UHC: Has to be affordable, high-quality, and also *not* have long wait times

Great Debates
261

No, you didn’t answer me. You deflected, joked, and then attacked the US system. And you dodged on why 10% of Canadians either have no prescription coverage or not enough. I think prescriptions is a place where Canada has problems. That’s probably why 2/3 of Canadians have to get some sort of private coverage to supplement on the things that Canada doesn’t provide (dental, home health care, ltc, drugs). Lots of holes in Canada.

One other thing, Canada doesn’t have as good a situation in terms of Cancer survivorship as the US. I didn’t even realize this until I started digging around.

https://www.cdc.gov/cancer/dcpc/research/articles/concord-2.htm

God forbid I ever get Cancer. If I do, thank God I’m in the US.

Seems like Canada also has problems with healthcare access for indigenous people. That probably is one of the drivers in differences in expected lifespan between them and the rest of Canada.

262

Yes, we seem to have been talking at cross-purposes. My apologies for contributing to it.

Any system needs to have financial controls to take into account the possibility of fraud; but that’s a different issue from ensuring someone gets the health care they need.

The doctors are the gate-keepers, trusted to make the decisions based on the patient’s needs. If a doctor abuses that gate-keeping position, the money can be clawed back and in extreme cases, they can face the risk of losing their professional accreditation, or criminal charges.

But if a patient got a treatment that they didn’t really need, to line the pockets of the corrupt doctor, that’s on the doctor, not the patient, unless somehow the patient is in on the scam. Personally, I’ve seen news items about doctors’ billing practices being under review, for not matching the payment profile, as outlined above. I’ve never seen a media account of a doctor and a patient somehow running a scam.

263

That’s a fair critique if health care funding is seen to be an insurance system. But that’s not how it’s seen in systems of UHC. It’s a public service, not really insurance. That’s the point I was making in the post that I quoted at Spoons’ request.

If, for example, police services were covered by insurance, you might have an issue with the police getting called out for very minor matters that could easily be foreseen. “That’s not what insurance is for”, would be the argument, “it’s for the major or catastrophic cases”.

But police services are a public service, not an insured service. Using insurance models doesn’t work.

Same for health care in UHC. It’s a public service, not an insurance service, so using an insurance critique doesn’t really work.

264

All I can respond with is that in our system, there aren’t middle level managers who have the power to veto payment claims by the doctors on the basis that they shouldn’t have provided the service to the patient, or should have provided a different service. The management process is to process the claims. Yes, there are financial controls put in place to check for fraud, as discussed above, but that’s not the same as rejecting claims to save money, based on the bureaucrats’ assessment of medical need.

That certainly sounds like a fair comment. If Medicare doesn’t pay high enough rates, and doctors are essentially accepting that their other patients are subsidizing their Medicare practice, there will be a problem in expanding it to all.

265

The majority of Canadians have supplemental coverage because virtually everyone gets it free as a minor benefit from their employer. If they didn’t, they likely wouldn’t bother with it. I never did during the many years that I was self-employed. You know why? Because basically it doesn’t matter.

I didn’t “dodge” the question of why. I suggested that if you don’t understand why – or even know that – outpatient prescription drugs weren’t covered, they you don’t understand the basic thinking behind how single payer is structured. I didn’t explain it then but I’ll explain it now. Every insurance system has mechanisms to control costs, but they differ radically in their moral basis and their impacts. Single-payer in Canada covers 100% of the costs of everything that is medically necessary except for enumerated exclusions that are generally commonly occurring nickel-and-dime events. If you suddenly end up in hospital and need an expensive procedure to save your life, as I did, it’s 100% covered, no questions asked. My five-day hospital stay and operation cost me not one dime. Private insurance will look for reasons to deny payments, and the more expensive the claim, the harder they look. Single-payer doesn’t set out to save money by screwing the patient, private insurance does. The things it explicitly doesn’t cover can either be covered with cheap supplemental insurance (it’s cheap for a good reason – it doesn’t do much) or out of pocket. In the large scheme of things, no one cares.

A useful way to think of it is that single-payer in Canada is like a benevolent rich uncle who is also a tightwad. He won’t give you a dollar for an ice cream because he knows you can pay for it yourself, but if you’re buying a house or a car or have some significant life crisis, he has deep pockets and boundless generosity for the really big important stuff.

A couple of side notes. I think I mentioned before that when I was in hospital, there were extensive discussions about the appropriate choice of treatment, one option being major surgery and the other being relatively minor and non-invasive. It’s significant that the discussions were entirely around the medical merits of each and the likely best outcomes. No one asked which one might or might not be covered, no one sought “pre-approval”, and the decision was entirely directed by evidence-based medicine, nothing else. This would not be the case under private insurance, and it’s likely that in a case where there is an expensive procedure and a superficially similar inexpensive procedure, the insurance bureaucracy would dictate the cheaper option regardless of clinical merit. That’s fundamentally immoral meddling in medical care.

You apparently not only fail to understand these facts, but you also are incorrect in some of your litany of things supposedly not covered. “Home care”, for example. When my mother had a chronic heart condition, she received at home and at absolutely no cost: (1) an oxygen concentrator, supply of backup oxygen tanks, and portable oxygen equipment for mobility, (2) regular visits by a personal care worker, (3) regular visits by a registered nurse, (4) regular visits by a dietician, and probably other things that I’ve forgotten (and her medications were covered, too). Explain to us again how home care isn’t covered. :rolleyes: And incidentally, when my brother in the US needed home care temporarily after a bad fall, his claim was denied. Furthermore, when he appealed the denial, he got two completely different explanations for the denial, and neither of them made any sense. (It’s almost like the insurance bureaucrats were just making things up!)

You seem extraordinarily inclined to thank God for things that are vanishingly insignificant. From the most recent CONCORD-3 study: “For most cancers, 5-year net survival remains among the highest in the world in the USA and Canada, in Australia and New Zealand, and in Finland, Iceland, Norway, and Sweden.” Moreover, as noted earlier, the US performs poorly in metrics of general health and overall survival rates from all causes; it has lower life expectancy and higher infant mortality than Canada and all other first-world nations; in the metric of “Potential Years of Life Lost” the US is dead last among the 11 first-world nations studied.

You know what I thank God for? I thank God that I will never have essential medical treatment denied because the insurer won’t pay for it, or because I can’t afford the deductible or co-pay. And that is something to be grateful for. Also the fact that, statistically, I’ll live longer being in Canada than if I was in the US.

266

I happened to get a prescription refilled yesterday which got me thinking about this discussion, and I am getting seriously pissed off at some of the misleading implications being made here about prescription drug non-coverage – a classic case of selective facts with important information omitted. I suspect that many folks don’t appreciate how little this matters to most Canadians, in part because of the ubiquitousness of cheap supplemental insurance and specific public programs that provide outpatient drug coverage, and in part because of the impact of drug price controls here. So let me say a few more words on this bit of digression about outpatient prescription drug coverage.

Let’s work through a specific illustrative example. The most expensive drug by far that I still regularly take is Brilinta, an anti-platelet medication that has no generic equivalent. Here is the US pricing. For 60 tablets of Brilinta 90 mg, retail prices are listed from a low of $418 to a high of $494, with discounted prices coming in at an average of around $400 provided you have a “free coupon” to qualify. They are taken twice a day and I get them dispensed in quantities of 180 for a three-month supply, so that would cost considerably over $1,200 in the US. In Canadian dollars at the current exchange rate, that’s over $1,597!

Now that’s serious money for most of us, and non-coverage begins to sound like an issue, but let’s look at what I actually pay.

First, drug prices are regulated in Canada through the Patent Medicine Prices Review Board, which requires justification of the prices charged for all patented (non-generic) drugs. The cost of 60 Brilinta 90 mg is just over $100 Canadian (approximately $75.06 USD), presumably the highest price point that AstraZeneca was able to justify. For a quantity of 180 my pharmacy currently charges $300.74 (instead of at least $1,597! :eek:), plus a standard dispensing fee of $8.83, so a total of CAD $309.57. Still a fair chunk of cash, but I was shocked at the price differential, even though it’s common knowledge that prescription drugs are generally much cheaper in Canada. (If you want something meaningful to argue about, US residents may well ask why they have to pay more than five times or even six times as much as the manufacturer is actually able to justify, which does in fact make prescription drug costs and coverage something of an issue in US health care.)

I’m retired, so I don’t have supplemental insurance. But for the same reason, I’m covered by the Ontario Drug Benefit. My total out of pocket cost? $4.11. Which is some weirdly calculated maximum dispensing fee. The amount is such a pittance that some pharmacies don’t even bother collecting it. Mine is not so generous, so every three months it costs me four bucks. Either way, the medication is essentially free.

What about younger people who don’t qualify for the Ontario Drug Benefit but who are unemployed or otherwise lack supplemental insurance and would find even the regulated cost hard to afford? In Ontario, they would likely qualify for the Trillium Drug Program for low income earners, so they wouldn’t be paying for expensive prescription drugs either. And the unemployed in the US? Let’s not even go there.

And let’s not forget that my example here centers on the most expensive drug I’ve ever had to take. Most others that I’ve been prescribed have generic versions and cost a pittance, even if it wasn’t covered by the ODB. It’s just never been a big deal, whether I was covered or not.

Meanwhile, as discussed many, many times on this board, on the big items like actual health care procedures, any health care I need, no matter how expensive, is guaranteed to be covered with no out-of-pocket costs at all, and no possibility of denial.

So, survinga, or anyone else, please tell me why I should prefer to be getting my health care in the mercenary clusterfuck of the US health care system.

Full disclosure: Because prescription drug coverage is an extra benefit not governed by the terms of the Canada Health Act, it’s an unusual case where an annual deductible applies. In Ontario the annual deductible is $100, but even that is waived for anyone whose income is below some threshold. I believe the $4 dispensing fee would be waived as well.

267

Because in the US they don’t need to justify anything. Same reason they can decide to gouge people on insulin. What in countries where healthcare is considered a social and therefore governmental responsibility would be seen as murderous, in the US is market forces.

268

Don’t get overly defensive here. This board is full of people attacking the US healthcare system. But when we look at alternatives from other countries, it’s not as if all “problems” go away. In all of my critiques of Canadian healthcare, I provided links, and did not mislead. I think Canada does have issues in some areas, including wait times, prescription costs for a portion of your population, and so forth.

269

First of all I should be clear that I’m not attacking the US health care provider system, particularly not its doctors, nor its medical facilities and outstanding research institutions. The clusterfuck that is US health care is not the doctors’ fault, although some of them are helping to promulgate it out of some misdirected concept of self-interest. My absolute loathing and disgust is directed at the parasitic and utterly useless health insurance companies that are responsible for most of the problems with the health care system and virtually all of its immoral malfeasance, including thousands of preventable deaths and financial destitution, and that culpability includes their malign self-serving influence on public opinion and Congressional legislation and regulation.

Secondly, we all recognize that no health care system is perfect. The issues you mention have all been previously addressed in these discussions, but here’s the point. It always comes down to priorities and tradeoffs – always – and most of us, especially those of us who are not highly acclimatized to the US health care culture and its obsession with “free markets”, believe that when tradeoffs have to be made, they should be made in the interests of medically-driven priorities and humanitarian compassion. Human health care should not be “market driven” and doled out according to how much money someone has, especially not in rich countries that can well afford to provide quality care for everyone. And in most advanced countries, that’s the case regardless of prevailing political ideologies, whether conservative or liberal leaning.

I will also say, with all respect, that some of your recent comments were indeed unintentionally misleading, I’m sure just due to lack of perspective or lack of complete information. For example:

Your claim of the terrific satisfaction that people allegedly have with their health insurance, including your own anecdotes, is contradicted by the statistics I cited for a high level of claims denials and personal bankruptcies. The claim of no hassles and no significant paperwork contradicts the detailed studies that ascribe upwards of $500 billion a year to useless unproductive administrative costs, and the personal experiences related here. And finally, “satisfaction” doesn’t really mean a lot except in comparative terms, and you’re not going to get much in terms of comparisons from a population that is uniquely insular in their knowledge of how things work elsewhere in the world. If they spend weeks arguing with an insurer, and finally get 75% of their claim paid for an exorbitantly overpriced medical procedure, they’ll be happy and just assume that’s how it always works everywhere. No, it doesn’t.

Your claim that “2/3 of Canadians have to get some sort of private coverage” (emphasis mine) is misleading for all the reasons I already explained; they don’t “have to” for any compelling financial or medical reason, it’s just routine and standard with employment, and those who are not conventionally employed often have access to other programs, and most of those non-covered gaps are nickel-and-dime stuff anyway. This is practically the opposite of why people need supplemental coverage for US Medicare – for instance, they need it to prevent being kicked out of a hospital into the street when their maximum stay quota is exhausted and Medicare stops paying. Which is a little different than someone having to pay a few dollars out of pocket for a prescription medication in the rare eventuality that it’s not covered.

Your claim that home care isn’t covered is spectacularly wrong. As I explained, my elderly and invalid mother was amazed and overwhelmed by all the home care support she received, at no cost. To top it off, some years later, my brother was denied home care in the US by his private insurer. Now the latter is just an anecdote, sure, but the former is a fact that disproves your claim.

You provided cancer survival statistics, and added the comment “God forbid I ever get Cancer. If I do, thank God I’m in the US.” But in fact the latest statistics show virtually no significant statistical difference in cancer survival rates among the USA, Canada, Australia, New Zealand, Finland, Iceland, Norway, and Sweden, and some of them outperform the US. The US also has lower life expectancy and higher infant mortality than those countries, and in the study I cited, the US is the absolute last out of 11 countries in “Potential Years of Life Lost”, which is essentially a measure of premature deaths. So actually, overall survival rates are higher in most advanced countries outside the US, where everyone is assured that they will never be denied health care for any reason.

270

You’ve never answered why self-insuring doesn’t solve these problems. Better yet, why doesn’t George Soros start a heath insurance company since it seems to be such a easy way to make money and he’s such a good guy?

I’m not a ideologue. I’m not opposed to single payer/ UHC because it’s socialism. But when something is too good to be true, it usually is… Cost is no object according your description of Canadian healthcare. It is completely implausible that costs do not need to be contained. But there are very few absolutes in the practice of medicine. Should a patient stay two or three or five days in hospital? It’s very subjective. And if costs weren’t a factor, then most doctors would say five instead of two. But that dramatically adds to the cost.

271

Here’s a good article by David Brooks of the New York Times. He makes a lot of the points I’m already making about what it entails when we throw out our current system in favor of single-payer. I think one point he doesn’t stress enough is how the Republican party will attack single-payer once it’s implemented. Right now, they tend to attack the ACA exchanges, and some of the Medicaid population (maybe overall about 20 to 25 million people). They would wreak far greater havoc of they could attack a single-payer. Anyway, it’s worth a read.

quoting from the link:

*"Doctors would have to transition. Salary losses would differ by specialty, but imagine you came out of med school saddled with debt and learn that your payments are going to be down by, say 30 percent. Similar shocks would ripple to other health care workers.

The American people would have to transition. Americans are more decentralized, diverse and individualistic than people in the nations with single-payer systems. They are more suspicious of centralized government and tend to dislike higher taxes.

The Sanders plan would increase federal spending by about $32.6 trillion over its first 10 years, according to a Mercatus Center study that Blahous led. Compare that with the Congressional Budget Office’s projection for the entire 2019 fiscal year budget, $4.4 trillion. That kind of sticker shock is why a plan for single-payer in Vermont collapsed in 2014 and why Colorado voters overwhelmingly rejected one in 2016. It’s why legislators in California killed one. In this plan, the taxes are upfront, the purported savings are down the line.

Once they learn that Medicare for all would eliminate private insurance and raise taxes, only 37 percent of Americans support it, according to a Kaiser Family Foundation survey. In 2010, Republicans scored an enormous electoral victory because voters feared that the government was taking over their health care, even though Obamacare really didn’t. Now, under Medicare for all, it really would. This seems like an excellent way to re-elect Donald Trump.

The government would also have to transition. Medicare for all works only if politicians ruthlessly enforce those spending cuts. But in our system of government, members of Congress are terrible at fiscal discipline. They are quick to cater to special interest groups, terrible at saying no. To make single-payer really work, we’d probably have to scrap the U.S. Congress and move to a more centralized parliamentary system.

Finally, patient expectations would have to transition. Today, getting a doctor’s appointment is annoying but not onerous. In Canada, the median wait time between seeing a general practitioner and a specialist is 8.7 weeks; between a G.P. referral and an orthopedic surgeon, it’s nine months. That would take some adjusting."*

272

I’m not going to spend a lot of time responding to this because all the answers are contained within this thread which you obviously have not read. Just for starters, I did respond to your question about self-insuring. Everything else has also been addressed, in many cases more than once.

I never said single-payer in Canada doesn’t practice cost containment. I explicitly said several times that*** it doesn’t try to contain costs by screwing the patient*** and denying them needed health care. It does it in different ways, such as negotiated fee schedules, simple streamlined payment systems, and – as we’ve just spent a lot of time here discussing – saving money by not covering a few common low-cost high-volume items. Need new glasses, for example? You get to pay for them yourself, or with supplemental insurance. Which might lead one to think, “wow, what a cheapskate health plan – if they won’t even cover a pair of glasses, what if I need major surgery?”. And this is part of how the system is counterintuitive, especially to those used to the scheming ways of private insurance, which this isn’t. The answer is that if a doctor feels that you need major surgery, then it will be 100% paid for and won’t cost you a dime, no matter what it costs the system.

The most important counterintuitive aspect of single-payer is the paradox that bringing in the government to manage a single-payer coverage system dramatically reduces bureaucracy, it doesn’t increase it. Instead of dealing with dozens of insurance companies with their own forms and policies and conditions, the health care provider submits one simple electronic form with procedure code(s) to one insurer for all patients, and always gets paid in full with no hassles. The most important aspect of simplicity and cost-saving here is that there is no bureaucratic scrutiny at the point of service delivery, which also means that both patient and doctor know that full payment is guaranteed. It’s not “too good to be true”, it’s just hard for some people to appreciate that it really can be so simple. It’s not at all like private insurance, nor is it at all like Medicare, which has to operate in a complex public-private environment. There is only one payer, that’s all there is.

Please go back and read the pertinent portions of the thread. Many people have spent a fair amount of time writing their comments, and I for one am not about to do it all over again.

273

David Brooks has some pretty conservative-leaning credentials and background, so it doesn’t surprise me that he’s taking the attitude of “single-payer may work everywhere else but it will never work here”, which we’ve all heard many times before about many different things.

Nevertheless, I’m always curious and always anxious to hear new perspectives, assuming he has any, so I’ll see what he has to say when I get a minute. Thanks for the link.

274

You are way too kind to Brooks. That was a pitiful column. For instance, his mention of raising taxes neglects the fact that premiums would be eliminated, and that much of the tax increase would be on businesses to offset the premium elimination. The poll no doubt made it sound like taxes would be raised with no reduction to what people pay for healthcare.
And he says that Canadians are less individualistic than Americans. Really.

275

OK, let me address a few of your points. I didn’t pull the home health care thing out of thin air. It’s not part of the basic benefits that Canadian Medicare provides. It’s funded part by private and part by public dollars.

See the attached for more details on that. There’s a table that shows that items like Dental & Vision come almost entirely from private dollars. Drugs are a mix, as are LTC, Mental Health Care & Home Health Care. Overall, about 30% of healthcare spending is from private source, either employers or people paying out of pocket (about half of the 30%).

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30181-8/fulltext

The link goes into detail on the problems on indigenous people in Canada, and the problems with wait times. Personally, I think having long waits for knee & hip replacements is not to be taken lightly. People who are in line for those types of surgeries are in a lot of pain. Also, the link talks about how 1 out of 4 Canadian households has someone who is not taking their meds, due to lack of ability to pay, which actually shocked me to read.

I’m not saying that the Canadian health care system is bad. But it does have problems. And everything I’ve brought up, I have backed up with links, and I have not misled anyone.

276

You’re wrong. I had provided home care (2hrs a day, 7 days a week!) in our home when we were caregiving for my fully bedridden MIL. All covered by basic care. No charge. For 6 yrs. Including, OT, PT, nurses for blood draws etc, and in home Dr visits. It included respite care, (short stay in a care facility) at a guaranteed slashed day rate. All covered. All at no cost to us.

There was a little red tape, and case manager home visits, but it was all covered.

277

Oh, FFS! Do you think I imagined all this? :rolleyes: Let me repeat exactly what I said in that post, once more:

She was in her 90s at the time, and rather than sending her to long term care, I took her into my own home, so I assure you that I know everything that went on, and she sure as hell wasn’t paying anything for this extensive home care, and neither was I.

We got this support through an agency of the Ministry of Health that was called CCAC at the time (Community Care Access Centres) that apparently has since been rolled into the Local Health Integration Networks – more info here.

Quite frankly I’m not about to go to the bother of registering with a British journal to get access to a paywalled article so they can explain to me how my own health care system works with respect to something that I’ve had extensive direct personal experience with. We didn’t pay a dime for any of the services I described. And this went on for years.

Correct, he is completely wrong. My mother’s experience was similar to yours.

278

Someone pointed out once at a peculiarity in American life expectancy that could be noticed in mortality tables by age. Although the average life expectancy in the USA was lower than in most other western countries, it was catching up at older ages. The life expectancy at 70 (IIRC) was about the same in the USA, and life expectancy at 80 was higher. Which meant that the extra deaths in the USA were happening when people were still relatively young, for whatever reason.

279

I’ve read about several examples of drug price fixing in France, and they gave me the distinct impression that they were more similar to haggling in a Moroccan Bazaar than to some streamlined process involving the Pharma companies justifying their real costs and such as depicted by wolfpup. They involved things like “What about we allow you to raise the price of this other drug by x% and you accept to reduce the price of this new one by y%?” or “If you don’t sell it at a lower price, this other very profitable and costly drug might somehow ends up being allowed for prescription only in hospitals and not by general practitioners”.

One recent example I remember is rather enlightening. Some small Swiss pharma company had discovered a new drug was was significantly more efficient than existing ones for some (relatively common, but can’t remember which) ailment. A big American (IIRC) pharma company bought the company just to get their hands on this patent. When it came to negotiate the price with the French healthcare system, they had a significant leverage because of the indisputable superiority of this new drug. They didn’t base the price offered on anything like costs. They simply took the current price of the previous less efficient drugs and multiplied it by some factor (say, 5 times, but I don’t remember). It had nothing to do with how much the drug costed to research or produce, and everything to do with how much they could try to bill for it. Which makes complete sense in a free market. If you have a monopoly on a product, you just sell it at the price that will result in the highest profit. And in the case of drugs, the demand is very inelastic, so that can potentially be a very high price.

280

I didn’t read the whole quote because I stopped at this one which is silly. Today with our ridiculous insurance system doctors have to bill (made up numbers for illustration) $500 for an office visit because they know the insurance company will refuse to pay $400 and the patient is only required to pay a $20 copay. It’s common knowledge that they never get paid their full amount. Medical provider price inflation is in part due to this - doctors trying to be compensated as much as they can because they have to fight tooth and nail with the insurance providers whose sole motive is to not pay out.

So in a single payer system as I understand it, there is no sillyChargemaster (rack rate) so medical providers don’t have to play silly games to fight the insurance companies. There is one price list for all treatments with realistic/reasonable prices and doctors never have to wonder if they’ll get paid or get screwed. Sounds to me more like the transformation that doctors would have to go through is an increase in confidence that they’ll be paid and a steadier income stream.