Please provide insight into nationalized health care.

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Health care in the US has phenomenal strengths and profound weaknesses. (A genuinely American trait, I think.) We have very strong voices (the majority party now) favoring the centralization of medical decision-making and payment. We have some government health care systems in the country and they are not terribly good. Specifically, the VA system and the Indian Public Health Service.

For example, my daughter who was a resident physician doing a rotation at the VA had a veteran walk into her clinic in the middle of an MI. The man had the EKG changes, the classic symptoms, the crushing chest pain and my daughter could not get him emergency treatment. (Inside the VA facility!!!) She came home furious. Said the next time that happened, she'd stick the guy in a wheel chair, roll him to the curb, call 911 and stay with him until an ambulance arrived to take him to a real hospital.

Though the VA delivers some valuable services to veterans, (mostly in terms of outpatient treatment and some prescriptions) you'll not find anyone in the nation who would want it to be their sole source of care. Most veterans (and I am one) use it as a care giver of last resort.

So here we Americans are debating a big policy step in that kind of direction.

Please give me your opinions. If you were the ruler of the universe, would you want to alter the system you have now?

Disclaimer: I am a staunch Republican who would prefer to find a way to empower patients, not the government. There are lots of ideas on how to do that, but because my party is not in power, they aren't getting much discussion.

Thanks so much.

I think thta many Americans would have a hissy fit if they had to spend much time in our hospitals.I have worked in the NHS for 26 years and have seen an increase in technology but a huge deterioration in general levels of cleanliness,availability of basics like bed linen and pillows,drastic cuts in the numbers of support staff (domestics and porters) and mosty importantly a lack of nurses.

We have so many levels of managers,matrons,OSMs ward managers and not enough hands on.It is common to have 1 RN looking after 15 patients especially on night shifts.

The only private rooms are for infected or dying patients and there may be only 2 toilets/bathrooms for 30 patients.

I have been a patient twice and was apalled at the nursing care I received,so much so that I thought about leaving nursing.

Someone said that the physician will not care how much it costs.Well that's not strictly true-he won't be able to prescribe what he may think is the best care because there are national guidelines and constrictions. He may also not be able to get you an MRI scan for your stroke because their isn't one at the hospital and currently radiology don't agree that it's needed.

If you are in a busy ER and you have been there for approaching four hours, to avoid the hospital being penalised you may be moved to a totally unsuitable area for your care,because there is no bed available anywhere else an the government set targets for patients not to spend moree than 4 hours in ER. Alternatively, a patient on the ward you need to go to for your stroke care may be "boarded out" to another non stroke ward in the middle of the night (for eg). I have used stroke here as an example but it could happen with anything.

Yes we have healthcare for all, but it is far from ideal and very national target driven,so the money goes to the areas where the targets are,doesn't matter that last week the target was something else.They will close down a service and move the staff to set up a service that helps to meet the current target.

A lot of the time it's almost as if the standard of care doesn't matter unless there's a national target that has to be met.

Soemone said that the money goes back into the health service which is probably correct, but it doesn't seem to go to nurses,although we seem to have a surplus of pharmacists and physiotherapists who progress up the grading system far more quickly than nurses seem to without having to do hoards of post grad qualifications.

Sorry, but I think it's important to see what is often the reality

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i agree that the nhs is not without its problems, but then have worked both sides of the atlantic to be able to compare as a nurse and as a patient and a dh who has continuing health problems. but state of the art equipment and being able to have every test known to man doesnt make the american system better, just different, the point i was making was that all uk workers pay into the system but americans can choose not to pay even when working and then get the same health care as everyone else, but normal everyday working people like nurses, still pay into the system and still get bills for our care, something that doesnt happen in the uk. my dh has cardiac problems which were probably exacerbated by worrying about how to pay medical bills after a car crash, and hasnt been able to get a penny from anywhere since then, something else that doesnt happen in the uk. like i always say, good and bad both sides of the pond.

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What do i think of the NHS. Well it is abused by some of the general populus beacuse it is free at the point of use. however most people acess healthcare when they need it. The main abuse comes from the goverment or the oppostion using it as a football scoring points.

The Unfortunate post code lottery means people in one area gets sub standard care wherear in another care in boith community/acute is good/excellent.

Yes we have targets and often having an outlier(pt who isn't on the right specilaity ward) is a pain both for the pt and the nurses trying to get that pt needs covered.

i am unsure about reducing prescription charges i think it should depend on chroinic condtions and means testing as the odd cost of antibiotc cream etc by a working person shoiuld be met.

i also think those that are well off should not take up an elcetive bed in the nhs.

I happen to work in a area with both the pct and the acute trust(my employer) striving to be the best in the country and has good reviews. We are not prefect but we try they are over employing new qual nurses to aim to get a 60% of nursig staff being RN as this is what the populs want(and i perfer working with).

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Specializes in Spinal Cord injuries, Emergency+EMS.
National Insurance contributions on average is 23% but does vary depending on how much you earn and whether employed or self employed.

are you sure ?

is that your final answer ?

phone a friend?

http://www.hmrc.gov.uk/rates/nic.htm

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thanks zippy for that link, we pay social security and medicare out of our wages over here, and they vary the same as the national insurance payments, what i said was that the americans think that any other system that has socialised medicine is very heavily taxed, they think that the lowest tax is about 40-50% to pay for the system,

we choose how much to pay from our wages because each year we have to file our taxes,,,in other words tell them how much we earned, how much we paid on our mortgage and how much we have in the bank and if we have enough to make any interest, and then they give you money back,,,especially if you have children or you end up owing them money, but the average tax payment is 25%, and then you pay for health care out of your wages on top of those payments and its not cheap, especially if you have a family to pay for.

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I think thta many Americans would have a hissy fit if they had to spend much time in our hospitals.I have worked in the NHS for 26 years and have seen an increase in technology but a huge deterioration in general levels of cleanliness,availability of basics like bed linen and pillows,drastic cuts in the numbers of support staff (domestics and porters) and mosty importantly a lack of nurses.

We have so many levels of managers,matrons,OSMs ward managers and not enough hands on.It is common to have 1 RN looking after 15 patients especially on night shifts.

The only private rooms are for infected or dying patients and there may be only 2 toilets/bathrooms for 30 patients.

I have been a patient twice and was apalled at the nursing care I received,so much so that I thought about leaving nursing.

Someone said that the physician will not care how much it costs.Well that's not strictly true-he won't be able to prescribe what he may think is the best care because there are national guidelines and constrictions. He may also not be able to get you an MRI scan for your stroke because their isn't one at the hospital and currently radiology don't agree that it's needed.

If you are in a busy ER and you have been there for approaching four hours, to avoid the hospital being penalised you may be moved to a totally unsuitable area for your care,because there is no bed available anywhere else an the government set targets for patients not to spend moree than 4 hours in ER. Alternatively, a patient on the ward you need to go to for your stroke care may be "boarded out" to another non stroke ward in the middle of the night (for eg). I have used stroke here as an example but it could happen with anything.

Yes we have healthcare for all, but it is far from ideal and very national target driven,so the money goes to the areas where the targets are,doesn't matter that last week the target was something else.They will close down a service and move the staff to set up a service that helps to meet the current target.

A lot of the time it's almost as if the standard of care doesn't matter unless there's a national target that has to be met.

Soemone said that the money goes back into the health service which is probably correct, but it doesn't seem to go to nurses,although we seem to have a surplus of pharmacists and physiotherapists who progress up the grading system far more quickly than nurses seem to without having to do hoards of post grad qualifications.

Sorry, but I think it's important to see what is often the reality

I don't believe the money goes back into the health service, it's just tax.

God forbid if you breach the 4 hour wait in A&E, you will be left there on the trolley and beds will be given to patients who haven't breached. I've seen people stay 2 days in A&E.

Moving really ill people because they are about to breach happens very often.

Target driven, media led healthcare.

My sister is an ER Nurse in the States and I am an A&E Nurse here in England. We swap stories. She is appalled at what I have to tell her, I am ashamed.

No-one has mentioned the 'Internal Market', 'Private Finance Initiatives' or 'Arms Reach Services', or the private out of hours GP service that the NHS pays for. How does a Trust achieve Foundation status? It's not measured by standards of quality of care, it's based on targets and money.

We need to learn from the Baby P case where the investigation reports state that one of the causal factors was the Social Services Department's reliance on quantitative not qualitative data.

The NHS is a wonderful service but it needs to get back to its roots. At the moment there are and awful lot of people making an awful lot of money out of it.

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In the UK we now have some very strict government targets that we have to meet for elective non urgent work, this is an 18 week referral to treatment time. The days of long waits for elective surgery is long gone. This time is even less for urgent surgery.

My one complaint would be that we all work extremely hard to get these patients dates to come in for treatment, optimising and making sure they are fit for surgery and then because our social care in the community is lacking there isn't enough capacity in our hospitals to accommodate them, therefore they are cancelled.

Not sure, I know there has been some controversy surrounding some of the cancer treatments that have not been approved by the National Institute of Clinical Excellence, however this is not government driven it is evaluated on the best use of resources, so the expensive drugs that have limited proven effectiveness may not been approved for use. To the patients that they are denied it may be the only hope for prolonged life, however these drugs are few and the decisions are made by clinicians

"It's sinking the British economy" (Who can tell what's sinking economies around the world... this may not be answerable.)

"People have no 'skin in the game', no reason to have good life habits because they don't have economic consequences of seeing a doctor or being a patient in the hospital.

From what I have read (and I haven't experienced any other system than the UK this is my impression from this site) health promotion and chronic disease management is very good in the UK, the GP's get insentives for managing these patients effectively and many of our departments have very active health education and promotion units.

I am not sure they are, if they are rich then they could afford private healthcare in the UK, I have yet to see statistics to support the comments that rich Brits are flocking to the US for treatment.

We haven't aggressivley recruited from overseas for many years now, we have waiting lists for entry to medical and nursing school and our new grads often struggle to find work.

If I may add my own experience into this, I injured my knee quite badly 2 years ago, I was seen in the emergency unit within an hour and given emergency treatment, then followed up in a fracture clinic the following week where I was referred to physio. I had a physio appointment withint 2 weeks, and got first class treatment. Unfortuntely this treatment was not enough, there had been too much damage to underlying tissue and I had to have surgery, from the date booked it took just over 2 months for me to get a date for surgery, it was my own choice to delay this for another 2 months. I continued with physio and followups with the surgeon and again needed more surgery. Within 2 month of this I will have a date for surgery in the next few weeks.

I have recieved first class treatment thoughout this experience.

I'm married to a Brit and have, obviously, British in-laws of all ages, shapes and sizes. I've been a beneficiary of socialized medicine (not in the UK, but in Switzerland and in Barbados, both by unexpected occurrences) and have seen good and bad. I have to confess - more bad than good.

But I'll guarantee you this - you wouldn't have had the initial two month wait here in the States.

Free isn't always the best way of doing business - nor is it always free. The UK tax rate is insane and my DH says all the time (as do the rest of my British in-laws) that the NHS is the most poorly managed governmental institution in England.

Our way of doing business is equally screwed up. At the very minimum (keep in mind we are a nation of 300 MILLION) I believe we should have universal primary care - since if we had that, I think a huge chunk of the problem (not to mention sequela) would go away. But the thought of being told that my knee surgery isn't 'urgent' according to the needs/wants of the NHS and that I have a two month wait is, to me, unacceptable. (A conscious choice is different, and is not what I'm referencing.) The NHS isn't the organization living with pain/inconvenience of the bad knee, I am - and that to me is the inherent problem. Plus, more damage may be occurring while I'm waiting - and then I'm the one who pays for it physically. Not my idea of fun.

I've read and been told too many outrageous stories by people regarding NHS decisions in allocating care - because it does have to be allocated, and that is what is being done, regardless of what they're calling it these days. When people find out I'm a nurse in the US, they're immediately interested. And I tell them - we're equally screwed up, just in a different way.

Neither system is the answer. I wish I knew - that SOMEONE knew - what was.

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I think thta many Americans would have a hissy fit if they had to spend much time in our hospitals.I have worked in the NHS for 26 years and have seen an increase in technology but a huge deterioration in general levels of cleanliness,availability of basics like bed linen and pillows,drastic cuts in the numbers of support staff (domestics and porters) and mosty importantly a lack of nurses.

We have so many levels of managers,matrons,OSMs ward managers and not enough hands on.It is common to have 1 RN looking after 15 patients especially on night shifts.

The only private rooms are for infected or dying patients and there may be only 2 toilets/bathrooms for 30 patients.

I have been a patient twice and was apalled at the nursing care I received,so much so that I thought about leaving nursing.

Someone said that the physician will not care how much it costs.Well that's not strictly true-he won't be able to prescribe what he may think is the best care because there are national guidelines and constrictions. He may also not be able to get you an MRI scan for your stroke because their isn't one at the hospital and currently radiology don't agree that it's needed.

If you are in a busy ER and you have been there for approaching four hours, to avoid the hospital being penalised you may be moved to a totally unsuitable area for your care,because there is no bed available anywhere else an the government set targets for patients not to spend moree than 4 hours in ER. Alternatively, a patient on the ward you need to go to for your stroke care may be "boarded out" to another non stroke ward in the middle of the night (for eg). I have used stroke here as an example but it could happen with anything.

Yes we have healthcare for all, but it is far from ideal and very national target driven,so the money goes to the areas where the targets are,doesn't matter that last week the target was something else.They will close down a service and move the staff to set up a service that helps to meet the current target.

A lot of the time it's almost as if the standard of care doesn't matter unless there's a national target that has to be met.

Soemone said that the money goes back into the health service which is probably correct, but it doesn't seem to go to nurses,although we seem to have a surplus of pharmacists and physiotherapists who progress up the grading system far more quickly than nurses seem to without having to do hoards of post grad qualifications.

Sorry, but I think it's important to see what is often the reality

And this is what I hear from my British in-laws - and what I saw for myself in the NHS facility I visited a family friend in. He spent five days in what amounted to a short stay unit; his dx was inadequately controlled DM and he was on an insulin drip. There were no rooms, so he was in a SHORT STAY UNIT. Hideous. It was obvious the unit was short staffed and it was so crowded they had patients in the hallways and were creating "rooms" by hanging bedsheets. Literally. And then the ward he was eventually put in with ELEVEN OTHER MEN looked like the old TB hospitals I've seen in pictures, except the photos were taken in 1930 and this was 2008. No privacy, no dignity. (And the infection control implications are nearly too much for me to think about. No wonder the MRSA problem. You think the government would get a clue - but of course, they're in the the BUPA hospitals, aren't they?) The place hadn't been remodeled since at least 1974 and had huge cracks in the plaster and tiling (yes, tiling) on the walls. I don't know how the nurses can stand it; I admire anyone that committed to the profession, because I wouldn't have bothered. God bless the NHS RNs. :bow:

Or the fact that NO MRI or even a CT w/contrast was done on my father-in-law because they couldn't get one - and as a result his thrombolytic stroke was misdiagnosed and he didn't receive TPN in a timely manner. Now he has permanent damage and you have to wonder how much of that could have possibly been avoided. I was appalled at what wasn't done when he was in the hospital, because I'm so accustomed to things being done a certain way over here. I'd be on the phone asking my DH all these questions, and I'm being told, "well, no, they didn't do so and so". And this was a state of the art facility (supposedly). It was like being transported back into the 1960s.

I do work at an academic facility, and I probably do expect more as a result! But I've seen what goes on in some really tiny hospitals as well, with family on the receiving end, and I've never really seen anything this bad (yes, it happens here too, but that's a given).

I know the NHS is a mess, but I also know that your primary care is some of the best around. You really can't beat the system of general medicine and trust-specific (like cancer and HIV) clinics the UK has; I'm in AWE of the primary care you have available. But I don't know how the hospitals do what they do - and maintain the necessary level of care expected by a developed nation. My hat's off to the workers in the NHS - and I mean that sincerely. :yeah:

I also know that not every NHS facility is like this; we all know there are some swanky ones in London that are held in high international regard. But that alone tells me there's some screwed up process with the allocation of resources to the various Trusts - because if the healthcare is indeed universal, then the hospitals in lower income areas should be just as equipped and - let's face it - just as nice as the ones in St Barts or Chelsea, for example.

It also tells me the money really, truly doesn't go back totally into the system (but of course, neither do my taxes) - because if it did, given your tax rate, there shouldn't be THAT much disparity among facilities.

I'm actually on the British side in this - great things come out of the NHS, yes. As I've said, your primary care is amazing. But like all bureaucratic organizations, it's horribly managed and out of sync with itself and the times we live in.

What's the answer? I don't know. But it's one we need to figure out, and the sooner, the better.

I think I hijacked this thread, and I'm sorry if that's the case.

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Specializes in Spinal Cord injuries, Emergency+EMS.
In the UK we now have some very strict government targets that we have to meet for elective non urgent work, this is an 18 week referral to treatment time. The days of long waits for elective surgery is long gone. This time is even less for urgent surgery.

My one complaint would be that we all work extremely hard to get these patients dates to come in for treatment, optimising and making sure they are fit for surgery and then because our social care in the community is lacking there isn't enough capacity in our hospitals to accommodate them, therefore they are cancelled.

Social care = local authoirties (i.e. 'city hall' for the left pondians )

Not sure, I know there has been some controversy surrounding some of the cancer treatments that have not been approved by the National Institute of Clinical Excellence, however this is not government driven it is evaluated on the best use of resources, so the expensive drugs that have limited proven effectiveness may not been approved for use. To the patients that they are denied it may be the only hope for prolonged life, however these drugs are few and the decisions are made by clinicians

also there seems to be a habit among the campaignersf or these drugs to concertrate solely on prolonged life , rather than symptom management - they are palliative treatments at best not curative so the cost -benefit analysis is somewhat different ... when people make this comments fro m the leftpond they kind of neglect to mention some of the practices of the HMOS and insurersin reducing what they pay ...

"It's sinking the British economy" (Who can tell what's sinking economies around the world... this may not be answerable.)

"People have no 'skin in the game', no reason to have good life habits because they don't have economic consequences of seeing a doctor or being a patient in the hospital.

I'm married to a Brit and have, obviously, British in-laws of all ages, shapes and sizes. I've been a beneficiary of socialized medicine (not in the UK, but in Switzerland and in Barbados, both by unexpected occurrences) and have seen good and bad. I have to confess - more bad than good.

frankly your assertions bunkum

But I'll guarantee you this - you wouldn't have had the initial two month wait here in the States.

that of course depends on your presenting complaint and /or the potential pathology behind your presenting

if your problem is clinically urgent you will be in a hospital bed before the end of the day

if your presenting problem is not clinically urgent but is possibly caused by Cancer oor Coronary Artery disease you will be sseen within 2 weeks - and the current record i'm aware of is " when can they get down " where a GP who was quite unsure ofa presenting problem spoke to theconsultant - who was equally unsure over the phone ...

Free isn't always the best way of doing business - nor is it always free. The UK tax rate is insane and my DH says all the time (as do the rest of my British in-laws) that the NHS is the most poorly managed governmental institution in England.

define 'insane' i've posted the links to the graphs on wikipedia but

http://en.wikipedia.org/wiki/File:Income_Taxes_By_Country.svg is a comparision of 'mean income tax rates' around the world which indicates a 'mean' i personal income tax rate of just shy of 30 % for the US and mid 30s% for the UK

but http://en.wikipedia.org/wiki/File:UK_tax_percentages_2008-9.svg shows a more realistic representation of the income tax + NI bills paid

Our way of doing business is equally screwed up. At the very minimum (keep in mind we are a nation of 300 MILLION) I believe we should have universal primary care - since if we had that, I think a huge chunk of the problem (not to mention sequela) would go away. But the thought of being told that my knee surgery isn't 'urgent' according to the needs/wants of the NHS and that I have a two month wait is, to me, unacceptable. (A conscious choice is different, and is not what I'm referencing.) The NHS isn't the organization living with pain/inconvenience of the bad knee, I am - and that to me is the inherent problem. Plus, more damage may be occurring while I'm waiting - and then I'm the one who pays for it physically. Not my idea of fun.

once again people forget that private health care isn't 'banned' in the uk, and for elective procedures is a viable option for those who purchase top up insurance/ benficial health plans or have sufficient liquid cash ...

I've read and been told too many outrageous stories by people regarding NHS decisions in allocating care - because it does have to be allocated, and that is what is being done, regardless of what they're calling it these days. When people find out I'm a nurse in the US, they're immediately interested. And I tell them - we're equally screwed up, just in a different way.

and the insurers and HMOS in the leftpond don't?

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Specializes in Spinal Cord injuries, Emergency+EMS.

with regard to the aforementioned report

as usual it demonstrates what happens when pursuit of a business target i.e. getting and keeping foundation trust status gets in the way of providing good clinical services ... it also needs to be noted that despite being located in the county town the hospital is considered a relative backwater compared to the teaching hospitals in the north of the county and across the W Midlands border ...

this can be summed up by the reports statement

"

reported by staff consistently highlighted

problems relating to the levels of staff, poor

care for patients, and poor handovers when

patients were moved from one ward to another.

Many of these issues required consideration and

resolution at a strategic level, but were rarely

considered by the board or by its governance

and risk sub-committees. ...

The trust reported it had made efforts to engage

clinical staff, but many senior doctors whom we

spoke to considered that the trust was driven by

financial considerations and did not listen to

their views. They gave credit for the trust having

a clear direction, but said that inflexible ways of

imposing change had left many feeling

marginalised. 2 ...

The trust did not have an open culture where

concerns were welcomed. Overall, the system

that was intended to bring clinical risk to the

attention of the board did not function

effectively, and the board appeared to be

insulated from the reality of poor care for

emergency patients.

"( p8)

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my responses in purple.

social care = local authoirties (i.e. 'city hall' for the left pondians ) some of us are well aware of the councils. in fact, because we own a business over there, we pay one - in surrey. don't even get me started on how they're mismanaged.

also there seems to be a habit among the campaignersf or these drugs to concertrate solely on prolonged life , rather than symptom management - they are palliative treatments at best not curative so the cost -benefit analysis is somewhat different ... when people make this comments fro m the leftpond they kind of neglect to mention some of the practices of the hmos and insurersin reducing what they pay ... i don't live in a "leftpond" - i live in the usa, and i don't use an hmo. actually, there's more screwed up regulation from our government - ah, the lovely fda - over orphan drugs than by insurance companies.

i said from the start, in both posts, that the american system of fee for service is equally hideous. so you as a 'rightponder' (sic) should have realized i wasn't defending the us as the gold standard. i personally think our system should be scrapped and rebuilt from scratch.

frankly your assertions bunkum actually, it's not. and when i said more bad than good, i was referring to the screwy way health care resources are allocated in the uk. and as i said, my husband, who's a brit, backs me up completely. and before he gets accused of living in the states for years and years and having his opinion colored, he's lived here less than two.

that of course depends on your presenting complaint and /or the potential pathology behind your presenting

if your problem is clinically urgent you will be in a hospital bed before the end of the day

if your presenting problem is not clinically urgent but is possibly caused by cancer oor coronary artery disease you will be sseen within 2 weeks - and the current record i'm aware of is " when can they get down " where a gp who was quite unsure ofa presenting problem spoke to theconsultant - who was equally unsure over the phone ... i doubt my cancer patients here on my unit would sleep well knowing that their condition will be taken care of in two weeks. . .and the nhs's way of determining 'clinically significant' is occasionally as disgusting as the way our insurers determine what treatment you're entitled to. the nhs is no more of a physician than our insurance company is - and we all know all this stuff is run like a business, by mbas, just like hospitals are.

define 'insane' i've posted the links to the graphs on wikipedia but

http://en.wikipedia.org/wiki/file:income_taxes_by_country.svg is a comparision of 'mean income tax rates' around the world which indicates a 'mean' i personal income tax rate of just shy of 30 % for the us and mid 30s% for the uk

are you including council rates? because the rates are ridiculous.

but http://en.wikipedia.org/wiki/file:uk_tax_percentages_2008-9.svg shows a more realistic representation of the income tax + ni bills paid

i pay less out of pocket for health insurance than my brother pays in nhs taxes - taxes for a system he opts to not use. so that makes the nhs tax rate insane. and btw - i pay less in medicare tax than he pays in nhs taxes as well.

once again people forget that private health care isn't 'banned' in the uk, and for elective procedures is a viable option for those who purchase top up insurance/ benficial health plans or have sufficient liquid cash ... i'm actually well aware of the existence of private health care in the uk - because neither my brother in law's family nor my own husband use the nhs. actually, the only brits i know who do use the nhs are my in-laws (father and mother) - because they don't want private health care.

and the insurers and hmos in the leftpond don't?

obviously with your last remark you missed my point entirely, which is exacerbated by the way my own quotes were taken completely out of context. the nhs is a disaster, and fee-for-service isn't much better. neither is the correct answer to the problem while i realize that my connections to the uk don't make me an expert, i've seen a bit more than many americans, and get firsthand commentary on the problem right at home. :).

and oh yeah - i forgot that i used to live in saudi arabia - where healthcare isn't free but boy was it cheap (an ed visit, with excellent care, was literally forty dollars - and that included my drugs!

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