Single Payer

At the first meeting with the head of Hematology, I was pleased that he wanted do more testing. And I was impressed that he ordered a change of medication. But it caused me to wonder all the more that the previous doctor had altered nothing after performing a bone marrow biopsy and changing my diagnosis. Did he think there was little point of doing anything else? Or for some reason did he really think wait and see was the best approach? Did he just not know enough? But then why not send me to someone else? Or did he not know enough to know that he didn’t know enough?

For at least sixteen years I had taken a medication, called anagralide, which inhibits the production of blood platelets. I started anagralide shortly after its introduction to the market. When I had the opportunity to take it, I was eager to do so because the very first medication that I had taken, hydroxyurea, was not recommended for men trying to become fathers. Anagralide seemed not to cross into the semen. That meant that BF and I could pursue our plan of having a child. Years later I had been taking anagralide since MF was just a twinkle in the eye. At 16 he is now taller than his mother, and nearly as tall as me. Innovations in medicine had made it possible for us to be a family.

The new meds go by the name Jakavi in Europe. The generic name is ruxuolitinib. It has only been on the market for a few years. Here is what the European Medicines Agency says about it: “Ruxolitinib, works by blocking a group of enzymes known as Janus kinases (JAKs), which are involved in the production and growth of blood cells. In myelofibrosis and polycythaemia vera, there is too much JAK activity, leading to the abnormal production of blood cells. These blood cells migrate to organs including the spleen, causing them to become enlarged. By blocking JAKs, Jakavi reduces the abnormal production of blood cells, thereby reducing the symptoms of the diseases.”

I took my prescription for Jakavi to the pharmacist. He typed something into a computer and then informed me that he would have to place an order for it. He looked up at me quizzically. Did I realize how much my insurance was being charged for this? No. “Over 4,200 euro,” he said. That was for a 25 day dosage. Gulp. “How much do I pay?” Ten euro, he said. Mind you that’s not because I have some sort of platinum private insurance available to elite European professors. On the contrary, that’s single payer at work. That same benefit is available to the vast majority of people living here, available to all of the 85 percent of the population covered by the mandatory publicly funded insurance program. Residents pay a tax of about 15 percent of their earnings for their government financed health care coverage. The insurance is administered by one of several non-profit firms that differ very little in coverage benefits because of the mandatory high level of minimum coverage. Doctors and pharmacists in private practice are reimbursed by these insurance administrators. Participation in this system is mandatory; top earners and state officials can opt out, but only if they purchase private insurance.

Universal coverage, including access to expensive treatments is an impressive feature of single payer, of course. But you might worry whether it comes at too high an expense or if health outcomes are low as a result. It is very interesting to compare Europe and the USA with these concerns in mind. In 2013 the Commonwealth Fund conducted a study of health and healthcare in the wealthiest countries in world, the OCED countries. It found that “In 2013, the U.S. spent far more on health care than these other countries. Higher spending appeared to be largely driven by greater use of medical technology and higher health care prices, rather than more frequent doctor visits or hospital admissions. In contrast, U.S. spending on social services made up a relatively small share of the economy relative to other countries. Despite spending more on health care, Americans had poor health outcomes, including shorter life expectancy and greater prevalence of chronic conditions.” In particular healthcare spending as a percent of GDP in the USA was just over 17 percent. For Germany and several other European countries it was just over 11 percent. For the UK it was just under 9 percent. More spending in the US does not result in more doctors to serve the population. There are 2.6 physicians for every 1000 people in the USA, and 4.1 per 1000 in Germany. More spending in the US does not produce longer life expectancy. Life expectancy at birth in the USA is 78.8 years, and in Germany it’s 80.9. Nor does more spending yield a healthier population. The percentage of the population over 65 with two or more chronic conditions in the USA is 68, in Germany only 49. And the number of infant deaths per 1000 live births in the USA is 6.1; in Germany it’s nearly half that 3.3. So, coverage is far better in Europe; the costs of care are less; and health outcomes are better. There are real benefits to single payer insurance plans. Americans are spending significantly more on healthcare, and getting much less. My sense is that this is not well-appreciated by ordinary Americans.

Patience Dear Patient

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