds available for the actual service.
The point of private enterprise is it has to cost less or be a better product to survive, which is why things like cars are unbelievably better than they were 50 years ago, or even 10 years ago.
E.g. saying a state-run car company would've done better because all that profit money would've been perfectly allocated is not right. Otherwise the government's perfect decision-makers would be starting car companies left and right and making a fortune, instead of working for the government.
Only if there is both competition and consumers can make informed judgements on the service.
In things that affect your health, I don't want to be the guinea pig that discovers the service I paid for wasn't up to standard. That provider may go bust in the long run, but in the meantime will do a lot of damage.
If fossil fueled cars burning leaded fuel on state funded roads and then getting bailed out not that long ago is your idea of free enterprise triumphing over the state, you might not be as capitalist as you think you are.
"Bob Lutz compares Tesla to socialism after GM took $11B from taxpayers under his reign"
I agree that cars are much better than they were 10 years ago. Thanks mostly to government regulations that the incumbent industry fought strongly, while Chinese state owned firms were taking advantage of the opportunity.
Roads aren't cars? I'm not saying that central planning is never a good idea, just that it's mostly not a good idea. "Where to put roads that a private company will build" is a reasonable role of government in a capitalist society.
> and then getting bailed out
I don't think they should've been bailed out. That was politicians buying car worker votes by doing politician things, like inflating the currency to make everyone's wages worth less.
Cars are better not mostly because of regulations, but because of manufacturing improvements, electronic/chip hardware and software improvements, and, most of all, competition.
This makes me wonder… if Conservative strategy is to run it into the ground and then privatise, which is an unpopular plan with the public, then how are they able to consistently win elections?
Largely because the Tories are also willing to be fairly openly xenophobic, which is very popular with a large portion of the public. "Making sure the poors don't take more than they deserve" is another one of their popular policies.
The more-well-off also think Tory policies will get them a house and security. In practice, the UK housing market is completely fucked and gets more so every year, but... it doesn't stop people believing it.
Basically the health of the NHS is about the tenth thing on some people's minds when voting, until they get cancer or break an arm, at which point they start complaining about it.
It is more nuanced than that. The issue is that a lot of western societies are falling into debt traps because of a lot of social and economic factors which are already straining these systems to the point that they cant keep up, and the conservative strategy (in my good faith interpretation) regarding this is reducing the cost of programs that they consider to be bloated. This can be interpreted as running it into the ground as the bloat is often in bureaucracy which can easily pass the buck to actual service providers which then suffer from lack of funding. In contrast a more liberal solution would likely involve increasing spending then trying to recover that through additional taxes, which conservatives would say doesn't solve the cost problem but rather exacerbates it since bloat remains and is paid for by more debt or taxes. Of course this is just a general simplification of the conflict.
Clearly the solution is probably somewhere in between, but political polarization has simply pushed people to their party lines and entrenched their positions such that no real progress can happen while things continue to fall apart.
NHS and Medicare have historically had both very efficient allocation of resources and excellent health outcomes. This NHS argument is about new data that to me seems impossible to deconflate with a global pandemic.
Basically, libertarians are just wrong on this. Government-run health care works great and we have many decades of evidence showing that.
This is the first time I have ever heard of Medicare being held up as efficient. Medicare is 13% of the US government budget. More federal money goes to Medicare than to the Department of Defense. In contrast, the care that people get from Medicare is substantially worse than what you get from private insurance in the US.
> Medicare is 13% of the US government budget. More federal money goes to Medicare than to the Department of Defense.
These are not measures of efficiency. Medicare outlays are about 30-40% of private insurance for the same demographics.
> the care that people get from Medicare is substantially worse than what you get from private insurance
And this is, in fact, not true at all. US citizens on medicare beat their cohorts not only vs. other nations but vs. private insurance in the US too. Don't make the mistake of comparing your corporate insurance for a workforce with a median age of 30 with what retirees in the private market have available.
There is no doubt that Medicare has the bargaining power to drive down hospital costs compared to private insurance: Medicare gets 10c/$1 on the chargemaster at hospitals (and hospitals set prices so that Medicare's payment rate has a small profit), while private insurance tends to be able to negotiate 15-20c/$1. Individuals who are good negotiators can reportedly end up paying only 20-30c/$1, so if you have a big hospital bill, it can pay to call them up and negotiate.
Retirees on the private market get completely shafted, though: almost everybody in their age group uses medicare, so the insurance will need very high premiums to cover their risks. From what I have heard, people who are on employer plans at that age have better health outcomes than retirees, regardless of where the retiree gets their healthcare.
> In contrast, the care that people get from Medicare is substantially worse than what you get from private insurance in the US.
I don’t think they are comparable. Medicare exists because private insurers refuse to cover old people at a reasonable price. It’s a good scam the private insurers have going: take peoples money when they are generally healthy and productive, drop them like a sack of shit onto the government’s lap when they aren’t.
The price of elder care in the US is not due to insurance companies, but due to the amount of attention someone demands before them die in a US hospital. Many socialized healthcare systems do not allow doctors to waste nearly as many resources this way.
That is why the life expectancy of the average obese, unhealthy American is about the same as the life expectancy of the average (much healthier) Japanese or European person. Americans are allowed to eat their way to an early grave and then have medical resources thrown at them to desperately keep them alive a few days longer.
EDIT: Also, I should point out that doctors generally demand a lot less end-of-life care than members of the general US population. They seem to understand that it is merely prolonging the inevitable rather than helping.
So when you say:
> It never had a great track record to begin with.
Are you talking about government institutions in general or the NHS? I maybe wrong, but I suspect you're speaking of US institutions which are an entirely different dynamic to UK and European ones.
If you are speaking of the NHS, then please outline how it doesn't have a great track record commensurate with its lifespan.