Introduction from Robin Lovelock in Sunninghill ...

I set up this page in January 2025, after old friends starting discussing the subject of Health Care, and how it is different in different countries, starting with the USA and UK. This was triggered by my annual "catching up" with friends around the World, after publication of my 2024 Christmas Newsletter . Tap or Click on pictures to expand, visit links, relevant pages, or play videos. My mugshot is linked to www.GPSS.co.uk . That photo on the right, taken in December 2024, is for those who say my mug shots make me look too young, and/or they don't recognise me now :-) In 2024, yet more "photo trail" videos were added to www.youtube.com/user/RobinLovelock/videos showing life with the Lovelocks in Sunninghill, and the state of our house and garden - better than it ever was - but needs "Handyman" work - particularly indoors ! ;-)
What follows are extracts from emails, and I will start with this page being "hidden". However, I hope, with my friend's OK, it can be public - not the same as "publicity" of course ;-) The obvious place is to put it as a link off my Grumpy page. Visit it if you dare - particularly if you are American ;-)
Email extracts will be the most recent first, and I've no idea how this page will develop - if at all ;-)

I started cautiously ( that "OLD STUFF" at end, now removed), redacting full names & locations, but great if OK to release more - maybe even (old) mugshots ? :-) Sorry about terrible lack of layout: one thing at a time - not so bad now ? ;-)
Update: Martin relaxed about it, since easy to find on Net, and - in due course - I'll add some muugshots - maybe old & new - started ;-)
New layout using pre and /pre helped, so now to get emails in correct time order... done ? Better layout using [p]. Corrections & more pictures soon ? :-) make those links active ? e.g. www.GPSS.co.uk or www.GPSS.co.uk/ferranti.htm & photo of Pete Wilson on right ?
Young Marty on Robin's Study wall below, and also current 2025 Grumpy Old Man photo - now smiling ;-)
"Tweaks" in progress, which may make the page clearer and/or more entertaining 0 including Robin's friends in 150+ countries ;-)
Yes, an email to Google Group ROBINLOVELOCKSFRIENDS is on Robin's "list to do" but see my COVID19 page with humour :-)

Extracts from emails, with earliest first ...

Hope I can get layout better with the pre and /pre html ... finding damn emails difficult enough ! :-)

On Jan 4, 2025, at 10:22 AM, Robin Lovelock on robin@gpss.co.uk wrote:

Our 2024 Newsletter on http://www.gpss.co.uk/xmas24.htm is complete, with LOTS of videos :-)
Sorry that this email may be later than last year, and if you got something similar before.
Believe it or not, I've been reduced to printing my AOL contact list & ticking guys I remember ;-)
I enjoy reading your replies, even if they often include sad news - Love & Strength !
Our household still includes myself Robin, wife June, and eldest daughter Samantha.
Plus our damn pussy cat Tody, and the big black fluffy Bentley from opposite.
But, for a few more days, we have youngest daughter Michelle from Coventry with us,
with her ( less mischievous ) cat Lady. All in the videos linked from Newsletter :-)
Wishing you a Happy 2025 !
Take Care
Robin
http://www.gpss.co.uk and http://www.nhscare.info and http://www.gpshobby.info
22 Armitage Court, Sunninghill, Ascot, Berkshire, SL5 9TA, England, UK.
Landline 00441344620775 Mobile 00447736353494
All above on "Contact" page http://www.gpss.co.uk/contact.htm including tracking us ;-)
Main Youtube Channel: https://www.youtube.com/user/RobinLovelock/videos

On Jan 4, 2025, at 2:39 PM, Martin B. Brilliant wrote: Hello, Robin,

Happy New Year (somewhat belatedly)!

That’s a blast from the past! According to my email archives, we haven’t been in touch for twenty years.

I turned 93 exactly a month ago, so that thirty-year-old photo no longer represents me. I look a bit older, feel a bit older, but people looking at me think I’m 20 years younger than my real age, and I feel the way I look.

At about age 78 I decided I was over the hill and had better start digging in my heels against the back slope. I started exercising in my basement, collected a few bits of equipment like barbells, dumbells, a squat rack, a weight bench, some second hand, the squat rack home made. A few years later something popped in my back as I walked from the deadlift station to the squat rack. For the next few years I had intermittent pains up and down the left leg, and it ended with some atrophy of the left quadriceps. Having decided I didn’t know what I was doing i started working with a personal trainer twice a week in my basement. The trainer decided she knew how I could do deadlifts safely—wrong! I now have intermittent pains up and down the other leg, along with lower back pain. The upshot is that I can’t walk more than about half a mile, and going up stairs is more of an effort than it used to be.

I won’t go into my other medical adventures. Nancy and I are still together in the same house. She cooks less and I cook more, but she still cooks more than I do. We gave up on the New Jersey Symphony Orchestra, partly because we didn’t like their music choices and partly because we didn’t want to drive to their evening concerts, and replaced it with the Red Bank Chamber Music Society, which holds concerts on Sunday afternoons and has more our style of music. In similar vein we’ve stopped going to New York theaters and have taken to attending the New Jersey Repertory Company, which has a small theater not too far away in Long Branch and shows new plays, good ones as they have some mysterious way of picking them, and Two River Theater, which is even closer in Red Bank.

I don’t have a recent portrait-style photo of myself, but here’s a photo taken by my trainer last March in the basement:

Do I look like a 92-year-old man in that photo?

Marty Martin B. Brilliant at home in Holmdel, NJ

Then: On Saturday, January 4, 2025 at 10:17:22 PM GMT, Martin B. Brilliant wrote:

Silly me! Of course we’ve been in touch since 2004. I was looking at the GPSS mailbox on my computer but I didn’t realize the emails were sorted by Date Received *ascending*! So what I thought was the latest email was actually the oldest. Then you must know most of what I just told you. Sorry about that.

On Jan 5, 2025, at 8:32 AM, Robin Lovelock on robin@gpss.co.uk wrote:

Good Sunday afternoon (UK time) Martin - in NJ USA ! :-)
Yea - email probs - with unstable stuff - tell me about it :-)
Great to get your reply, including health stuff, and I'll CC to myself and women here.

Also, my old workmate Pete Wilson, from Ferranti days in 1970/71 http://www.gpss.co.uk/ferranti.htm
You have to scroll down to see him, near photos he took at our Wedding in 1971.
I won't go into the mischief we got up to, like pranks, during our bachelor days ;-)
Why CC Pete ? Well, last year, he insisted on changing his nationality from British to Yank ! :-)
Since you are in New Jersey, I guess it's not so many miles from you to him ?
Route 66 ? Memories of watching Easy Rider back in the 1960s with him and others :-)
BTW Pete: do you have any old photos you don't mind being public, from those days ?
I do recall, on my stag night, riding on the roof of that mini, from the pub, to Duncairn bachelor flat :-)
Pete had a stroke last year, but by all accounts, he is now back to travelling & mischief making ;-)

Cooking ? Yes, I used to do that, particularly in my bachelor days. The low point was a Ribena omelette :-)

Since I'm a very politically correct guy, I attach photos, including my being dressed for a caribean party ! Problem was that my blacking kept coming off on June's white trousers, on the dance floor ;-)

Thanks again :-)
Robin
http://www.gpss.co.uk

On Tuesday, January 7, 2025 at 02:57:05 PM GMT, Martin B. Brilliant wrote:

Hi, Robin,

I have a question for you, about some medical practices in the UK vs. the US. I have to have a procedure that involves anesthesia. It’s “elective,” even though it has to be done, because it doesn’t have to be done immediately. So I can plan for it, in fact I have to plan for it.

The practice here seems to be to discharge patients before they’re fully recovered from the anesthesia, often even before they can walk without help. According to my doctor, I can only be discharged to the care of a family member (although once, after a procedure by a different doctor, I was discharged to a high-priced limo). I’m not allowed to drive home by myself, and I can’t be taken home by a taxi or Uber because the doctor says they’ve had trouble with lawsuits—I suppose on the grounds that the doctor or hospital discharged the patient prematurely.

Is that the way it’s done in your National Health Service?

(The actual problem is that there are no family members who can drive me home from the hospital where the procedure will be done.)

With regard to my cooking, by the way, I own two woks (12 inch and 10 inch) and I’m the designated stir-fry cook. I also have some small cast-iron skillets and larger carbon-steel skillets that Nancy never uses, and an enameled cast-iron Dutch oven that I haven’t used yet.

On Jan 7, 2025, at 11:33 AM, Robin Lovelock on robin@gpss.co.uk wrote:

Hi Martin (Brilliant in NJ USA)

You ask about how we get back from hospital, after an op', here in Sunninghill, Ascot, Berkshire, England, UK.

As it happens, I raised this topic, during coffee, after pub lunch, with Grumpy Old Men today. The oldest and wisest is Stuart, now 88, who knows how to cope with weaknesses in our NHS, which - in my opinion - are mostly in the GP surguries, that have always been businesses.

The direct answer to you question, is that , in Sunninghill, we have no such problem in finding a taxi company, of any network, including Uber or our local Ascot Taxi, to provide the lift after discharge. In fact, we have a local charity, which will provide such lifts, completely free of charge.

Perhaps, more importantly, our local Heatherwood Hospital, recently modernised and under the management of "Frimley Health" - once called Frimley Military Hospital, near Sandhurst Military Acedemy. - is excellent, fast, & efficient.

I am also CCing Dr John Raffetto who you will see on http://www.gpss.co.uk/johnman.htm Interesting European history in the late 1970s - that "Roman Communist War" BUT, even more interesting - the possibility that the best hospitals in UK ( with a UK military connection ) MAY have had USA tax-payers money fed in - covering the chance that US military personnel might need their use ;-)

Of course, Dr John (of https://ambassadorcare.com/ ) might say "You might say that Robin, but I could not possibly comment" ;-)

As my newsletter on http://www.gpss.co.uk/xmas24.htm and youtube videos explain, as I'm writing this, in early January 2025, June has not even had the date of an appointment given her, let alone the person & place, to see a specialist and get a proper diagnosis of her persistent cough & cold.

Stuart is ith the same surgury, Magnolia House, but know how to "use" them ;-) I changed from Magnolia House o Lightwater Surgury 10 years ago after I was dissatisfied with them. e.g. not sending you to the hospial of your choosing, and you not getting consultant reports back directly - having to go in and ask for them in the surgery, within a week for the examination !

On this occasion, I will also CC youngest daughter Michelle, perhaps* wisest in our family, and eldest daughter Samantha - who I want to take over housework from June ;-) * I'll also CC "sensible Saskia", daughter #2, in Yately, near Blackbush Airfield ;-)

I don't know if this email ( & our earlier ones ) will be of any use to anyone - but who knows ? :-)

Thanks Dr John for your reply ref my newsletter >>
Thank you, Robin, and best wishes to you and your family. John
<<<

Take Care All :-)
Robin
http://www.gpss.co.uk and http://www.nhscare.info and http://www.gpshobby.info

On Tuesday, January 7, 2025 at 06:05:55 PM GMT, Martin B. Brilliant wrote:

Thank you, Robin, for that info. But I would like to have a clear answer about the state of the patient when discharged. I have often been discharged before I am able to walk unassisted and unaided—“assisted” referring to the presence of one or more assistants, i.e., people, to keep me upright, and “aided” referring to the use of “mobility aids” such as a walker or cane. Do they do that to you and yours?

In other words, you say that in your area they have no problem letting you get into a taxi to get home, and I doubt that they would do that if you were not in full possession of your faculties.

I did find a local charity here that provides medical transportation free of charge, but only to people who don’t, or no longer, drive at all. I can drive well enough when sound and sober, so I wouldn’t be eligible.

On Jan 8, 2025, at 6:36 AM, Robin Lovelock on robin@gpss.co.uk wrote:

Good Moaning* Martin. In short: patients sometimes spend time in a "discharge ward" getting physio therapy.

The most expert on this subject of discharge is daughter Michelle still here. It is normal for guys to spend time - whatever needed - in a "discharge ward". To get things like practise in walking, going up & down stairs, etc - with physio therapy. BUT what I've seen has been at that excellent Frimley Park (Military) Hospital.

* from 'Allo 'Allo the WW2 Comedy TV series - the UK secret agent disguised as a French Policeman ;-)

Michelle went through discharge the year before last: 2023. - was fun visiting her & fellow patients. It's many years since I would visit father in law Jack Ponsford, going through similar procedures. As I understand it, her problems were mostly poor diagnosis & treatment in a Coventry hospital.

I think that's the answer to your question, but it triggers memories of a local old lady who went into Frimley Park Hospital several years ago for an operation, so she could walk better. She always had a wicked sense of humour, and told me about the banter between her and the doctors, including what they wrote in her paper notes, shared with the other staff.

It came to when the physio therapist said she was ready to try getting out of bed, and walking across the ward, aided by a walker. Her bed was surrounded by a curtain, as is normal.

She said "yes" and she wanted to know who the guy was in the next bed, since there had been some banter.

When she saw him, she was greeted by a smiling face, and words like "it was banter between you and the doctors that has kept me going ! :-)". This guy was a serving soldier who had just got both of his legs blown off in Afghanistan. She told me his name, and visited him after his discharge.

Guess that'll do from my consultancy. My Frimley Park Hospital page is headlined on http://www.gpss.co.uk Lots of the staff there are still serving. When the doctor was examining my rear end I asked "you are not gay, are you ?" ;-)

Take Care who you seek advice from Martin :-)
LOts of stuff in my in-tray today, including other replies, and maybe getting my beard & hair trimmed ;-)
Robin
http://www.gpss.co.uk and http://www.nhscare.info

On Wednesday, January 8, 2025 at 02:26:20 PM GMT, Martin B. Brilliant wrote:

Doesn’t that reinforce my impression that the US is backward compared with the UK (and Europe).

And the latest political turn doesn’t help. Of course we want to “Make America Great Again,” but our new President hasn’t the least understanding of the problem.

On Jan 8, 2025, at 12:10 PM, Robin Lovelock on robin@gpss.co.uk wrote:

Thanks Martin. USA backward on health care Martin ? Trump* ? :-)
I've always found the info about healthcare more reliable from USA.
Big business everywhere has been the complicating factor.
I guess the name of the game, whereever you are in the World, is to exploit & cope where you can ;-)
I'll CC family, but also, again, relevant friends n USA like Pete Wilson, Rod, Levine and Dr John Raffetto.
Busy here, not long back from places like Sunninghill Comrades Club & expecting another 'phone call soon from Scotland/Switzerland - "Swiss Gnome" friend from 1980s http://www.gpss.co.uk/easams.htm
Kicking the arse of Hughes Aircraft in billion pound sterling contract for Malaysia ;-)
* I suggested some weeks ago that, if Trump withdraws USA from NATO perhaps the USA would like to join The British Empire (Comonwealth ) again ? You would then be fighting fo "King & Country" ;-)
Robin
http://www.gpss.co.uk and http://www.nhscare.info

from Martin Briliant on Wed, Jan 8 at 5:51 PM

Yes, the US has the best healthcare in the world. But it's not in the system we ordinary people use. It’s for rich people who can afford to go out of the system and pay the full price, like oil-rich sheiks from Saudi Arabia.

Actually we don’t have a health-care system. We have a system for paying for health-care, and it’s a mashup of Medicare, Medicaid, and a variety of private insurance plans, most of which are regulated in some way. In fact Medicare is a mashup of federal “traditional Medicare” and a variety of privately operated, federally subsidized “Medicare Advantage” plans. Some companies provide health insurance for their employees and retirees, some people have to manage without that help. I have a choice of my retiree plan and Nancy’s, and Nancy’s is better. Even so, sometimes our Medicare Advantage plan denies payment for a test or procedure that has been prescribed for me, or sometimes has already been done, and I don’t know how that plays out.

My first clue that the US is backward was in a trip to Europe in the 1960s, when we rode in subways that were clean, quiet and comfortable, in all respects unlike the subways we were accustomed to in the US. The impression was reinforced in a later trip when our US-issued credit card was refused on the grounds that it didn’t have a chip.

The US has gone downhill in the last half century or so. I read recently that World War II was won largely because the US had enough productive capacity to churn out war materiel faster than the enemy could destroy it. We now depend on the productive capacity of East Asia, including China. I guess the next biggest producer in the WWII era was Germany—do they still have it?

I don’t think the US would join the Commonwealth. We have this idea of “American exceptionalism.” We are the only country, outside of Liberia and Myanmar, that officially uses the “Imperial” system of measurement—which the Commonwealth does not. We imagine that we are the greatest country in the world—so what does Trump mean by “Make America Great AGAIN”?

Pardon me if I get a little incoherent. I grew up in an era when the US really was the greatest country in the world, and I seem to be stuck in something else.

On Jan 8, 2025, at 12:04 PM, Robin Lovelock on robin@gpss.co.uk wrote:

Wise words Martin - that I will share with those others :-) It's all a matter how you define "great" ? :-)
Of course, it is the Russians who won WW2 for us. Hitler should not have bitten off more than he could chew.
BUT you yanks did invent "insurgency" with that Boston Tea Party ;-) I do love banter between friends ;-)
Robin
http://www.gpss.co.uk and http://www.nhscare.info

On Jan 8, 2025, at 6:11 PM, Pete Wilson wrote:

Having tried three systems - UK’s NHS, USA’s offerings, and the French system, there’s a few points and opinions it may be worth making

i. Things change over time. When I was in the UK - until my 30-somethingth birthday - the NHS seemed to work reasonably. You could see your GP without much of a delay, if any, and hospitals seemed capable of treating people. It seems very much worse now. Fixing it is probably impossible without wholesale rip up and replace.

ii. The USA has very good health care. But it costs a lot - so you need to make provision to use until Medicare kicks in at 66 or so. To make provision you need insurance for at least risks that may land you in hospital or as an outpatient, and then you could probably get by paying out of pocket for routine doctor visits. But although the state doesn’t pay for housing, food or clothes, people seem to expect that health care is provided to them magically. It’s not as important as food and shelter, which people “willingly” buy (they don’t like the price sometimes, but they do pay). The trouble with healthcare is not only that the human body is complex and can go wrong in so many interesting ways but that the ways of treating the problems can be horribly expensive. A prime case for insurance, you’d think, but the next problem is that folk don’t want insurance, they want a get out of hospital free card. If you own a high end car, you know that insuring it costs more than insurance a bottom of the range Kia - that is, your payments increase as the amount covered s\increases. Won’t work for healthcare without some catastrophic insurance to back up the ordinary health insurance, because folk a.) don’t want to pay more for better coverage and b.) they don’t want to be refused treatment because they’ve hit a coverage limit. So that all needs sorted out, including (my opinion) making it at least exceedingly unattractive for employers to supply insurance - because when individuals can’t see the real cost of things, there’s little pressure to have stuff like ‘basic care’ done cheaply. Why does an MRI on a ten year old machine cost as much as it does - plus buckets of cash for the analysis of the results? You’d expect that with price pressure you would find that older MRI machine - having paid for themselves - could be coupled with computer-based image analysis for a cost 5x less than current rates… Not as good, but much better than not having the scan...

iii. The French system has good points - for example, I get an hour of physical therapy for $20. That’s what my uncovered expense is getting PT in Austin - Humana pays about 80% of the amount charged, which is reduced from the notional price by a web of complex agreements on price reductions. A doctor in France visit is $25 (just gone up, I think). You have state paid healthcare that works something like - they pay 80%, you pay the remaining 20%; you can get complementary insurance that’ll pay the 20%. (Numbers for example - they’re probably about right.) But the state never has to be told you’re cured, or as cured as you ever will be so - if I was covered by the French system - I could get physical therapy for ever. That can get very expensive for the state..And you need to schedule MRIs and even CAT scans - sometimes a week or less, but often more. Here in Austin, CAT scans are almost walk-ins, and MRI’s are tomorrow or the day after. There are probably a dozen MRI machines in Austin, plus those in hospitals. We have one here in Cedar Park (an Austin commuter town). You can get a full body scan with diagnostic info on the presence or absence of cancer in 13 different organs - price includes the scan and the interpretation - for under $2k; only $3500 for a couple. That’s a level of ‘medical service’ that you wouldn’t expect find in France - and it’s cheaper than the last service on my car. (In the UK you’ll get a letter telling you when your appointment for a scan is, but it’ll probably be delivered after the date, or go to the wrong person; then you have to try again…)

Not an easy problem to solve, but state control, state price-setting, and state provision of services probably aren’t things that help…

— Pete

On Jan 8, 2025, at 6:59 PM, Martin Brilliant wrote:

Thanks, Pete, for that comprehensive review. I might compare healthcare with police protection and fire protection, which we get free of charge at point of service, paid out of general taxation. We don’t pay for healthcare that way, but as Pete says, “The trouble with healthcare is … that the ways of treating the problems can be horribly expensive.” In that way, healthcare is like police protection or fire protection. Healthcare is different in that although we get routine police protection, for instance, like traffic control and routine patrols, it’s not personal the way routine healthcare is. You can be asked to pay for an exam, but not for getting stopped at a traffic obstruction.

And then, it’s hard to say exactly where routine healthcare ends and catastrophic care begins. I suppose you could say that examinations are routine and should not be covered, while treatments, regardless of cost, should be covered. The trouble with that approach is that if you pay for exams yourself you’re likely to skip them, and then treatment will be more expensive.

That leads us to the problem of incentives. If the patients pay for routine exams, they're likely to spend less on them. If providers are paid according to the amount of service they provide, they will find excuses to provide more expensive services. The NHS avoids that incentive by paying doctors on salary. But then the NHS apparently has gone the way of our (US) Postal Service and the New York City subway—government wants to spend less, so service deteriorates. Private insurers try to counter the providers’ incentive to do more for more by telling you which services you don’t need, but they don’t really know what you need.

By the way, Pete, you say you were 30-ish when the NHS started to fall apart, but I don’t know when that was because I don’t know how old you are. In the interest of fairness, I’m 93. I was in my early teens when our family physician died, and I asked my mother what would happen to all my medical records. “They’re gone,” she said. Based on some simple arithmetic, that was in the mid-1940s.

One problem with healthcare in the US, at least where I live, is that there’s no system. There are specialists and there are primary care physicians (PCPs). The specialists are paid well when they do procedures. The PCPs don’t do much in the way of procedures so they aren’t paid well, so they don’t have time to review what the specialists do. And there’s no network: when I need a specialist I have to find one myself, and make an appointment that’s usually weeks away. As Pete implies, the doctors are competent (for the most part) and good equipment is available, but getting it all together is a hassle.

What would the perfect healthcare system look like?

from Pete Wilson:
Martin

Congratulations on getting to 93. You’re ahead of me: I was born in 1947. But to level the playing field I had a stroke which turned off my right side for a while in mid 2022 (the right hand side now works, sorta, and is continuing to improve)

So let’s think aloud on what a better approach to health care might be. Better means better for people, not health care professionals or companies, and could be measured by price, availability, quality of results, and % covered….

I think a useful guide to what a health system should look like is the existing food system, the existing house provision system, the existing computer system, etc. The are all non-existent, and we get better shops, food supply, houses, cars and computers as a result. The house system is, however, actually not a good example. Here in the USA an established monopoly imposes a 6% or so tax on every sale, while on the whole adding less value than a Google search - and forswearing all liability. And government planning rules (especially bad in the UK) impose as well. But the others are pretty good examples of working marketplaces. Why can’t we buy health care in the same style? Real competition - where the individual is not cushioned against seeing and experiencing true costs by hiding them behind employer or state provided insurance - will reduce costs and prices, as it does in every other field. (In the UK, supermarket margins were 6% until Lidl and Aldi entered the fray; now it’s more like 3%, as one example.)

And while cars, computers, carpets, furniture and roof tiles are all things I as a consumer might want or need, there isn’t “a system” for delivering them. There’s a meta system - the marketplace - which as a result of it mostly being "free to enter" (you don’t really need permission to sell rooftrees, although there are start up and ongoing costs and sometimes the need for a license - all of which impose a startup cost on any who wants to get into business - but on the whole there is not a regulatory body which can say “we’ve reached the quota for faeries, so you can’t open one” so the marketplace is ‘free to enter’)

Yes, the human body is complex. So’s a BMW, but you don't have to go to medical school equivalent for half a decade to service BMW’s, Yes, we do want competent doctors, but we also want competent drivers and mechanics and car designers and braking system designers and food packaging and storage engineers. And getting an incompetent actor in any of these things mean that your body can be badly damages as a result. But we leave the resolution of those problems to the courts, after the event: folk who build and sell stuff are liable for the results of their errors.

So, to cut to the chase, it seems to me that we could - over time - change how the delivery of health care works. Much of the stuff handled by GPs could be handled via automation, with some human oversight. There could perhaps be an apprentice system with constant learning opportunities where a determined individual could accumulate real worlds skills and knowledge without the traditional medical school.

Surgeons would need some care, because they get to dissemble bodies, ad most patients will want the body to be put back correctly.. But surgery has in places been replaced by machines: you don’t cut out every chance, for example. You block it from eating by having drugs which bind to it so it can’t and dies; or you zap it horribly with radiation; or directly target it with designer drugs which preferentially kill cancer cells, not others. And there are fields where the surgery is performed, but the cutting is done by machinery - a fine possibility for eventual at least partial control by machine and algorithm So even surgery - classic surgery - might slowly move to being a knife under the control of a bunch of algorithms running on an integrated circuit.

And the key effect of that is that it all becomes dirt cheap because the things are high volume manufactured. So you buy Apple Doctor software for your home computer (Apple because they’re fairly serious about privacy, and over time your home has more”medical sensors” (example:your watch already can do a lot, and could do more with a bit of patent-cleansing and law changing). Software could give you diagnosis with a margin of error, recommending (increasingly rarely with time) to check with another source if it’s not sure. Eventually, ‘robot surgeons’ used in clinics will be offered to the public for home purchase or rental; MRI machines and their ilk are unlikely to be - but perhaps ultrasound gets better...

So, to summarise: we don’t need a heath system, we need a health care delivery market where the prices are visible so people can seek out what suits them, as they do with food, shelter, transport and so on and where innovation is easily possible to keep driving costs down. As with other areas, some folk can’t pay; we address that by first reducing the costs (one can imagine having a home doctor, even if most people wouldn’t install the surgeon peripheral - they’d rent that) and the by having a safety net that is annoying, unpleasant or socially ‘unacceptable’ so that those who need care can get it, but few will wish to freeload.

But of course there are major obstructions to going down this road; the major one is “unions” - doctors like a quota system which strongly limits the number who can enter the trade; and the law-enforced closed shop where it’s illegal to do medical things unless you’re a doctor. So the law will have to change, which means politicians will have to be bought. So.. non-trivial problem. And any change will result in mistakes, so expect lots of coordinated attacks from the usual suspects.

Thoughts?

— P

On Jan 8, 2025, at 6:59 PM, Martin Brilliant wrote:

Thanks, Pete, for that comprehensive review. I might compare healthcare with police protection and fire protection, which we get free of charge at point of service, paid out of general taxation. We don’t pay for healthcare that way, but as Pete says, “The trouble with healthcare is … that the ways of treating the problems can be horribly expensive.” In that way, healthcare is like police protection or fire protection. Healthcare is different in that although we get routine police protection, for instance, like traffic control and routine patrols, it’s not personal the way routine healthcare is. You can be asked to pay for an exam, but not for getting stopped at a traffic obstruction.

And then, it’s hard to say exactly where routine healthcare ends and catastrophic care begins. I suppose you could say that examinations are routine and should not be covered, while treatments, regardless of cost, should be covered. The trouble with that approach is that if you pay for exams yourself you’re likely to skip them, and then treatment will be more expensive.

That leads us to the problem of incentives. If the patients pay for routine exams, they're likely to spend less on them. If providers are paid according to the amount of service they provide, they will find excuses to provide more expensive services. The NHS avoids that incentive by paying doctors on salary. But then the NHS apparently has gone the way of our (US) Postal Service and the New York City subway—government wants to spend less, so service deteriorates. Private insurers try to counter the providers’ incentive to do more for more by telling you which services you don’t need, but they don’t really know what you need.

By the way, Pete, you say you were 30-ish when the NHS started to fall apart, but I don’t know when that was because I don’t know how old you are. In the interest of fairness, I’m 93. I was in my early teens when our family physician died, and I asked my mother what would happen to all my medical records. “They’re gone,” she said. Based on some simple arithmetic, that was in the mid-1940s.

One problem with healthcare in the US, at least where I live, is that there’s no system. There are specialists and there are primary care physicians (PCPs). The specialists are paid well when they do procedures. The PCPs don’t do much in the way of procedures so they aren’t paid well, so they don’t have time to review what the specialists do. And there’s no network: when I need a specialist I have to find one myself, and make an appointment that’s usually weeks away. As Pete implies, the doctors are competent (for the most part) and good equipment is available, but getting it all together is a hassle.

What would the perfect healthcare system look like?

On Jan 9, 2025, at 9:31 PM, Martin B. Brilliant wrote:

Pete, I know more about economics than I do about medicine, so I’ll respond from that standpoint.

First, with regard to automation, I’d like to repeat a little fable that i like to tell. Suppose everything anybody wanted grew on trees, so nobody would have to work, ever. Would that be paradise? No, it would not, because somebody would own those trees, and they would want to be paid for anything anybody took off them. But nobody would have anything to pay with, because nobody needed their work. Only people who owned magic trees would have anything at all.

If you’re creating a straw man, the least you can do is test your hypothesis out on several versions. Suppose no-one owned the trees? Suppose some people liked television(TVs and broadcasting and networks can’t grow on trees?).

Apple products are expensive. You want Apple software for your computer to diagnose your ills, and maybe Apple machinery to treat them, and not everybody will be able to pay for them. Are you happy with that? And computers - like the pocket supercomputers that people call “cell phones” - are so cheap that in the USA even very poor people have them. Apple was an example; turns out anyone can write software for an Apple computer. And anyone can write an equivalent for a Linux computer. Or a cell phone. Or a Raspberry Pi.

Getting back to healthcare as it actually is, it’s economically quite different from food, housing and computers. For those goods you can have a market. A well-functioning market requires that seller and buyer both have more or less equal knowledge of the commodity, that there be many potential sellers for each buyer and potential buyers for each seller, and that buyer and seller both have time to think about the transaction and choose whom to deal with and what to buy or sell. That’s true of food, houses and (to a lesser extent) computers, but it isn’t true of healthcare. A “free market” for healthcare can’t exist.

No, it’s illegal to diagnose sans a medical license. So you’re right; the law makes it impossible to have a free market. But I get ill relatively rarely; I need food every day. If the law required both that food preparers had a doctor’s degree and that it was illegal to supply food or prepare it without one, we couldn’t have a free market in food. But for food, the law is more reasonable: basically, if you prepare and sell food it mustn’t knowingly cause harm, and the customer has a right to know how much it costs and what it is. There foods which are risky to consume: undercookable meat, seafood etc. The risk is labelled; consumer’s choice..

Another factor is that we—many of us, anyway—consider healthcare to be a human right. We believe everybody should have food, and everybody should have a house, but there’s a difference between what poor people get and what rich people get, and it doesn’t bother us as long as everybody has enough food and enough housing. But the idea that some people should get poor healthcare if they can’t afford proper healthcare is—to many of us—unacceptable.

Alas, the notion of ‘poor healthcare’ is a moving target. What even Medicaid (or Medicare) offers today is much, much better than royalty had access to under 100 years ago. As a practical issue, what’s poor healthcare and what’s proper healthcare? You feel everybody should have access to the Zuckerberg or Biden levels of healthcare? Or is a lower level acceptable?

Given those considerations, the market for healthcare is more like the market for police protection and fire protection than lt is like the market for food, houses and computers. The provision of police and fire protection follows exactly the definition of socialism: public ownership of the means of production. The NHS is an attempt to do just that. What we have here in the US is an attempt to avoid just that, because our people have been brainwashed to be afraid of socialism. It’s not that I think a socialist approach would work, but that I’m pretty sure that a capitalist approach can’t work. The solution has to be something else.

Police protection is function of the state, hopefully addressing a very limited problem (most places, not everybody is an active, practicing criminal). So healthcare isn’t like that - we’d wish to avoid a state monopoly in healthcare provision, and it’s for everyone. So the preferred way to address the - real! - problem of expensive healthcare is to reduce costs. And to have a financial safety net for those unable to pay. Having the state provide $$$ to unfortunate folk is a whole lot better than having the state offer a quasi-monopolistic healthcare system.

Anyway, Pete, if you were born in 1947, and the NHS started to fall apart when you were 30-ish, that must have been about 1977. That’s about when I think the productive capacity of the US started to fall apart.

Hmmm. Turns out that by even 1950, the USA was incapable of producing even historic numbers of stage coaches and buggy whips. Even more starkly, the USA has had a catastrophic decline in agriculture; in 1850, about 60% of the population worked in agriculture; today it’s 2% or less. Obviously, this is awful and is evidence that the USA is collapsing.

Could it be possible that what it’s worth producing changes with time, leveraging advances in technology

— Pete?

from Pete Wilson on Sat, Jan 11 2025 at 9:54 PM

Martin

I think that in one area we’re saying very similar things: the inconvenient fact about people is that not only do they want different things, what they want can change with time - perhaps because of ‘fashion’, perhaps because of encountering better alternatives. So any health care ’solution’ will likely piss off - or at least disappoint - most people.

But one area where we vehemently disagree is the notion that healthcare is a ‘human right’. No, it isn’t - or, perhaps better put, yes, good healthcare is nice to have, but isn’t something which has higher priority than food, for an example. Calling something that’s good to have a right doesn’t say anything much in the real world, because the real world doesn’t know what a right is (if you doubt this, ask a hungry tiger or a forest fire or even an otherwise harmless, predator-free desert to respect your rights)

A society can agree that some things are good, some things are bad, and that the society will seek to maximize the good and minimize the bad. But it is incapable - at current levels of knowledge - of providing enough MRI machines or COVID vaccines (even if they worked as well as ‘real’ vaccines do) or perhaps even hospital beds for flu patients for everybody. That’s because it’s an unbounded cost. So it is - my opinion - at best unhelpful to label something already recognized as desirable with the term ‘human right’ - it doesn’t add anything, because it ain’t a right because it’s not deliverable. And different societies priorities different things, or have a different ordering of what’s higher or lower priority.

And you can’t stop richer people from buying things. If Zuckerberg wanted to, he could buy himself a state of the art hospital and staff it. So could Musk. Biden effectively has one already, because of his job. There is no way I could get access the moment I want it or need it to that level of care. And if you forbid Zuckerberg from buying ‘privileged access’ to healthcare, he can go elsewhere. And presumably the rest of us would be stuck with whatever the government of the USA determined was acceptable access to acceptable care.

But that’s a monopoly, and I thought that standard economics says that a monopoly is a far from optimal solution. So why on earth would anyone support it?

A better approach to getting better healthcare for everyone has four major aspects:
	- reduce the cost as much as possible of as many things as possible, continuously
	- improve things, continuously
	- make full information on price, efficacy, and risk freely available
	- financial safety net for those currently unable to pay

I was concentrating on the rich opportunities to reduce cost through technology and the removal of the closed shop. I think these are the key factors to actually reducing the cost of healthcare. But ’society’ - politicians and doctors as a whole - are a formidable barrier

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