Left Wing Loons and Obamacare

[agricola]

Nice to see Fox and its fair and balanced reporting:

http://www.youtube.com/watch?v=2c-JEx-Kfvc

 

[Ryan in Maine]

Obama has officially sunk so low as to get into an argument with the citizens of the United States of America.

[Iain]

IBD editorials just don't stop:

"The new law also contemplates end-of-life counseling. With this approach, it is only a matter of time before your children will be offered bounties for persuading you to take an early exit."

http://www.investors.com/NewsAndAnalysis/Article.aspx?id=503472

[Headless Thompson Gunner]

I haven't yet seen an IBD editorial that was actually false.

[agricola]

I haven't yet seen an IBD editorial that was actually false.

Thats because they edited the Hawking one.

[HankB]

If government death panels are created, I want to get on one immediately.

(I have a list . . . )

[Headless Thompson Gunner]

Thats because they edited the Hawking one.

The gist of the IBD editorial was that if Hawking had had to rely solely upon NHS, and not upon some private health care and/or his prestige, he wouldn't have fared so well.  This appears to be true, so far as it goes.  Nothing we've seen so far refutes it.

[FTA84]

The whole Hawkings debate doesn't make sense any since he got sick near the peak of his quality adjust life years.

[agricola]

The gist of the IBD editorial was that if Hawking had had to rely solely upon NHS, and not upon some private health care and/or his prestige, he wouldn't have fared so well.  This appears to be true, so far as it goes.  Nothing we've seen so far refutes it.

Thats a remarkable reinterpretation of what the IBD article said.  The editorial initially opined:

People such as scientist Stephen Hawking wouldn't have a chance in the U.K., where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless.

Now for a start the NHS has had multiple chances to bump Hawking off as a waste of resources, most recently in April when he was both disabled and a pensioner.  How on earth can you honestly extract that sentence to say what you claimed it said?  Interestingly, they have now edited it to remove every reference to Hawking, beyond to an initial clarification that says:

Editor's Note: This version corrects the original editorial which implied that physicist Stephen Hawking, a professor at the University of Cambridge, did not live in the UK.

http://www.ibdeditorials.com/IBDArticles.aspx?id=333933006516877

[Headless Thompson Gunner]

We simply don't know whether Hawking would have had a chance to remain alive if he had had to rely solely upon NHS.  We know that Hakwing has received some life-saving care from NHS, but we also know that he felt the need for non-NHS care as well.  Unless we can identify the exact nature of care he received from both sources, we cannot identify whether NHS care alone would have been fully sufficient to keep him alive. 

I covered this previously, perhaps you didn't see it.

OK, so Hawking has used both NHS and private care to keep himself alive.  

But this leads to more questions than it answers.  He got some care from NHS, and that care kept him alive.  Could he have gotten that care without the NHS?  Would he have gotten better care through the private system?  Worse care through the private system?  If the NHS was caring for him, why did he bother involving "several foundations" in his care?  Was there something available through the foundations that wasn't available through NHS?

IBD went into some specifics on the how the "quality adjusted life years" cost-benefit-analysis is done in NHS.  Based on that, IBD seems to have a point.  If a given treatment is too expensive, and the patient's quality of life is deemed too low, then the NHS doesn't provide the treatment.  This forces the patient to find private sources for the treatment.  We don't know this for certain, but this is a plausible explanation for why Hawking needed to get some of his care from private sources.

[agricola]

We've seen that Hakwing has received some life-saving care from NHS.  But we've also seen that he felt the need for non-NHS care as well.  Unless we can identify the exact nature of care he received from both sources, we cannot identify whether NHS care alone would have been fully sufficient to keep him alive.  We simply don't know whether NHS alone would have served Hawking well, which is what IBD was speculating on.

I am sorry, but that is an absolute lie when viewed against what the IBD actually said, which I repeat below:

People such as scientist Stephen Hawking wouldn't have a chance in the U.K., where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless.

How you can honestly extrapolate what you claim the IBD meant from what they actually said is a mystery to me; the original editorial clearly suggested that Hawking would not have a chance in the UK because of his disability - something both utterly wrong and with precisely no basis in fact, at all.  Hawking himself has said:

"I wouldn't be here today if it were not for the NHS," he told us. "I have received a large amount of high-quality treatment without which I would not have survived."

 

[Headless Thompson Gunner]

All we know is that Hawking received some of his care from NHS and some of his care from the private system.  You cannot honestly claim, based on what we know here, that the NHS care he received was the only care he needed to stay alive.  The NHS care saved his life at some points, but based on what we know you can't say that his private care didn't save or prolong his life as well.

What would have happened to Hawking if he had been an average British person? 

Would he still be alive if he had used NHS care alone? 

Would the NHS 20,000 pound per QALY limit have been exceeded, and would he have been denied important care?  Would his disabilities and their attendant lower QALY have disqualified him for certain NHS-funded treatments that he could have benefited from?

Why did Hawking feel the need for some private care?  Was it due to some inadequacy or deficiency in the NHS care he was already receiving?

We don't know.  Perhaps you have some more information about this case that you haven't posted here...?

Nothing in the Hawking quote you keep repeating answer the questions I've asked.  The gist of the IBD editorial was that NHS rations care, and as such Hawking wouldn't have survived under NHS alone.  This may or may not be true, we just don't know based on that quote you keep repeating.

[agricola]

All we know is that Hawking received some of his care from NHS and some of his care from the private system.  You cannot honestly claim, based on what we know here, that the NHS care he received was the only care he needed to stay alive.  The NHS care saved his life at some points, but based on what we know you can't say that his private care didn't save or prolong his life as well.

No, thats not what we know.  We know that Hawking is British, and that he has said that but for treatment from the NHS he would not be here.  The statement - which was abundantly clear - in that IBD editorial said that in the UK he "would not have a chance" because of his disability.  One would have thought that would be enough to say that the IBD article was entirely wrong, but of course we are discussing the UK here and so it must mean something else that avoids admitting an American perspective on the NHS might, just might, be entirely wrong.

What would have happened to Hawking if he had been an average British person?

As has been explained already, he was "an average British person" when he was diagnosed with (and for much of the treatment of) this illness.   

Would he still be alive if he had used NHS care alone?

Yes. 

Would the NHS 20,000 pound per QALY limit have been exceeded, and would he have been denied important care?  Would his disabilities and their attendant lower QALY have disqualified him for certain NHS-funded treatments that he could have benefited from?

No.

Why did Hawking feel the need for some private care?  Was it due to some inadequacy or deficiency in the NHS care he was already receiving?

We don't know.  Perhaps you have some more information about this case that you haven't posted here...?

Nothing in the Hawking quote you keep repeating answer the questions I've asked.  The gist of the IBD editorial was that NHS rations care, and as such Hawking wouldn't have survived under NHS alone.  This may or may not be true, we just don't know based on that quote you keep repeating.

The questions you have asked are irrelevant when talking about the IBD editorial.  The IBD editorial did not discuss them, it did not weigh carefully the effect that public and private healthcare had on Hawking, whether all of his needs were met by one or the other.  It limited itself to saying:

People such as scientist Stephen Hawking wouldn't have a chance in the U.K., where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless.

That is entirely wrong.  It would be nice if you would admit it.

[Iain]

The only other thing to say is that not all care that someone like Hawking needs is necessarily provided by the NHS, but can instead come through social care. Still state funded. People I know get things like Direct Payments, there is also something called an Individual Budget. The way these can work ranges from all being done for you - care packages are provided and the burden of employing someone to care for you falls on the state or on state-funded organisations like the Penderels Trust. Alternatively you can be given the money and purchase your care solution by yourself, take responsibility for making the National Insurance payments for your employee, your carer. There are various in-between options too.

http://worcestershire.whub.org.uk/home/wccindex/wcc-social-buyingfreedom/wcc-social-bf-wdavies.htm - watch the video, this guy is a trustee at an organisation I do some work for.

Direct payments are cash payments given to service users in lieu of community care services they have been assessed as needing, and are intended to give users greater choice in their care. The payment must be sufficient to enable the service user to purchase services to meet their needs, and must be spent on services that users need.
Like commissioned care, they are means-tested so assume that, in many cases, people will contribute to the cost of their care.
Direct payments confer responsibilities on recipients to employ people or commission services for themselves. They take on all the responsibilities of an employer, such as payroll, meeting minimum wage and other legislative requirements and establishing contracts of employment.

Some of these services can be contracted out and many councils have commissioned support organisations to help service users handle these responsibilities.

- http://www.communitycare.co.uk/Articles/2009/04/08/102669/direct-payments-personal-budgets-and-individual-budgets.html

[Headless Thompson Gunner]

Cool.  It sounds like you do have some more information about this case, something I haven't seen yet.  I'd love to see it.  Can you please share it?

Would he still be alive if he had used NHS care alone?

Yes.

Ok.  Based on what?

Would the NHS 20,000 pound per QALY limit have been exceeded, and would he have been denied important care?  Would his disabilities and their attendant lower QALY have disqualified him for certain NHS-funded treatments that he could have benefited from?

No.

Ok.  Based on what?

If we now have some solid evidence behind these answers, then I'd be willing to agree that the one sentence in the IBD editorial about Hawking is in fact wrong.

Why did Hawking feel the need for some private care?  Was it due to some inadequacy or deficiency in the NHS care he was already receiving?

We don't know.  Perhaps you have some more information about this case that you haven't posted here...?

Nothing in the Hawking quote you keep repeating answer the questions I've asked.  The gist of the IBD editorial was that NHS rations care, and as such Hawking wouldn't have survived under NHS alone.  This may or may not be true, we just don't know based on that quote you keep repeating.

The questions you have asked are irrelevant when talking about the IBD editorial.  The IBD editorial did not discuss them, it did not weigh carefully the effect that public and private healthcare had on Hawking, whether all of his needs were met by one or the other.  It limited itself to saying:

You did read the IBD editorial, right?  I mean, you read the whole editorial and not just the one poorly written sentence about Hawking, right?

The main point of the IBD editorial had nothing to do with Hawking.  It was about end of life counseling, rationing of care, and the sort of life or death cost-benefit analyses that take place under NHS and NICE.  It was about what these sorts of things might mean Americans if they were to become the norm here.  The Hawking remark was entirely incidental, a poorly written example inteded to illustrate the main point.

I've not seen any evidence that the substance of the IBD editorial (claims about rationing, QALYs, NICE, or the prospects of something similar coming to the Unites States) is wrong or false.  In fact, the more I learn the more satisfied I become that IBD is right on the mark.  I was willing to discount the prospect of life and death CBAs as sensationalism, but I've now seen from NICE directly that it's true.

And, truth be told, when I look at the Hawking sentence in the context of the entire editorial, I'm not completely sold on it being wrong either (pending confirmation of the answers you've provided above). I suspect it's a case of shoddy writing, saying "in Britain when what was meant was "under the NHS system".

[Headless Thompson Gunner]

The only other thing to say is that not all care that someone like Hawking needs is necessarily provided by the NHS, but can instead come through social care. Still state funded. People I know get things like Direct Payments, there is also something called an Individual Budget. The way these can work ranges from all being done for you - care packages are provided and the burden of employing someone to care for you falls on the state or on state-funded organisations like the Penderels Trust. Alternatively you can be given the money and purchase your care solution by yourself, take responsibility for making the National Insurance payments for your employee, your carer. There are various in-between options too.

http://worcestershire.whub.org.uk/home/wccindex/wcc-social-buyingfreedom/wcc-social-bf-wdavies.htm - watch the video, this guy is a trustee at an organisation I do some work for.
 - http://www.communitycare.co.uk/Articles/2009/04/08/102669/direct-payments-personal-budgets-and-individual-budgets.html

Can you explain these systems, social care, direct payments, individual budgets, and the like?  Is the "Penderels Trust" the sort of thing that Hawking might have referred to when he said he received care from "several foundations" in addition to the NHS care?

[Iain]

The community care link explains some of it.

The Penderels Trust, amongst others, is a service that will deal with some of the paperwork of being an employer.

Some of these services can be contracted out and many councils have commissioned support organisations to help service users handle these responsibilities.

- from communitycare link above

Basically it works something like this (this is an approximation of the case of J, who I did some work with two years ago):

J had an accident and was rendered paralysed from the waist down. Lives with his father who doesn't make a substantial wage, live in a very very modest house. After being discharged from hospital they needed services and adaptations.

GP refers to Occupational Therapy who come out and fit ramps to the steps up the front and install a wheelchair accessible platform lift in the lounge because stairs are an impossibility. Also there is a referral to social services, who come out and make an assessment of what J's needs are, they also assign him a worker who is tasked with helping him return to a normal life, look for social and educational opportunities. This worker also calls me in to help with the benefit situation.

I help him fill in forms for Disability Living Allowance, because he is paralysed he gets the highest rate of mobility component, which can be used to purchase an adapted car, or not, up to you. Because he is not continent and needs substantial help with his toilet needs, day and night, he also gets the highest rate of the care component of DLA. In total that's about £110pw, non-means tested.

Because he is getting above the middle rate of care, and his father is no longer working so is earning below the ceiling, his father can get Carers Allowance for looking after him. That's £53.10pw. Then there is Income Support, with various disability premiums added on to it. Housing Benefit too. If the person was working and making National Insurance contributions for a qualifying period then Incapacity Benefit (now called Employment and Support Allowance) is a possibility. Doesn't add up to a lot of money, but it's not bad, helps people a great deal.

Going back to the social services assessment - you have two basic options. You never see the money involved and social services purchase services for you. Alternatively, as in Direct Payments or Individual Budgets, you are given the money, you have to spend it on social care. You then employ people yourself, taking on the employers responsibilities, or you can pay some of the Direct Payment money to someone like Penderels who do the paperwork and take responsibility for making sure that the employers responsibilities and duties are met. Direct Payments give you the freedom to purchase the services you want and employ the people you want.

People of independent means have the freedom to bypass all this completely and purchase the care they want directly from their own pockets. Also, there are trusts, foundations and charities set-up to help people, usually something specific like a spinal injuries trust etc. There's a local trust that I know of that only makes payments to other small charities to help fund core admin costs, something that can be difficult to recover from projects funded by govt or big national organisations. Someone like Hawking may well have had a trust set up in his name to help cover some costs, the one area that fame may well have influenced his care - something that J doesn't get.

Bear in mind though that we are purely talking about social care and care at home. The care that Hawking receives in an NHS hospital is not dependent on any of the above.

On the subject of the IBD editorial - we haven't established where exactly the day to day care he is getting now comes from or how it is funded. The above should show that a very significant level of social care is possible without being independently wealthy, the govt's care agenda is all about independent lives and choice, but this is not the NHS it's a different structure.

We have established though that Hawking developed his ALS long before he was well-known, he was still a graduate student, much NHS care would have been necessary. He did survive.

[huzzah]

Does it really matter that much about one single example...?

[Headless Thompson Gunner]

The community care link explains some of it.

The Penderels Trust, amongst others, is a service that will deal with some of the paperwork of being an employer. - from communitycare link above

Basically it works something like this (this is an approximation of the case of J, who I did some work with two years ago):

...

And all of these services are separate from NHS?

On the subject of the IBD editorial - we haven't established where exactly the day to day care he is getting now comes from or how it is funded. The above should show that a very significant level of social care is possible without being independently wealthy, the govt's care agenda is all about independent lives and choice, but this is not the NHS it's a different structure.

We have established though that Hawking developed his ALS long before he was well-known, he was still a graduate student, much NHS care would have been necessary. He did survive.

This is what I'm trying to understand.  IBD seemingly made a mistake, either assuming that Hawking didn't get any medical care from NHS, or writing a piss-poor sentence that made it look like they assumed he didn't get any care from NHS.  This led all sorts of critics to pounce on IBD, basically saying "Hawking is British, therefore he got all of his care from NHS, duh!".  But this isn't correct either, as it's entirely possible, even likely, that Hawking received important care from non-NHS sources. 

In order to get to the bottom of it, we'd need to know just what care Hawking has received over the years and where it came from.  All we know is that he got some care from NHS and some other care from non-NHS sources, and that's not enough to either prove or disprove IBD's contention that Hawking wouldn't have survived if he'd had to rely on NHS alone.

[makattak]

And all of these services are separate from NHS?

And, if so, does that mean that the reported cost of medical care does not take these services into account?

[Iain]

Ok, some of this is 'talking past each other'

Here are the facts:
1. Hawking developed ALS young, well before he was famous.
2. Hawking himself has stated that he received life saving care from the NHS
3. In terms of personal care* it is possible that a person like Hawking could receive what I have described, but quite likely he is paying for it himself.

* - personal care is the care that someone like Hawking needs on a day to day basis - help with changing, washing, toilet, cooking. Depending on things like pressure sores, or stoma or tube feeding there may be a medical element to it, but it's not medical care that is beyond the wit of a relatively untrained person, family do most of this stuff, my mother used to put butterfly needles into me every three weeks. If someone needs daily attention from a medically trained person, then that will be NHS funded, or perhaps funded by set-ups like the Macmillan nurses who seem to be part state and part charity-funded. There's actually not that much that carers or family members can't be trained to do. If you wish to refer to this as an 'unreported medical cost' then remember it goes unreported almost everywhere. Social care costs certainly are reported on.

Now for my sober reflections - because of the single payer, single provider system (which is not what is on the cards for you) it is quite rare that significant medical emergencies or complicated operations happen in the private sector. My dad had a stroke two years ago, had BUPA through work. The NHS hospital he was in had a private hospital in the grounds, but he wasn't cared for there at all. Instead BUPA paid us £50 a day for each day he was in the specialist neuro ward in the NHS hospital. You probably should be wary of this, and I suspect that my father would have done at least as well under your model, because he was working, had always been healthy and had medical insurance.

(BUPA didn't actually fund anything directly, all his physio was funded by the NHS. The only thing BUPA has directly funded was physio on an unrelated shoulder problem)

4. (which isn't a fact but a reasonable deduction from the facts) It is very likely that in cases like Hawking's bout of pneumonia a few years ago, he did receive care in NHS hospitals. At the very least, as far as I am aware, all ER's in this country are NHS. You need a broken bone seen to you are going to an NHS ER.

(Quick bit of research indicates that there are two private neuro facilities in the UK, Oxford and London. Oxford seems to share the same facilities with an NHS hospital. London is a private hospital. Because of the way consultant and surgeon pay is structured it is more than likely that the surgeons working at this two places are also NHS employees, you can do a certain amount of private practice in addition)

[Iain]

I'm not trying to be adversarial here, I'm trying to provide a picture of an imperfect system that is not allowing people to rot. What made me bridle in Palin's comments was the use of the word 'evil'.

Let's take Palin's baby, Down Syndrome. We are correcting heart defects young now, we haven't always, which was wrong. Now that life expectancy in Downs is in the 60s, there is an increasing issue with heart transplants in Downs patients, and where pulmonary function has been affected then heart-lung transplants are also an issue.

Because of a lack of availability of organs a figure I just read suggest that we only do about 40 heart-lung transplants a year. That had better improve before I need mine. Our first series of Big Brother hit the headlines in part because the winner used his £250,000 winnings to pay for a Down syndrome girl to fly to the US for a transplant. It was a controversial issue, and he shed much needed light on it. Frankly it is wrong to assign a lower preference to Downs patients, although it isn't as simple as thinking they are worth less, there are also issues of post-surgery medical compliance that are not simple issues to resolve. Everyone has to have a track record of compliance with drugs, except George Best.

Which brings me to my dilemma over state-funded and private-funded healthcare. Wrongly we have been questioning the ability of Downs patients to cope with and comply with medical regimes post-transplant. I'm saying this as someone who will effectively be competing with Downs patients for the rather limited sets of lungs available. I'd posit that the dilemmas are not solved by leaving it to be a matter of who can pay and who can't. George Best drank himself to death, as a former footballer he had a huge following and massive reputation as an alcoholic. In 2002 he had a liver transplant, which it seems was privately done. He continued to drink and in 2005 he died.

These are complicated medical and ethical questions, and I'd be very surprised if the ethical factors and associated quality of life and reasonable expectations of success are not being assessed over there. The NHS I suspect is getting beaten with a stick for doing something that is only avoided elsewhere by the power of green, which is not something that very many people have. George Best and little girls who are given £250,000 are the exceptions.

-----------------------------------

Now that I've tried to be straight-forward and not particularly partisan about I how view this issue, I'd like to hear about your concerns about your own model. I'm sure you have some.

Also - this quote from the Economist:

Though it has a shameful history, the insurance industry has done a U-turn of late. It now accepts the need for a radical overhaul of insurance markets through measures such as guaranteed issue of coverage and the creation of health insurance "exchanges". But its leaders are increasingly unhappy about the shrill attacks. Can Mr Obama continue to bash the insurers one day and rely on them the next?

Can anyone give me an outline of what guaranteed issue of coverage and these exchanges would change?

[Balog]

And must we refer to Republicans as Pubbies?  I lose about five IQ points every time I read that. 

Huh? How is that an insult?

[Jamisjockey]

http://www.armedpolitesociety.com/index.php?topic=11378.0

Its childish and unnecessary.

[Balog]

http://www.armedpolitesociety.com/index.php?topic=11378.0

Its childish and unnecessary.

I'm so confused. It's just a way of shortening the party name, like saying Dem's. Except you can't say Rep's because that leads to confusion with Representatives. It's not an insult, or any kind of commentary. I had no idea people thought it was.