Debbie Hirst, not Stephen Hawking

by on August 13, 2009 at 1:46 am in Medicine | Permalink

Didn't I cover this story once before?

One such case was Debbie Hirst’s. Her breast cancer had metastasized, and the health service would not provide her with Avastin,
a drug that is widely used in the United States and Europe to keep such
cancers at bay. So, with her oncologist’s support, she decided last
year to try to pay the $120,000 cost herself, while continuing with the
rest of her publicly financed treatment.

By December, she had
raised $20,000 and was preparing to sell her house to raise more. But
then the government, which had tacitly allowed such arrangements
before, put its foot down. Mrs. Hirst heard the news from her doctor.

“He
looked at me and said: ‘I’m so sorry, Debbie. I’ve had my wrists
slapped from the people upstairs, and I can no longer offer you that
service,’ ” Mrs. Hirst said in an interview.

“I said, ‘Where
does that leave me?’ He said, ‘If you pay for Avastin, you’ll have to
pay for everything’ ” – in other words, for all her cancer treatment,
far more than she could afford.

Officials said that allowing
Mrs. Hirst and others like her to pay for extra drugs to supplement
government care would violate the philosophy of the health service by
giving richer patients an unfair advantage over poorer ones.

I'm not saying Obama wants to do this, I am saying there are some unacceptable features of Britain's NHS (update: the policy was reversed in 2008).  The point is not to compare those features to the problems with the U.S. system.  The point is that everyone is gainsaying the Hawking example without recognizing there have been other people in similar predicaments.  How could such a policy ever have been adopted in the first place?  This is just a reminder, it's not a prompt for you to repeat the familiar story that the U.S. pays more without getting better health care outcomes.

If you want to do a broader comparison, here is more on the NHS and drugs.  Did you know that Rilutek, the main drug (its efficacy is debated) for treating ALS (Lou Gehrig's disease), has been available in the UK since 1997.  It was approved by the FDA in 1995 though covered by Medicare only after the prescription drug bill.  As of 2004, single-payer system New Zealand wasn't offering the drug at all.  If you're wondering, single-payer Canada had approval of the drug in 2000, but with partial early usage in 1995.

By the way, Medicare does cover ALS, even if you're not 65, but various important forms of home adaptation and assistance are left uncovered, as is often the case with Medicare.  It seems the U.S. is the best place for drugs but quite possibly not the best coverage overall for ALS.  If you're looking for one good health care reform, consider dropping the reimbursement rate penalty for home care.

My knowledge of ALS-related issues is not extensive, but aren't such comparisons more interesting than reading another blog post bashing idiots? The more you bash the idiots, the more you are playing into the hands of…the idiots.

1 C August 13, 2009 at 2:12 am

Good post.

2 DG Lesvic August 13, 2009 at 3:15 am

When you’ve guaranteed health care for me, food for me, clothing and housing, let me know. I’m retiring.

And don’t forget the beer and television.

3 jaduncan August 13, 2009 at 4:05 am

This policy no longer exists. Thus this post is both disappointingly disingenuous and ironically close to the ill-researched statements that you defend from legitimate criticism when you say that ‘The more you bash the idiots, the more you are playing into the hands of…the idiots.’

An academic should do better research, Tyler.

4 rhhardin August 13, 2009 at 5:23 am

“Intra-system goals come first.” John Gall, _Systemantics_, on how human systems behave.

5 TheophileEscargot August 13, 2009 at 6:03 am

The thing is, you’re playing into a false conception that private healthcare cannot coexist with state healthcare.

In the UK it’s very common to combine private and public healthcare. As Matt says, you can get private health insurance in the UK by providers like BUPA.

But moreover, it’s very common for the middle class to “go private” for particular operations. The waiting lists are generally for non-urgent, non-critical operations. So if you need minor surgery on your knee, you pay a few thousand pounds to get a private operation immediately, rather than wait months to be treated free.

There’s nothing illegal about this, and it breaks no rules. But conservative blogs give the impression you’d be hurled into prison if you tried it.

Since the NHS provides a safety net for life-threatening illnesses, private medicine in the UK tends to be less based on insurance, and more based on paying for what you need when you need it.

6 Tomasz Wegrzanowski August 13, 2009 at 6:19 am

Get your facts right. Here’s Wikipedia:

In 2008, the FDA approved Bevacizumab [=Avastin] for use in breast cancer. A panel of outside advisers voted 5 to 4 against approval, but their recommendations were overruled. The panel expressed concern that data from the clinical trial did not show any increase in quality of life or prolonging of life for patients – two important benchmarks for late-stage cancer treatments.

Wikipedia says it doesn’t have any evidence of working for breast cancer, even to prolong life. It goes very much against the claim it’s “widely used in the United States and Europe to keep such cancers at bay”. No it’s not. Or if it is, it’s not evidence-based medicine, so it shouldn’t, not at such ridiculously high cost.

7 Charles Young August 13, 2009 at 7:51 am

I think previous comments have demolished this case, but even if the facts had been right, they would only have had any persuasive power if it could be shown that no private insurer ever has acted or ever would act in a similar way. I am not convinced that state ownership is a necessary condition for an insurer to take the view that was reportedly taken by the NHS. Presumably the doctor estimated her chances of survival as lower if she combined the Avastin treatment with the treatment on which he had embarked than if she pursued either separately.

Would a private health insurer be happy for me to interrupt a course of, say, chemotherapy in order to undertake a visit to Lourdes and continue the treatment at higher cost later? I am not asserting that Avastin has as little clinical justification as a visit to Lourdes, but that any insurer, whether privately or publicly owned, must make some judgment about the types of treatment that are effective enough to qualify for funding.

8 Mike August 13, 2009 at 9:03 am

Although I prefer, from a political perspective, that people wealthy enough to pay more for more care should be allowed to do so, articles like this miss another point, which is, from an economic standpoint, it is a waste of resources for people to buy (and sell) drugs like Atastin.

If we valued human life to the tune of hundreds of thousands of dollars per few months, there is a huge host of new (costly) safety regulations that we should impose on other industries.

9 dearieme August 13, 2009 at 9:46 am

“How could such a policy ever have been adopted in the first place?” Good question, but it means that you have no idea just how shabby the motives of the Labour Party are.

10 Candadai Tirumalai August 13, 2009 at 10:05 am

There is an article in the Washington Post today
by its resident British correspondent, which
looks at the problem of trans-Atlantic perception
in the matter of health care. It takes a skilled
interpreter to translate the ways of one country
for a different one. Americans long resident in
Britain and Britons long resident in America
can make a contribution.
I lived in England for 20 years, and had some
experience of the National Health Service.
You cannot select your own specialist but on
the other hand you do not have to worry about any
bills at a time when illness is on your mind
(unless your treatment is very expensive, when
financial constraints may dictate NHS decisions).
I chose my own cataract surgeon and that meant
a hefty bill. Medicare, which I have been a part
of seven years, is like the NHS, except that you
are still responsible for 20% of most bills, to cover
which you can get Supplementary insurance, but that
can be expensive, depending on what it includes.

11 James August 13, 2009 at 10:32 am

Tyler,

Glass houses my stupid friend, glass houses.

12 Pete August 13, 2009 at 10:49 am

All the people talking about freedom: you do know you can get health insurance in the UK? It’s much cheaper too, as the state takes most of the unprofitable cases.

13 Cody August 13, 2009 at 11:09 am

I think all of the stuff about Stephen Hawking is less about how great the NHS is and more about the state of the healthcare debate. The IBD’s assertion that thr UK would let people like Stephen Hawking die was a complete fabrication designed to scare people. This kind of thing has become very prevalent lately.

14 mulp August 13, 2009 at 11:15 am

Clearly Tyler is making the point that US politicians should be dictating to US insurers what they must cover in their insurance policies. If Debbie had been denied the drug by a US insurer, a law would have been passed mandating its coverage by all US insurers.

Or it would have been added to Medicare.

15 Vehical Driver August 13, 2009 at 11:32 am

The point is… when an insurance company denies coverage, it is because they are “evil” and “greedy”… when the government does it, people will rationalize it as good and claim that the person who wanted the treatment was “greedy” and “evil”.

Government has the benefit that it controls education, the media, and co-ops deep rooted feelings of nationality and identity. Most people view government as a godlike super-being, not what it is: the biggest and meanest private corporation on the block. The real danger of government health care is that for many people, talking bad about the government is like talking bad about Jesus Christ. People have been raised and psychologically conditioned by the government from cradle to grave, and very few people have the ability to be objectively critical of the government.

16 Andrew August 13, 2009 at 12:17 pm

Here’s the thing. Most chemotherapies are ineffective. Sometimes they are effective. And those crazy people with cancer are willing to take that chance.

17 Travis August 13, 2009 at 12:32 pm

A lot of missed points in here.

If she paid into the system, she should get what they will give. If it isn’t enough she should be able to sell her house and buy more, without having the NHS care cut out.

Clearly her marginal value of a *possible* extra few months of life was higher than that of her house. Pulling the rug out from under the entitlement care just because she was willing to make that decision seems like poor system design to me.

18 Martin Brock August 13, 2009 at 1:29 pm

In careful studies, Avastin increases cancer survival rates by a few months on the average, for some cancers but not for breast cancer. The drug has no significant effect on breast cancer survival. Even if it did, a few additional months of cancer survival, in the late stages of a debilitating disease, hardly seems worth the cost.

So this woman raised $20,000 of the $120,000 cost of treatment. Does she borrow the rest? Even if she expects to buy a few months of additional life, what rational creditor lends it to her? How does she expect to repay the credit in these few months? If she earns $20,000/month, she hardly needs the credit.

Personally, I wouldn’t spend my children’s inheritance this way. I wouldn’t forbid someone their choice of desperate measures either, but this argument against rationing in the NHS is not compelling. The NHS was right to deny this woman the treatment, and forbidding her to take the additional treatment while covered by the NHS is not an unreasonable policy. Cancer treatments interact. Desperately adding some treatment of questionable efficacy could undermine the effectiveness of covered treatments. Why throw good money after bad? The policy reversal seems the more political act.

With a rapidly aging population requiring unprecedented medical attention, we need to get used to the idea that human beings are still mortal and likely always will be. We can easily spend every spare resource on endless life extension. I’d rather not, and I have a living will to prove my sincerity. More life is not the solution to exploding health care costs. More death is the solution. Let’s face this reality.

19 Doug August 13, 2009 at 2:00 pm

“I agree with J. Bang that it would be shocking if no private insurer has ever refused to fund a course of treatment nominated by the patient but judged ineffective by the experts.”

Yes, and it would be equally shocking if a private insurer ever told a patient that it would withhold all covered treatments if the insured paid out-of-pocket for a non-covered treatment. One of the problems with government run “insurance” is that the government does not need to concern itself with pesky little things like breach of contract or insurer bad faith claims. That is why this scenario is far more likely to eventually play out in a public option than under a private option, regardless of whether or not it is intended or enacted when the public option is initially put into place.

20 joan August 13, 2009 at 2:03 pm

Why is it that people continue to talk about England and Canada which have systems that almost no one in the US wants here, but not France which is ranked as the best. It cost more than the UK but much less than the US, so if we are going to copy anther country it seems to me to be a better choice. The fact that it is almost never mentioned by opponents of universal health care leads me to believe that it really does work well. Correct me if I am wrong.

21 Bernard Yomtov August 13, 2009 at 2:22 pm

I think you’ve missed the point of part of the angry response to the Stephen Hawking editorial.

Whatever the facts of the Hirst case, the fact is that a presumably respectable conservative publication was willing to publish a stupid, obviously false, editorial about Hawking opposing Obama’s plan without bothering to spend even one minute – literally all it would have taken on Google – fact-checking the content. And they still AFAIK, not retracted it. (They did later note that Hawking is British, but said nothing about the implications for their argument).

It sounded good so they went with it. This reflects the intellectual standards of a great deal of the criticism of the plan. The anger is at the thuggishness and dishonesty, not sensible criticism.

22 Martin Brock August 13, 2009 at 2:51 pm

Yancey,

I’ll say fifty percent, so the person may have whatever chance at life extension half a million buys, or she may improve her legacy by investing the entire million.

A progressive consumption tax, of the kind I support, taxes only consumption, so her choice is between consuming half of the wealth or investing all of it. Marginal income does not simply signal marginal productivity. It can also signal entitlement to rents, so I see nothing fundamentally wrong with this choice on the margin. The state enforces her right to extraordinary consumption as well.

23 hubbabubba August 13, 2009 at 4:22 pm

was it not elprezidenteblowjobking that allowed drug companies to charge us (u.s.) as much as they wanted as long as they didn’t do the same to mexico and canada….or do I have only part of it?….anybody….

24 BK, MD August 13, 2009 at 5:57 pm

oncodoc,

that kind of reasonable and nuanced position will not be tolerated on these internets

25 Brett Dunbar August 13, 2009 at 10:27 pm

The ban on co-pays was put in when Aneurin Bevan established the NHS. I think the reasoning was along the line that if co-pays were allowed they might become required for most treatments and that would conflict with the free at the point of use principal and might make healthcare something only for the rich. Nye Bevan was rather upset when that principal was compromised with the introduction of prescription charges in 1951, he resigned as Minister of Labour.

26 norse_dog August 14, 2009 at 12:06 am

Two points:

(a) The way drug companies monetize their research is counterproductive to national health. Attempts to maximize per-dose revenue will inevitably cause a huge load on total healthcare costs or human tragedies. It would be interesting to see how an auction with governments right of first refusal to buy the (clinical-trial proven) results of research for the public domain might improve performance.

(b) Total health-care costs are also impacted by the problem that control over treatment is enacted by self-interested agents, in whose best interest it is to select frequent high-cost procedures and medications. I don’t see a possible solution here other than to remove that self-interest and enforce flat-pay services instead of fee-driven ones.

27 Sam August 14, 2009 at 1:03 pm

“If we valued human life to the tune of hundreds of thousands of dollars per few months, there is a huge host of new (costly) safety regulations that we should impose on other industries.”

But “we” don’t. I value the lives of my family quite highly, and would spend lots of money to keep them healthy and happy. I’m not willing to pay nearly so much to help the guy down the street.

28 Martin Brock August 14, 2009 at 1:34 pm

Yancey,

I’m willing to speak frankly in your language, but your choice of words is only that. “Tax the guy to death” is a political construct. You employ it to cast doubt on a competing system of forcible propriety. You don’t advocate no force, and you don’t advocate no deadly force. You only advocate different force.

I would not entitle your hypothetical person to a million dollar cancer treatment by writ of forcible propriety, just as I wouldn’t entitle Hirst to the treatment through the NHS; however, your person remains entitled to invest in lowering the cost of the treatment, so that she and others may consume it.

There. The difference is entirely superficial, but the new formulation sounds better than “tax the person to death”.

You could do me the courtesy of also frankly acknowledging the forcible propriety you defend, but I don’t expect you to do it. I’ve known too many nominal “libertarians”.

29 Lorenzo (from Downunder) August 16, 2009 at 8:25 pm

I notice people in the US never seem to look at the Australian example, where we have a basic public insurance (Medicare) and you can purchase private insurance.

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