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Grim Meathook Future, English style

I am very lucky; I live in Scotland, where healthcare is a fully devolved issue under the control of the Scottish parliament.

If I lived in England, though, I would be getting alarmed right now.

If you live in England (and not under a rock) you can't possibly be unaware of the Health and Social Care Bill (2011) that is working its way through parliament. Short version for foreigners: the Conservatives are unhappy to be presiding over a socialist healthcare system that works, so they've decided to break it by turning it into a single payer insurance system. Or so they say: the truth is actually rather worse.

Various medical folks have spoken out against it, including the Royal College of Surgeons, the British Medical Association, the Royal College of Nursing ... it's not a short list.

Anyway, this paper (PDF) is the lead item in the British Medical Journal today. I'm going to crib from its preamble, per Dr Ben Goldacre's blog:

"Entitlement to free health services in England will be curtailed by the Health and Social Care Bill currently before parliament. The bill sets out a new statutory framework that would abolish the duty of primary care trusts (PCTs) to secure health services for everyone living in a defined geographical area. New clinical commissioning groups (CCGs) will arrange provision of fewer government funded health services and determine the scope of these services independently of the secretary of state for health. They may delegate this decision to commercial companies. The bill also provides for health services to be arranged by local authorities, with provision for new charging powers for services currently provided free through the NHS (clauses 1, 12, 13, 17, and 49), and it will give the secretary of state an extraordinary power to exclude people from the health service. Taken together the measures would facilitate the transition from tax financed healthcare to the mixed financing model of the United States. [my emphasis] We provide an analysis of the key legal reforms that will govern policy development and implementation if the bill is enacted."
Note that the authors of this paper are a professor and a senior research fellow at one of the leading medical teaching colleges in London.

Yes, it's worse than you thought. They're not merely trying to turn the NHS into a single-payer insurance system, they're trying to turn it into a copy of the most notoriously bad private healthcare system in the world (as measured by the ratio of inputs to outcomes).

Allegations of corruption and conflict of interest surrounding the bill have not been addressed. Meanwhile, the government refuses to publish the risk register relating to the bill despite a court order to do so. Finally, if you're wondering why copying the US system at this point would be so very, very bad, read this RIGHT NOW. (TL:DR; the US insurance system is doomed, thanks to the impending arrival — within the next two years — of cheap genome sequencers. Massive insurance premium inflation will ensue. And Lansley thinks the UK should copy a system that's about to collapse ...?)

318 Comments

1:

Hahahaha!

Let's list some good ideas: Italy starting Soviet style production in 1989, the US introducing serfdom in 1789, ...

It's beautiful to see a real commitment to ideological purity regardless of reality.

2:

Insurance link makes no sense. Adverse selection is an issue only if the insurance companies are legally barred from any sort of use of them. If they aren't, then everyone gets more-efficiently-priced insurance, and healthy people will see their insurance prices plummet, as any company savvy enough to use the info will be able to offer them cheaper insurance. Sick people will see their prices rise to reflect the true cost of caring for them - which is only an issue if you for some reason expected the insurance to simultaneously function as some sort of socialized subsidy of them, which can be done by the government.

(And as usual, people vastly overestimate how much genomics will do. There's not much of a problem in the first place - how's all that personalized medicine working for you? The usefulness of genomics will be measured in single percentage points...)

3:

This is selfish and cruel -- and breath stealing stupid. The dimension of the chaos this will cause throughout all the social organization of the nation is nearly impossible to imagine. Except I am imagining it, I guess.

This is exactly how pirates, pillagers and colonialists behave.

Love, C.

4:

Discriminatory insurance pricing based on genetic testing is illegal in the USA.

It's not explicitly illegal in the UK (although it might breach the Human Rights Act), but the insurance industry agreed a moratorium in 2007 (to avoid legislation) that expires in 2017.

5:

"Adverse selection is an issue only if the insurance companies are legally barred from any sort of use of them."

Except that in fact they are barred from use of them, for the very good reason that correcting for genetic risk in no way involves any meaningful feedback loop about resource allocation --- if the middle class in the US doesn't feel that they have safe access to health care, you're going to see a collapse of the entire cultural infrastructure.

But other than those things, you're right on the money.

Pseudo-rationalism really burns me up.

6:

Charlie, this makes me wonder: in view of this sort of behaviour from Whitehall, what are your thoughts on the likelihood and/or desirability of Scottish independence in the foreseeable future?

I had always thought this was one of those not-very-serious ideas that politicians sometimes make noises about but don't actually intend to implement, but I'm curious about it after a recent discussion on the generally sane blog Arms Control Wonk that took the possibility seriously and discussed England's options for basing its ballistic missile subs if the Scots kick them out of Faslane. (The consensus among those who seemed to know what they were talking about was that there weren't any suitable ports in England - the only existing submarine ports large enough, Devonport and Plymouth, have too much civilian population density to allow the construction of a nuclear weapons storage facility - and the rump UK would have to choose between giving up its independent nuclear deterrent or talking to the French about sharing Brest.)

7:

Well, in view of David Cameron's position (that he thinks Scotland has too much autonomy as it is, and -- implicitly -- that if Scotland rejects independence at the referendum he'll take it as a mandate to rule), I'm afraid this only makes Scottish independence more likely. Because otherwise we'd be back to the bad old 1980s, only this time the oil is played out -- "grim meathook future" pretty much describes the future for Scotland under conservative rule from the south east.

I am not an enthusiastic supporter of Scottish independence. If Devo-Max is on the table in any form whatsoever I'll grab it with both hands in preference. But if it's an up/down choice between uncertain autonomy or being ruled by radical conservatives (who represent less than 10% of the electorate up here), I'll take the former.

As for the Trident fleet, remind me again why the UK needs the ability to turn Moscow into a smoking hole in the ground at 15 minutes' notice? (This isn't an argument for nuclear disarmament per se, but it is an argument for moving the debate on from the early 1980s.)

8:

If you want to see what a pernicious mix of US-style private healthcare and European-style socialised medicine looks like, cast your eyes left and look to Ireland. Here, we have a so-called public healthcare system that supposedly covers everyone, but which runs in parallel with several companies providing private cover. Both systems are implemented in the same hospitals by the same medical staff.

The result? The public system is kept in a state of near-permanent catastrophe, just in case anyone with more savings than the average twelve-year-old might be incentivised to rely on the State for primary care. Worse, the medics are complicit in this, as it allows them to draw two incomes from the public and private schemes. The egalitarian outcome is that Irish patients have one of the worst patient outcomes in Europe, while Irish medics are amongst the best paid in the world.

England: You need to fight this. You need to fight it hard.

9:

People don't get to choose their own genetics; from an individual's perspective, it's random. There will be some who will be fortunate; others who will be subject to horrific disease. (Probabilistically in some cases, but with near-certitude in others.)

Is it really moral, fair, or humane to target such people for much higher healthcare costs than the rest of us?

Alternatively, is it really in my own selfish interests for such people to bear the burdens of costs themselves -- quite possibly unsuccessfully? Would I be better off without the likes of Hawking, to name a famous example?

Particularly if I am one of those so afflicted?

10:

God damnit and I'm atheist, what the hell is happening in Europe? The whole thing seems to be on the hands of people dead set to bring us back to the 80's, or the 30's , or just aping whatever nonsense the Americans do because hey! Its American!

11:

Dear god, not even that evil creature known as Thatcher would have dared to screw up the NHS. Is Cameron actually mad or just trying to destroy one of the things that has made the UK the envy of many countries... its health service.

I know that many Americans (though I would like to think that those who read here are much more enlightened) seem to think that our national health service is some kind of commie plot. That we receive inferior treatment and are even point blank refused treatment. Erm no. That more often the case in the US if you are unable to pay. Everyone here pays if theyre employed, so that those who have no money or a low income need never be afraid of a massive health care bill. That is the simple basis of it. And the best of it is we hardly even notice the cost. From what I hear from Americans, not something that can be said of their Health Insurance.

Now, I am not saying our system is perfect, because its not. But it does work. We are taken care of from cradle to grave and we never have to fork out huge amounts for it. Or rather we didnt. Thank you Tories.

I am also fortunate enough to live in Scotland so with luck this bullshit that is another way of making someone who's rich into someone REALLY rich will not hit here. After all, an insurance company may literally have the choice of life and death over you. And more importantly, how much they're going to pay their shareholders. To them, its in that order.

12:

Would I be better off without the likes of Hawking, to name a famous example?

Ah, but you seem to have already forgotten: if Stephen Hawking had been born in the UK, the NHS death panels would have condemned him to an early death!.

13:
everyone gets more-efficiently-priced insurance


One of the thing you need to figure out is that health / health insurance is the type of economic activity where the classical market rules are the worst fit.

Health does not go well with a market-based approach because the "consumers" do not have a choice. The classic demand-and-offer that leads to efficient pricing assumes that economic agents have a choice. If something is priced too high, I won't buy it.

Except that, for health, I do not have the choice. If I'm ill, I need medical assistance. Or I die, or get handicapped (or, in light cases, I lose a part of my income because I can't stay up and working due to lack of assistance).

None of the customers have a choice in the matter of health. They can't decide to use health services today "because it's priced right", nor defer the anti-cancer treatment to next year in hope it's priced better.

And without that ability, the idea that a market system will "price right" healthcare for people is stupid.

14:

I wouldn't say that Klein's article says that the US insurance industry is about to collapse under the weight of skyrocketing premiums -- he says it would if not for an individual mandate requiring (virtually) everyone to buy health insurance.

The US has one of those; it hasn't gone into effect yet but it's part of the 2010 healthcare act.

Of course, there's still a chance the Supreme Court could throw it out, in which case yes we're pretty well fucked.

Not sure how the English proposal stacks up -- it sounds, from the quoted section, as though it'll give insurance providers and the Secretary of State the ability to refuse healthcare to sick people, which, absent an equivalent to the US's Genetic Nondiscrimination Act, means insurance rates won't skyrocket, they'll keep them down by letting a bunch of sick folks die. (Or so the theory goes -- in the US, anyway, those people mostly wind up in ER's, at which point taxpayers wind up paying for their healthcare anyway, to the tune of a whole lot more money than they would have if we just had taxpayer-funded preventative care. But hey, that's no skin off United's bottom line!)

But yes, if they wind up with a health insurance system that (1) allows healthy people to opt out, (2) allows sick people to get the care they need, and (3) is run for profit, then yes inevitably they're looking at genomics leading to ridiculously high costs.

Anyway. Sounds like the English Conservatives have finally hit a point where they're as conservative as America's Democrats.

15:

Whilst I agree that people overstate the power of genomics, there is hardly a 1:1 relationship between general genetic tendencies and health outcomes.

Also the idea of more efficiently priced health insurance is a misnomer - if the provision of insurance is parcelled up and dispersed the way companies do it, then those who have had bad accidents through chance or poor potential genetic outcomes will pay massively higher premiums and the fit and lucky will pay much much lower. This making it also a class issue. The true cost of caring for ill people is hidden in the current system, because it is shared across everyone, which some think is a form of evil because it inhibits market mechanisms, and others like myself think it perfectly sensible.

There are numerous other issues to contend with. Any 'market' based solution suffers from massive information problems. People don't all have the time and knowledge to be able to research the best place to go and have surgery, or have the ability to take time off work to get it done 400 miles away.
Moreover with a 'market' system there is a huge increase in bureacracy associated with marketing, sales, billing and so on. The NHS has already had a doubling in % of behind the scenes paper pushers, but the figures are only good to about 2001 or so. An increase in managers has been noticed for years now:

http://www.guardian.co.uk/society/2010/mar/25/nhs-management-numbers-frontline-staff

Oddly enough Tory scum decry this, whilst now wishing to foist an even greater parasitical structure upon the NHS.

It seems odd that the condems are willing to cut an important lifeline of the population of the country in a way which is guaranteed to increase costs whilst driving down pay of the lowly workers within the system, in a period which they claim requires austerity as a response. If they really believed austerity was the best answer, they would move the NHS back to something more like it was under Thatcher - underfunded, but still providing a comprehensive service on a pittance.

A note for the lib-dem readers - I appreciate that the older system, indeed even the current one, has insufficient points of feedback. But you should pause to consider the commercial reasons that whistleblowers are so heavily persecuted, i.e. their words endanger not just the managers or health workers, but the financial stability of their workplace, simply because of the botched and expensive 'reforms' already put into place under new labour.

And lets not get started on the perniciously evil PFI/ PPP.

The interesting task for those of us of a more social democratic and socialist frame of mind is how to create organisations which have national scope and scale, with the benefits that brings, whilst allowing the public to have proper involvement. I maintain that is impossible under any such privatisation, including the current one.

16:

And lets not get started on the perniciously evil PFI/ PPP.

I will note that here in Scotland the government has been buying out -- nationalizing -- PFI/PPP hospitals to bring them fully into the state sector. Scottish healthcare policy is diametrically opposed to the English path, which I suspect is one of the reasons Cameron is harshing on Scottish autonomy so much these days; an autonomous region within the UK that still has working socialised healthcare is deeply subversive of the conservative state of permanent [market-driven] revolution.

17:

Rather than quibble over the loaded word "entitlement" -- since I've been paying taxes and health insurance for around 40 years, let me comment on your prediction about genome sequencing's impact of health care.

First, it may be crucial to fighting cancer.

"Intratumor Heterogeneity and Branched Evolution Revealed by Multiregion Sequencing", New England Journal of Medicine, in the past couple of weeks. Not only do solid tissue tumnors have different genes expressed than do healthy tissue, different parts of the same tumor have different genome.

Since my mother, her mother, my father, his sister, and several of my cousins died of cancer, I have a vested interest in the biomedical community advancing past medieval chirurgeon methodology.

Second, I've had many extended conversations with Leroy Hood, during and
after his being Chair of Biology at Caltech, and since he and his team
moved up to greater Seattle (I hear rumors that he's had a falling out with his sponsor Bill Gates), hence tend to agree: Leroy Hood, of the Institute for Systems Biology in Seattle, described Dr. Venter’s
report as “glitzy” but said lower-level genes and networks had to be understood first before it would be worth trying to design whole organisms from scratch.

So a Nobel Prize short-list guy (Leroy Hood) agrees with Charlie that genome sequencing is disruptive of the medical industry. He was one of the first to propose the Human Genome Project, and everyone called him nuts, until he explained that Moore's Law has an analogue in DNA-eeading equipment.

18:

In the UK, insurance pricing based on previous medical history most definitely IS a fact. (I know this because I am a cancer survivor, and have just been discussing life insurance with my financial advisor) and it isn't exactly a huge step to 'Risk of illness high due to previous medical history* to Risk of illness high due to genetic markers (Given that they already look at your family history)

Also, insurance companies are not exactly transparent on their pricing, so on the question of whether they did or did not ramp up your premiums based on a genetic result... How would you ever know?

*Which isn't of course true, my particular cancer (testicular seminoma) with the early surgery and chemo treatment I received, now has a survivability rate of something like 99% and under the NHS I'm also under a surveillance regime that starts of with quarterly checkups and reduces to annual checks including bloodworks, x-rays and 4 full body CTs over the decade.

By the way... Guys... This can happen to ANY of you and survivability depends on early detection. CHECK THOSE CROWN JEWELS REGULARLY!

19:

The questions I have for our lords and masters would unfortunately require a team of experienced interrogators to answer them.
Questions like:
Do you really want us to move towards the American economic way of doing things? I.e. lower wages, more stress for ordinary workers, higher gini coefficient, even less mobility between social levels?

Why must we privatise and centralise things (e.g. the court interpreters, where they basically handed it all over to a private company who offered peanuts to the professional interpreters who previously had contracted with the courts themselves) in such a way that there is less direct public accountability and involvement? Instead of trying some sort of anarchist method, instead everything has to go to large corporations, why is that?

20:

I remember having a conversation with a capitalist American over the dinner table at uni.

I said 'no-one is denied healthcare for being unable to pay more than ten pounds". Which misses out dental care, but I was a little drunk.

He says "Well, why is that?"
Me "Because it's better!"
Him "Who profits from this?"
me "I don't care!"

He went bright red. Then said "well, we may have to see about that".

21:

[ TROLL DELETED BY MODERATOR ]

22:

Do you have room for a lodger, Charlie?

If it passes, I'm moving to Scotland. Possibly to Wales, because their assembly does protect against some of the worst excesses for health care policy and education policy.

I am, a little hopeful still that the level of opposition from the people the government needs to make it work will cause it to fail. The House of Lords, all sides, is antsy. The Lib Dem conference might pass a resolution forcing their MPs to vote against it too.

But as per my advice yesterday - follow the money. Someone stands to make a lot of money out of this. How a system that makes a profit, pays shareholders and the like improves the quality of service still has to be explained to me.

23:

It's way simpler than all this. No need to argue about the insurance genomics link. Irrelevant.

Privatizing an already paid-for service without lowering taxes commensurately: Theft from taxpayers.

Handing contracts to companies to handle this guaranteed extra income: Cronyism, sinecure, further theft from taxpayers.

Setting as goal to emulate the least-efficient, worst-outcome, already proven failing heath care system in the world: Indefensible, even ideologically. The only possible reasons are those listed above.

Any issue that makes people argue about ideology, or entitlement, or the effectiveness of the US system, is just distraction from the simple obvious truth. Cameron and pals want to steal the tax money you currently contribute to your heath plan, make you pay for it twice, and give the extra to their friends. Are you going to protest or not?

24:

Do we need to worry about this? Labour are opposed, so at worst we'll have three years of silliness before Milliband rolls it back in 2015.

25:

I've not been paying enough attention to this. That was a mistake. I've just emailed my MP (who will ignore it, as he's in a safe labour seat and hence doesn't really give a shit, but will be voting against the bill anyway).

It seems to me that one of the first and prime functions of a civilised society is to provide heath care for it's inhabitants (note i didn't say citizens).

26:

You could have said "we all do!" and it'd be just as true. No idea how he'd have reacted to that, however.

Can't believe the tories could be so vicious, and why would they want to emulate /our/ healthcare system anyway?

27:

Why in God's name would *anyone* want to copy the American healthcare system? And I ask that as an American.

28:

Because the goal isn't to help everyone, the goal is to help the powerful stay that way, and become more so, especially at the expense of others.

29:

There is a particular channel of public opinion in the UK that can best be described as starry-eyed Americanophiles -- not merely liking Americans, but thinking that if something is American, it must be better. Cars, burgers, airliners, nukes ... healthcare systems? Yup!

The conservatives are the party of the well-off; they're thereby the natural party for the Americanophiles, because to be rich in America is glorious (at least compared to what it was like to be rich in the UK before the mid-1990s).

Finally: a chunk of this nonsense is coming out of big management consulting firms. They sell their services to US health insurance groups. The UK is a tempting market -- 60 million folks, only a small, stunted private health insurance sector at present, what's not to like about the idea of colonizing it?

But first they have to smash the NHS.

30:

Um... even if it's reverted right back to the current state, that implies contract buyouts of the profiteers. Why waste the money?
Also, without a big enough stink now, Miliband might start seeing the good side of having this in place.
And it's ALWAYS easier to prevent something being enacted than stopping it once it's under way.

31:

Oh if only us Americans could have single payer! We couldn't even get a public option this time around.

As for genetic discrimination, it might be illegal at present, but the insurance companies will find ways to undercut that. Their entire profit motive at this point is denying care.

32:

If you believe (as some still do) that Obama is a super Judo genius, then his prior actions have all been in service of setting the table for single payor as the health insurance system is set to fail soon for a variety of reasons. It would be quite odd if ten years from now, we had something that mostly worked and you were digging out of this mess. I doubt either side of that future comes to pass, but you never know.

33:

Milliband, in case you hadn't noticed, is politically right between Nick Clegg and David Cameron. Which is to say, he'll accept the destruction of the NHS as a fait accompli in 2015 or 2020, just as Tony Blair accepted Thatcherism in 1997.

About the only major party that isn't on board this train to any degree is the Scottish National Party. I used to think it'd be a cold day in hell before I voted for them. Now ... I'm not so sure.

34:

Indeed.

At least in America there's kind of a Stockholm Syndrome excuse for some people thinking our system is at least better than all the others.

I took a trip to the ER in 2010 (I'm currently working on the script for a comic-book retelling of the story, so it's on my mind).

At the end of a very long day there, I was standing outside with a couple of elderly tourists who had also been there all day, waiting to be picked up.

We talked about how long and godawful our stay had been, and one of them made a bitter remark about how much worse the waits would get if government healthcare passed. (This is back when the Obama Administration was pretending that there would be a "public option" in the healthcare bill; it was later reported that his people had assured the insurance companies pretty much from day one that that language would never make it into the final legislation.)

I don't know why strangers solicit my political opinions.

Hell, I don't know why certain members of my own family solicit my political opinions.

I said something lame about "Maybe, but at least I won't have to pay out of pocket."

I will give myself a better line in the comic version I think. Something like "Look, I work hard, and I'm here because I got sick working hard. I have insurance but I've hit my annual cap, so after 13 hours of just wasting my time, I'm looking at a $2000 bill for absolutely nothing. The system is broken." Except I fear I would be crushed beneath the weight of such a dialogue balloon.

35:

Very long post ...


Below is the wiki list of U.S. HMOs and comments re: their healthcare (non-)performance.


Aetna -
In the California Health Care Quality Report Card 2011 Edition, Aetna received 2 out of 4 stars in Meeting National Standards of Care and 1 out of 4 in Members Rate Their HMO.

(This is so telling of the industry ... )

In 2000 Aetna hired John W. Rowe as CEO and executive chairman. Rowe cut approximately 15,000 jobs and raised insurance premiums by 16 percent per year. He also shrunk Aetna's customer base from 19 million members to 13 million by abandoning unprofitable markets, including almost half of the counties nationwide in which it offered Medicare products.[16][17]. In 2006 John Rowe ended his 65 months as CEO and executive chairman of Aetna; during his tenure, the former Harvard geriatrician earned $225,000 a day (including Sundays and holidays).

Blue Cross Blue Shield Association -
Operates under many names. The Seattle Times published an article on feb 9, 2012, alleging non-profit insurance outfits, including Premera Blue Cross, Regence BlueShield and Group Health Cooperative, are stockpiling billions of dollars in reserves while increasing their rates at the same time.


CIGNA -
In California's Office of the Patient Advocate 2011 Health Care Quality Report Card, CIGNA scored 3 out of 4 stars in Meeting National Standards of Care and 3 out of 4 stars in How Members Rate Their HMO.In December 2007, CIGNA was criticized after the company refused to pay for a liver transplant of a California teenage girl, Nataline Sarkisyan, justifying their refusal to pay by claiming that the procedure was experimental, even though there was a liver ready and waiting to be transplanted and doctors estimated she had a 65% chance of surviving at least six months.[6] In response to much protest and public scrutiny, CIGNA reversed its decision, though Ms. Sarkisyan died awaiting the transplant.[7]


Kaiser Permanente -
As of 2006, Kaiser Permanente operates in nine states and the District of Columbia, and is the largest managed care organization in the United States. - Each unit is managed for-profit and autonomously. In the California Healthcare Quality Report Card 2011 Edition, Kaiser Permanente's Northern California and Southern California regions, Kaiser received 4 out of 4 possible stars in Meeting National Standards of Care. Kaiser North and South also received 3 out of 4 stars in Members Rate Their HMO.[41]A 2004 Consumer Reports survey of planholders ranked Kaiser Permanente overall as average or better. It showed below average ratings in the Colorado and Mid-Atlantic regions for two measures of quality of care: 'care from doctors', and the 'quality of their primary care physician'. The same survey ranked Kaiser Permanente's Northern California region as the best HMO overall among rated plans.[43] KP's performance has been attributed to three practices: First, KP places a strong emphasis on preventive care, reducing costs later on. Second, its doctors are salaried rather than paid per service, which removes the main incentive for doctors to perform unnecessary procedures. Thirdly, KP attempts to minimize the time patients spend in high-cost hospitals by carefully planning their stay and by shifting care to outpatient clinics. This practice results in lower costs per member, cost savings for KP and greater doctor attention to patients. A comparison to the UK's National Health Service found that patients spend 2-5 times as much time in NHS hospitals as compared to KP hospitals.[44] Their habits of offering preventive care and managing chronic disease led a journalist writing for The New York Times to propose the Kaiser system in 2004 as a model for U.S. healthcare.[45]


Humana -
Featured in Michael Moore's Sicko. Humana has presence in both consumer and military health (non-)delivery: Humana Military Healthcare Services. .... "On May 30, 1996, Linda Peeno, who was contracted to work for Humana for nine months, testified before Congress as to the downside of managed care. “I wish to begin by making a public confession: In the spring of 1987, as a physician, I caused the death of a man... I was "rewarded" for this. It bought me an improved reputation in my job, and contributed to my advancement afterwards. ... "good" company doctor: I saved a half million dollars."


Health Net -
"Health Net, Inc. (NYSE: HNT) is among the United States of America's largest publicly traded health insurers" (and apparently among the most litigious, which explains why ...) "In California's Health Care Quality Report Card 2011 HealthNet (CA) received 2 out of 4 stars in Meeting National Standards of Care. In 2007, Patsy Bates, a California beautician, sued Health Net claiming that they wrongfully terminated her care in the middle of her chemotherapy treatments. Internal company documents made public during the law suit revealed that the company had tied bonuses to dropping coverage in order to encourage its analysts in charge of recission reviews to discover reasons (such as application fraud*) to discontinue coverage to clients who the company deems will cost them money. *(The Humana agent - not the client- filled out the form. How convenient!)


UnitedHealth Group -
"... serves approximately 70 million individuals nationwide." Serious/major legal issues: "In February 2008, New York State Attorney General Andrew M. Cuomo announced an industry-wide investigation into a scheme by health insurers to defraud consumers by manipulating reasonable and customary rates."
"On December 6, 2007, the SEC announced a settlement under which McGuire was to repay $468 million, including a $7 million civil penalty, as a partial settlement of the backdating prosecution. He was also barred from serving as an officer or director of a public company for ten years." "Through 2010 and into 2011, UnitedHealth senior executives have been meeting monthly with executives of leading health insurers to limit the effect of the health care reform law."


Wellpoint -
"... is the largest managed health care company in the Blue Cross and Blue Shield Association."

"In July 2008, WellPoint subsidiary Anthem Blue Cross agreed to a settlement with the California Department of Managed Health Care. To resolve allegations of improper policy rescissions (cancellations), WellPoint paid $10 million and reinstated 1,770 policy-holders whose plans they had cancelled. They also agreed to provide compensation for any medical debts incurred by these policy-holders in the meantime. However, WellPoint did not officially admit liability.[7]"

"In 2010, a report in Reuters alleged that the Anthem Blue Cross subsidiary improperly singled out women with breast cancer for cancellation of their policies shortly after they were diagnosed with breast cancer. The Reuters story said that Wellpoint "using a computer algorithm, identified women recently diagnosed with breast cancer and then singled them out for cancellation of their policies."[8][9] The story not only caused considerable public outrage, but led Secretary of Health and Human Services, Kathleen Sebelius, and President Barack Obama, to call on WellPoint to end the practice.[10]"

----

To U.K. posters: Seriously, is this what you want your medical system to turn into?

36:

In the United States, large employers are able to bargain for bulk discount rates on health insurance that aren't available to individuals. When I was laid off several years ago I considered going freelance, until I found that the cost of continuing my affordable employer-negotiated health insurance as an individual would be $15,000 per year.

I believe the current system of health care in the United States is supported by business-owning economic conservatives because it serves as a barrier to keep individuals from competing with them, and to keep employees from leaving.

37:

So, I'm American, and a cancer patient, and have already met my premiums and max out of pocket for the year (so now the only thing I pay is doctor/specialist office visit co-pays and my prescriptions). Haven't even had the surgery yet or radiation therapy. I'll be billed for in the neighborhood of $4000-$5000 for my portion this year (not counting what I'm still paying off from previous years). If I were a UK citizen, would I be looking at similar or is it not even remotely close?

38:

Seriously, is this what you want your medical system to turn into?

No. And most of us didn't vote for it. (Arguably, even those who voted Conservative didn't vote for it, since Cameron was very careful not to spell out that this what he was up to in the last General Election. Those who voted Labour and Liberal Democrat didn't vote for it, though Lib Dem voters voted for politicians who are now supporting it, which is a rather different matter).

39:

Additionally, my son's kidney surgery was scheduled before my layoff for a date that would occur after I switched insurance plans. As a result, some of the doctors involved weren't specifically subscribed to the new provider, so the new provider refused to pay $30,000 of the charges. They paid eventually, but only after I personally collected all the paperwork proving there were no subscribing doctors that I could have used. Otherwise, I'd have been stuck.

So yeah, the National Health Service sounds wonderful from over here.

40:

No, not at all.

You go see your doctor. No money changes hands. If appropriate your doctor refers you to the specialist. No money changes hands. The specialist treats you. No money changes hands.

The NHS is, largely, free at the point of demand. UK tax payers pay for in their taxes, but not when they need it. Everyone else freeloads on the system. Dentists, if you can find an NHS dentist are allowed to charge for some things for odd historical reasons.

If you supplement this with private health care (some people do), then a lot of their services are based on purchasing from an NHS provider. You tend to get more control over appointment time but in your position, the NHS would step up. I'm not sure of the details about limits to expenditure. I assume there must be some, but not sure where.

41:

Living here in the U.S. I have always viewed Europe, England included, as a more sane place, perhaps even a place to imitate. I see I may have been wrong. What is going on? This is really depressing. Why is the whole lot of Europe decided to go in the wrong direction? Why? It really makes me feel we are doomed as a species. Next Europe will demand creationism in schools, deny birth control to women, and teach Ayn Rand at school. Was this planned? Or it is just innate human stupidity.

42:

If I were a UK citizen, would I be looking at similar or is it not even remotely close?

As of 2011, under the NHS, no. If you had private insurance, no.

Evidence: last year two of my relatives had cancer. One had private insurance; the other went NHS. The observable difference in quality of their care was ... well, the NHS patient had to share a bay with three other patients while recovering from surgery, while the private patient had a room of their own. Co-pay? What's that?

Private insurance in the UK for an 85+ with cancer is on the order of £6-8,000 a year, by the way. Probably held artificially low because there is the NHS as a perfectly workable fall-back.

43:

so they've decided to break it by turning it into a single payer insurance system.

OK. I'm a bit dense. The US isn't a single payer system. So how is this a single payer system. Or is this a false description of the proposed UK system.

44:

"They decided to break it by turning it into a single payer system" -- which is broken, by comparison with the NHS, because it has huge parasitic profit-seeking overheads -- and then they went further and decided to turn it into an exact copy of the US system. Which is worse than a single payer system, yes.

Oh, and none of this was in any political party's election manifesto at the last election. We've been mugged.

45:

The NHS has issues. Like any large organisation it has slackers, bad apples and the like.

If you're ultra-rich you can (possibly) get better care in the US. There is a budget that is more or less fairly shared out. This means some really tough choices on available therapies. However much it makes sense in the abstract, when it's your mum, wife, daughter that's not getting a treatment that *might* improve their lot, understanding it in the abstract tends not to be in abundant supply.

But, by and large, it provides a very high degree of service really quite efficiently.

And, yes, I am an unashamed advocate of he concept and the system. And a former employee of it. There are places it can be improved, although not so many obvious ones. Because we spend a lot of tax money on it every government insists on tinkering. It takes time for the system to change and before they see the impact of their last changes they tinker again. Such are the joys of politics.

46:

Google "veil of ignorance" or "original position". Alternatively, consider from a utilitarian perspective or Kant's categorical imperative.


A paper I read recently (*) makes for interesting - and indirectly relevant - reading.
It discusses the link between greed and economics education. The authors report on three studies:
1: Students with a strong economics component to their studies keep more money in a money-allocation task than do students not studying economics.
Study 2: Economics education is associated with more positive attitudes to greed, and to one’s own greedy behaviour.
Study 3: A short statement on the benefits of self-interest led to more positive ratings on the acceptability of greed (also amongst non-economists).

The reason for this, they say, is the fundamental assumption of self-interest in rational choice economics, which dominates the discipline. They point out the dominance of economics-related modules in MBA training.

These authors are hardly alone: there is an increasingly loud debate in business/management education about the negative social effects of management schools. It can be summed up in the title of a 2005 paper: 'bad management theories are destroying good management practice'. The financial crisis and its aftermath are speeding the process up.

(*) Wang, L., Malhotra, D., & Murnighan, J. K. 2011. "Economics education and greed." IN: Academy Of Management Learning & Education, 10(4): 643-660

47:

The US system is absolutely bonkers. We've only just made outright denial of coverage based on pre-existing conditions (like pregnancy!) illegal, though that still allows for exorbitant pricing. Worse, the determination of premiums is based on any possible factor they can grab- family history, medical history, credit score, geographic location. The friction against cheap genetic printing here is that people are afraid that information will leak into a medical file.

What's worse is that your health can determine your job prospects. While it's technically illegal to terminate someone based on a medical condition, or to discriminate in hiring, most states have at-will employment which means that employers that make those decisions simply have to not cite any reason at all. Since most reasonable health coverage is through employers, they have good reason to whittle away employees that are raising premiums. That goes for any dependents as well.

48:

I agree that Milliband and new labour are agin the NHS reforms.
However their intellectual bankrupcy/ centre right tendencies were obvious with the university fees brouhaha, when they seemed to think that only charging up to £6,000 was a sensible compromise. Instead of saying "no your changes are insane and expensive, we would get rid of them all."

People tend to forget how much new labour set things up for privatisation. The Forensics service wouldn't be sold off so easily if new labour hadn't set it up as a a government owned company and deliberately created a 'market' in forensics which led to it losing money.

49:

It is also important to note that new labour was janus faced. The NHS did really need more money put into it, and some to much of that money has been spent on things like bringing cancer outcomes up to or near the European level, rather than the much poorer situation 15 years ago. But then a lot more was spent on consultants, salary increases for managers, a botched IT system sourced from a useless corporation or two, and the PFIs. I don't have the background knowledge or access to resources to be able to say how much money was wisely spent and how much wasted.

But suffice to say, destroying the NHS and making people pay more obviously for their healthcare is a vote loser, unless you do it so slowly that poeple don't notice.

Which is the other question that I want to ask the politicians. Are you doing this stupid thing because you genuinely believe it will improve things, or because you and your pals will benefit?

50:

As a USian woman who has been screwed every which way AND loose by the corps and the politicians, let me stress that this is the opening for an eternal war. Once these ilks propose something that screws you for their beneift, no matter how often you beat it back, it's never beaten back all the way. And each time they get a little more and you have a little less.

You have to mobilize and smash the proposal completely the first time, otherwise it will never be finished for even minute thereafter, until they have it all and you're grubbing in the cold street, barely clothed and have no contraceptives and are hung for having a baby out of wedlock that dies from starvation because you don't have any food for yourself, much less for the baby.

That sort of thing happened, not all that long ago, in terms of history. Victorian English novelists found many a storyline in these conditions.

Love, C.

51:

At last! Oh, thank God that at last the United States will no longer be the only industrialized nation in the world without universal health care. Thank you, thank you, thank you?

52:

Now I have to make a comment. There are a couple aspects:
- outcomes
- cost
- access

Ideally, you maximise outcomes, cover everyone and minimise costs. Now because healthcare is a bottomless pit (clearly, there is some marginal gain from having everyone go through 3 CT scans a year) at some point there must be some limit.

A centrally planned system, free at the point of delivery is clearly globally optimal. It is locally suboptimal if you are amazingly wealthy (basically, you are Steve Jobs and you can get your tumour genome sequenced before the seminal paper is published in Nature). But as the Jobs case shows, even with practically limitless money, you do not get significantly better outcome than anyone else. In fact, as inequality makes outcomes worse for everyone, a US-style system is probably worse even if you are a billionaire. cf the number of super-rich going to France to get healthcare...

Now assume that for ideological reasons, you refuse to admit there exist such things as imperfect markets and externalities (and it is surprising how many people fall into that category). Then you need to create the illusion of a market. The Swiss system does that: you have to buy insurance. The contract is predetermined, and insurance companies have to accept you. To keep the pretence, you get to change your company every year if you want to! Result is that you have to pay for the overhead of a large number of companies for no benefits whatsoever. In the end, you get good outcomes and full access.

But maybe you are not yet satisfied (it is not free enough!) Then you have the Obamacare system: everyone has to get insurance. That way everyone is covered. It looks a bit like the Swiss system, but there is much leeways and loopholes. Outcomes not so bad. Expensive. extensive access.

Of course, if you are dumb (and clearly, there is not alternate way of describing that, because as explained above, even f you are super-rich, this system is bad for you) there is the ex-US system, where Insurance companies have lots of leeway, and there is no individual mandate. This is crazy expensive and yields terrible outcomes. There is no way that such a system can work. Ever. Access is at uncivilised levels.

53:

I don't have a particular problem with healthcare providers making money. Or with management consultants doing there thing. I am ready to believe that a profit motivated private company could provide a better service at a lower price than a team with a guaranteed source of direct government funding. Or not. Colour me neutral.

But I do care that the system works.

This looks very like the disaster of rail privatisation, with made up markets, faked competition, and a maze of legal contracts. And no accountability.

This time around, we are adding a couple of layers of bureaucracy at the same time as we ruthlessly cut back on administrators. If you take the politics and economics out of the picture, there is simply no way that the admin can work. Waiting lists will go up to levels that make the previous Conservative nightmare (more than a year for many basic, time critical operations) seem like a golden age. Anyone with any cash at all will be forced to go private. It'll be like dentistry, only worse. And by the time Labour get back in, there'll be nothing left. And no money to start again.

Another link from Dr Ben's Blitzkrieg today was a short, surgical dissection by an NHS administrator of how we got here and just how much trouble we'll be in.

http://myemail.constantcontact.com/Who-would-vote-for-this.html?soid=1102665899193&aid=yXFmt3dKHv8

He also makes the point that many of the issues arose from genuine attempts to fix issues from the first pass. Which itself probably seemed a good idea to the latte swilling strategists in opposition. When they were still far from the messy discipline of actually trying to make something work.

I have dutifully tweeted the potentially floating Liberal MPs. (If anyone hasn't already, please do so right now: http://bit.ly/AlTfqx - another from Dr Ben ) and written to my MP. John Redwood is an intelligent man: I'm confident he'll make Cameron see sense before he commits messy electoral suicide.

This is Cameron's Poll Tax. Scots will no doubt take a grim satisfaction in seeing it trialled on the English this time around.

54:

This looks to me like the latest move in the Disaster Capitalism initiative, by which the richest of our oligarchic rulers buy up everything they don't yet own and make the ordinary citizens pay for it (and pay for it, and pay for it, unto the nth generation). Because it worked so well in Chile, and Russia, and is now working so well in the US, the rest of the world must follow.


55:

I've just been re-reading the diamond age. The whole 'neo-victorian' idea is starting to seem quite worrying.

56:

Ya think?

No, they'd never dare bring disaster capitalism home to the G8 after they've tried it everywhere else! Why, where would they be able to live afterwards, with their ill-gotten loot?

(Quick, nobody mention Dubai!)

57:

A lot of the time I can't fathom the Conservative infatuation with US policy, given the poor outcomes, compared with our Northern European neighbours.

(And I'm not against the insurance model - the German model is a pain of bureaucracy to get through as an outsider if you visit, but in terms of delivering basic care to the majority of the population it works).

Then I remember, that to those at the top, a harsher, more unequal system is actually attractive.

On another level, it's interesting to see how the language has shifted from 'coalition' policies to putting the blame firmly on the Tories. Who should really remember that they have no mandate from the electorate (less than 25% of eligible voters).

Charlie - surely the answer to 'where would they live' is in privately policed cities.

58:

"They're not merely trying to turn the NHS into a single-payer insurance system, they're trying to turn it into a copy of the most notoriously bad private healthcare system in the world."

But it's not the worst healthcare system in the industrialised world. At least from the point of view of the private health care companies who are doing their absolute best to keep their profits flowing.
Some of which profits incidentally ended up in Andrew Lansley's pocket, and guess what? He wants to introduce the same system over here. Funny that.
You got much space for English refugees in Scotland? You're going to need it.
Which does raise a question. Suppose Scotland splits and maintains its left of centre direction while England sinks lower and lower into a long nightmare of neo-liberal slavery hegemony, how many English would move north of the border? Would you see a brain drain of the squeezed middle classes, especially those in the academic sector who have PHDs and no jobs down south? Just thinking out loud, but anecdotally, all of a sudden the oft repeated 'fuck these people, I'm moving to Scotland' is starting to look more appealing.

59:

Actually what you should do is agitate for northern England to become part of Scotland. Then repeat until only London and the home counties are by themselves. Then we invade and take over, kick out the disaster capitalists and everything'll be fine...


I also have a proposal for privatising the government. It would be cheaper to do so because we wouldn't need all these election thingies, and the customer interface operatives could be put up in a purpose built hotel block when in London and subject to performance reviews based on certani criteria such as attendance to debates and time spent talking to constituents.
Government functions would be outsourced, e.g. I'm sure the US department of defence would be able to put in a competitive bid on the defense side of things, or the Adam Smith institute for economic policy.

After all, if they are determined to reduce the government to a board of directors overseeing a host of private companies, lets do it properly.

60:
As a USian woman who has been screwed every which way AND loose by the corps and the politicians, let me stress that this is the opening for an eternal war. Once these ilks propose something that screws you for their beneift, no matter how often you beat it back, it's never beaten back all the way. And each time they get a little more and you have a little less.

Of course, you could always push back by proposing legislation that moves in the opposite direction . . . Look at how many times initiatives for the legalization of marijuana have been proposed and defeated in the U.S. before they started to gain some traction with the citizens.

61:

best thing to do , once a rational government gets in, is to immediately nationalize all their toys. no money paid. and then promise that you'll do it again, if they're ever privatized in the future
stop these vampires building empires

62:

Here in the U.S. it is widely known (or at least believed) that the FIRE ratchet is driven by a combination of bad campaign financing practices and the revolving door connecting government officials and private industry. I'm told this is not the case for English electoral politics, or that at the least these types of perverse incentives are greatly reduced.

So how does it work in England? That is, (in this specific instance and also in the more general case), what do the politicians get out of sponsoring what is apparently widely considered to be a very bad piece of legislation?

I do not for one second see this attempt to make over the NHS as ideologically driven, btw. But that's just me kibitzing from afar on general principles.

63:

The answer seems obvious enough.

You can write to your MP

http://www.writetothem.com/

And you can tell them that if they vote for this heap of crap, you will never vote for them again.

I'm lucky, this is a marginal seat. It feels like I have a one-shot weapon, but if this bill passes, it could kill me. At its best, it might drag everything down to the level of NHS dentistry.

Anyway, that's the ultimatum despatched.

64:

And reply received, in the form of a chunk of cut-and-paste sent from a Blackberry.

I don't expect to vote for the guy.

65:

I did write to my MP. A week later he gave a tory MP a broken nose and concussion and assaulted 3 others. Maybe it was my letter that drove him over the edge, I can quite understand the urge to agression when faced by tories, but still...

Or maybe it was the drink he had had and his long standing drink problem.

ScentOfViolets #62 - the best short description of how corruption works in Britain is in Christopher Brookmyre's novel "Quite ugly one morning". The book is also good entertainment.

I can assure you that both those issues you mentioned are alive and well in the UK. In fact new labour intensified the revolving door between private companies and the civil service. Private Eye have pointed out dozens of such connections over the years.

66:

Charlie, I'm not going to defend the US system, but I want to point out that it is illegal for insurance companies to use genetic information to deny coverage to charge higher premiums for customers. (Employers are also barred from using it).

http://www.gpo.gov/fdsys/pkg/PLAW-110publ233/content-detail.html

67:

The thing is, once the government is no longer the ones providing the health care, they don't get the anger directed at them when cuts are made or prices (taxes) raised....

68:

The NHS is about the closest thing the UK has to a sacred institution. Cameron is playing with fire.

69:

Along with my fellow citizens, I will attest that the US has an utterly insane system of delivering health care.

And, here was I, enduring the Republican primaries thinking we really must have a monopoly on craziness. I forgot to take into account the Right's tendency everywhere to turn gold into dross.

70:

Okay, here's a little point which appears to have been forgotten by a lot of folks in this discussion: the current proposals regarding the UK health system aren't actually moving forward. They're moving backward. They're taking the English health system back to the one they had back in the era when the UK was a vibrant, expanding empire, with readily increasing wealth and a thriving and expanding wealthy and entrepreneurial class.

The problem is, that era was back in the 1600s - 1700s, and it was winding down toward the middle of the 1800s. The Victorian era so beloved of Mrs Thatcher was the last gasp of British imperialism, and okay, it looked good from the top, but there was a lot of discontent all the way down. The effort to return to the social and economic systems of that time-frame in an effort to recreate the economic growth of the era is voodoo economics in its most irrational form possible.

Granted, the servant problem was minimal, and unemployment wasn't a major problem either (if you were unemployed, you starved - no problem, in so far as the upper classes were concerned). However, there were people dying in the streets of preventable illnesses, there was rampant crime (housebreaking, muggings, highway robbery, assault, rape etc) and massive debt (this was an era when going bankrupt resulted in a long stretch in a debtor's prison) as well as phenomenal overcrowding in the prisons. Begging was widespread. Treatment for various medical conditions really did depend firstly on whether you could afford a practitioner at all, and secondly on whether you could afford a trained practitioner (if you were wealthy and urban, you got yourself a doctor; if you weren't so wealthy, well, maybe an apothecary or their assistant; if you could afford a couple of pennies or if you lived in a rural area, well, maybe the local witch could help you out).

71:

I did write to my MP. A week later he gave a tory MP a broken nose and concussion and assaulted 3 others.

Not a bad start, then. At least if your Tories are like our Tories…

72:

If Scotland maintains a working health system while everything goes to hell down south, will the Scots be able to manage the influx of healthcare tourists or even refugees? The US and Canada already have something of this relationship, especially with regards to pharmaceuticals.

Down the road, if a for-profit healthcare system takes root and serves to drag down the English economy to the degree that it affects that of the US, I'd think you could expect economic migration similar to that between the US and Mexico. At least Scotland already has a border fence that's been laid out since Roman times.

73:

What was that about?

74:

[SARCASM ON]

I don't know what you're talking about Charlie.

The health care system here in the US works great if you're a government official and/or wealthy and/or don't have any serious health problems. I'm sure that the sick are just a small minority we can easily do without. If an insurance company wants to screw over their customers, then those people can just take their business elsewhere, right?

The people in support of the bill at Whitehall are clearly representing the interests of their friends and thems-- the constituents that put them in office. As things should be in a democracy.

[SARCASM OFF]

Nothing like this would ever fly in Canada despite the conservatives having a choke hold on things there as well. They get a nice front row seat to how awful things are in the US.

The rash of loony conservative politics spreading across first world democracies, that these people are being elected by the folks they're screwing over, reminds me of that line by H.L. Mencken.

"Democracy is the theory that the common people know what they want, and deserve to get it good and hard."

75:

That border fence is all in England. and sited to stop the Scots coming south.

76:

Are you sure Wall Street is not in this. Our R/W has been screeching for decades that your health care can't work. They fill the papers up with tall tales about how bad it is. They have been cheering for a couple of years about how they were right and its finally coming true. Back in the 60's I was not in love with the way you did things. Then I found out what we really had. I can't tell you how bad it is now. If you let them get away with this, you will get what you have coming. And you will hate it.

77:

I'd just like to point out that the UK spends less per capita on the NHS than the US Government spends per capita on health care. You could indeed end up paying twice if you copy our system - we do.

Oh, and enjoy rescission. It truly is an indescribable experience.

78:

Don't be too sure that Harper and his so-called conservatives can't touch our beloved Medicare. He could unilaterally cut off federal transfer payments to the provinces for all health care matters, invoking the fact that in the constitution health matters are a provincial jurisdiction. He's already decided, without any provincial consultation, to cut funding growth for the next three years.

Don't count on the fact that we have a front row seat on how awful things are in the US. We can already see that the US states which have implemented minimum mandatory sentencing have had disastrous results from this. But Harper is going ahead anyway because he wants to look tough on crime.

Same thing for the destruction of the long gun registry. We have a front row on how the US is letting loonies control firearms laws yet we're heading in the same direction with Harper.

All these measures and more free market, right wing lunacy of the same kind are popular in Alberta and a few ultra right parts of the country, but they are considered madness in Quebec. And Quebec is the Scotland of Canada, remember?

Except that the PQ, the independence party of Quebec doesn't want something like maximum devolution. It wants full and total independence with a seat at the United nations, nothing less. And Quebec isn't in a remote corner of Canada, up, up above, it's right in the middle. And it's the largest province of Canada in area and the second largest in population.

So Prime Minister Harper is doing actually WORSE than David Cameron because he's creating the perfect right-wing storm to get left-wing Quebec to vote yes in the next referendum, and split up Canada forever.

79:

I'm gob-smacked! No other 'polite' expression for it. One of the many reasons I wouldn't/ couldn't ever consider moving back to the US is the impossibly chaotic and expensive medical care system.

THE MEDICAL CARE SYSTEM IN THE US DOES NOT WORK!
Are Cameron and his cronies really so stupid they can't see this?

When is the next election. I hope, for the well being of all my UK resident friends - it's soon.

80:

@Lunamoth #37

If you lived in Spain (no need to be a citizen, just to be a resident, which means you'd pay your taxes here), you wouldn't pay a penny. I think our system, now dangerously threatened by budget cuts, was designed after the British NHS.

Lots of luck!

81:

Everyone
The NHS NEEDS reform - most notably in the admin ... BUT: the healthcare itself is superb (I had a very useful minor operationlast year, which was a brilliant success) and again - BUT:
The proposed "reform" that Charlie is talking about is going to be a disaster.
One can hope the (unelected) Upper House will trash it ....
Straw in wind.
Even the Daily Telegraph is very uneasy about this Health Bill.

Scottish Independance.
I do hope Salmond loses.
He's a greasy little pile of untrustworthy shit.
That said ...
We NEED "Devo-Max" - which Camoron does not want, because then the English would get it as well ...
Go figure.
IF Salmond "wins" the celebrations will last about a day.
At which point, the plug will be pulled.
All the businesses that can, will relocate, the subsidies from the South will stop, and real actual, serious border-controls will be put in place.
I would predict Scotland looking like Greece, only worse, within 6 months.
All because of two people's arrogant stupidity - the aformentioned A.S and a certain madwoman from Grantham.

Errr
Charlie @ 12
CAREFUL
Some of our USSA friends would not recognise the, ahem, IRONY in your statement.
Some of them really believe that nonsesnse, you know?
& @ 16
Except that it won't have if Salmond gets his way, because Scotland will be multiply bankrupt.

Arnold Bocklin @ 25
Forget it.
Mr Milibean is un-electable.

Lunamoth @ 37
Excuse me, don't you understand?
YOU WOULDN'T BE PAYING A SINGLE FUCKING CENT!
AT ALL.
There, is that clear enough?
You wouldn't have had to take out "insurance" in the first place, either ....
[ Head / Desk ]

Walter @ 41
They've tried all of those.
So far they've all been told to eff off - with one exception.
Some section of the NHS (!) won't provide contraception because of "religious conscience" GRRRR ...
[ There is a very anoying example less than 500 metres from here ]

Andrew G @ 67
That exact same thing happened to our railways ...
And NuLieBour refused to do anything about it.
It is now (highly nominally) "private" and very expensive, and no-one seems (yest) to have the gumption to fix it.
Though there are noticeable stirrings beneath the surface in the past 6 months.

Alain @ 78
Yes that's a good description of our problem ..
"Our Dave" Camoron and Salmond are both really unpleasant people, with the capacity to really screw over their respective countries.
NOT good, I assure you.

82:

"Why in God's name would *anyone* want to copy the American healthcare system? And I ask that as an American."

From a little browsing around the internet:
Average net (post-tax) income for a general physician in the US (expressed as 2005 US dollars): 98,268.
Average net (post-tax) income for a general physician in the UK (same 2005 dollars): 62,520.

It'd be tedious to list specialty physicians, but the difference is considerably greater there.

If you think your doctor went into medicine for your benefit rather than his, you may well be a fool.

83:

The MP for Falkirk, Eric Joyce, assaulted 4 people in the House of Commons Bar a few weeks back. Yesterday he pleaded guilty, banned from said pubs and fined £3000 for the offence.:
http://www.bbc.co.uk/news/uk-scotland-scotland-politics-17310549
Apparently he'd had a few too many, shouted 'there's too many fucking Tories in here' before head butting one and punching three others. Of course some think he should be given a medal and a place in the shadow cabinet for his actions....

84:

This is another of my issues with the privatisation of public services. It replaces a service ethos based on some form of national identity and nice feelings with a money focused approach.

The end result of promoting by ambition can be seen in the police, where the top brass are busy selling the system out to private companies to make money for themselves, because, especially during the blair years, the result of all the managerialism is to promote ambitious people rather than people who are focused on public service.

So with the medical side of things. Once you privatise it, you end up with money taking first place.

Another loss when you privatise it is the unpaid work. Many nurses, teachers, police etc have done months worth of unpaid work, because of the public service ethos, feeling themselves part of a larger organisation which is necessary for the good of the company, so they didn't make a fuss, just stayed on to get the job done.
Once you privatise it all you find that a) the monkeys you employ don't see it that way and service suffers because of the unpaid work not being done (unless you have a method for forcing unpaid work out of people) and b) if you want the work to be done you end up having to pay more, both for the quality and time of personnel.

85:

best thing to do , once a rational government gets in, is to immediately nationalize all their toys. no money paid. and then promise that you'll do it again, if they're ever privatized in the future

The problem is that the UK does not exist in a vacuum. (Neither does the USA, or any other country, however much some of the backwoods citizens might wish it to be so.) In general, the corporate actors who benefit from government outsourcing are multinational. They have other patrons/clients, including other governments and large financial institutions. A modern government that goes down the expropriation-without-compensation route is going to find it hard to "do business" with other companies, banks, and governments: any time they look for investment the question that will be asked is, "is our money returnable"?

It's not an insuperable proposal, but it's one that needs an answer.

The real issue, to my mind, is why successive conservative governments (I include New Labour under the "small c" conservative banner) have felt it worthwhile to either asset-strip our national infrastructure, or to take out huge loans secured on the sweat of future taxpayers' shoulders to replace bits of it. Meanwhile, living high on the hog and hosting foreign tax dodgers by the boat-load to such an extent that the non-dom hyper-rich have warped the economy of London.

86:

We don't have the US-style bad campaign finances. We do have the boardroom/cabinet revolving door.

I will note that both Tony Blair and Gordon Brown appear to be worth multiple millions of pounds. Neither of them did terribly well compared to their predecessor John Major, who stepped out of office and into a directorship at the Carlyle Group (a large private equity firm). Margaret Thatcher doesn't count, having started out by marrying a millionaire corporate raider, but I think we're seeing a pattern here. Certainly the last years of the Major government (1992-1997) were notorious for ministers resigning due to some scandal or other and popping up in the boardroom of a large corporation connected with whatever they'd been in charge of previously.

Also note: privatization of state infrastructure and assets has been a foundation stone of Conservative ideology in the UK since 1975. They started with the phone company (formerly part of the post office), the state airline, state car manufacturer, state plane manufacturer, and so on. These days they're in the process of finishing the privatization of the air traffic control system and trying to work out how to sell off the road network. (No, I'm not making this up.) Privatization for its own sake is an unquestioned axiom of their ideology, and privatizing the NHS is completely logical when viewed through their lenses.

87:

You're quite correct: in the USA it is illegal for insurers to discriminate on the basis of genetic testing.

What you missed is that genetic testing is getting ridiculously cheap and that it is not illegal for individuals to take out more or less comprehensive insurance coverage on the basis of their own genetic tests.

Luckily genetics are not deterministic, but even so, this is going to cause headaches for the insurance industry. For example: so far, we've focussed on genes that predispose people to succumb to nasty illnesses. But what about combinations that confer resistance? If a young woman is lucky enough to have a combination of genes associated with a much lower than average incidence of breast cancer, then would she be prudent to reduce her out-goings by opting out of breast cancer coverage?

Personal genome sequencing is going to distort the US insurance market even if insurers remain unable to use it as a basis for cherry-picking customers.

88:

Well here in the UK we don't have the same need for a billion pounds for campaigning, but there is an odd correlation between giving money to the party machine or to important people within the party in order to pay for helpful things, and the outcomes of decisions made later.

The most glaring example being the honours system, where getting an honour is correlated with donating money to political parties and causes.

89:

"It replaces a service ethos based on some form of national identity and nice feelings with a money focused approach."

You're assuming that service ethos existed in the first place.
Oddly enough, this seems to be at the crux of a lot of the US vs. Scotland contrasts that pop up here- are the people around you closer to family or simply resources? The opinion in the US tends toward the latter, which is evidently a confusing as hell thing to someone in a country where people value each other for non-economic reasons.

90:

Thatcherism was genuinely popular - it made perfect electoral sense for Blair to appear go along with it. (That didn't mean that they genuinely went along - Labour in office did a lot behind the scenes to ameliorate it's worst effects.)

This on the other hand? Once the British people figure out what's going on, any party that promises to repeal it will be a shoo-in for election. Expect abolition to be at the core of Labour policy in 2015.

As for the Scottish Nats? The way they're getting into bed with Murdoch looks pretty suspicious to me...

91:

Well of course having a policeman for a father and a primary school teacher mother, apart from meaning I was generally a well behaved child, did perhaps give me a skewed view of public services. But I doubt it. Not just internal propaganda but also the comments by many people over the years (in real life and on television) reinforce the importance of the public service ethos, although it has been under attack for years now.


Cultural differences are important, although in this case it can be tricky to distinguish daily mail style "all our kids are evil rude thugs" style complaining from whether or not there has been an increase in unpleasantness.

92:

"Cultural differences are important, although in this case it can be tricky to distinguish daily mail style "all our kids are evil rude thugs" style complaining from whether or not there has been an increase in unpleasantness."

I don't think that profit motive need correlate with lack of pleasantness. I'm in healthcare myself, am generally perfectly polite and helpful to the best of my ability...but I'm in this job for the money and no other reason. Polite's and helpful is part of the job description. If impolite and obstructive were part of the job, then I'd be impolite and rude as possible with equal zeal and emotional dispassion.

93:

Greg,

Scottish Independance. I do hope Salmond loses. He's a greasy little pile of untrustworthy shit.

You've said that before. Evidence?

That said ... We NEED "Devo-Max" - which Camoron does not want, because then the English would get it as well ... Go figure.

It's not about you. If you want regional devolution, campaign for it. Why would England need Devo-max when it already has full fiscal control?

IF Salmond "wins" the celebrations will last about a day.
At which point, the plug will be pulled.
All the businesses that can, will relocate, the subsidies from the South will stop, and real actual, serious border-controls will be put in place.
I would predict Scotland looking like Greece, only worse, within 6 months.

You really need to reign in your fevered imagination.
Who has this plug which us going to be pulled?

There are no subsidies from the south. Scotland is a net contributor to the UK economy.

On relocation of businesses, why would that happen? All Scotland would need to do is start a policy of fiscal expansion compared to the contractionary mismanagement in England and businesses would locate the other way.



All because of two people's arrogant stupidity - the aformentioned A.S and a certain madwoman from Grantham.

Again with the blind attacks on Salmond. If you really think he is stupid then your judgement has to be considered suspect.

My position

I've lived in London for 20-odd years, nearly half my life, but I'm seriously considering moving back.

My position on independence/devolution is similar to Charlie's. I'm not pro-independence, but given the situation in England, a fiscally devolved Scotland with some proper left of centre parties would be infinitely preferable.

My main areas of doubt are recent links with Murdoch, and the SNP's authoritarian streak, although the latter isn't much different from most other UK parties.

I'm also a bit excited by the 'Early Days of a Better Nation' thing.

94:

and the other thing pushing me back is the constant stream of arrogant, ill-informed Englishmen telling me what I should think on the subject.

95:

Well-oiled delusions and the gaily-painted meathook future...

Despite repeated explanations, and links to factual articles on political funding, a substantial minority of comments here express surprise that any political party would pursue a policy that does not work, is clearly understood not to work, and ought to be electoral suicide.

I refer to this as the "All the oil in Iraq" fallacy - criticising a policy as if the measures for success and failure were the stated - or the openly-acknowledged - aims.

Bear with me here: this isn't about Iraq - but "All the oil in Iraq" is a catchy label for a valuable analogy that's all too relevant to the destruction of the NHS.

Let's begin by stating that democratising (or even stabilising) Iraq was never going to be worth the money, and all the oil in Iraq was never going to pay the costs of invasion and occupation. Never would, never will, and no-one involved in the decisions ever believed it to be so.

On the face of it, their acts were utterly irrational. Delusional, even.

But who was actually deluded?

Consider the beneficiaries: it was and is perfectly rational for defence contractors and oil companies - they get the money (or mineral resources) by the generosity of US taxpayers, and of Chinese bond purchases. It's cost-free, for these powerful non-taxpaying beneficiaries.

Consider the decision-makets: it was and is perfectly rational for the senior government officials - they get to retire into lucrative consultancies and non-executive directorships.

...As do the elected politicians: it's their retirement plan, too, for old age or the rainy day they finally lose an election. More importantly, it's their re-election funding - media coverage, campaign administration, attack ads on the rival campaign; and the lack of well-funded ads from rivals, together with suppression of actual 'dirt'.

It's also the election plan of *any* opposition party with any hope of gaining a seat: it's the same money, the same game, and the same set of policies fom - barring labels and rosettes - the same people.

"All the oil in Iraq" and all the costs to the taxpayer, and all the deaths, didn't damage any political careers. The outward irrationality of it is utterly obvious; the underlying rationality and profitability are known but never stated 'in polite company'; and the polititical damage is negligible.

So who's deluded about the NHS? Is Andrew Lansley deluded when he says the reforms are of benefit to all?

It isn't delusory to utter a profitable lie.

It *is* delusional, and a damaging diversion, to criticise Lansley and his profiteering fellow-travellers, as if the only criticism is that they are mistaken in pursuing a bad policy.

They are not mistaken. They know exactly what they are doing, and the damage that they will do. It is pointless to state that they are 'wrong', as if this were a policy debate, because they are right, in terms of material gain for themselves and their patrons, to say and do exactly the things that have now been done.

It remains to be seen whether they will be re-elected for this; but Labour's chances of mass media support in an election are a function of their continuing support for the Conservative agenda on fiscal austerity, welfare 'reform' and - in all probability - a pro-forma 'opposition' to restoring National Health Service that will take on the forms of a consensus acceptance of fait-accompli, with some ineffectual 'codes of practice' about recission and abandonment.

If, indeed, any front-bench MP or spokesman in the Lords actually wants to restore national healthcare: you might ask why - and when - hospital and area health trusts were restructured in a legal framework optimised for private-sector management.

All the oil in Iraq won't change that. A recognition of why these decisions were taken and a full exposure of who profits would be less delusional.

And the big delusion? A first-past-the-post 'majority' of the electorate will consistently vote themselves into destitution, disease, danger and death, if led to do so by effective media campaigns, rented 'representatives', and delusionary models of their own self-interest.

And *that* is the gaily-painted meathook future: it's isn't grim for a fortunate few, and it usn't seen as a meathook by the many.

96:

My apologies for lumping you all together.
I was perhaps thinking more of the known US police oppressive them versus us approach to things, as opposed to the more community oriented British approach.

Also I believe it is more an organisational thing - I am trying to describe an entire culture and approach to things which as you said treats people more as family than resource to be used.

As I keep saying, Salmond will get into bed with anyone who may help him towards his goal, which is an independent Scotland with him as president/ prime minister. Note for example the love in with Donald Trump a while back, which has now reveresed because trump doesn't want the rich fuckers on his golf course to see any wind turbines out at sea.

97:

Arnold Bocklin @ 90
Expect abolition to be at the core of Labour policy in 2015.
Yeah, like stopping "Beeching" in 1964,and re-nationalising the Railways in 1997 were part of their manifesto policies.
Trust tem to actually DO IT, once they are in power?
That is another thing entirely.
Re Murdoch/Scots Nats sorry wrong word.
The one you should have used was: "crooked".

Jim Smith @ 93
My opinon of Salmond is based on Charlie's analysis, and that of a freind who has currently just finished his degree at Edinburgh
Net contibutor? Really? What are you drinking - I'll have one of those too!
Agree about Devo-max. I thnk we all want it. We want a federated United Islands of Britain, PLEASE?
But we are not going to get it, unfortunately.
You really need to worry about the SNP's christian-authoritarian streak, especially if associated with Murdoch.

... see also guthrie's comment about Salmond.
Syas it all, really.

98:
Jim Smith @ 93 My opinon of Salmond is based on Charlie's analysis, and that of a freind who has currently just finished his degree at Edinburgh

So hearsay. Try actually collecting some information.

Net contibutor? Really? What are you drinking - I'll have one of those too!


"Scotland generated 9.4 per cent of UK tax with 8.4 per cent of the population - the equivalent of 1,000 extra for every man, woman and child in Scotland" (2010)

See
this for the detail.

As I said. Arrogant and ill-informed.

99:

Health does not go well with a market-based approach because the "consumers" do not have a choice.

Actually, they have a choice if you look on a wider picture. The absence of choice is true only in a narrow class of situations when
a) you already have conditions which require medical assistance and
b) this conditions affect your in a way that makes curing them the most valued choice.

This is not always the case even in the narrow view - consider 'I lose a part of my income" situation, if a price of an assistance is bigger then a share of an income your lose than the preferred choice is one where you refuse an assistance and save your money.

But the 'health' thing itself is much wider then just 'curing illness'. It is a result of a long chain of choices through all your life. You can eat healthy food, do exercises and avoid situations where you may be injured. Or you can drink heavily, eat twice calories than you can burn an have unprotected sex with strangers. In each case you make a decision whether you put your resources in a better health or you put them into something other. The same is true for the healthcare in the narrow 'medical assistance' sense - you _do_ make choices how much and in which form in which kinds of your healthcare to invest (and whether you invest in it at all or you prefer to take higher risks of early death/illness in exchange for some more valued things).

Actually, you have lesser number of choices under a healthcare system of 'socialistic' kind. You can not chose the supplier of services, you can not chose which specific service to by, you can not dose amount of spending and you even can not refuse to buy services at all.

---
A kind of a disclaimer:

* This comment is about 'choices and healthcare' theme, it is not about whether socialist/capitalist healthcare system good or bad. There are a lot of parameters other than a number of available choices to consider.

* This comment is not about comparison of current and proposed England healthcare systems too. I live too far from England in both geographical and memetic spaces to make any informed comparison.

100:

Despite the perceptions railway privatisation actually worked fairly well. The railways have lower running costs and a higher customer levels than virtually any other system as well as one of the world's densest networks (a legacy of massive over building of trunk routes during the first railway bubble). Ticket prices are relatively high, due to the subsidies being relatively low, although they still make up about half of revenue.

On a related note what Beeching mostly closed was a lot of barely used and never viable branch lines built during the second and third railway bubbles (given more comprehensive traffic data some of the lines could have been kept based on seasonal traffic (possibly up to 30%) but most were hopeless). The overbuilding of trunk lines and consequent overcapacity is why Britain hasn't built high speed lines, the existing capacity is more than adequate which made building more hard to justify even if this means that some lines are very slow.

101:

Good point, I hadn't looked at it that way.

Though health insurance is still largely tied to employer in the US. Most people have a choice between plan A or plan B, one being slightly more expensive and offering a different combination of coverage, co-pays, and drug coverage.

I could see where testing causes insurers to raise prices for privately purchased plans across the board though. People buying those plans have more ability to tailor their choices and could adjust to their actual risk.

(The whole US system is a baroque combination of direct government payments, out of pocket private purchases, and tax-free compensation by employers. All of which are sacred to a vocal bloc of voters.)

102:

I'm not sure about the case in the UK, but in the US doctors often graduate with a very large student loan burden, up in the 6 figures. They also usually have to carry significant malpractice insurance, since Americans love to sue each other at the drop of a hat and lawyers are always willing to take a case like that on contingency.

(Unlike the UK, the US allows contingency fees as a percentage of the award no matter what the usual fee would be.)

103:

I think that after an independent Scotland the SNP vote would collapse

104:

In other words, nothing short of the end of NHS.
And I thought things were getting bad here in Australia.

105:

Finagl, you're wrong on multiple points.

The absence of choice is true only in a narrow class of situations when a) you already have conditions which require medical assistance and b) this conditions affect your in a way that makes curing them the most valued choice.

Firstly, humans discount long-term risk -- we're notorious for that cognitive bias. So mostly we don't pay attention to our health issues until they bite us, hard. So your point (a) is true but utterly irrelevant. As for point (b) not wanting to cure medical conditions you have noticed is not exactly rational, is it?

Moreover, we all suffer from declining health resulting in death -- unless a piano falls on us or we commit suicide. The decline may be unnoticed until it turns fatal -- undetected cancer or hypertension leading to metastasis or a sudden stroke -- but it's there. Part of the human condition. Given that most of us aren't medically qualified, much less qualified medical statisticians, we're not equipped to accurately assess our long term healthcare needs and to prioritize preventative care accurately. Should a 20 year old bother paying for annual colonoscopies to check for bowel cancer? Obviously not ... unless they're one of the tiny cohort who get bowel cancer before they turn 40. Oops, no way of predicting that. (Bayes' theorem is great for looking at populations, but lousy when you have a sample size of one.)

Actually, you have lesser number of choices under a healthcare system of 'socialistic' kind. You can not chose the supplier of services, you can not chose which specific service to by, you can not dose amount of spending and you even can not refuse to buy services at all.

Wrong on every single count (at least as per the NHS as it is today). The only point where it's not 100% wrong is the final one (refusal to buy services), but that's only wrong in the same sense that if you live in a US city, you don't get a choice over whether to pay tax towards funding your school district regardless of whether you have children who will benefit directly from it or not: the point is, just as if you have kids then you've got the use of the schools, so in a socialised system you benefit from your neighbours' good health (even if you yourself go private every time): viral epidemics don't give a shit about who pays for the vaccines, and your neighbours' disabling illnesses impose other costs on you, personally (even if you discount them).

106:

There is a valid point to be made about end of life costs. Just how much is it worth spending to keep someone alive a couple more months?

107:

There is a valid point to be made about end of life costs. Just how much is it worth spending to keep someone alive a couple more months?

Under the current UK system, we score really high on international surveys of end of life care -- the NHS normally fights until death is inevitable, but then switches to hospice/palliative care to ease the dying.

Under the proposed private system, we can expect the American way of dying to arrive: long-drawn-out agonies on (very expensive!) life support. Typically the last two months in the US account for a large percentage of the entire lifetime healthcare bill -- prolonging the inevitable, no matter how unpleasant the process is for the victim, because it's more profitable than dosing them up on morphine and letting them die peacefully.

108:

The SNP was supposed (in their original constitution) to disband after independence. But that was a long time ago ...

I think that if Scotland gets independence, the SNP will persist, much like Fine Fail or Fine Gail in Ireland; it'll position itself as the major party of government and try to push Labour into opposition. How well they succeed is an open question, but I would like to note that the Tories regularly poll under 10% of the vote north of the border, and the LibDems have committed electoral suicide.

109:

The electorate has a very short memory

110:

Sorry to be off-topic, but does anyone had any thoughts about the latest stonings in Iraq over "emo" haircuts? Why are Western leftists so silent in the face of an enemy that is orders of magnitude more reactionary and aggressive than anything modern Christendom can muster? I'm still awaiting a hard-hitting discussion of Islam among this crowd. If you want to silence the right, you on the left must stop ignoring the elephant in the room, which is Islam's open war on the West. As the Iraqi "Moral Police" prove yet again, Islam spells literal death for all liberals and liberal ideas!

111:

What we have in the United States is an actual health care system, but the financial health of investors is the primary goal. Don't let it happen to you. And before you start in, I voted for Kucinich in the 2008 primary, since he was the only actual liberal on the ballot.

112:

If you wanted a secular Iraq then you should have left Saddam in charge.

113:

I think that Americans could have good effect arguing for a public health care system for everyone if they took "private health insurance discourages entrepreneurs" as a slogan. Unfortunately, there are very powerful interests, with vast propaganda resources, invested in the current system there, because its a very efficient form of rent extraction.

114:

Sorry to be off-topic, but does anyone had any thoughts about the latest stonings in Iraq over "emo" haircuts?

You don't follow me on twitter, do you? @cstross

115:

I think that after an independent Scotland the SNP vote would collapse.

I'm not so sure about that. People aren't voting SNP because they want independence. They are voting for them because they are the best option for government. (The only other option is Labour and they suffered from a combination of performing badly in holyrood and being tainted by association with the UK labour party.

After independence, if it happens, the tories and lib dems are still likely to be marginal and we might see a more left wing labour party or another left wing party, but the SNP are likely to be major players.

116:

I'm from Sweden.

The socialist public health care has a good reputation internationally, but it has some bad problems which can't be fixed because the political will isn't there (and they probably can't make a centrally planned system like that work, anyway).

They tell me that when you are in the Swedish system, it works well. I wouldn't know. There are problems in finding health problems.

The doctors that see patients to diagnosie problems seem to have an impossible situation and burn out -- on the other hand, there doesn't seem to be any overview of their work quality...

Unless you have a very obvious medical problem ("this piece should be attached"), the health care system is just unlikely to find the problems you have.

Some personal experience: I had knee problems for a couple of decades that were easily fixed, when finally diagnosed. And most of my life I had problems with being tired a lot (allergies). This has lowered my life quality and lowered the tax paid to the state by many times more than working diagnosis would have cost.

All that said, the US system makes the Swedish system look good. :-(

I don't know much about how the British health care systems work, but why copy the worst?!

I've read good things about the German health care system, couldn't the English copy that, make it work and export it to Sweden?

117:

I've read good things about the German health care system, couldn't the English copy that, make it work and export it to Sweden?

Well the French system is often considered the "best", but it is relatively expensive and you have to have everything by suppository.

118:

Yeah, the the updating of the West Coast Mainline (complete with vapourware moving block signalling and insane contractual commitments to Virgin Trains) went really well didn't it, and privatised infrastructure maintenance hardly killed anyone....

119:

Trying to copy France on public policy matters is always a dubious plan, simply because the french state is very good at executing certain types of policies due to institutions and traditions that you may, or may not have a snowballs chance of emulating.
Copying the laws does not cause a crop of grand ecole graduates to show up of thin air and execute.

However, there is one example of a high quality health care system that every first world nation *ought* to be able to copy. The WHO study that ranked France as number one? Ranked Italy number 2. And if the italians are kicking your ass at the provision of a public good, you have got to be missing a trick or seven.

120:

Yes! Silvio is looking for a new job...

121:
Trying to copy France on public policy matters is always a dubious plan,

I think this is always the case when someone says "why can't we do it like the $FOREIGNERS". There are always infrastructural and cultural complexities which it more complex than it seems.

However, there is one example of a high quality health care system that every first world nation *ought* to be able to copy. The WHO study that ranked France as number one? Ranked Italy number 2.

I'm afraid this just activated my stereotype gland...


  • the inspectors were bribed...
  • only 40% of costs are actually above the line, the rest is all black economy
  • anyone who doesn't get well will sleep with the fishes

Only the second one is likely

122:

Most countries need to improve their end-of-life healthcare strategies, starting with education about AND (allow natural death). The AND concept is gaining favor because it focuses on what is being done, not what is being avoided (i.e., DNR).

123:

But subsidies are high, as are ticket prices, with increases well ahead of the rate of inflation, e.g. an off peak return from near me to Edinburgh used to be £5.70 back in 2006 or so, is now 8.40.

Subsidies were increased for privatisation, and the rolling stock sold at an artificially low cost, so low that major profits were made by re-selling them despite no new stock being purchased.
Basically, one can say that the current system works, but is hardly cost effective or as efficient as it could be. The privatisation of BR is a textbook example of how not to do it.

Why, they can't even run the trains on time better than BR! And have a higher rate of complaints!

Data from:
http://www.transportmyths.co.uk/Privatisation.htm

124:

but it is relatively expensive and you have to have everything by suppository.

Is there any particular reason the french like giving medicines up the ass more than other people? Is it a cultural thing?

125:

I'm old enough to have lived in Canada before our province-based Medicare system came into effect.

Canada is now denounced in a regular fashion as having a "socialistic" health care system, by right wingers and libertarians in the US.

They say we have no choice now, with all our "socialistic" medical care.

This is an absurd claim.

Before Medicare, when it was private enterprise all the way we had incredibly less choice than we have now. There were less young people going into the medical arts, and in the end less medical generalists and specialists, because the people who needed them simply could not pay.

After Medicare we lost home visits by GPs (except for the severely ill) but we ended up with an even greater choice of nurses, doctors, etc. The doctors are not allowed to over-bill their provincial "paymaster" above set rates but they remain independent providers of the healing arts. They can set the hours they want, work how they want and when they want (they can afford longer, costlier vacations thanks to the regular stream of money from Medicare) and stay alone in a single practice or set up a corporate shop with colleagues. Given this "new" abundance of doctors and other health people, we can choose the doctors we want, and make as many visits as we want to other doctors for competing diagnostics. The only limiting factor to our choice is time.

And from what I've seen by my tours in Europe (and from my work in a government agency involved with health) this is also true in France, Germany and other industrialized countries who health care denounced as having "socialistic" medicine by US libertarians and right wingers. There is also a similar level of choice there.

Finally, the big insurance companies fought against the creation of Medicare in Canada but now 60 years or so later they are making incredibly more money than ever because the ready availability of medical care raised the health awareness of the population and people sought to patch up the holes not covered by Medicare through private insurance.

Of course, Harper and his so-called conservative government (they are in fact former Reform party neo-libertarians) are trying as I speak to throw a monkey wrench in all of this because it does not conform to their twisted, malevolent ideas of what a free market should be.

126:

Is there any particular reason the french like giving medicines up the ass more than other people? Is it a cultural thing?

No idea really, and I think the stereotype is out of date. I believe it is in decline.

Pharmacologically, if I remember my very old training correctly, there is much to be said for rectal administration[1]. More reliable and consistent absorption for example.


[1] As opposed to A Rectal Administration, which is what you get if $REPUBLICAN_NUTJOB gets elected.

127:

My understanding (caveat: this is by way of 25-year-old lectures on the subject) is that it's a cultural thing. French pharmaceuticals tended to go via le cachet or via suppository. The former is now more or less obsolete, replaced by the gelatin capsule; the latter ...

128:

Blame the Lib Dems and everyone who voted for them. Instead of being loyal to their own principles and working to curb the more authoritarian tendencies of New Labor (by working with labor, not against them), the Lib Dems turned their backs on where they came from and sided with the enemy, for a cheap grab at power.

It was stupid to empower the Conservatives for whatever reason. This single bill does more damage to Britain than Labor could dream of doing in a whole term.

129:

Jim Smith @ 98
In which case I will let an Edinburgh resident (OGH) dis-abuse you of your delusions ....

Brett Dunbar @ 100
Excuse me, but bollocks
Beeching was MArples' hored hatchet man.
Look it up.
In fact approx 1/3rd of the "beeching" closures" - the lines should never have been built.
1/3rd were borderline, couild probably have been kept with proper economic management, and
1/3rd should never have been closed
NOT a good result!

130:

The railway companies must be doing something right as the number of passengers per year has nearly doubled since privatisation (750 million journeys per annum in the mid-90s to 1330 million in 2010).

As for safety the old nationalised BR had a litany of major fatal incidents even with the much-reduced traffic on the system compared to the period after privatisation. We do expect better these days though even if paying for it in ticket price increases causes screams of anguish from the punters.

131:

Greg:

What the fuck are you talking about? If you think I am delusional please be more explicit. Otherwise apologise of fuck off.

You are not the only one with contacts in Edinburgh, and I also tend to read more widely than you appear to.

You really do lower the tone.

132:

The main thing is doing right is existing. That is all it needs to do when the economy is booming and more people want or have to get to work in more, different areas.
Of course BR wasn't perfect safety wise, but then as we all know, neither are the new companies, even with all the extra money given to them. Besides, like the NHS, it seems likely that had BR been kept nationalised and allowed to utilise modern technology to improve, maybe even with a decent rate of subsidy, it would have improved.

133:

The problem is that rail travel is for some reason I cannot work out, vastly more expensive than travel by car. It costs me about £5 in fuel to go to London in my car, but around £15 on the train. That's excluding another £3 on LT to finally get where I'm going.
As for other car stuff, like servicing, tax, depreciation etc it still only adds on about £3 and I have to pay that anyway.

134:

The Lib Dems did explore the possibility of going into partnership with Labour after the last election. Labour's reply was that they'd be happy to have the Lib Dems support but they weren't going to give them any say in what a Labour government would do; no Cabinet posts, no input into proposed legislation, nothing.

Basically by the end of the last election Labour were burned out after Blair and Brown had had their time in office in much the same way the Tories had after Thatcher's three decades. Labour didn't want to be in power any more and they made this pretty clear to the Lib Dems who got a better offer from the Tories. The only other solution would have meant more elections as soon as a Tory minority government fell to a vote of no confidence. In the worst case we'd have a Government-of-the-month a la Italia.

135:

I work in the railway. The privatisation has not worked.

The whole way it was done was frankly insane. One company owns the track. Another own the trains and leases them to another company to run, who then have to pay the track owner for access. Oh and they get charged by the track owner for being late after being held at signals controlled by..... the track owner. It is a license to print money for someone. And its being paid for at the tax payers expense in the form of subsidies.

The only good thing to come out of it is the wages of the rail companies is not too bad now, though the working conditions and shift rotas are pretty much Dickensian. How about a 10 hour shift with two 20 minute breaks in there? And that is for train drivers, the one guy on a train you do want to be refreshed and not tired.

The last I heard, but I am far from certain of the figures, was that the railways now cost an astronomical amount more in subsidies than they used to. Mostly to pay for all the stupid charges Network Rail doles out. And of course the railways are no safer. So I have to ask. How is that a success?

136:

The railway ticket buys you the train, the driver, the tracks and signalling equipment, the staff, the buildings, the track inspections, equipment upgrades etc., not just the energy to get you where you want to go. Even then what you pay is nothing like the real cost of the journey you make.

Your car journey costs you the fuel, depreciation, servicing, taxes, MOT inspection, road construction and maintenance, safety patrols, lighting etc. as well as your time and effort as a driver/operator on the trip.

It costs money to travel any sort of a distance. Shoe leather or even bicycling will only get you so far and only if you are moderately fit. For anything quicker or more convenient then you have to reach into your pocket and pay for it, one way or the other. In some cases subsidised train tickets are more expensive, in other cases less.

137:

I'd note, as an American, that saying you have more choice here is, at best, highly theoretical. Most people that have insurance have it through their work or through the government (mostly seniors).

In either of those cases, you have very little choice in what insurance you get - at work you either take what they offer or don't. Likewise, government funded healthcare.

Within in those systems, you have some options about who your doctor is, but it's not any particularly large amount of freedom.

If you don't have insurance provided on one of those two ways, you're paying for it yourself. Good insurance is expensive, and bad insurance MIGHT protect you from getting wiped out from unexpected illness or injury, but does very little to defray the (highly expensive) costs of routine medical care.

That's assuming you can get insurance, because of pre existing conditions (which the recent healthcare reform addresses) and that you aren't dropped from it for whatever reason the insurance company dreams up.

Having to stay in a job and not create or innovate because you can't afford insurance isn't freedom in any meaningful way. Nor is having to delay treatment or run yourself into debt in order to be able to pay the rent.

Compared to having to pay more in taxes? That's a measureable and meaningful reduction in choice.

One of the most tiresome aspects of American politics (and judging from this post, it's present in UK politics) is this idea that freedom means that you are free from government interference. That, in itself, is near meaningless.

I could drop you off on a desert island, declare it your own sovereign state, and you would have, according to that construction, perfect freedom.

But, unless you were a very strong swimmer, you'd have no actual choices by which to exert that freedom, esxcept perhaps the freedom to choice to drown yourself before you starve.

Freedom is only a useful construct when viewed through the lens of what allows people to pursue the things that make them happy, however they define it. The American system, as it is, is substanially less free than the UK system.

Until they ruin it, of course.

138:

"The railway ticket buys you the train, the driver, the tracks and signalling equipment, the staff, the buildings, the track inspections, equipment upgrades etc., not just the energy to get you where you want to go. Even then what you pay is nothing like the real cost of the journey you make.

Your car journey costs you the fuel, depreciation, servicing, taxes, MOT inspection, road construction and maintenance, safety patrols, lighting etc. as well as your time and effort as a driver/operator on the trip."

Yes, but why is one so much cheaper than the other? A rail carriage is nowhere near as complex as a car. The rail takes less space, there is only one driver for hundreds of people and from a fuel POV is no doubt cheaper than a car. Even a big railway station is less complex than my local Tesco, and employs fewer people.

139:

The question of increased use of railways made me look for data on road use. The RAC has a nice roundup, although it is 1988 to 2008.
In that 20 year period:
The number of households with a car grew by 39%, from 14 to 19.5 million
The number of households with 2 or more cars grew by 95%, from 4.3 to 8.4 million
The total number of drivers grew by 29%, from 26.1 to 33.7 million
The number of women drivers grew by 50%, from 10.2 to 15.3 million
The total number of vehicles on our roads grew by 46%, from 23.3 to 34.0 million
The number of cars on our roads grew by 49%, from 18.9 to 28.2 million

The average number of car journeys we make increased by 11%, from 387 to 430 per year
The total amount of car miles driven increased by 32%, from 190 to 250 billion per year

Which is interesting.
Back on the railways, I'd like to know what percentage of increased passenger numbers is people commuting in London

140:

One statistic I saw was that about 1 rail journey in 6 starts and/or ends in London.

141:

Within the evil, choiceless British system you can change your GP or in many cases shop around within the practise until you find one who takes you seriously. You don't have to sit with the one who belittles your complaints until you turn out to have a long term illness that they missed for years (as happened to someone at a place i used to work).

Robert Sneddon #139 - that wouldn't surprise me, but also suggests a widespread increase in numbers across the country. Which fits with the increase in commuting places. Now we just need the breakdown for increases in segments of the population (eg students and oaps) and whether weekend or weekdays.

142:

Jim, you are being given a yellow card. Please calm down and behave better.

143:

Due to the technology in use the ticketing used at the time didn't provide traffic data. So that had to be gathered by a survey this was fairly expensive so was done on one day. This missed that some lines carried heavy traffic at certain times of the year and were quiet at others, given data covering a larger part of the year perhaps a third of the lines carried enough holiday and other seasonal traffic to be worth keeping open, the other two thirds was doomed whatever happened. About half the network carried about 5% of the traffic, that's what Beeching closed.


Modern ticket arrangements gather detailed traffic data as an incidental, so planning now has far better data to work from.

144:

I actually have a very accommodating doctor. When I had rosacea I asked him to prescribe some tetracycline for my experiments, which he did.
http://www.neopax.com/Artemis/rosacea/index.html

I actually sorted it out by synthesizing some copper salicylate and dissolving it in a 60% soln of DMSO. The alternative was a life on antibiotics.

145:

From my point of view, as a low-income Englishman, I fear that Scots Independence will kill the left in the Westminster Rump. There are more pandas in Edinburgh than Conservative MPs in Scotland. That's some 50 votes. gone from the potential Opposition.

Can we get the Conservatives to poison their own well without wrecking the NHS? On today's news, I'm not sure. The Lib-Dems seem to be joining the suicide pact.

And, in the last election, the Conservatives had an absolute majority in England: 61 seats.

146:

Yes, and independent Scotland would mean a perpetual Conservative government, barring unforeseen circumstances.

147:

Looks like the UK is getting hit with the same tactics that put in place (and kept in place) the US medical system.

Fascinating.

Good luck dealing with it.

Oh, and for my friends in the UK? Remember that not only is the UK not the US, it's sometimes a good idea to flash mob any nob who wants you to imitate us.

148:

"Typically the last two months in the US account for a large percentage of the entire lifetime healthcare bill -- prolonging the inevitable, no matter how unpleasant the process is for the victim, because it's more profitable than dosing them up on morphine and letting them die peacefully."

This one I actually chalk up to cultural differences rather than just the quest for profit. I work in a hospital and the number of family members who cannot be convinced that their relatives are going to die and that it's time to swap away from treatment to palliation is amazing.
If you left it up to the docs, they'd probably yank the plug at appropriate moments...but the instant you start talking about that decision being taken away from the family and put in the hands of a third party, someone starts screaming about "death panels".

149:

"Pharmacologically, if I remember my very old training correctly, there is much to be said for rectal administration[1]. More reliable and consistent absorption for example."

Depends on the drug- since things absorbed from the upper GI tract go through the liver first (because our ancestors weren't picky eaters and sending all the input through the detox plant was a good idea), there are a few things that get degraded by that first pass by liver enzymes- morphine and nitroglycerin pop to mind, but the list is long. Other things, doesn't matter much or at all.
Things absorbed from the colon just go right into the bloodstream without processing. Since the level and type of liver enzymes can vary from person to person, it's not a bad idea pharmaceutically.
On the other hand, if you have, say, ten drugs to take, pills start looking like a much better option.

150:

If anyone outside of the Net suggests I put nitroglycerine up my arse I will politely refuse.

151:

Ummmm. I just got an explanation of rectally applied nitroglycerine from a pharmacist friend. The dose for anal nitroglycerine is 0.1%, and it's a treatment for swelling (not hemorrhoids, but similar), because it's a vasodilator.

Once a pharmacist made a mistake and provided the 2% cream used for cardiac application on the skin. The patient who put 2% nitroglycerine in his rectum died of hypotension. Getting the concentration wrong on nitroglycerine can be lethal. That's even without the dynamite casing and the fuse.

This is why they pay the big bucks for those PharmD degrees. It also suggests that telling someone to stick it up their ass can have, ahem, unintended consequences.

152:

So if Charles suggests I take my opinions and apply them rectally I shall assume it's due to his knowledge of pharmacology.

153:

No, it means that Charlie thinks you'd be happier if you took your opinions and wrecked 'em.

154:

"as the Jobs case shows, even with practically limitless money, you do not get significantly better outcome than anyone else"

My understanding is that Jobs rejected his doctors' advice in favour of a particularly ill-considered regime which he had cobbled together for himself based on alternative therapies, including a special diet. He did not go for surgery immediately, which would have greatly improved his chances of survival. Given these facts, I think it's rather hard to say that his money was the issue here. The prognosis for neuroendocrine tumors in the pancreas is generally rather good, given proper treatment and prompt surgery. This type of tumour is famously slow to grow and patients often die with it, rather than of it.

As for the NHS "reforms" - if this doesn't bring down the Tory government (sorry, I meant the coalition of equal partners, can't think why I overlooked the Lib Dems!) then nothing will. I just don't see how Cameron survives this act of utter folly electorally, especially when you consider that his plans for the economy are producing nothing but pain. What else was to be expected from a politician who finds the idea of an industrial strategy much much too complex for his short-term mind? I must confess that I don't find Labour remotely impressive and have not done since Blair destroyed the heart of the party for 13 botched and wasted years in power. The more I contemplate British politics, the more I find myself remembering Cavafy's great poem which ends with the speaker saying:

"The almighty gods ought to have taken the trouble
to create a fourth, a decent man.
I would gladly have gone along with him."

http://cavafis.compupress.gr/kave_44.htm

155:

Someone remind me please why do I pay tax and national insurance?

156:

I get a yellow card because I said Fuck, while Greg's insulting behaviour goes unpunished.

Odd.

157:

I find it better just to skip over certain long term contributors, and I'm sure they do likewise for my poor efforts

158:

That's a double plus special yellow card for saying fuck again.

159:

But Cameron and his cronies are doing it for the good of the nation. We are being misled by those who benefit from the flaws in the current system. and anyway, the bill as it now stands is very different from the original proposal.

My response to this would be short and vulgar, and would start by questioning why they even made the original proposal as a starting point.

Essentially, the Cameronite Party is fixated on reducing expenditure and, unlike the struggling family they evoke as an example of such a strategy, cutting their cloth according to their budget, they are doing sweet F.A. to increase income.

160:

I can't promise never to use that word here, but I hope to reserve it for an expression of extreme distaste for some opinion or event, clearly questioning the sanity, morals, and intelligence of those responsible.

As far as the Cameronite Party is concerned, Whiskey Tango Foxtrot has become my default reaction.

But I have a certain soft spot for that long-time political pundit, William Tare-Fox, whose approval of ill-considered sound-bite proposals is legendary.

161:

The US system is in trouble but I doubt if it is due to collapse due to genetic testing. Two simple fixes:
(1) Congress changes the law so that insurance companies can take acount of genetics.
(2) Insurance companies restrict their range of policies to 2: full insurance, or none. Most people with good genetics would still want insurance - e.g to deal with a broken leg.

The US seems much more likely to go for a fix like this than allow the whole system to collapse, or replace it with a sensible (ie not made in the USA) one.

162:

A speculation on the effects of an efficient privatised insurance-based health-system replacing the tax-funded NHS.

1: Those of us on low incomes will get less healthcare. We will not get enough tax reduction to pay the insurance for full cover.

2: With the money flowing through an insurance system, a percentage will be skimmed off as profit, even if actual costs do not change.

3: Those on high incomes already pay a significantly reduced rate of NI contributions on the majority of their income (and i am not sure that they pay any NI on share dividends: must check).

Conclusion: even the current system tends to rob the poor to pay the rich. The Cameronite system will be worse.

163:

So: £5 by car, £15 by train.

But for the whole journey in the car, you have to drive the car. Whereas your time is your own on the train.

What value do you put on your time?

Seems (almost) like a rational pricing policy - if your time is worth so little you'd rather drive, then you can.

164:

(and i am not sure that they pay any NI on share dividends: must check).

They don't.

165:

GTN (glyceryl trinitrate -- we don't talk about "nitroglycerine" as a medicine, it scares people) applied to the skin as a cardiac vasodilator is new to me (although I confess to being out of touch); the standard formulation in the UK used for angina is (was) a 500 microgram dose in tablet form for sublingual dissolution -- stick it under your tongue and it dissolves rapidly. The tongue/buccal mucosa has a similarly good blood supply to the rectum and gets it into circulation fast, without the dosage headaches of an ointment/cream (quick! How many centimetres of ointment are you meant to squeeze out? How long should you let it stand on your skin before you put your clothes back on?).

Random factoid: back in 1989, the wholesale price of a 50-dose bottle of GTN tablets was on the order of £1. The prescription tax was more than double that ...

166:

I apply different standards to people I know IN PERSON, as opposed to comments from people I only know as a name attached to their postings.

This is not a matter of spurious "fairness", it's just a matter of my being able to distinguish between, say, a random drive-by troll with a sock-puppet and a guy I know in the pub getting a bit shouty and excitable. (The latter, if he gets too noisy, I can address via a back-channel. The former? No such back-channel exists, so I have to hand out a yellow card via the blog -- or via the proxy of one of my trusted moderators.)

167:

But for the whole journey in the car, you have to drive the car. Whereas your time is your own on the train. What value do you put on your time?

That's an interesting question.

Last weekend I went on a round trip from Edinburgh to Leeds.

My options were: to drive, or to get the train. I got the train.

Cost of an off-peak second-class return ticket (not booked in advance: I made the trip at 24 hours' notice): £97.50.

It took me 50 minutes to get to the station, buy the ticket, and get on the train (I just missed one by 10 minutes). I was then in a cramped second-class seat for 3 hours. Attempted to work on the laptop: too much vibration/noise to do so effectively, and too little space, so I settled down with a book instead. Finally, 15 minutes to get to destination by taxi (£ 6.50).

The return journey ... I wimped out and upgraded to first class for £20. There, I was able to work effectively.

Total journey time: 8 hours return, at a cost of £124 (half first-class, half second-class, weekend and off-peak discounts applying). Ability to work: 3 hours.

Now, I've done that journey by car. I have timed it. I can do the drive, one way, in 4 hours and change (not less than 3 hours 56 minutes, non-stop door-to-door, without exceeding the speed limit by enough to get ticketed). Mileage: 450 miles return, in a vehicle that gets 34 miles/gallon ... works out at around £80 in fuel. Ability to work en route: none, but see also my experience in a second class railway seat.

If we bundle in depreciation, wear and tear, and maintenance on a new car, obviously the cost of driving rises. But my car's 15 years old and not going to depreciate any further unless I drive it into a brick wall. Maintenance ... 450 miles is about 5-10% of a single service interval (cost: £200) so we can write down £10-20 in additional costs.

Price-wise, the car and the second class railway experience are a photo-finish. The first class railway experience is nicer than driving (or second class) but costs significantly more -- if you do it without the weekend cheap upgrade it'll cost roughly twice as much.

TL;DR: I got home wishing I'd driven, and I don't enjoy driving. That's the state of the UK rail network today.

168:

Over here we go ahead with the nitroglycerin name...people get used to the name after an initial adjustment period. Although dropping a bottle of the tablets and yelling "boom" is fun to do to new technicians.

Anyhow, sublingual tablet's for really short term relief. The ointment comes with an overlay patch with a measuring "ruler" printed on it. Half an inch to an inch, usually. Squeeze, slap onto the patient ointment side down, keeps it all tidy.
Long-term use would involve an actual transdermal patch- a bit slower, but less work since it's daily.

169:

Similar to the way that NMR became MRI - being stuck inside a Nuclear Magnetic Resonance scanner scared the punters.

170:

I didn't add the rest of the story on the nitroglycerine, which was that the cream application is unusual enough that a pharmacist has to compound it, either the 2% cream or the 0.1% cream.

Personally, I was impressed by the 20-fold difference in absorption rates between skin and rectum. That's useful information, but it speaks to the dangers of using rectal administration.

171:

Any sense of "choice" in the US is a joke. We have in network providers, but I am on a so-called "Consumer Driven Health plan", which means I don't pay any premium to my employer but pay the first $4k a year myself.

You cannot find out pricing information before going to a doctor, it is literally impossible. They don't know, the hospital won't tell you, and the insurance company has a vested interest in you not finding out. Additionally, there is a law in California which says everyone gets billed the same amount - which is completely true, but the law also says nothing about the level of discount you receive, so self-pay tend to pay the full amount (if they are rich) and the insured pay about 60% less.

I think one of the big employers (GE?) have the same system, but they bullied their providers into allowing them to build a database with the actual costs in it, so their employees actually can meaningfully comparison shop. They did have to threaten to leave their health care management company to get the information though. As GE is self-insured, it is in the companies interest to drop the expense by having informed consumers, and they were big enough to actually get meaningful data.

The other issue is that you have the same umbrella group (Scripps for me) but a zillion individual practices within that umbrella. So my own doctor charges $150 for a consult, when I wanted to see a doctor quicker (same building, different floor) it was $325. Insane.

So although choice theoretically exists, in reality it really doesn't.

172:

You have to pay to see a doctor?!?

173:

"I didn't add the rest of the story on the nitroglycerine, which was that the cream application is unusual enough that a pharmacist has to compound it, either the 2% cream or the 0.1% cream."

I can just imagine them getting the big bottle of nitro off the top shelf and pouring it into the mortar and pestle before grinding it with some paste to make a cream.

BTW, dissolving a drug in DMSO and water can result in very rapid skin penetration. So quick that you can taste the DMSO within 30 seconds of applying.

174:

@Charlie:

Same here in Ireland, (though the numbers are not quite so bad). Even with health insurance, the first visits to a doctor (or dentist) up to maybe 500 Euro are paid by the patient. If I was on welfare / severe medical condition, I could get a Medical Card (good luck these days, though!) that would give me "free" access, except for prescription and A&E charges.

Note: we have notionally free public health care, but I think a recent poll showed most people who could afford it get Health Insurance rather than risk the delays not going private would mean. (Hearing anecdotes of post to doctors from hospitals, giving results from tests: private patient post went to one cubby hole, and was dealt with by the secretary immediately, the public patient mail opened "several days later, when someone got round to it". Never mind the waiting lists for hospitals.

Moving _away_ from an Irish / US style system was seen as a matter of urgency by political parties in the election, even when finances were so bad. Really, you don't want to go there. Good luck with protecting the NHS in England. At least we will still have Scotland as a role model.

175:

As I understand it, the medicos can't tell you how much something costs, because the cost is determined after the fact by negotiation between the hospital and the insurance agency. If you're paying out of pocket, you get gouged at the maximum rate.

Or to use the example of my pharmacist friend, pain in a hospital is rated on a scale of 1 to 10, not on a scale of how much you're willing to pay to stop hurting. While many people would probably want to use the monetary scale, the pharmacist doesn't know how much the meds will cost the patient until after they're administered.

176:

Painkillers are cheap as dirt, all the way up to morphine.

177:

I was once VERY expertly treated (knuckle cut to the bone in a bizarre accident while visiting my 99-year-old great-uncle-in-law) at Edinburgh's Royal Infirmary, a major acute teaching hospital, with a 24-hour accident and emergency department. They refused to take any payment. "Sir, you are a guest in Scotland."

178:

Indeed, and US hospital pharmacies charge upwards of $10 for two aspirin or ibuprofen tablets for pain relief. They're "cheap as dirt" to the pharmacy, not to the patient.

179:

To clarify the hospital billing department charges $10 for ibuprofen. The pharmacy does know the wholesale costs, but they don't know what shows up on the patient's bill.

The bigger point is that in the US, the patients aren't the customers. The insurance companies are. It's analogous to the eyeballs model for advertising rates. This might be why I listen to public broadcasting as much as possible...

181:

I've yet to encounter an insurance program that doesn't have a copay for Doctor visits, although I imagine they exist.

My regular check ups, which I have about four times a year, consist of me getting my blood pressure taken and weighed, along with the doctor asking if anything new is wrong with me. Which costs 125 bucks without insurance.

The only reason that I need them is so the doctor can write new prescriptions for my drugs. I doubt the usefulness of me needing new prescriptions for the same drugs I take all the time which, being for the treatment of diabetes, are nigh impossible to abuse. But it is what is.

With my insurance, it's cheaper (which is to say free for me) to go to the emergenct room than it is for routine health maintance.

182:

Of course - this is America, land of the fee!

Not for routine check-ups, but for anything else, I have to pay.

The model is supposed to reduce costs by making employees shop around, but what actually happens is that they stop going to the doctor (empirically true - I see the usage reports).

Annual health screenings are done at work, height, blood pressure, weight, waist circumference, blood draw for cholesterol, triglycerides, diabetes etc. You can opt out of the screening, but then your costs are $120 a pay period - the healthier you are, the lower the costs per pay period (I pay $1.70 as I am fat but otherwise OK).

So that's how we roll.

183:

The first time I took my daughter to a paediatrician here in France I walked out without paying. Much embarrassment ensued. When I explained that you didn't have to pay in the UK she was amazed.

184:

Malpractice insurance is overrated as a source of medical costs (that PI attorneys usually are Democrats means that there is often a partisan undercurrent in attacks on trial attorneys). The thing about contingency fees is that that the attorney gets nothing if they lose, so lawyers don't take cases they don't think they could win. When I worked at a personal injury firm doing client intake, weak cases were dropped like hot rocks. Based on my observations, the best way to get someone clamoring for a personal injury suit was to be an asshole. The second best way was for the injured plaintiff to not have any other way to pay for medical care, so I strongly suspect decent universal healthcare would reduce PI suits.

185:

According to one GP I know, most of the patients are time wasters who would not turn up if they had to pay even a small fee.

186:

I have been well-treated in American Emergency Rooms, and believe that my life has thus been saved. But this is, in part, because I do these little things:
* have a physician phone the ER while I'm on the way by ambulance;
* when first greeted by an ER person, point out that I've been published in the biomedical literature since the early 1970s.

If an American lawyer, physician, or law enforcement officer thinks that you're a mere civilian, you might expect to be treated as a mere civilian.

Conversely, if American lawyer, physician, or law enforcement officer is immediately informed that: My son is an attorney; I've taught Anatomy & Physiology; I won a unanimous Opinion in California Supreme Court which your Supervisor might want to review -- then there is a chance for "professional courtesy."

See also "Rollerball" -- if you work for the Food sector of corporate-owned-Future-USA then you eat well...

187:

"best thing to do , once a rational government gets in, is to immediately nationalize all their toys. no money paid. and then promise that you'll do it again, if they're ever privatized in the future
stop these vampires building empires"

right on comrade!!

188:

Jim Smith @ 131
Ignoring the ad hominems, can you explain how Scotland is viable, given the "Barnett formula"?
And I did politely refer you to Charlie, who knows A LOT MORE THAN I DO on the subject ....

Ian Aitken @ 135
Actully the railways are a lot safer now.
The screw-ups which killed people when Railtrack (shudder) were "In charge" had a salutary effect.

Dirk @ 138
A good modern railway carriage will cost approx £250 -500k AND is expected to last AT LEAST 35+ years, and run 50 Million miles+ - which is why they cost.
Go figure.

guthrie & Robt Sneddon et al
& - everyone
Yes at least 1/5th of all railway journeys are London-based, but rail travel is really increasing - I'm involved in this peripherally, I help out doing passenger surveys and counting, and the numbers are scary.
It's not unusual to get peak-hour trains into Liverpool Street, Victoria or Waterloo (of 8 coaches) disgorging over 1000 passengers.
...se also Brett Dunbar @ 143!

C @ 148
YES!
I have heard this also from a US resident who know
we spend money on children's illnesses, but the USA spends it on people who are going to die anyway.
BUT we have the Hospice movement ...
A very important cultural difference, which I'm not going to delve into now.
Please do your own resarch on this one!

Dave Bell @ 162
Higher income earners DO NOT benefit from reduced NI contributions.
Someone has sold you a pup, there .....
Share income is still INCOME - and it adds up, so worng again.
Ask my wife, she's the TAX expert!
Jim Smith - it's INCOME - see above.
If total income exceeds higher-rate limit, they pay more tax.
Simples.
Or were you asking a different question?


189:

Same thing happened to me when I took a three week vacation in Germany some years ago. I had a big infection, a really big lump between my toes on my foot. I was immediately taken to a doctor, who drained the infection, bandaged me and gave me a few pills. Where do I pay for this? You don't. Can't I pay for the bandage or the pills? No!

190:

Here's my tin-hat conspiracy understanding of why it's so hard to get national payer health care in the US.

It's about Jobs in Ohio.

See, about 8-10% of the Ohio workforce (~79,000 of ~810,000 employed in the private sector) are in insurance. Of those, 13,600 are in health insurance

National healthcare would gut the American healthcare insurance industry. Many of their jobs are duplicates, brought about because there are a bunch of companies competing with each other. Under US national insurance, there would be no need for the marketing apparatus associated with competition.

Anyway so if you nationalize healthcare, you put a bunch of people out of work in Ohio.

The problem is, Ohio's one of the key battleground states in the Presidential election. The state is pretty evenly split old liberal north vs. ultra-conservative south, and it's had more than its share of economic problems. Those insurance jobs would disproportionally hit in the blue northern part of the state, which would cost the democrats the key voters they need.

While it would make a lot of sense for the Republicans to impose national healthcare, just so they could win in Ohio, I don't think that would sit too well with their base. The democrats won't do it, because they don't want Ohio to go republican again. Hence, we're stuck with the mess we're in, until Ohio finds some other way to employ its citizens. Maybe in the fracking industry or something.

191:

Greg, I was checked the rates on the HMRC website at http://www.hmrc.gov.uk/rates/nic.htm

Unless they're not mentioning something, Employee's Primary Class 1 rate is 12% on earnings up to the upper earnings limit, and only 2% on income above that.

192:

Mine doesn't. It's an HMO style plan through the university's health center. All of the medical personal are employed by the university I work for, and all of the facilities owned by them. They also have a hospital partially owned by them if I need that.

No premiums, but a small copay on drugs. They tell me it is worth about $12,000 for the 2-person coverage I have. Though I don't know how they arrive at that figure -- are they dividing the costs by the number of people covered or looking at what comparable coverage from external insurers would cost?

193:

Yeah, when people have to pay they cut back. Fewer doctor visits until it gets really serious. That's why most dental plans cover cleanings once or twice a year, for example.

The same thing works with sick days. If you combine sick and vacation into a paid time off pool - giving people the option to spend the time off however they like - call out sick less and are more likely to come in when they are ill. They view the PTO as vacation time and see calling out sick as wasting a vacation day. It doesn't matter if the total number of these PTO days are the same as the vacation + sick they had before...

194:

Sarcasm? Yes, after we, and our employers pay medical insurance, we have to pay again to see a doctor, can't have anyone getting something for "free". Sort of an example of how welfare for business works, the government mandates as many people with their hands out between a citizen and a needed service as possible.

195:

"Indeed, and US hospital pharmacies charge upwards of $10 for two aspirin or ibuprofen tablets for pain relief. They're "cheap as dirt" to the pharmacy, not to the patient."

Overhead. If you want to go to the store yourself and buy some advil to take in your house, it's cheap. If you want a trained professional to hand you an ibuprofen in the middle of a rather expensive building, it's ten bucks.
Compare it to making coffee yourself versus buying coffee at Starbucks.

196:

"Personally, I was impressed by the 20-fold difference in absorption rates between skin and rectum. That's useful information, but it speaks to the dangers of using rectal administration."

Well...for some drugs. Others, it won't make a bit of difference. (Acetaminophen/Paracetamol is the same going either way, for example).
Now, figuring out all the things that affect drug absorption and bioavailability (how much makes it into the bloodstream, from what makes it into the body) is a bear. It varies by drug, by route, by vehicle (some things are absorbed better from creams than ointments, other things vice versa), by presence of food, by presence of fatty food, and probably every damn thing but phase of the moon.
Then we move on to problems of distribution- once it's in the body, where does it go? Some stuff likes fat and so a double-chub patient's going to respond differently than a skinny one. Some stuff it doesn't matter.

Mind you, knowing this makes the "grapefruit juice cocktail" assassination in Rule 34 more interesting- trying to figure out exactly how plausible it is- it's godawful mismash of drug-drug, drug-enzyme, and food-enzyme reactions, all going in the body through a slightly unconventional route.
(Final opinion- if the guy absolutely, positively, 100% needed to be dead, I wouldn't count on it...but I'd sure as hell warn anyone trying it not to)

197:

"You have to pay to see a doctor?!?"

You don't pay a tax specifically for your health system?
You pay for the option to see a doctor, whether you see one or not, and for everyone who is consuming more in services than they pay in taxes. On the other hand, you know the maximum cut healthcare'll be taking.

It's fairly efficient to just smooth what everyone's paying into an average and go with that...but in the US we have a tendency to argue from a fairness angle rather than a compassion or risk management angle- and once you start doing that, it gets surly quickly.

I suspect it's related to the oddly high US level of optimism- rather than seeking to cap your maximum cost if sick (because we could get brain cancer tomorrow), we'll try and minimize the chronic expense when healthy (because we're all eternally youthful and healthy! Rah!).

198:
Jim Smith @ 131 Ignoring the ad hominems,
You don't know the meaning of the phrase, although you use them all the time. "what are you drinking...", "delusions" Learn
can you explain how Scotland is viable, given the "Barnett formula"?
How about you address the points I made? The Barnett formula is a recipe for funding within the United Kingdom. It isn't a description of Scotland's economy. Can you describe which parts of the Barnett formula say Scotland isn't viable?
And I did politely refer you to Charlie, who knows A LOT MORE THAN I DO on the subject ....
You didn't do anything politely.

You can't "refer me to Charlie". If Charlie wants to argue with me he can choose to or not. I've read most things Charlie has posted here over the years. I agree with most of it but not all and if I felt strongly enough about the points of disagreement I would post to say so.
Just because Charlie knows more than you, it doesn't mean he knows everything, or is the ultimate authority. That sounds like a "My daddy is smarter than your daddy" argument.

Anyway, time to stop feeding the troll.

199:

Greg: "Dave Bell @ 162

"Share income is still INCOME - and it adds up, so worng again."

Sort of. It attracts income tax from an individual recipient at the same rate as any other form of income but it doesn't attract NI (employer or employee) and can also provide a mechanism for splitting a single income stream between two recipients to make full use of tax allowances.

If what you do for a living is compatible with a freelance or consultancy model, you can clear the (not totally unreasonable and far from insurmountable) hurdles HMRC set, and your income puts you into the 40% tax band then making a non-working (or otherwise low earning) partner a shareholder in a Limited Company and paying a substantial chunk of the companies income out in the form of dividends rather than PAYE salary will make a substantial difference.

I did exactly this (not something I feel particulalry proud of but it allowed my wife to give up a boring job which she hated to stay home when our boys were tiny and I was working away from home for extended periods so what are you going to do...?) and when a couple of years ago a company closure forced me back into the contract/consultancy employment model I thought I'd escaped from the model was still viable and the numbers hadn't changed appreciably...

200:

That is all perfectly reasonable, widespread and legal. The freelance job market wouldn't work without it, and if you have diverse sources of fee income it is indispensible.

The income splitting thing is slightly dubious, but no biggie.

Where it becomes wrong is when senior civil servants and heads of quanqoes are paid on the same basis, thus avoiding substantial amounts of tax and NI. There have been a number of cases reported over the last couple of months.

201:

"Except that in fact they are barred from use of them, for the very good reason that correcting for genetic risk in no way involves any meaningful feedback loop about resource allocation --- if the middle class in the US doesn't feel that they have safe access to health care, you're going to see a collapse of the entire cultural infrastructure."

We've seen steady reductions in safe access to healthcare by the middle class in the USA for a couple of decades now, and the cultural infrastructure hasn't collapsed.

Warped and changed for the worse, perhaps, but it has not collapsed.

202:

"People don't get to choose their own genetics; from an individual's perspective, it's random. There will be some who will be fortunate; others who will be subject to horrific disease. (Probabilistically in some cases, but with near-certitude in others.)

Is it really moral, fair, or humane to target such people for much higher healthcare costs than the rest of us?"

Also, the odds are that everybody carries at least one major, known genetic timebomb (aside from mortality), which means that everybody will probably be unable to insure at least one likely major medical condition.

203:

"Do we need to worry about this? Labour are opposed, so at worst we'll have three years of silliness before Milliband rolls it back in 2015."

When the goal is destroying a system for the profit of the elites, one can do a lot in three years, and one can do a lot which is very, very hard to reverse.

It's easier to paddle downstream than upstream.

204:

If you want help 'hyperlinking' to information on the 'internets', you could just ask :)

205:

Slightly different: when in hospital being approached every 90 minutes (or was it every 2 hours?) and asking if your're in pain and want a painkiller. If you were, its a paracetamol (or ibuprofen, alternately?) and 10$ on the bill.

Not so much like going to Starbucks, more like abusing a semi-awake patient to fleece them. I've heard of a friend walking out of hospital, wondering why they were so determined he took so many tablets, then seeing several hundred for paracetamol on the hospital bill.

206:

"I don't have a particular problem with healthcare providers making money. Or with management consultants doing there thing. I am ready to believe that a profit motivated private company could provide a better service at a lower price than a team with a guaranteed source of direct government funding. Or not. Colour me neutral."

As has been pointed out (see Krugman for examples), it it pretty clear that in healthcare, government-run services tend to outperform private services for many things.

207:

"Why, where would they be able to live afterwards, with their ill-gotten loot?"

I know that you're speaking tongue in cheek, but everybody should remember that a country can be quite trashed, and the elites can still live quite well.

208:

When I was a student, we (on behalf of the ward resident[1]) would do the daily blood-letting, collecting samples for a battery of tests. One american patient got quite exercised about the number of tests we were doing. It wasn't until later I realised he was probably worried about costs.

Back then there wasn't much fuss about foreigners getting free care in the NHS as someone upthread mentioned. I think they are stricter now.


1. Different from an american resident I think. The most junior doctor, less than a year out of medical school, known then has a House Officer. Called resident because they lived in, on call.)

209:

"The NHS is about the closest thing the UK has to a sacred institution. Cameron is playing with fire."

Thatcher played with fire quite a bit(from my USAian knowledge) and got away with it. It's true that she had to keep her hands off of the NHS, but that could be viewed as 'one thing at a time', and she did lay the groundwork for the Tories now.

210:

"At least Scotland already has a border fence that's been laid out since Roman times."

And look at the good side - this would make for a great reality show: 'Were you a Tory? (or L-D)'.

Refugees could be screened at the wall, and those with a Tory/LD record could be forced to justify their admission to Scotland. Those who failed could be (literally) tossed back. Follow-ups could be done, to see what happened to them.

211:

"That border fence is all in England. and sited to stop the Scots coming south."

Just turn the stones and ditches around :)

212:

I really do think the UK "free at the point of access" system is really one of its strengths. It removes stress from patients, it removes one quite serious barrier to access (dentistry isn't free, although very cheap, and people do avoid going to the dentist on cost grounds). And there is none of that embarassment over how much to tip.

Everything you get in hospital is free. Your "discharge drugs" are free.

In England, you pay £7.40 per item for out of hospital prescriptions, but children, pensioners, pregnant women, welfare recipients and people with certain long-term illnesses don't pay. There is also a kind of season ticket which saves you money if you don't qualify for free prescriptions but need a lot anyway.

In Scotland and Wales prescriptions are free.

213:

Dave Bell @ 191 & J Green @ 199
Yes, so?
"National Insurance" is PART of the tax system -= it was originally supposed to be "ring-fenced", but now of course, it's part of the general taxation pot.
Higer-rate taxpayers pay less NI above a certain figure (I forget what) but also above (a different IIRC) figure personal allowances are frozen, whilst, of course, Income tax continues to take more money i.e. it is "progressive" as it should be.
There are (quite strong) indications that the so-called 50% highest-band tax rate is counter-productive anyway, though I would strongly suggest that none of us should be getting into that particular argument, or not now, at any rate.
My wife is the real tax expert round here - that's what she earns her money doing.
Her principal complaint is that the UK's tax system is too complicated - yes, she would prefer to have less work to do (!) - and that all that happens at present is that the cheating just gets more inventive.
One of the reasons for complaints and witchunts about "avoidance" as opposed to "evasion" at present, in fact, is that all guvmints have not actually simplified the system.
And "soaking the rich" and "making the top band pay 90%" is not an answer, any more than the US system of soaking the poor is an answer, either.

The present debate seems to be concentrated on finding "Villians" rather than looking for causes ... which can not, ever find a viable answer, really.
I'm reminded of the sacandal over MP's expenses.
Where the true cause was (is) the ridiculously LOW wage handed out to MP's, which was then supplemented by a byzantine and sususceptible expenses-claiming arrangement. And which still has not been fixed, incidentally.

Jim Smith @ 198
The Barnett formula ASSUMES that Scotland is poorer, and more in need of suport and guvmint cash, and needs preferential treatment wrt the rest of the UK, and specifically, England.
You are saying this is either irrelevant, or not true, then?
You appear to have also carefully ignored my own comment(s) which state that I'm in favour of devo-max ...
Or are you deliberately trolling in Salmond's favour, to get a rise out of me - in which case, you succeeded - wasn't that clever of you?
Meantime [Note] Charlie lives in Scotland, has daily contact with the issues that I don't see so much of, and I usuallly respect his opinions, even if I disagree with him (like the desireablity of "us" having nuclear weapons as a last-ditch "defence" for example).
BTW, PLEASE, everyone, we don't want to discuss that particular one in this thread - it's just an example.

Barry @ 203
Yes.
Rail privatisation being the classic example.
Why Camoron is doing this, contra to all the pre-election party manifestoes, is anyone's guess.
Unless he has had his arm twisted by people behind the scenes?
( Do I now need a tinfoil hat? )

[Note: "Meantime" is also a prize-winning brewery in London, in Greenwich, hence the name; do try their beers!]

214:

Greg, instead of regurgitating Daily Snail lies, how about checking the National Audit Office figures? According to the NAO, Scotland pays about £1000 per capita more of UK taxes than it receives in expenditure,: The real subsidy junkies are in London, where the expenditure is about £300 per capita higher than the tax take.

215:

The break point for the season ticket is about 14 prescriptions in a year (it's a bit more if you have shorter run season tickets, but only about 16/year on the shortest term one).

Since GPs are encouraged to only prescribe a month at a time, if you have more than one medication to take routinely the season ticket makes a lot of sense.

And it's also worth pointing out that most GPs and chemists will point you at generic OTC medicine. Paracetemol is about 2p/tablet if you buy it off the shelf. Ibuprofen other than branded names a similar price.

216:

Thatcher's big crime was cutting off state subsidy from various industries, and letting them fail. Most notably the car and coal industries.
The big privatizations eg telecom, water etc were quite popular. Anyone who can remember dealing with the Post Office, later to become BT, will remember why.

217:

"If a young woman is lucky enough to have a combination of genes associated with a much lower than average incidence of breast cancer, then would she be prudent to reduce her out-goings by opting out of breast cancer coverage?"

I *think* that in general, in the USA at least, that individuals have little such selection power.

218:

As a Northumbrian by upbringing, I'd welcome an independent Scotland from Hadrian's wall upwards, but I suspect the border would probably be the present-day one.

My S.O. and I are already talking about moving across the border; her greatest worry is that of deserting England & Wales to the Tories, but I reason that that's what democracy is about. Thought experiment: you have a country, with two major political parties, which are pretty evenly matched. Fortunately, their supporters are pretty simply geographically distributed; you can draw a line (indeed, there's already perforations) and separate the country into two regions, each supporting one of the parties by a huge majority. Isn't the best thing to do in the circumstance to split them up into two nations, which we might refer to as Slovakia and the Czech Republic? Otherwise their democratic gov't will remain beset by Multiple Personality Disorder, without any clear direction or principle, and both sides will constantly blame the previous administration over and over until the whole place sinks into the Atlantic.

219:

as a researcher with an (albeit, personal) interest in pharmacogenomics: Having an ultra-fast way to sequence the human genome is brilliant. The primary bottleneck, however, is understanding that massive chunk of data you've just generated.

This problem has been highlighted in some recent research projects looking at cancer mutations, of which the Cancer Research UK blog did a pretty good layman's summary: http://scienceblog.cancerresearchuk.org/2012/03/07/on-the-origin-of-tumours/.

I'll just steal a paragraph from it:
'The computers that power LRI’s next-generation DNA sequencer form a huge black monolith that now takes up half of the building’s 7th floor. Swanton and his team used it to analyse the entire genomes of seven individual samples taken from a 10cm wide tumour that had been removed from a patient’s kidney. This was a Herculean effort that saw the machine running flat-out for four months solid.'

That's 7 genomes. 4 months on a not-too-shabby supercomputer.

The level of investment needed to roll personalised medicine out to millions of people would be insane. Why would insurance companies bother if they can just say 'no' to people for a multitude of irrational reasons anyway, as lots of cases in the US have shown?

220:

You obviously didn't get the memo; you're supposed to be talking up Iran. Iraq is to stuffed in the memory hole.

221:

And it's also worth pointing out that most GPs and chemists will point you at generic OTC medicine. Paracetemol is about 2p/tablet if you buy it off the shelf. Ibuprofen other than branded names a similar price.

Indeed. I have joint problems and buy a lot of painkillers. Sainsbury's is your friend.

I was once carded in an Asda because I was buying a lot of Paracetamol and Ibuprofen at once before goind on holiday!

On the other hand $MIRACLE_DRUG is also £7.40

222:

Note - I tend to skip over Greg T's remarks, especially as he uses some really bad formatting, and mashes multiple replies together. There's simply not enough good stuff to justify the pain of reading it.

"That's a double plus special yellow card for saying fuck again."

Actually, they just take the existing yellow card, and pass it through the pub for a good p*ssing on.

223:

"The tongue/buccal mucosa has a similarly good blood supply to the rectum ...."

I would phrase this as 'has a good blood supply, comparable to the rectum'.

Unless there's a new blood vessel that I'm not aware of.

224:

"You have to pay to see a doctor?!?"

In many cases, yes.

Just when you thought that the US system was only so frightening,.................................

225:

Critical typo in the last clause. It should read:-

The real subsidy junkies are in London, where the expenditure is about £3000 (Three thousand pounds) per capita higher than the tax take.

226:

"BTW, dissolving a drug in DMSO and water can result in very rapid skin penetration. So quick that you can taste the DMSO within 30 seconds of applying."


Which means that there's a massive spike in the dose; I'd guess that for practical purposes this would be like an injection, if not an IV injection.

227:

Yeesh! Do you have a source for those astounding numbers? I'd like to be able to use them on other people...

228:

"Moral being, bring your own"

They **************really**************** don't want that; when somebody's admitted they'll not only ask for a list of prescriptions, but they want anything that the patient has on them.

Otherwise the hospital and the patient are administering drugs, with little coordination.

229:

You don't actually have to sequence the entire genome. You won't know what to do with it anyway. Just screen the known mutations. You know: primers, PRC, sequence... couple of days and you are done.

BTW, those researchers in the article? They were sequencing much more then just 4 genomes. As far as I understood, they were sequencing the samples many times to study the heterogeneity of the tumor cells.

230:

Solution: ask friends to bring you your own drugs and refuse to eat hospital's.

That almost what happens in Russia. Hospitals simply don't have drugs. They tell you what to buy. Oh, you are unconscious and have no friends? Peace be with you...

231:

One source for the Scottish figures is the

GERS site I linked to above.

GERS (Gov Exp and Rev in Scotland) was actually set up by the UK Labour government with the intention of showing that Scotland could go it alone, but the figures have actually turned out the other way.

232:

Like catastrophic failure in mechanical systems, catastrophic failure in civilizations is nonlinear. A support member can take stress up to some point, then suddenly collapse, and I expect the US health system is going to do the same. The other point about nonlinearity is that it makes predicting where the collapse will occur very difficult. But there's one point of failure that's been obvious for decades: corporate and government raiding of retirement and health care funding has set us up for a massive collapse when the bulk of the Boomer generation hits the high maintenance years, say in about 10 years.

Me, I'm planning on taking a trip into the mountains when I get the news of imminent cognitive failure, finding a nice ravine somewhere, and taking a massive dose of something to stop my heart (suggestions, Charlie?). I'll let the coyotes and the worms do the cleanup, and keep my relatives from having to throw all their savings into a deep hole to keep me going as a vegetable.

233:

showing that Scotland couldn't go it alone,

234:

http://en.wikipedia.org/wiki/Euthanasia_in_Switzerland

Alpine meadows. Snowy peaks. DEATH.

Accept to substitutes.

235:

I'd like to take exception to your proposed test; some of us voted L-D in the expectation of them entering a coalition with the other bunch. Because, you know, their pre-coalition policy platform looked a lot more left wing than it does today.

Maybe if you asked, "did you vote L-D again after 2010" ...?

236:

"The computers that power LRI’s next-generation DNA sequencer form a huge black monolith that now takes up half of the building’s 7th floor"

That's about 20 years away from something that fits in your pocket.

237:

I suppose it might well result in a big spike, but it really depends on the size of the molecule being transported. I have yet to try mixing DMSO with a few milligrams of (say) codeine and wiping it on my arm. Something like copper salicylate, the transport is not all that effective. NaCN, OTOH...

238:

Wrong. That's 0 years from something that fits in your pocket.

http://www.nanoporetech.com/technology/minion-a-miniaturised-sensing-instrument

239:

Think of Greg as the resident shouty old man. He's known to people in real life and been around long enough that you screen out a lot of his stuff without thinking about it.


Having said that, don't be silly greg, nobody is talking about 90% tax rates, and they'd never pass any sort of representative parliament. All we want is the corporations and rich folk to pay their already lawfully agreed percentage instead of finagling it and bribing people to look the other way etc etc. Then we'd get a good 10 to 20 billion more income which would be enough to sort out lots of problems.

Come to think of it, any sort of 90% tax rate is a bit silly, although I seem to recall that some commenter here had found a little issue where you got over 100 % on some money in certain circumstances. Why not just nationalise it all if you're going that high.

240:

"Taken together the measures would facilitate the transition from tax financed healthcare to the mixed financing model of the United States"

As a beneficiary of above healthcare system, I'll attest to the bizarre/dysfunctional toboggan ride that trying to treat any major illness is in this country. Debilitating anemia caused by Leukemia, or Multiple Myeloma? Better Hope Not! Because you if you can't work, you don't have the insurance you need to pay for the treatment.

241:

That's 7 genomes. 4 months on a not-too-shabby supercomputer.

Now let's apply Moore's Law. (I'm going to assume for the time being that it keeps on rolling ...)

7 genomes in 4 months = 7 genomes/12 million seconds of supercomputing time = 1.7 million supercomputer-seconds per genome.

Apply Moore's Law and ten years later that's 1.7 thousand seconds of supercomputer time, on an equivalent machine, or about half an hour per genome.

Assuming we're looking at something on the order of, oh, a high-end Cray from the old days, we're looking at a machine costing on the order of $20M to procure, obsolescent after 5 years, running costs of well under $1M/year. So $5M to write down per year. That gives us 17,520 genomes per $5M or a bit under $300 of supercomputer time per genome.

(Whereas it's costing $300,000 per genome to do that analysis today.)

Now, you can argue that Moore's law won't continue, or that I low-balled the supercomputer's price by an order of magnitude (whoop-de-do: it adds a couple of years to the price curve) but if we posit the continual progress that we've become used to over the past 50 years, then it is reasonable to assume that personal genomics will become cost-effective within around a decade.

242:

Eloise @ 215
What about "Repeat Prescriptions" ??
Once you have one of those, you only need to go to your (designated) local pharmacy, give your name, and the prescription(s) description.
Bingo!

Paws4thot @ 225
Ah, is that PERSONAL tax-based, and ignoring the erm, corporate and business-tax-take from London?
I suspect "The boss" would disagree with you to the point of ripping your head off - so I won't tell her!
& dr_demento @ 227
No, as a Londoner, I don't believe it, either.

Jim Smith @ 231
Now, isn't that interesting?

Charlie @ 235
Yes, well, that's happened down here, as well.The local LD's have been "entritifed" by a religious grouping - so neither of us will vote for them.
The local tories seem to be to the right of Thatcher, rather than being with MacMillan, and the local MP is Stella Greasy, oops, Creasy ....
Now what? - We don't have Monster Raving Loony candidate - who would look sriously sane compared to these goons.
Sigh.

243:

Anatoly, you're confusing the sequencer with the sequence matching that is performed on the data it delivers, after the event. Which is indeed still a big-time supercomputer chore. (But see my comment above about Moore's Law.)

244:

I think Moore's Law had got at least 20 years left in it, and possibly up to 60 in the original form. Think printing on tens/hundreds of square metres of graphene sheet and rolling into a tube. However, there are indications that we might hit a different barrier before then concerning diminishing returns in power per bit processed.

245:

how would you define the set of 'known mutations'? There are some, of course, which are well known, things like Duchenne muscular dystrophy, several other inherited genetic disorders, some oncogenes etc.

Many others have a lot less evidence backing them up, and as we develop a better understanding of the genetic links to the development of disease, things are going to change significantly (as the researchers discuss in my link above: individual sites in one tumour displaying totally different genetic mutations is quite a jump in our understanding.)

As regards the multiple sequencing aspect: a 'normal' sequencing run requires a x40 coverage, meaning that the sequence has to be read 40 times to ensure the fidelity of the sequence. The median coverage in the study I cited was around x74 (at the identification stage, this increased for other parts of the study)

246:

If you believed that then you were ignoring a lot of pre-election reports that said Labour were not interested in sharing power with the Lib Dems. They would quite happily accept votes from the Lib Dems to support the Labour Party's policies (like the National ID scheme, for one) and keep the Tories out of power but letting them get involved in setting policy, giving them Cabinet seats, indeed permitting them any sort of constructive input to the political side of things? No way. Of course the Blairites figured that the Lib Dems had nowhere else to go -- who'd have thought they'd cut a deal with the Tories? Not the Super Geniuses in the Labour Party HQ.

247:

Since much of the comments have been about primarily English speaking areas such as Canada, USA and UK I thought I would point out that an article about health cast issues in Costa Rica has been published.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2960380-8/fulltext
I am not an expert on Costa Rica or the Costa Rican health care situation but I found it to be an interesting article.

248:

I'm half expecting someone at the GOP convention to play "Bomb, bomb Iran", (A 1979 parody to the tune of "Barbra Ann"). Mass destruction works so well at distracting the little people.

249:

You still pay the £7.40 per item. It's items on the script that cause the charge, not visiting the doctor.

250:

The older, more industry oriented readers will recall the tendency in the 50's to 70's for medium sized companies to do quite well growth etc wise, until they got above themselves and got offices in London, miles away from the factories and essentially in a different economic culture. Thus leading to inefficiencies and lots of new expense on the London offices.

Of course London gets lots of money because of corporate taxe and suchlike, that is the value of being the centralised head of the nation and stuff the rest of the country. Companies need to locate there because that is where the bankers and politicians they need to get money or subsidies from, are. If you have a devolved Scotland they'll have to have some representation at Holyrood.

251:

Er. I wasn't trolling. I *was* objecting to the view that the NHS is a wonderful sacred cow and is therefore exempt from criticism.

Anyway, it seems as though my tone was off. From memory i was having a bad day; I'll try to be a bot more objective in future...

252:

bit, dammit, not bot. Sigh. Mondays.

253:

Eloise @ 249
Unless, of course it's related to contraception or you are over a certain age .....
( one for her, and one for me! )

Tingles @ 251
I agree.
Like I said, a LONG way back up, the NHS needs reform.
But this one ain't it!

255:

Of course the reasoning of the NHS bill becomes obvious when you investigate systematically who gains-

http://socialinvestigations.blogspot.com/2012/02/nhs-privatisation-compilation-of.html?m=1

As with the corrupt awful management of the economy (designed as always by thR Tories to increase unemployment to suppress wage demands and enrich Tories multinational backers), privatisation and dismantling of public services etc there is a wholesale corruption of politics. We are living in a kleptocracy with the givernment enacting policies that enrich its members and backers.

This is only possible due to the media. And the only resistance we can mount us direct democracy

256:

This all assumes your Conservatives haven't taken a whack at the NHS beehive in order to keep attention away from something else they would like you to miss...

257:
Here's my tin-hat conspiracy understanding of why it's so hard to get national payer health care in the US.

And here's my Murder-on-the-Orient-Express version as to why health care costs are so high in the U.S.: it's because they're all in on it. Yes, everyone is in on the scam in this version - the insurance companies, big pharma, the hospitals and the doctors as well as a couple of other bit players. Every actor in this scenario figures that hey, the system is corrupt anyway. So why not carve a piece out for yourself?

This version of what's wrong with USian health care also neatly explains why reform is so hard; it's because every point of attack is so zealously defended by corrupt guardians. It also serves as a cautionary tale illustrating the dangers of systemic corruption.

258:

"Like catastrophic failure in mechanical systems, catastrophic failure in civilizations is nonlinear. A support member can take stress up to some point, then suddenly collapse, and I expect the US health system is going to do the same."

This is an assertion by analogy, and without proof. A 'collapse' could happen over decades. To history students 1,000 years from now, of course, it'd be viewed as instantaneous - 'during the 21st century....'

259:

American healthcare does really suck. Most healthcare here, and that's offered through the current corporate entity I work for, are "deductible" plans of the high or low sort. Both suck. Basically you pay up to a certain amount like $1500 or $2500 USD then the insurance will start to pay a certain percent of all costs after that. So one would still be paying a lot of money out while the insurance pays little or nothing. Mine, I think, would pay 25% of costs after my detectible is met. So what most current healthcare in the USA is just paying the insurance companies for the privilege of being "insured" while they actually offer little or nothing in return. So you pay money for something you don't use (if you're in relatively good health that is) and then pay more money for when you need to use it. The monthly fee doesn't go toward the deductible amount only what it costs to go see a doctor. "Pay and keep paying". Anything that cites American medical care should be avoided like the plague.

260:
Of course the reasoning of the NHS bill becomes obvious when you investigate systematically who gains-

http://socialinvestigations.blogspot.com/2012/02/nhs-privatisation-compilation-of.html?m=1

As with the corrupt awful management of the economy (designed as always by thR Tories to increase unemployment to suppress wage demands and enrich Tories multinational backers), privatisation and dismantling of public services etc there is a wholesale corruption of politics.

This goes hand in hand with my pledge not to argue economics with family members any more. They're for the most part over 40 and as a consequence are dead certain they "understand" economics whatever formal instruction they have had in the subject and however far back in the past any instruction (formal or otherwise) lies. As a consequence, pointing out just what a free market entails, for example, is going to fall on deaf ears.

But the arational arguments - ah, they're primed for those. I get a considerably more sympathetic hearing from those same relatives when I emote about how the insurance companies or the banks or whatever are Ripping Us All Off.

So the good news is, I guess, is that the American people are getting there. But - just like space exploration - it's taking a lot longer than a lot of us would have liked :-)

261:

That is frighteningly possible, but the NHS is such an emotion-arousing target that just as a distraction it could kill your political hopes. And there is such a pattern of abusive behaviour from these scum that they will be lucky to get re-elected.

The scenario I can see is that this move would encourage Scots devolution, which would give the Conservatives a majority in Westminster-without-Scotland.

They'd have to lose big-time in a post devolution election before anyone else would stand a chance.

262:

We can nitpick about the procedure but Barry's idea sounds like fun nonetheless (using catapults to toss tories back south of the border would make for a fantastic webcam/screensaver, too).

On the general question of a possible Scot secession and "have the englishmen gone bonkers", what do you make of this, Charlie ?

263:

You said:

We've seen steady reductions in safe access to healthcare by the middle class in the USA for a couple of decades now, and the cultural infrastructure hasn't collapsed.

Warped and changed for the worse, perhaps, but it has not collapsed.

Which sounds to me like you're saying that it hasn't collapsed so it's not likely to. I disagree, and I gave a reason why I think it could collapse quickly (and an example of the cause of such a collapse, which you didn't address); you disagree and say there could be a slow collapse, which is an assertion equally without proof. We'll see who's right in the next few years.

264:

Moore's Law: What if it DOESN'T have a limit, at least within the next century or so?

The new Theory of Everything explains that the quantum limit isn't really a limit after all....

265:

Let me rephrase it - in the USA, we've seen 30 years of reductions, harming the majority of the middle class, and the political system has had little problem with this. Individuals, of course, have been devastated.

I see no reason why things (for most people) could not just get worse, and then worser.

This idea of things failing suddenly is just wierd - how many times has that happened in Western societies?

266:

Can you give me a pointer as to which black hole my earlier comment fell into? It didn't get posted.

267:

Why restrict it to Western societies? Even if you do I would count the beginnings of civil war or other major civil unrest to be a sudden failure. So the English Civil War, the American Civil War, the French Revolution, the Revolutions of 1848, and for that matter the First World War, all count. If you want a more recent military event, the economic meltdown of 2008 was a rather sudden and very catastrophic event in which millions of people had the economic rug jerked out from under them.

268:

I think governments rely on people failing to understand the implications of their policy choices. Explaining the economy is fairly simple but it takes 2,000 words whereas the media will take 20 out of context words to explain a policy.

269:

referring to @ 225 & 227
Again
Re the idea that London is supposedly a tax drain (!)
You what?
Excuse me, but whoever origonally suggested, before it was passed on to this dicussion, was talking bollocks.
It is exactly the same as the rethuglican states in the USSA claiming that "the coasts" are draining all the subsidy and leeching off the rural hardworking rugged ....
Whereas it's the other way around.
I'm told that a city of about 100 000 or more is a net generator of tax revenue. (Source - the boss)

270:

Ascerbic letter sent to my local lLabourMP, ascerting I'll not vote for them again, if they back this. (For all the good it will do.)

Have to say I'm a little peaved at the attitude that seems to be coming out,of wishing to leav the English to their apparent chosen Tory future. As someone of mainly Scottish dissent born in London, from a generally Labour voting family. I'd like to highlight the obvious. England is a more populas and diverse country than the other nations in the UK. Tory support is clumped in pockets of generally middle claass, suburban or comparritively afluent rural areas. They are not the party of the urban working class or the rural poor. Key marginals decide general elections and millions are spent on chasing these few thousand voters. I'm not endorsing Labour but just wouldn't like our US friends to get the impression the English can be characterised as backing this government. And bares repeating these NHS reforms were not outlined to the electret in 2010 other than in the vaguest terms of needing reform due to spending constraints.

271:

Well, excuse me for thinking that the National Audit Office is likely to be a more reliable source of economic data than your Significant Other! ;-)

272:

Appologies for spelling errors. I'm using a screenreader and have no spellcheck on here. (Plus I should be working.)

273:

Do we have to remind you that Scotland has twice as many Giant Pandas as Northern Ireland, Scotland and Wales combined do Con Party MPs?

274:

ha. Not at all. But that's my point. I'm not anti Scottish independence. How could I be. It's not my choice. But what's being done to our public health infrastructure isn't about the broad political differences between England and Scotland. The neoliberal vandles and theives are a threat to all but the super rich.

275:

paws4thot
You are claiming that London is a nett drain on the revenue of the country - yes or no?
London MAY get more support in tax spend, but how much revenue does it generate?
In other words, is London a NET generator of revenue, yes or no? (Repeated to try to get measasge across!)
Which is the question I thought we were trying to answer .....

In Scotland, f'rinstance Edinburgh, Glasgow, Dundee, Aberdeen are garuanteed revenue-generators.
More people, paying more taxes.
Who will also require more support, because there are more of them.
Now, which way do the overall equations balance out?

276:

You are claiming that London is a nett drain on the revenue of the country - yes or no?
NO! I am quoting the NAO figures. If you won't accept figures from the definitive source on UK Government expenditure then you are in fact Trolly McTrollerson of the "Underbridge Times", and I claim my £10! ;-)

277:

I think that one of the things which complicates the issue is that businesses and the financial markets can be "living" in London, and not "working" there. British Aerial Equipment could be making trampolines in Sweden and vaulting poles in Los Angeles: if the head office is in London, is that where we should place its wealth creation? If Vintage Sausage Enterprises Ltd owns a butcher's shop in Barrow-in-Furness and has a formal legal address at a Solicitor's office in East Finchley, which one matters for where the money is made?

I don't have an answer, but I can see how people can disagree.


278:

I think you completely misunderstand London and why it is such a significant economic centre.

In *economic* terms London is - and always has been - a trade-oriented city, not a government-oriented one. In fact a smaller proportion of workers in London work in the public sector than the national average (quite the opposite of, say, Edinburgh) and a higher proportion in private business. Public expenditure in London is slightly more per head than the UK average - mainly due to higher wages - but is lower as a proportion of local GDP.

You seem to think that growing businesses get too big for themselves and go to London to die. The opposite is true. Small businesses tend to start in London and move out. The place is a net generator of new businesses.

And London-paid tax subsidises the rest of England (though not, particularly, Scotland). By quite a lot. The real subsidy-junkie region in the UK is Northern Ireland. Parts of Wales don't do so badly either. (Just one of many reasons why Welsh nationalism is much less focussed on complete indepenence than Scottish)

279:

paws4thot @ 276
So that's "don't know" then?
I quite accept the figures on tax expenditure per resident in London.
What I want to know is the REST of the equation, otherwise we don't have a picture, at all, do we?

280:

Patience, it's only a matter of time before the ultra-materialist money worshipers devise a financial scheme beyond the ability of central bank compensation, and the festivities will be for everyone.

281:

Iain Aitken wrote: I work in the railway. The privatisation has not worked.

BR privatisation wasn't meant to work. It was designed to fail. The Tories at that time had a cultural prejudice against public transport, and especially railways. (Which, to be fair, they have since outgrown) It was Margaret Thatcher who said that any many over the age of 30 who still uses the bus is a failure.

The whole way it was done was frankly insane. One company owns the track. Another own the trains and leases them to another company to run, who then have to pay the track owner for access.

Yes its as insane as US healthcare. And for some of the same reasons. Each player has to employ a redundant army of contract managers and negotiators and dealmakers and cost adjusters to monitor the others and make sure they get their cut.

The separation of roles between franchisors was carefully designed to fail profitably. Most public attention falls on the Train Operating Companies (who recieve the subsidies in return for legal obligations to run trains) and the track owners (now mostly in public hands again, which is one reason ity is less crap than it was ten years ago). They also have leagal obligations and controlled costs. But a lot of the profit goes to the train franchise companies, the owners of the vehicles themselves. And they can charge what they want. So they screw their prices up, forcing the profits of the TOCs down, and diverting subsidy from new infrastructure to the pockets of the owners.

Which is of course where it was really meant to go all along. Its one of those famous licences to print money that the Tories love to come up with in the name of "private enterprise". I could mention ITV back in the 50s & 60s, or BT and British Gas oin the 80s, or the water and sewage scams... they aren't really interested in free trade or competition, all theyt want is to pass laws forcing the rest of us to give money to their pet big businesses.

282:

"Why restrict it to Western societies? Even if you do I would count the beginnings of civil war or other major civil unrest to be a sudden failure. So the English Civil War, the American Civil War, the French Revolution, the Revolutions of 1848, and for that matter the First World War, all count. "

None of these were 'collapses', which is my point. Life s*cked for many people, and ended prematurely.
Civilization kept on chugging along.

"If you want a more recent military event, the economic meltdown of 2008 was a rather sudden and very catastrophic event in which millions of people had the economic rug jerked out from under them."

Yes, and if you count *that* as a collapse of civilization, just let me know your village's name, and I'll send a rider along with a case of real canned food, in exchange for all of your useless US dollars from Before the Crash (if you haven't burned them to keep warm).

I think that you really don't know what a collapse of civilization means.

283:
Which is of course where it was really meant to go all along. Its one of those famous licences to print money that the Tories love to come up with in the name of "private enterprise".

What is it in "Profits in a mature and perfectly competitive industry go to zero" that these supposedly finance and economics savvy types don't get ;-)

That's why actually trying to reply to these yobos on their own terms doesn't work and why the DFHers were brushed off twenty-odd years ago when they pointed out that bog-standard economics predicted something other than the rosy scenarios that were flooding the airwaves wrt to all those then-new trade treaties. The purported economic and financial justifications for those treaties were quite beside the point.

284:

Ken Brown:
"BR privatisation wasn't meant to work. It was designed to fail."

It's worse than that, it's worse than you could possibly imagine. As far as I can work out the whole privatisation project turned on being able to generate/attract enough money to finance the refurbishment/re-engineering of the West Coast Main Line and whatever they did the consultants charged with coming up with a plan simply couldn't make the numbers work. Not that is until someone hit on the bright idea of applying a completely untested, immature technology which only existed on paper to the problem and then signing a contract with Virgin Trains which hinged on being able to deliver said technology (Moving Block Signalling) on time with huge penalty clauses attached...

Full, mind boggling story (in two parts) begins here...

http://www.guardian.co.uk/world/2004/apr/01/transport.politics1


Note the publication date of April 1st. You couldn't make this stuff up, and in this case, in spite of the dateline, they didn't...

285:

Ken Brown @278

How are you calcualting the proportion of public sector workers in London?

Are you basing it on the population of London or on the population of the London metropolitan area?

286:

Sorry, we're talking past each other. I was originally talking about the collapse of the US health system, not the entire civilization. As for civilization, I have to say that when 15% of the working population is out of work and has no prospects for employment in the next 3 or 4 years and hundreds of thousands of families are having their homes taken (mostly illegally) by banks that caused the failure of the housing market, civilization may still consider itself in good shape, but a lot of the citizens may not think so.

287:

Moore's law was a specific prediction about planar silicon integrated circuit processes. Moore has never endorsed any other interpretation of his law. When he proposed the law he felt that the limit that would be reached would more likely be economic rather than physical.

I'll be surprised if any significant quantity of chips are ever manufactured at less than 10 nM. Note that a silicon atom is about .25 nM. For economic reasons I also will be surprised if we move to any material other than silicon in less than 15 years. The sunk cost is the price of the wafer fabs, the design software, the skill sets of the fab workers, the electronic engineers who design the chips, and the peripheral industries that support all the above.

Eventually we reach a point where it is more economical to work on making better use of the transistors we can fab rather that going after greater density. Note the increasing proliferation of ARM processors in relation to x86 processors.

A few months ago I heard a presentation on memory technologies. The lady giving the presentation pointed out that she had written a book ten years ago on coming memory technologies. In the ten years since not one of those technologies has made any headway against dynamic ram. It is cheap and good enough. This is the same advantage that silicon has against any of the contenders we read about.

288:

Not sure I want to start off yet another discussion of Moore's Law, but I do want to second what Stuart is saying, and point out the the major problems with circuits at the current technological lower bound (18-20 nM) are 1) high leakage current in the off state that results in excess power consumption accompanied by excess heat, and limitations in increase in clock speed due to signal propagation delays from the central clock to the rest of the chip. There are two initiatives in circuit design that will probably enter production before we go below 14 nM that have the potential to fix these problems:

  • Adding local power control to sections of the chip, to turn off circuits not being used in the current computation (and changing that status at near the circuits' clock rate) to reduce the excess heat.

  • Changing the synchronous clock paradigm of circuit design to one of asynchronous processing of inputs as they arrive (if you know what Petri Nets are you have some idea of what inspired this concept), and so to eliminate clock skew problems as well as reduce signal latency and increase throughput.

Those 2 techniques, plus completely removing circuitry that's never used in a given system (making chip designs highly customizable often results in chip real estate that isn't needed for a variant still having the circuitry on it that another vaariant needs) should give 2 or 3 addition generations of scaling after we hit the geometry limit, which I agree is not much below 10 nM even if we use a single atom as a bit store (there has to be a lot of overhead in connections and signal routing).

I guarantee that companies like Intel, AMD, Hitachi, and so on will squeeze every last bit of life out of the fundamental IC technology that dominates the market today: silicon CMOS transistors on silicon substrates fabricated by short wavelength optical (actually deep ultraviolet to soft X-rays) lithography.

289:

But isn't Gallium Arsenide just a few years away?

Seriously, what did happen to Gallium Arsenide? Technical problems, or just not suffiently improved to displace silicon?

290:

"And London-paid tax subsidises the rest of England (though not, particularly, Scotland). By quite a lot."


Oh? Has the effect of the City been factored in?
How much has the City taken in direct damage from the rest of the UK in the past several years? How much subsidy is it getting?

291:

Barry @ 290
"The City" has been making a steady profit since the Corpoeration was founded - a VERY long time ago.

STOP IT, folks!
Whatever the idiocies of the derivatives traders and some gambling bankers, the city as a whole is what is keeping us afloat, plus our slowly revivifying manufacturing industries.
London makes a large Nett PROFIT - OK?

These days, "London" usually means "inside the M25" - approx 10-12 million people

292:

"Sorry, we're talking past each other. I was originally talking about the collapse of the US health system, not the entire civilization."

OK. However, the 'collapse' of the US healthcare system can be both gradual and enduring. We've been in a downward trend on access for a couple of decades now (?), and the situation continues. I could see in a couple of decades a situation where only a quarter or so of the US population has reasonable access, while the rest struggle with jack sh*t. And the politicians convince people waiting 24 hrs in an emergency room for care that any changes will be **soshulist**.


" As for civilization, I have to say that when 15% of the working population is out of work and has no prospects for employment in the next 3 or 4 years and hundreds of thousands of families are having their homes taken (mostly illegally) by banks that caused the failure of the housing market, civilization may still consider itself in good shape, but a lot of the citizens may not think so."

This is a loooooooooooooooong way from a 'collapse', and even a loooong way from what we've seen in various developed countries over the past few decades.

IMHO, you keep confusing 'bad situation' with 'collapse'.

293:

"STOP IT, folks!
Whatever the idiocies of the derivatives traders and some gambling bankers, the city as a whole is what is keeping us afloat, plus our slowly revivifying manufacturing industries.
London makes a large Nett PROFIT - OK?"

Greg:

1) The City could show a net profit and still be a drag on the rest of the country.

2) In the past several years, what has been the ratio of *direct, measurable* damage to the alleged benefits?

294:

Gallium Arsenide is a niche player. It's used for low noise amplifiers in RF front end applications such as cell phones. Also in multi gigahertz applications and for space flight. GaAs is more radiation tolerant than Silicon.

After CMOS and biCMOS operating frequencies were pushed out to several gigahertz a lot of potential applications for GaAs were cannibalized by Si.

295:

BArry @ 293
The City could show a net profit and still be a drag on the rest of the country.
Justify that statement.
Where would the money come from, otherwise?
Show please.

296:

There is of course the point that in the past, a government financial policy which benefited the city such as higher interest rates did not benefit manufacturers and others.
Of course the pound being quite strong due to north sea oil was of benefit to someone, I can't recall who.

297:

I'm not a Marxist and this definition does have its problems, but Marx defined profit as "that which is extracted from the workers".

If Company1 wishes to buy Company2, and the only way to do so is through "The City" who charge Company1 2% of the value of Company2 for acting as middlemen, then where did their "profit" come from other than from the capital reserves of Company1?

298:

There is the well known extractive effect of the Citie's management fees of your pension and suchlike, by which they transfer billions every year into their salaries and bonuses, despite the evidence being that their management of your money isn't actually that good. (Yes I am aware that there are plenty of poorly paid people working in the finance sector; of course they'd be better off after the revolution)

299:

ISTR a tale from the "Thatcher boom" of one "stockbroker" who advised his clients by throwing a dart at a dartboard and telling them to buy or sell depending on which side of the centreline it stuck in. Said tale indicated that his advice was no better or worse over a long run than anyone else's!

300:

Me: "The City could show a net profit and still be a drag on the rest of the country."

Greg: "Justify that statement.
Where would the money come from, otherwise?
Show please."

The rest of country. Please think about this.

301:


Serco;s managing director of clinical services gives the game away, regarding the NHS privatisations:

"It has to cut £20bn a year. It can't invest, but we can invest to improve quality and generate efficiency. We have to bid to deliver at prices that are a lot lower than the NHS to win contracts and that gives the NHS more money to put into the NHS itself."

http://www.guardian.co.uk/society/2012/mar/15/devon-nhs-childrens-services-privatisation

What he means is, the game is rigged so that only private companies can do anything because they have access to the extra capital. If the NHS has its budgets slashed, the only source of investment is outsiders. As we all know from the PFI/ PPP projects, such investment is more costly than the government doing it. This is an old method of getting what you want, see also the Royal Mail and the way its profits were stolen by the treasury instead of re-invested.

302:

See #297 - You haven't shown where "The City's" "profit" comes from that isn't "everyone else". What do they do that adds value to goods or indeed to services supplied to parties in other nations?

303:

Well, at the moment I gather that some City firms are making a tidy profit by creaming a few points off the money the BoE is injecting into the systme through Quantitative easing.

Working out where that comes from is beyond my knowledge of economics and finance but I suspect the answer turns out to be a variation on "magicked into existence out of nowhere".

304:

One argument is that the "city" makes large projects possible by spreading the cost across a large number of investors. And they take a fee for doing that.

I can refute that scenario, but it implies that the some of the profit for the "city" is not linked to the success of the investment that is enabled. And a great many dodgy deals have been devised to take advantage of that feature. The banks walked away with their profits even as the mortgage market collapsed and the value of the ingenious derivatives plummeted.

There are a great many necessary functions in a market where skimming off some of the wealth is justifiable. Markets need a certain amount of speculative trading to ensure that there are always willing buyers and sellers. But that's just moving wealth around, it's not creating anything.

In some ways, the fees paid to the corporates of the "city", are a sort of tax on doing business. And when the capitalists of the past were classed as "robber barons", one might wonder what these tax-like payments get. Do they do anything for the common good?

"trickle-down" is not what it was claimed to be. As much as anything, the rich don't spend all their money. The poor do, and every penny "wasted" on the poor will pass through multiple hands before in sticks in some place, saved or invested and paying the bankers the usual modest fee.

305:

"See #297 - You haven't shown where "The City's" "profit" comes from that isn't "everyone else". What do they do that adds value to goods or indeed to services supplied to parties in other nations?"

That's my side of the argument. I think that you meant to reply to Greg.

I think.

306:

"One argument is that the "city" makes large projects possible by spreading the cost across a large number of investors. And they take a fee for doing that."

Yes, there are a lot of standard Econ 101 explanations for how the net impact of Big Finance is positive.


Most of those don't look so well. And then there's the trillion-dollar asteroids that Big Finance slaps on us.

307:

The Banks are obviously today's Kulaks.

308:

#303&304 - Which is pretty much my argument. The City takes a cut just for existing rather than for adding value.

If it's taking a cut of QE money then it's taking a cut of our pensions when we retire and of our children's future tax bills.

309:

I think a major part of the problem is that the genuinely useful elements of the "city" have become such a small part of the whole. You can point at aspects which facilitate wealth creation, but does the gain from them even come close to the skimming that takes place?

Apparently the daily global turnover in foreign exchange markets is USD 4 trillion. According to the World Bank, global GDP per day is about USD 0.17 trillion.

Those figures have all sorts of problems, but a ratio of over 20:1 between speculation and production doesn't look good. It's the sort of William Tare-Fox wild-assed guess which ought to make you start thinking.

310:

Dave Bell has it right. If you have a money and debt based market economy, you need something like the City in order to provide financial services etc. However due to deregulation and other cultural changes, e.g. that spoken of by the guy who just left Goldman Sachs, the City has been allowed/ driven to become more of a parasite than a useful thing. There are of course bigger issues such as a declining rate of profit, lack of big investment opportunities in the UK since we are a mature economy, and our declining relative share of global gdp.

311:

#308, 309 and 310 - I think we may all be in concensus. The issue is not the use of the City for raising capital and trading (part) ownership of a business.

Rather the issue is the belief of the individual traders that doing so is an economic activity in its own right, that shares are a short to medium term investment...

312:

Gallium Arsenide is a niche product.
Just about everything in electronics is soon to be overwhelmed by carbon in the form of Graphene

313:

The real problem with "the banks" is deregulation, allowing some short-sighted greedy idiots to wreck the show .....
Are we agreed on that one, at least?

314:

#313 - I'll second that.

315:

"The Banks are obviously today's Kulaks."


Thank you for conceding that you don't have useful anything to add to the discussion.

316:

Yes. The whole problem is when an unregulated sector gets to the point where even an honest politician will vote for a bailout, rather than find out what a multi-trillion dollar/pound/Euro collapse does.

317:

Yep, we have to pay to see the doctor. (Yes, the question was long since answered, and yes, it may well have been ingenuous or rhetorically to start with, but ...) Do we ever!

Depending on the insurance plan:
* A single office visit can run anywhere from $10* for a gp to hundreds for a specialist.
* Tests are extra, under many plans.
* A visit to the emergency room is likely to require a copayment of $100 to $150 ... to discourage "frivolous" use of services. Because, of course, everybody has that extra several hundred to hand

All of that, of course, is before counting the health insurance bill, which purchased on the "open" market** for one healthy person, is likely to be around $600 per month for a medical plan with limited access to care (few choices of pcp, for instance, or an hour's drive to see a participating ob/gyn) and a high annual deductible.

Those "copays", by the way, are in the line of a best-case scenario. They assume that one has already fully paid the deductible, which for the plan above is likely to run $3,000 per year of point-of-service medical bills that one must pay out of pocket -- and some expenses may not count -- before the insurer I a dime. One plan at my old workplace had a per-person deductible of $5,000 per year.

Then there is the cost of prescriptions. $15 to $75 or even $150 per month per drug is not unusual, for the limited and ever-changing list of medications that are covered. After the deductible is paid, of course.

Without insurance, the cost is far higher***; a common antibiotic might go for more than a hundred per month (really), that "cheap" morphine somebody cited for far more. Even better, the insurers pay less than half the consumer price for most prescriptions, so the people who cannot afford insurance are subsidizing Blue Cross and UnitedHealthcare.

Yes, meds are far cheaper almost anywhere in the world than even the insurance company price here, but importing is bad and wrong, or at least, illegal.

(* Somebody somewhere may still have a plan with no point-of-care copayment ... but the folks I know are paying $20 and up to see the gp, and $40 or more for anything else, including eye exams -- if covered -- and physical therapy visits.)
(** Competition varies by state, but a "free choice" between two plans from one insurer is not unusual. For individuals and families, that is; businesses have access to far more options ... and discounts of 50 percent or more off retail.)
(*** I spare you the rant on ER costs, among others.)

318:

In New Zealand our right wing government is trying to wreck the health system too.

Up until (about) now it has always been hilarious to watch Americans marvel at how I can walk into any hospital and get free treatment, they look kinda glazed and mutter something about "How can that be?".

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