[robbiep]

>>As we move into an era of personalized medicine, we'll be subsidizing better healthcare and better outcomes for some ethnic groups over others.

I think you miss the point of universal healthcare. It is not that one group has a higher utilisation of the healthcare system and therefore should pay more - the principle is that everyone is guaranteed the same provisions for healthcare, regardless of their risk factors.

Personalised medicine contributes nothing to the concept of universal healthcare; except for the noble aim of enabling better treatment of people through understanding individual responses. ' The idea that someone should be restricted in their level of healthcare utilisation under a universal system is absurd; As is the notion that someone should be forced to contribute extra (apart from the incremental addition of a high income earner through increased taxation) due to a perceived increase in risk.

>>The faulty assumption behind universal healthcare is that a one-size-fits-all prescription is good for everyone,

Again, I feel like you are trying to talk about personalised medicine inside of the concept of universal healthcare. Forget about personalised medicine. What the US needs first is access that won't bankrupt. The fact is we don't know enough about personalised medicine to give people different treatments based on genetic characteristics. And we won't for years. Sure, you can look at 1 or 2 isolated instances at the moment (ACE-inhibitors and ARBs in Black people for instance) - but none of this matters when it comes to life-saving care, for which the treatment is going to be the same for everyone anyway, unless you happen to have some rare blood disorder in which case racial profiling and blood tests at the time of intervention will dictate management.

>> so in a way, it's a subsidy for rich white people.

How so? Because they live longer anyway? Because they are less likely to indulge in the risk factors that result in early mortality? Again, Universal healthcare doesnt discriminate. But since rich black/brown/yellow/white/green people pay a higher proportion of taxes anyway, shouldn't your argument here be that Universal healthcare is a tax on rich people?

Additionally, just because you are on a high dose of a Statin, in a high risk population, doesn't mean you are developing myopathy. CK levels should usually be checked after a month or 2 of Statin therapy in line with followup for new lipid levels, and in the absence of symptoms it can be fairly safely ruled that you aren't experiencing a complication of a statin drug. But you probably already know this.

[dnautics]

>is that everyone is guaranteed the same provisions for healthcare

You're missing my point. If those provisions are the same, that's exactly the problem. It's only worse if they aren't the same (because who chooses?)

CK levels warnings are only triggered when you are having a serious complication from the statin. When you have a lesser complication, like, "going to the gym sucks instead of making you feel good", and you aren't aware of what's happening, and it's making you fatter, and your quality of life is going down, then what?

[robbiep]

Again i'll have to insist you are missing the point. Not my point, although I am advocating it; but the point of universal healthcare is to enable everyone access to the same level of healthcare for free. (Or, paid for by the taxpayers if you insist).

The principle is not about ensuring that someone with a specific amino acid substitution receives a specific drug, because this is an example of the specific medical management of a specific patient. If you are going to continue to insist that your dad was treated inappropriately, and I have no reason to be able to assume one way or the other from my current position on the other side of the planet without a through examination of your father and his medical results, then what you are complaining about is not universal healthcare per se but in fact poor care by the treating physician. Which could happen under any system, anywhere.

[dnautics]

can you define for me what you mean by "the same level of healthcare"?

>universal healthcare ... poor care by the treating physician

These issues are entangled. I should let you know, that despite being in the US, my father is effectively being treated by a "universal healthcare" system - the VA.

[robbiep]

Access to life saving treatment when required, as required, access to free hospital and cheap/free out of hospital medication.

The issues are no more entangled than that 'healthcare providers' are a subset of 'healthcare' and within healthcare providers are going to be doctors administrating care that is not up to the best evidence. Universal healthcare is no defence against that, but either is any other form of healthcare. If you select your own doctor you have every chance of choosing one that may give you treatment against the best evidence.

It seems you are saying that universal healthcare means that you will get poor healthcare. I vehemently disagree with this proposition, not just based on your single anecdote but because I live in a country with a universal healthcare system and I have worked within it and in a few months I will be dispensing care from within it as a doctor. Every system has failures but this criticism isn't an indictment of the entire system

[dnautics]

no, I am saying in universal healthcare, you will get poor or no healthcare if you are poor and you will get good healthcare if you are rich. You will simply shift around who gets marginalized. For example: If you have a country that aggressively hounds, say, educational debtholders - because, maybe the nation decided to socialize educational debt. How long will it be till the bureaucratic machine calculates the bottom line and decides to use the system to redflag people and those people are effectively forced to avoid the government healthcare system. It could be anything else, say, "child support deadbeats". Or "illegal immigrants".

If you think that there will be an effective firewall between the two systems, I've got a bridge I want to sell you.

>Access to life saving treatment when required, as required, access to free hospital and cheap/free out of hospital medication

What happens when that medication is fundamentally uncheap, like herceptin, in New Zealand? Sure, herceptin is contrived, because that's a patenting issue. what if it's discodermolide, which doesn't exist in more than ~10 g quantity in the universe and is rediculously expensive to manufacture? Who gets/who doesnt?

Ultimately, no treatment is life-saving. We all die. Which ones are worth it? Who makes a valuation on life? How long until we find a hyperexpensive drug that prolongs the life of a politically-connected child with an orphan disease, and people begin to question, "why is this person's life subsidized", but not mine?

[robbiep]

> no, I am saying in universal healthcare, you will get poor or no healthcare if you are poor and you will get good healthcare if you are rich.

Well, there you go, you've said it yourself. What you are talking about is not universal healthcare. Debate over, closed; we aren't even talking about the same thing. You are in no way, shape or form talking about universal healthcare, don't even delude yourself that you are - in trying to define it you are explicitly defining against it.

> What happens when that medication is fundamentally uncheap, like herceptin, in New Zealand? Sure, herceptin is contrived, because that's a patenting issue. what if it's discodermolide, which doesn't exist in more than ~10 g quantity in the universe and is rediculously expensive to manufacture? Who gets/who doesnt?

Well, let's first look at the other side of the coin. What happens in the US if you want access to this Drug? What happens in Africa? These new monoclonal antibodies are presenting big challenges to health economics everywhere. As far as I can ascertain NZ currently will pay for 52 weeks of Herceptin, as best evidence suggests is most effective, in line with most other countries with universal healthcare. So in these countries, regardless of who you are, how much money you have, how old you are - if you have a HER2+ breast cancer you will receive a year's worth of Herceptin, along with all your other medical treatment. So that's Initial screening mammography , Ultrasound, FNAB, Surgcial resection +- sentinel node biopsy, radiotherapy (if local excision performed) and THEN chemotherapy.

Your cost? In australia, that would be 4.20 per filled prescription of you are a health-care card holder (low income) or $23 if you don't. All that for around $40,000 worth of surgery/Investigations and another $50,000 of chemotherapy.

In the US? I guess it would depend on your insurance but if you don't, I guess you go without.

>>Who gets/who doesnt?

Whatever way you try to spin this, more people have access in countries with universal healthcare. In the US you can either afford to pay or you can't. In other countries with universal healthcare, it is either provided free to all (thereby increasing uptake and availability of care); or, in the case of newer biologic treatments in the tens of thousands of dollars, it may not be approved, and you will then go without or for the top order who can afford to pay for it themselves, get access. So if you want to be really anal you can point and stare at that glaring inequity which occurs in very expensive drugs that have not yet been approved, or you can say that 'the system works! people are getting access to lifesaving medicines!' - which is what is actually happening

>>"why is this person's life subsidized", but not mine?

Again, the scenario you are making doesn't happen in the brutalistic 'death panel' terms you are attempting to cast it in. Yes, some medicines aren't available on government subsidy as mentioned before. But a hyperexpensive drug that prolongs the life is an example of Herceptin; it increases the survival of patients with HER2+ cancers, previously a poor prognisticator, to that of the hormone-receptor positive tumours. The actual decrease of recurrance was approx 13% over 5 years. So here we have a perfect example of a hyperexpensive drug, that improves survival, in a small subset of the population, that was relatively rapidly approved by the government for treatment. "why is this person's life subsidized", but not mine? - This doesn't happen. No-one is making those types of decisions. Anywhere. I don't know why everyone in the US who wants to argue so strongly against universal healthcare believes this is going to be the case. It simply doesn't happen and if your proposed system is looking like these things WILL happen then you should be trying to make your systems more like ours.

Bottom line: Universal Healthcare works. It delivers good outcomes to everyone without imposing a financial burden that will cripple for the remainder of life. It does this without 'death panels' that decide who gets care and who doesn't. If you want to argue differently, then you are not understanding how Universal healthcare actually works in the countries that have had it implemented for over 70 years. Is it perfect? No; but it does seem inherently more just.