[1] Health spending averages $9 892 per person in the United States, almost two-and-a-half times the average of the 35 OECD countries# ($4 003) and 25% above Switzerland, the next highest spender (adjusted for local living standards). Compared with the other G7 countries, the United States spends almost 80% more than Germany and more than twice as much on health care per person as Canada, France and Japan. Health spending amounted to 17.2% of GDP, more than eight percentage points above the OECD average.

[2] No insurance: In 2018, 30.4 million persons of all ages (9.4%) were uninsured at the time of interview, Looks like 8.8% from this Census report (table 2)- 2017. + Commonwealth fund: “Twenty-eight percent of working-age adults in the United States who had health insurance all year were underinsured in 2016” = 37%

[3] Specifically, a person who is insured all year is underinsured if: • out-of-pocket costs, excluding premiums, over the prior 12 months are equal to 10 percent or more of household income; or • out-of-pocket costs, excluding premiums, over the prior 12 months are equal to 5 percent or more of household income if income is under 200 percent of the federal poverty level ($23,760 for an individual and $48,600 for a family of four); or • deductible is 5 percent or more of household income

[4] “People who are underinsured face problems affording health care at rates similar to those seen for people with no health insurance at all, and they are almost as likely to skip needed care and to end up in debt when they get sick.”...More than half of the underinsured (52%) had medical bill problems and 45 percent went without needed health care because of cost.

[5] No insurance: In 2018, 30.4 million persons of all ages (9.4%) were uninsured at the time of interview, Looks like 8.8% from this Census report (table 2)- 2017. + Commonwealth fund: “Twenty-eight percent of working-age adults in the United States who had health insurance all year were underinsured in 2016” = 37%

[6] “According to a report published in 2017 by the Commonwealth Fund, a think-tank, 28% of American adults under 65, or 41m people, are underinsured, meaning that in addition to their insurance premiums they spend more than 10% of household income (or 5% for poor households) on topping up their health care.” in reference to this report: (doesn’t include people without insurance) https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_issue_brief_2017_oct_collins_underinsured_biennial_ib.pdf

[7] Specifically, a person who is insured all year is underinsured if: • out-of-pocket costs, excluding premiums, over the prior 12 months are equal to 10 percent or more of household income; or • out-of-pocket costs, excluding premiums, over the prior 12 months are equal to 5 percent or more of household income if income is under 200 percent of the federal poverty level ($23,760 for an individual and $48,600 for a family of four); or • deductible is 5 percent or more of household income

[8] “People who are underinsured face problems affording health care at rates similar to those seen for people with no health insurance at all, and they are almost as likely to skip needed care and to end up in debt when they get sick.”

[9] https://www.whitehouse.gov/briefings-statements/president-donald-j-trump-stands-lies-medicare-none/ 

[10] "U.S. health care spending grew 4.6 percent in 2018, reaching $3.6 trillion or $11,172 per person"  

[11] As a share of the nation's Gross Domestic Product, health spending accounted for 17.7 percent.

https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical 

[12] In 2016, the United States spent 17.8% of its GDP on health care (range of the other countries, 9.6%-12.4%; mean of all 11 countries, 11.5%) (Figure 1 and Figure 2) and had almost double the health spending per capita (mean, $9403) compared with the other countries (range, $3377-$6808; mean of all 11 countries, $5419)

[13] As a share of the nation's Gross Domestic Product, health spending accounted for 17.7 percent." (in 2018)

[14]https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/#item-average-wealthy-countries-spend-half-much-per-person-health-u-s-spends

[15] Prices of labor and goods, including pharmaceuticals, and administrative costs appeared to be the major drivers of the difference in overall cost between the United States and other high-income countries.  

[16] Increases in US health care spending from 1996 through 2013 were largely related to increases in health care service price and intensity

[17] https://ssa.uchicago.edu/ssascholars/h-pollack

[18]  One major reason why healthcare spending is much higher in America than in other countries is that our prices are exceptionally high.

[19] The cost of a hip replacement in the United States is over five times the cost in Brussels and the U.S. price includes fewer services…  For instance, an MRI in Japan is $160, while in

the United States it averages $1,700.5

[20] Prices of labor and goods, including pharmaceuticals, and administrative costs appeared to be the major drivers of the difference in overall cost between the United States and other high-income countries.  

[21] Increases in US health care spending from 1996 through 2013 were largely related to increases in health care service price and intensity

[22] https://www.healthsystemtracker.org/indicator/spending/prices-of-common-services/ 

[23] https://jamanetwork.com/journals/jama/article-abstract/2674671 Figure 9

[24]https://www.healthsystemtracker.org/chart-collection/how-do-healthcare-prices-and-use-in-the-u-s-compare-to-other-countries/#item-the-average-price-of-an-mri-in-the-u-s-is-significantly-higher-than-in-comparable-countries_2018 (2014) shows UK being $788 and in the US $1119,

[25] exhibits 3 and 4 in https://sci-hub.tw/https://doi.org/10.1377/hlthaff.2017.1367 "

[26] The cost of a hip replacement in the United States is over five times the cost in Brussels and the U.S. price includes fewer services…  For instance, an MRI in Japan is $160, while in

the United States it averages $1,700.5

[27] https://www.ncbi.nlm.nih.gov/pubmed/29536101 The United States spent approximately twice as much as other high-income countries on medical care, yet utilization rates in the United States were largely similar to those in other nations. Prices of labor and goods, including pharmaceuticals, and administrative costs appeared to be the major drivers of the difference in overall cost between the United States and other high-income countries."

[28] https://www.healthaffairs.org/doi/full/10.1377/hlthaff.22.3.89 

[29] In many situations, prices are set administratively (usually by regulators), rather than being market determined. ... In this situation, when competition among firms occurs it will be via non-price means, which we call quality. …. [also see section 5. Provider Price Negotiations and Network Formation ]

[30] The mean 3-year total cost of care in HCC [hepatocellular carcinoma]  patients was $154,688 (standard error, $150,953-$158,422) compared with $69,010 (standard error, $67,344-$70,675)

[31] The negotiating leverage of these large hospitals and physician practices is reinforced by the reluctance of many employers to adopt benefit structures with limited-provider networks, which weakens insurers’ negotiating power and undermines their ability to rebuff provider price demands.

[32] While the hospital sector increased its importance in the economy, it simultaneously became more concentrated. In particular, a large hospital merger wave swept through the country during the 1990s, increasing the concentration of many hospital markets … There have been over 1,000 mergers in the U.S. hospital industry from 1994 to [2015], with activity picking up in recent years … In 1990, approximately 65 percent of MSAs were classified as highly concentrated. By 2006 more than 77 percent fell into that category …

[33] This consolidation wave has also been recognized by the Federal Trade Commission

[34] Private physicians are consolidating 

[35] Private physicians are also  joining hospitals or organizations owned by hospitals

[36] Data on Physicians getting swallowed by hospitals - driving prices up http://www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/021919-Avalere-PAI-Physician-Employment-Trends-Study-2018-Update.pdf?ver=2019-02-19-162735-117

[37] See figure IX on effect of hospital monopoly, duopoly and triopoly on price increases

[38]  In 2016, 90 percent of MSAs were highly concentrated for hospitals (See exhibit 3 for population numbers - hospital = 113 million for high and moderate HHI scrutiny) 

[39] Hospital and health insurer markets have become more concentrated since the 1990s…see figure 1 https://www.aeaweb.org/articles?id=10.1257/jel.53.2.235...hospital mergers also increase prices of neighboring competitors

[40] As the Medicare Payment Advisory Commission noted, “[o]ne key driver of higher prices in the United States is provider market power. Hospitals merge and physician groups consolidate to gain market power over insurers to negotiate higher payment rates.”17 Such power is a pervasive feature of healthcare markets, enabling many hospitals, physician groups, and manufacturers of patented drugs to charge more or provide less than a competitive market would permit.

[41] Fortune 500 companies - this article points out the 5 healthcare providers that are in the fortune 500. One doesn’t sound like a hospital system (DaVita), so that leaves four: .  67. HCA Healthcare (Nashville, Tennessee) “The health care facilities operator— one of the country’s largest with 179 operating hospitals” ;)172. Tenet Healthcare (Dallas); [The Dallas-based health care provider and its subsidiaries operate acute care and specialty hospitals]; 223. Community Health Systems (Franklin, Tennessee); “One of the largest operators of acute care hospitals in the U.S.” and 293. Universal Health Services (King of Prussia, Pennsylvania). “has more than 350 acute care hospitals, behavioral health facilities and ambulatory centers across the U.S.,”

[42] See exhibit 1 for examples  https://healthcarepricingproject.org/sites/default/files/hlthaff.2018.05424.pdf

[43] See page 20 “Universal Health Services (UHS), one of the nation’s largest and most respected providers of hospital and healthcare services”http://www.physiciansadvocacyinstitute.org/Portals/0/assets/docs/021919-Avalere-PAI-Physician-Employment-Trends-Study-2018-Update.pdf?ver=2019-02-19-162735-117

[44] See FIGURE X 

[45] reviews of studies of hospital markets have found that concentrated markets are associated with higher hospital prices, with price increases often exceeding 20 percent when mergers occur in such markets. Of even greater concern, the reviews found that these price increases did not appear to improve quality: In some cases, higher hospital concentration was associated with higher mortality rates.

[46] "Using data on hospital mergers from 1996-2012, we find support that this

mechanism operates within state boundaries: cross-market, within-state hospital mergers yield

price increases of 7-9 percent for acquiring hospitals, whereas out of state acquisitions do not

yield significant increases." https://www.nber.org/papers/w22106.pdf 

[47] The vast majority of these studies find price increases of at least 10 percent due to merger, with some estimates of price increases due to merger of 40 percent or greater." http://www.andrew.cmu.edu/user/mgaynor/Assets/Gaynor_Consolidation_Statement_1.pdf 

[48] Monopoly hospitals are associated with 12% higher prices

[49] Increased health insurer concentration could result in lower premiums to employers and consumers along two pathways… To some extent, research shows that this is happening, with higher health insurer concentration being associated with lower hospital and physician prices. However, the evidence shows that these price reductions are not passed on to consumers. A number of studies have found that higher health insurer concentration leads to higher premiums including for employers and for individuals purchasing Marketplace plans.

[50] Lacking support from employers to hold the line against provider demands, health plans in many cases effectively called a truce with providers, leading to the existing environment where higher provider payment rates are passed on to employers — and ultimately to employees — through higher premiums.

[51] Research shows consolidation in the private health insurance industry leads to premium increases, even though insurers with larger local market shares generally obtain lower prices from health care providers. (so even when you have insurance company leverage… doesn’t necessarily mean they’re lowering prices)

[52] https://naic.org/documents/topic_insurance_industry_snapshots_2018_health_ins_ind_report.pdf

[53] https://www.advisory.com/daily-briefing/2019/05/29/fortune-500 (insurance companies, drug and biotech companies, pharmacies)

[54] One notable cause is the escalating prices of new brand name prescription drugs. Kalydeco, a new specialty drug, now costs more than $300,000 a year,10 and UnitedHealth Group has estimated that specialty drug spending could quadruple in less than a decade, from $87 billion in 2012 to $400 billion in 2020.11 Similarly, the prices of anticancer drugs have soared, with new treatments now costing more than ten times what they cost two decades ago

[55] E.g. Cancer drugs are so high in the US https://www.mayoclinicproceedings.org/article/S0025-6196(15)00101-9/fulltext?mobileUi=0 

[56] https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2017.0858?journalCode=hlthaff  "The five largest US commercial health insurance companies together enroll 125 million members, or 43 percent of the country’s insured population.

[57] US spending on pharmaceuticals was almost double the spending in comparison countries. Previous work suggests that this is driven by high prices for brand-name drugs rather than by utilization

[58] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5559086/ 

[59]  When a drug is approved, drug sponsors are essentially free to market drugs at a price of their choosing, though exceptions exist, particularly with regard to government health care programs such as the federal-state Medicaid and the federal veterans affairs (VA) programs https://link.springer.com/article/10.1007%2Fs10198-006-0028-z 

[60] Hospitals that have stronger affiliations w/physicians have been found to have higher prices:

https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2013.1279 

[61] https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2463591

[62] U.S. price inflation compared to other countries: the data suggest that the main driving factors were likely related to prices, including prices of physician and hospital services, pharmaceuticals, and diagnostic tests, which likely also affected access to care. In addition, administrative costs appeared much higher in the United States.

[63] a $933.5 billion increase in annual US health care spending between 1996 through 2013. prices and intensity of care to be largely related to increases in health care spending over the past 15 years and negatively associated with disease prevalence or incidence.

[64] Administrative costs of care (activities relating to planning, regulating, and managing health systems and services) accounted for 8% in the US ; its 8% of Total Health Spending, which for 2016 was 3,347.4 billion = 268 billion (see table “NHE Summary, including share of GDP, CY 1960-2018 (ZIP)”  here)

[65] . Administrative costs of care (activities relating to planning, regulating, and managing health systems and services) accounted for 8% in the US vs a range of 1% to 3% in the other countries

 See Fig 1-- governance and administration. https://jamanetwork.com/journals/jama/article-abstract/2674671 

[66] [This paper] concludes that the country’s most powerful buyer, the federal government, should be allowed to negotiate the prices of prescription drugs used by Medicare. … because a profit maximizing health plan would exploit whatever anticompetitive power it gains through merger, harming small physician groups, for example, or forcing consumers to pay higher premiums.

[67] Medicare, rather than negotiating with providers, sets prices administratively based on legislation enacted by Congress (CMS, 2015)... For each procedure and service, CMS has established a fee schedule, which is publicly available. Medicare then adjusts this fee schedule based on geographic marketplace and hospital type (e.g., teaching hospital, CAH). For hospital services, Medicare uses different price-setting formulas, depending on the type of hospital and the type of service."

[68] In 2018, Medicare covered 59.9 million people: 51.2 million aged 65 and older, and 8.8 million disabled.

[69] In 2012 Medicare adopted the Resource-Based Relative Value Scale (RBRVS) in an attempt to ground prices in something closer to the costs of delivering specific services, as measured by the amount of work and practice expense involved in delivering each service.

[70] Every year the CMS update their fee schedule (rates).

[71] https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2015.0706 see Exhibit 1 Average Standardized Payment Rates Per Inpatient Hospital Stay, By Primary Payer, 1996–2012

[72] https://www.cbo.gov/system/files/115th-congress-2017-2018/presentation/52818-dp-presentation.pdf see “Variation in Average Prices Across MSAs, Relative to Medicare FFS” for surgeries - lots of other examples here (brain MRIs are the most different); See Page 11

[73] The cumulative effect of this hospital management strategy, as well as Medicare payment policy enacted in the Affordable Care Act that mandates annual productivity gains, is that Medicare and Medicaid now pay hospitals significantly less than their estimated average costs (86.8% and 88.1% of costs, respectively (86.8% and 88.1% of costs, respectively; Medicaid and Medicare payments include Disproportionate Share Hospital payments in this calculation), whereas private payers pay hospitals more than their average costs (144.8% of costs on average).

[74]  https://www.cbo.gov/system/files/2019-05/55150-singlepayer.pdf CBO found that three major insurers’ commercial payment rates for hospital inpatient admissions in 2013 were 89 percent higher, on average, than Medicare FFS payment rates for the same types of admissions

[75] Exibit 1 https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2015.0706#EX1

[76] These analyses all say the power of the federal government to drive down prices would save money if we switched to a medicare for all plan: CBO report “Single-payer systems typically have stronger purchasing power” Political Economy research Institute: “establishing uniform Medicare rates for hospitals, physicians, and clinics” would save money, Urban Institute- The impact of the coverage and benefit expansions on expenditures would be partially offset by the government’s use of its bargaining power to lower provider payment rates and, in turn, overall health care spending”,

[77] (CBO) report   “It would probably have lower administrative costs than the current system…” Urban Institute- “Administrative costs would also be lower” Political Economy research Institute:1) administration (9.0 percent savings in total system costs); Mercatus working paper:  This analysis assumes substantial administrative cost savings generated by replacing private insurance with national single-payer insurance, specifically a reduction of seven percentage points (from an estimated 13 percent to 6 percent)

[78] https://publicpolicy.wharton.upenn.edu/live/news/3038-medicare-for-all-an-economic-analysis

[79] https://www.healthaffairs.org/doi/10.1377/hlthaff.2017.0218 Second, we show that the uninsured use other types of care such as outpatient visits or hospitalizations much less than the insured.

[80] Enacting M4A would increase healthcare utilization by covering the previously uninsured, by eliminating cost-sharing for those already insured, and by increasing the range of health services covered. These effects are estimated to add $435 billion to national healthcare spending.

[81] https://www.peri.umass.edu/publication/item/1127-economic-analysis-of-medicare-for-all (pdf download link) At present, roughly 9 percent of U.S. residents are uninsured and 26 percent are underin- sured—i.e. they are unable to adequately access needed health care because of prohibitively high costs. The demand for health care services by these population cohorts will rise sig- nificantly under Medicare for All.

[82] E.g. Medicare spends less on admin than average of insurance companies. “Medicare’s administrative expenditures are 1 percent of total Medicare spending, while the latest NHEA indicates the figure is 6 percent.”

[83] Spending would be similar in 2022 and 3 percent lower by 2031, with the ten-year cumulative net savings being about 2 percent, if administrative costs and growth in provider payment rates are reduced… Increases in the utilization of health care services under the NYHA could be offset by decreases in provider payment rates and health plan administrative costs.

[84] E.g. “National health expenditures (NHE) are currently projected to be $4.562 trillion in 2022.5

Subtracting the $10 billion decrease in personal health spending, as calculated in the previous

paragraph, and tting the plan with $83 billion in administrative cost savings results in an

NHE projection under M4A of $4.469 trillion. Of this, $4.244 trillion in costs would be borne by

the federal government. ($4.562 trillion - 4.469 trillion = 0.093 trillion/ $93,000,000,000/ 93 Billion)

https://www.mercatus.org/system/files/blahous-costs-medicare-mercatus-working-paper-v1_1.pdf

[85] According to Commonwealth Fund survey from 2019 “Most adults (85%) were satisfied with their current health coverage, with those enrolled in Medicaid and employer plans the most satisfied.” https://www.commonwealthfund.org/publications/issue-briefs/2019/sep/what-do-americans-think-health-coverage-2020-election

[86] https://news.gallup.com/poll/245195/americans-rate-healthcare-quite-positively.aspx “solid majorities of Americans rate the coverage (69%) and quality (80%) of the healthcare they personally receive as   excellent or good,” according to 2018 poll.

[87]  The survey consisted of interviews conducted via web and telephone in English or Spanish among a random, nationally representative sample of 4,914 adults, ages 19 to 64, living in the United States. “Most adults were satisfied with their current health coverage, with those enrolled in Medicaid and employer plans the most satisfied.” - 48% with employer insurance

[88] https://www.bbc.com/news/uk-england-29787528

[89] Coverage is universal. All those “ordinarily resident” in England are automatically entitled to NHS care, largely free at the point of use

[90] The majority of funding for the NHS comes from general taxation, and a smaller proportion from national insurance (a payroll tax). 

[91] Responsibility for health legislation and general policy in England rests with Parliament, the Secretary of State for Health, and the Department of Health.1 Under the Health Act (2006), the Secretary of State has a legal duty to promote a comprehensive health service that provides care free of charge, apart from services with charges already in place.

[92] Depending on what type of insulin therapy you select or require, you may need to check and record your blood sugar level at least four times a day.

The American Diabetes Association recommends testing blood sugar levels before meals and snacks, before bed, before exercising or driving, and if you suspect you have low blood sugar.

Multiple daily injections that include a combination of a long-acting insulin combined with a rapid-acting insulin more closely mimic the body's normal use of insulin than do older insulin regimens that only required one or two shots a day. A regimen of three or more insulin injections a day has been shown to improve blood sugar levels.

[93] Anyone who has type 1 diabetes needs lifelong insulin therapy…. You'll regularly visit your doctor to discuss diabetes management. During these visits, the doctor will check your A1C levels.... Over time, type 1 diabetes complications can affect major organs in your body, including heart, blood vessels, nerves, eyes and kidneys. Maintaining a normal blood sugar level can dramatically reduce the risk of many complications.

[94] Among chronic diseases, diabetes has been a focus of performance measurement for many years, and it stands as one of the first conditions for which disease-specific indicators based on evidence-based clinical guidelines have been used to evaluate the quality of care and preventive services.2-4

[95] "The rising cost of insulin in the United States can be attributed primarily to two phenomena. First, U.S. law allows pharmaceutical manufacturers to price their products at whatever level they believe the market will bear and to raise prices over time without limit. Second, direct competition in the insulin market is lacking." https://www.nejm.org/doi/10.1056/NEJMp1909402 

[96] T1 International survey: US: $501…(Of this, on average $157 on insulin, $71 on test strips, $169 on pump…) UK: $155 (Of this, $2 on test strips, $117 on CGM/Flash Glucose monitoring supplies

[97] “Between 2007 and 2017, the average wholesale price of 4 of the most popular insulins has more than tripled in price. Between 2010 and 2015, the monthly wholesale price of Humulin, the most popular insulin, rose to nearly $1100, up from $258 for the average patient.”

[98] T1International’s 2018 access and supply survey that says 25.9 percent of U.S. respondents have rationed insulin

[99] 2018 study in JAMA Internal Medicine of 199 patients surveyed at Yale Diabetes Center, found (25.5%) reported cost-related insulin underuse (this combines t1 and t2 patients). Of T1 patients, 26.5% ration insulin

[100]In a congressional hearing in April, 2019 NIH researcher William Cefalu cited a 2018 study by the American Diabetes Association saying that 1 in 4 diabetics ration insulin due to cost

[101] https://www.ncbi.nlm.nih.gov/pubmed/21775761 

[102] Of 115 type 1 diabetics in the UK surveyed by T1 international, 1 reported rationing insulin at least once per month, no others reported rationing https://www.t1international.com/access-survey/ 

[103] insulin doesn't cost anything for UK citizens.

https://www.diabetes.org.uk/guide-to-diabetes/life-with-diabetes/free-prescriptions

-----note: they have some copay costs for management/appointments of diabetes, about $65 a month (~18% of what someone in the US would pay)

https://www.t1international.com/insulin-and-supply-survey/

[104]Over time, too much sugar in your blood can lead to the blockage of the tiny blood vessels that nourish the retina, cutting off its blood supply. As a result, the eye attempts to grow new blood vessels. But these new blood vessels don't develop properly and can leak easily.

[105] Diabetes- more hospital admissions rates in the US- 74 vs 170 per 100,000

[106] https://www.sciencedirect.com/science/article/pii/S0140673618309942?via%3Dihub Chronic Kidney,  Rheumatic heart disease and Hypertensive heart disease fig 3

[107] Continuous glucose monitor: 3-5% estimate in UK https://www.bmj.com/content/363/bmj.k4675 

[108] and 30% estimate in US https://www.ncbi.nlm.nih.gov/pubmed/30657336 

[109] Insulin pump use increased to 63% in 2016-2018 https://www.ncbi.nlm.nih.gov/pubmed/30657336 

[110] 17.7% https://www.nice.org.uk/guidance/TA151/uptake 

[111] https://www.nice.org.uk/process/pmg6/chapter/assessing-cost-effectiveness

[112] Do not offer real‑time continuous glucose monitoring routinely to adults with type 1 diabetes. [new 2015] https://www.nice.org.uk/guidance/ng17/chapter/1-Recommendations#blood-glucose-management-2

[113] https://www.nice.org.uk/guidance/TA151/chapter/1-guidance 

[114] https://www.nice.org.uk/guidance/ng17/chapter/1-Recommendations#blood-glucose-management-2 “Do not offer real‑time continuous glucose monitoring routinely to adults with type 1 diabetes.”

[115] https://www.bmj.com/content/363/bmj.k4675 Julie Wood, chief executive of NHS Clinical Commissioners, which represents CCGs, said, “Unfortunately the NHS does not have unlimited resources, and ensuring patients get the best possible care against a backdrop of spiralling demands, competing priorities, and increasing financial pressures is one of the biggest issues CCGs face.

[116]https://www.nice.org.uk/Media/Default/About/what-we-do/Into-practice/measuring-uptake/impact-diabetes.pdf: The current guidance states that an insulin pump is recommended as an option for people with type 1 diabetes who have poorly controlled or persistently high HbA1c levels despite multiple daily injections

[117]https://www.independent.co.uk/news/health/diabetes-type-1-blood-sugar-theresa-may-glucose-monitor-health-nhs-postcode-lottery-a8622811.html 

[118] In both the British and American health care systems, not all patients who might benefit from or desire access to expensive cancer drugs have access to them. The popular characterization of the United States, where all cancer drugs are available for all to access as and when needed, and that of the British NHS, where top-down population rationing poses insurmountable obstacles to British patients’ access, are far from the reality in both countries. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2888017/pdf/milq0087-0789.pdf

[119]https://www.sciencedirect.com/science/article/pii/S2452302X16300638?via%3Dihub Despite assertions that drugs are approved more slowly in the United States, analysis indicates that they actually reach the public more quickly in the United States than Europe. Whether there is a true “device lag” between Europe and the United States is less clear.

[120] More than half of the underinsured (52%) had medical bill problems and 45 percent went without needed health care because of cost."

[121] https://www.commonwealthfund.org/person/robin-osborn 

[122]https://interactives.commonwealthfund.org/2017/july/mirror-mirror/assets/Schneider_mirror_mirror_2017.pdf Appendix 6. US 3.6 UK 9.2

[123] A 2009 study comparing stroke rehab across countries also found that patients in stroke rehab centers typically get more specialized care (at least three hours/ day of occupational therapy, physiotherapy and speech language pathology) compared to systems in Canada, UK, New Zealand etc.

[124] This 2005 study of ~1000 acute stroke patients in U.S. and New Zealand found that U.S. patients had “had more intensive input from physiotherapists and occupational therapists”

[125] https://international.commonwealthfund.org/stats/breast_cancer_survival_rate/ 

[126]https://www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries/#item-mortality-rate-for-certain-cancers-2015 

[127]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2888017/pdf/milq0087-0789.pdf  In the case of England, low breast cancer survival has been attributed to late diagnosis and the underuse of radiotherapy ...(Gatta et al. 2000; Sant et al. 2003)

[128] Coleman et al: “Most of the wide global range in survival is probably attributable to differences in access to diagnostic and treatment services”

[129] Allemani et al: 2013 US vs Europe- colorectal cancer  “The wide differences in colorectal cancer survival between Europe and the USA in the late 1990s are probably attributable to earlier stage [see figure 2] and more extensive use of surgery and adjuvant treatment in the USA”

[130] Ciccolallo et al (2004) - another US vs Europe- colorectal “US-Europe survival differences in colorectal cancer are large but seem to be mostly attributable to differences in stage at diagnosis. There are wide variations in diagnostic and surgical practice between Europe and the USA.”

[131] Preston and Ho - Prostate and Breast cancer in US “We have argued that these unusually rapid declines are attributable to wider screening and more aggressive treatment of these diseases in the US”

[132] See Fig 1, for example https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2019/11/QAR-Commentary-1920-Q2-9wefu.pdf 

[133]https://www.nao.org.uk/wp-content/uploads/2019/03/NHS-waiting-times-for-elective-and-cancer-treatment.pdf 4.2 million in March 2019-- this more recent report says “The number of RTT patients waiting to start treatment at the end of September 2019 was 4.4 million”

[134]https://www.commonwealthfund.org/publications/surNHS Performance Statisticsveys/2019/feb/2018-biennial-health-insurance-survey download survey questionnaire and search for “wait” and “same day”

[135] https://international.commonwealthfund.org/stats/able_to_get_appt/ 

[136] Though funding for the Department of Health and Social Care continues to grow, the rate of growth slowed during the period of austerity that followed the 2008 economic crash. Budgets rose by 1.5 per cent each year on average in the 10 years between 2009/10 to 2018/19, compared to the 3.7 per cent average rises since the NHS was established.

[137] The highest rate of growth during any parliament was an average of 8.9% between 2001/02 and 2004/05, with a commitment by Tony Blair’s Labour government to raise spending on health care to the EU average.

A key priority for the coalition government between 2010/11 and 2014/15 was to reduce the national fiscal deficit. While health spending was protected relative to other public spending, this was one of the lowest periods of funding growth in the history of the NHS, rising by an average of 1.1% a year.

[138] Waited two months or more for specialist appointment, US: 6% (pretty good) UK: 19%

[139] Appendix 3: Waited two hours or more for care in emergency room US 25%, UK 32%

[140] https://international.commonwealthfund.org/stats/waited_four_months/ 

[141]https://interactives.commonwealthfund.org/2017/july/mirror-mirror/assets/Schneider_mirror_mirror_2017.pdf appendix 3 and https://international.commonwealthfund.org/stats/waited_four_months/

[142] Waiting times to see a specialist were longer for national health service and single-payer systems (ie, percentage with wait times longer than 2 months: Canada, 39%; United Kingdom, 19%; Sweden, 19%) compared with insurance-based systems (Netherlands, 7%; Switzerland, 9%; Germany, 3%; France, 4%), with a mean of 13%

[143] https://www.youtube.com/watch?v=4As0e4de-rI starts at 44 min

[144] Private health insurance (PHI) is readily available and offers more choice of providers (particularly in hospitals), faster access for nonemergency services, and rebates for selected services. ….Nearly half of the Australian population (47%) had private hospital coverage and nearly 56 percent had general treatment coverage in 2016.8

[145] Public sources account for over 85% of total health expenditure; the majority of private health financing comes from households out-of-pocket payments.

[146] France population coverage 100% https://www.oecd.org/health/health-systems/health-at-a-glance-19991312.htm

https://www.oecd.org/france/health-at-a-glance-france-EN.pdf

[147] Germany 100% https://www.oecd.org/health/health-systems/health-at-a-glance-19991312.htm 

https://www.oecd.org/germany/health-at-a-glance-germany-EN.pdf

[148] Germany made health insurance mandatory for the whole population in 2009.

[149] France: Coverage is universal and compulsory https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_fund_report_2017_may_mossialos_intl_profiles_v5.pdf 

[150] In France-- the health insurance system is intended to match households’ financial contributions to their ability to pay and to guarantee individuals on low income access to good quality coverage https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00580-8/fulltext

[151] “SHI eligibility is universally granted under the PUMA (Protection universelle maladie, or universal health care coverage) law.” https://international.commonwealthfund.org/countries/france/

[152] Public insurance, financed by both employees and employer contributions and earmarked taxes, is compulsory and covers almost the whole population, while private insurance is of a complementary type and voluntary. https://app.dimensions.ai/details/publication/pub.1078364645

[153] However, it also introduced free complementary private insurance covering user charges for people with very low incomes, and it subsidized this private coverage for people with low incomes.

[154] Germany introduced a cap on out-of-pocket payments for health care, set at 2 percent of household income in general and at 1 percent for people with chronic conditions

[155]https://link.springer.com/article/10.2165%2F11588320-000000000-00000 “It is up to the hospitals to negotiate a price with the pharmaceutical companies that is within the reimbursement price cap. This new system, implemented in early 2005, is called the ‘responsibility tariff’

“In the frame of this agreement, prices of drugs are negotiated between each pharmaceutical company and CEPS.” pg 70.

[156] Germany: All drugs, both patented and generic, are placed into groups with a reference price serving as a maximum level for reimbursement, unless they can demonstrate added medical benefit. For drugs with added benefit (evaluated by IQWiG but decided on by the Federal Joint Committee), the Federal Association of Sickness Funds negotiates a rebate on the manufacturer’s price that is applied to all patients. 

https://www.healthaffairs.org/do/10.1377/hblog20161229.058150/full/ “...if the G-BA accepts the IQWiG recommendation and the new drug is ranked in any of categories 1-2-3, then the newly established clinical value rating sets the basis for negotiations between the drug maker and the National Association of Statutory Health Insurances, the organization of all public insurance providers in Germany. If parties cannot reach agreement, the matter is submitted to an arbitration panel for a decision based on other international prices.”

[157] France: “The increasing price of drugs is addressed in two ways: 1) by using earmarked funds and capping the total cost of treatments at EUR700 million (USD843 million) in 2015, thus providing treatment to successive waves of patients by decreasing severity; and 2) by negotiating price-volume agreements and undisclosed rebates with manufacturers.

[158] For Germany: AMNOG requires the G-BA and the IQWiG to judge new treatments according to what they consider to be the best comparator. For drugs that are judged to be an improvement on the comparator, companies can negotiate a price in line with or even higher than what they had originally asked for, but if the level of innovation is not deemed sufficient, it is left to the government to set prices at a lower level with reference to the comparator.

[159] All four countries [includes France and Germany] have central mechanisms to set prices for health care. Prices are set or agreed on through negotiation at the national or regional level instead of being determined by individual purchasers and suppliers…The greater use of public budgeting and price-setting mechanisms, along with the much higher public shares of health care financing in these countries, remain the greatest contrasts between them and the United States.

[160] Germany: Hospitals are reimbursed almost exclusively on the basis of DRGs. Prices are mostly calculated at the federal level.  France: Since 2014, the Ministry of Health has introduced a volume price control mechanism at the individual hospital level…. The actual prices per GHM are not exactly equal to referencecosts. They are determined by the Ministry of Health taking into account the overall budget for the acute hospital sector (ONDAM target expenditure) and public health priorities. In order to contain the level of hospital expenditure, national level expenditure targets for acute care (with separate targets for the public and private sector) are set by the Parliament each year.

[161] Buttigieg: “Pete’s Medicare for All Who Want It plan will cost about $1.5 trillion over 10 years. It will be paid for by rolling back the Trump corporate tax cuts, which will generate $1.4 trillion in revenue, and the rest from cost savings that result from empowering the federal government to negotiate drug prices with pharmaceutical companies.”

[162] Repealing the outrageous exception allowing drug corporations to avoid negotiating with Medicare over drug prices. https://joebiden.com/healthcare/

[163]https://khn.org/morning-breakout/trump-administration-seeks-to-expand-medicares-negotiating-power-in-effort-to-curb-high-drug-prices/ 

[164]Several experts and key stakeholders have recommended legislative action to permit the CMS to negotiate drug prices. https://www.researchgate.net/profile/Kevin_De_Jesus-Morales/publication/315057511_The_high_price_of_anticancer_drugs_origins_implications_barriers_solutions/links/59dfdd950f7e9bc51256c743/The-high-price-of-anticancer-drugs-origins-implications-barriers-solutions.pdf 

[165] This pattern, both internationally and within the United States, suggests that America ought to take greater advantage of buyer power. By allowing buyers to combine, or letting the biggest buyer of all, the federal government, play a larger role in setting national healthcare prices.. “Congress ought to allow the federal government to negotiate the prices of prescription drugs provided by Medicare”

[166] https://international.commonwealthfund.org/stats/waited_two_months/ and https://international.commonwealthfund.org/stats/waited_four_months/ 

[167] Germany 3% waited longer than 2 months to see a specialist v 6% US; 0% waited 4 months or longer for elective surgery in Germany, 4% in US https://interactives.commonwealthfund.org/2017/july/mirror-mirror/assets/Schneider_mirror_mirror_2017.pdf

[168] https://www.sciencedirect.com/science/article/pii/S0140673618309942?via%3Dihub Figure 3