Episode 512: How Breaking Bad Breaks Away From The Sopranos And The Wire And Why Vince Gilligan Should Run the SEC 
Allen St. John Contributor 
Breaking Bad Episode 511: What Just Happened? Allen St. John Contributor 
The Guns Of Breaking Bad: The AR-15, The NRA And Walter White's Not-So-Little Friend Allen St. John Contributor 
Hilary Kramer Contributor There’s a slightly strange idea going around that if Breaking Bad were set in some European country, one with universal health care, then the major premise of the show simply would not exist. Which is a lovely thought it’s just that it isn’t true, certainly not of the health care system in my native UK, that National Health Service. In fact, Walter White might well be offered simple palliative care and be told to prepare to die. I’m afraid this “free health care” thing is a little more complicated than people seem to think:
A few have noted that Breaking Bad couldn’t be set in any other country but the U.S., something star Cranston acknowledged in a 2011 Rolling Stone interview. “If we did have universal health care five years ago, the show might not have worked,” he said. “Thank God Obamacare wasn’t in play five years ago. Whew!”
An Internet meme imagined if Breaking Bad were set in Canada, which has socialized medicine. The Canuck Breaking Bad wouldn’t last long, it turns out.
“You have cancer. Treatment starts next week,” says the doctor in the first frame.
There’s only one other panel.
“The End.”
That’s a bit fanciful I’m afraid. The one thing that socialised medical systems are not very good at is being responsive. The idea that treatment would start within a week has been, for most of the time the NHS has been in existence, and absurd hope not a reflection of reality. While things have got better, specifically for cancer treatments, it’s not unusual to find people being asked to wait 8 or 12 weeks before a course of treatment does start. And there are certainly cases where the delay in treatment has led a cancer to move from being treatable to being terminal.
This is a second cartoon trying to make the same point. And it uses, specifically, the NHS as its example and the thing is, on the NHS, White simply would not get that $90,000 cancer treatment at all. No, it’s not that the government doesn’t pay for medical treatment: it’s that the government does pay for medical treatment but will not pay for expensive medical treatment.
The economist Glen Whitman comments on the basic idea here:
Eventually, health costs do become an issue when Skyler pressures Walter to undergo treatment after all. But it’s not because his HMO won’t pay. It’s because Skyler finds an oncologist who is not just one of the best in Albuquerque, but one of the top 10 oncologists in the nation. It turns out this super-doctor with his fancy cancer treatment is not covered by the HMO, and the out-of-pocket price is $90,000. Some will say that’s the smoking gun that indicts the U.S. healthcare system. But there is no system in the world that offers high-end care to everyone. The vaunted U.K. and Canadian systems offer care to every citizen, but they don’t offer the best care to every citizen. That’s just not possible. A single-payer system is essentially a giant public HMO, and just like private HMOs, they sometimes deny treatment or (more relevant here) deny the highest-quality treatments. Citizens who aren’t happy with the coverage provided by the government system have to pay for it themselves, either through supplementary private insurance or out of pocket. Sometimes they even travel to foreign countries, like the U.S., for that care.
The basic background point is that every medical system, of whatever type, structure or financing, rations health care in some manner. This is inevitable: we could spend the entire production of the globe on nothing but medical care and yet people would still die of things we cannot as yet cure for want of more time and or money. Thus there does indeed have to be a rationing system.
The way the National Health Service does this is through the National Institute for Clinical Excellence, NICE, which is a great name for a body set up specifically to deny you clinically excellent medical care but such are the vagaries of bureaucratic nomenclature. The way this works is that it looks at both the clinical effectiveness and the price of any new medical treatment. The measurement here is “QUALY”, or quality adjusted life years. So a treatment that saved your life but left you a drooling vegetable would fail on the quality part, even if it passed on the years part. Similarly, something that left you just absolutely fine but only for three weeks would not score highly. This is then measured against the costs and the rough rule of thumb is that a treatment that costs more than £30,000 (around $45,000) per QUALY does not get paid for by the NHS. There are a few treatments that are paid for over this, some cancer ones at £50,000. But it’s a rare occurrence: that basic rule is that, even if you’ve been paying in your taxes religiously for 30 years, if your disease costs more than $45,000 to treat to give you another year of decent life then you’re just plain out of luck.
There is of course an alternative here: you can do just what White does and go private. That $90,000 treatment, if you can raise the money (presumably without cooking meth) can be bought on the open market even if the tax administrators have abandoned you. However, back in 2008 when the show started there would have been a little oddity to the system. Fortunately this has now been changed but it most certainly was true back then.
If you go private for treatment for a disease then the NHS will withdraw all taxpayer funded treatment for that disease. It’s actually happened too: people have wanted to try out some very expensive cancer treating drug that the NHS will not pay for. So, they go private to gain access to that particular drug. At which point the NHS withdraws all treatment for that cancer. No visits even to a GP for monitoring, certainly no access to the public hospitals while the treatment is being given. No, you must enter the private medical system entirely and wholly if any part of your treatment comes from that private sector.
Meaning that White’s financial situation would have been worse under the NHS than it was under the more free market US system.
Under the NHS White would have been offered, upon the receipt of that incurable lung cancer diagnosis, palliative care until his death. Fortunately the NHS does offer decent drugs, as many opiates as one might need. The actual final part, death, would probably not have been in a hospital but in a hospice. Hospices are not part of the National Health Service, they are purely private and charitable organisations: they are not paid for from tax revenues.
And that’s pretty much what would have been offered.
If White had wanted to try an expensive treatment from the private market, one that the NHS did not offer (as with his HMO in the TV show) then not only would White have had to pay that treatment directly, he would also have had to pay for all of the NHS treatment that he had already paid his taxes to receive. Including, for example, that palliative care and those opiates if the treatment did not work.
Please do note that I’m not particularly supporting the American health care system. Nor indeed am I supporting the National Health Service system of organisation. As it happens I think that health care systems will work best when there’s a mixture of taxpayer financing and possibly provision and private money financing and private service provision. I tend to think that the American and UK health care systems are using particularly bad mixtures of them, particularly bad from opposite ends of the scale. And Singapore, for example, a particularly good mixture and the French one better than either the UK or US.
But the important point I want to get over here is that White would not simply have had all his treatment paid for under Britain’s NHS system. The expensive treatment he desired simply would not have been available from the tax paid system at all. And if he had bought it privately then all of the other treatment from that tax paid system for his lung cancer would have been withdrawn.
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