In that case, Sam, Canada is a very special case and even then, as you say, they can choose private treatment, just not in their country. In the UK there are all manner of private health options like BUPA.
I cannot imagine that a system whereby you are actively prevented from paying for your health out of your own pocket as well as making the necessary tax contributions will remain in place for too long.
In that case, Sam, Canada is a very special case and even then, as you say, they can choose private treatment, just not in their country. In the UK there are all manner of private health options like BUPA.
I cannot imagine that a system whereby you are actively prevented from paying for your health out of your own pocket as well as making the necessary tax contributions will remain in place for too long.
Fair enough but you said in your other post
So the waiting list to get a harmless cyst removed may be 16 weeks but to see your doctor is a different thing altogether. That’s why people are questioning you. You were originally talking about going to a family doc not have non-emergency surgery.
As for not being able to go private. Well that’s mad. I’m not familiar with any other socialised system that you can’t also have your own insurance if you so wish but I’ll grant you I’m not that familiar with the health system of most Euro countries apart from Ireland and the UK.
Sam: Let’s see, we now have cites or references to Pacific Research Institute, Fraser Institute, and National Center for Public Policy Research.
[sarcasm]Don’t you think we ought to throw in CATO, National Center for Policy Analysis, and Hudson Institute to provide a little balance?[/sarcasm]
By the way, I am not claiming that wait times in Canada aren’t too long for some things. But, I think you have to be careful do do detailed cross-comparisons with the U.S. rather than looking at one country only as the Fraser Institute study does. It’s not all wine-and-roses on this side of the border either.
Leaving aside the huge issue of uninsured or those with poor insurance, even those of us with very good insurance through our employment living in a city known for having relatively good health care access and good insurance plans run into problems. I know of a recent issue of a friend who was put through hell when she wanted to go see a specialist after she felt her GP misdiagnosed her. (When she finally got to see the specialist, he agreed that she was likely right and her GP wrong, pending further tests to determine this for sure. And, the diagnosis has very important implications for the course of treatment.)
Another issue we face her in the U.S. is that insurance is so tied to our jobs that if we want to switch jobs, or heaven forbid, take some time off or something, we constantly have to deal with the issue of insurance coverage…And this can become particularly dicey if we have pre-existing conditions.
Northern Piper said:
I have to concede on this one. The first cite I quoted said the waiting list was for seeing a GP. But that 16.2 weeks is the exact number quoted by the Fraser Institute, so clearly the first cite was wrong. The waiting list appears to be for non-emergency procedures - so the arthritis example above applies. And in fact, that arthritis example was not a cite - it was personal experience. My wife came down with the syndrome, and it took her a couple of weeks to get in to see her GP, who referred her to a rheumatologist - the earliest she could get in was 3 months. The rheumatologist put her on some pretty evil drugs - and scheduled an appointment for four months down the road. The initial dosage was too low, and it took her months to get back in to get an increase. Then after a few months the arthritis exacerbated, and she had to make another appointment - again, it took three more months. We’ve been dealing with this situation for two and a half years now, and let me tell you, it’s pretty hard to keep it under control when it takes months to get in to see the specialist.
My daughter started coughing at night a while ago. We went to our GP, who suspected allergies. It took three months again to see an allergist. This is pretty common stuff.
Here’s an interesting cite that shows mortality for various cancers for each state and Canadian province. The one constant across all the tables is that the Canadian provinces cluster in the bottom half of each group. From their conclusion:
No wonder almost 5% of our cancer patients seek treatment in the United States. How many more would choose to go to the U.S. if they had an insurance plan to cover U.S. treatment, as the majority of U.S. citizens do?
Here’s a really scary table: Mortality/Incidence Rates: Colon and Rectal Cancer, Male.
The best state in the U.S. has a mortality rate of 29.4%. The best province in Canada (aside from the statistically insignificant NWT) has a mortality rate of 40.9%, and our best province ranks 36th out of 62 provinces and states. Note that almost all Canadian provinces are clustered at the very bottom of the list - only 5 U.S. states are in the bottom 13.
The report continues:
How would you like to be diagnosed with a cancer that needs treatment within four weeks to be effective - and then have to wait for two months just to see an oncologist?
Why is there a shortage of health care professionals in Canada? Mainly, because we have socialized medicine. Both Britain and Canada saw severe ‘brain drains’ of health care professionals when their health care system was socialized. Rigid fee structures, bureaucracy, inability to be rewarded for personal excellence… These are the hallmarks of government-run systems, and the best and brightest flee from them. Want to know where our best Canadian doctors are? I suggest starting with Johns Hopkins.
Again, if you limit the price people can charge, you’ll restrict the supply. Fewer people will choose to go into medicine - especially the very best who can stand to attain much more in other, less regulated fields.
I know what of I speak here - my wife is a senior nurse in one of the largest hospitals in the Province. She’s probably the best nurse on her unit, and she desperately wants out, so she’s going back to school after 20 years in the field. The bureaucracy keeps growing, the quality of care keeps going down, the can’t-fire-me-I-work-for-the-government mindset of other nurses leads to chronic slack-ass behaviour and over-use of sick days requiring the diligent nurses to put in overtime to cover the shortages. And of course, there are general nursing shortages which makes all these problems worse. If the best nurses and doctors make exactly the same as the worst ones, the incentive to excel goes away. Those that continue to do their best despite the system become frustrated as they wind up picking up more and more of the slack of their less talented/motivated peers, who suffer no punishment for their behaviour. Eventually, the best leave or burn out.
There are other distortions in the system. For instance, doctors get paid by the government on a rigid fee schedule based on number of patients seen. So the way to make more money as a doctor is to see more patients. The last time I saw a GP, I was in his presence for no more than five or ten minutes. The way it works is they book in four or five patients at the same time. There’s a small examination room for each patient. The doctor then moves between them like an assembly line. A nurse will come in, and ask you to prepare (get undressed, whatever). Then she’ll leave. Then you’ll wait for the doctor. Eventually, he’ll show up and ask you what’s wrong. You tell him, and he leaves again. A nurse comes in to take blood, or otherwise prep you for the next step. Then the doc will come in again after he goes around to the other patients and spend another couple of minutes with you. Then he’s gone again. At the end of it all, you get another couple of minutes while he gives you a referral or his advice.
Is that the way it is in the States? I’ve never been to a doctor in the U.S., so maybe this is standard practice.
Sam, I think there are similar complaints by nurses in the states…Overworked, underpaid, etc., etc. The only difference is the assignment of blame. It is not the government bureaucracy, it is the medical bureaucracy and the push for ever higher cost savings (and, for those hospitals that are for-profit, profitability).
Absolutely…To a T. (Just substitute “by the HMO” for “by the government”.) Actually, sometimes you can’t get an appointment with the doctor and see a nurse practicioner instead…This is probably a better deal anyway since they tend to spend more time with you and give you a chance to ask questions. I just saw my GP yesterday and was in his presence for 3 minutes max…And, to be honest, it didn’t even bother me. I considered it a good visit as far as these things go. I see a urologist for my on-going problems with kidney stones and I don’t think he has ever spent more than 5 minutes with me. (I was going to say 3, as that would almost certainly apply to most visits, but decided to err on the side of caution in case I’m forgetting some anomalous visit.) My reaction with your “5 to 10 minutes” estimate of how long you saw your GP was, “Good, God! I wouldn’t know what to do in the presence of a doctor for 10 minutes.”
SS: The last time I saw a GP, I was in his presence for no more than five or ten minutes. […] Is that the way it is in the States? I’ve never been to a doctor in the U.S., so maybe this is standard practice.
Yup, doctor’s visits in the US are often very brief and frequently interrupted, in exactly that way.
Why is there a shortage of health care professionals in Canada? Mainly, because we have socialized medicine.
I’m not sure that’s true. It doesn’t explain why we also have severe shortages of health care professionals in the US, especially in urban centers and rural counties. And our nursing crisis is if anything worse than yours. US doctors and nurses may be plentiful up at the top end, but that doesn’t mean that the average person—even one who can afford private health coverage—has adequate access to them.
In fact, I think you may have a grass-is-greener perspective in general on this subject (as, to be sure, many US advocates of publicly funded health care may also have, in the reverse direction.) You seem to be evaluating the average or worst aspects of the Canadian system against the best aspects of the US one. If you and those around you actually had to depend on the US system for all medical care, instead of just cherry-picking a few high-end services from it when you need and can afford them, you’d have more of a sense of why so many Americans are so desperate for a reform of our system.
So… I take it then that you have Canadian recruiters down in the States attracting all those nurses to the better working environment in Canada?
See, I don’t know of a single nurse that came to Canada to escape the horrible nursing situation in the U.S. On the other hand, we have recruiters from U.S. hospitals routinely set up shop here to attract nurses to the U.S., and plenty of them go. In fact, 24.8% of all emigrants to the United States from Canada are in the health professions - 11% are nurses, 8 percent doctors, and the rest other health professionals. That is a significant ‘brain drain’. And what’s worse, a survey of graduates from Canadian universites who emigrate to the United States shows that 42% of them were in the top 10% of their class. We keep the average ones, you get the best. (source: Human Resources Canada).
From the cite:
This despite the fact that the unemployment rate for nurses in Canada and the U.S. is nearly identical (and almost nonexistant at about 1.5%).
Doesn’t it at least give you pause to hold up Canada as an example for a health care system, when our health care workers are fleeing it in droves?
SS: Doesn’t it at least give you pause to hold up Canada as an example for a health care system, when our health care workers are fleeing it in droves?
Remember, Sam, nobody here is trying to claim that we think Canada has a perfect health care system. And as posters from other socialized-medicine countries have pointed out, it is perfectly possible to maintain parallel public/private plans (geez! please pardon my proliferating p’s 
) in order to get a better combination of broad coverage and competitive service. You seem to be trying to paint this as being necessarily an either/or situation.
And again, you seem to be glossing over the problems with the alternative. I could turn your question around and ask: Doesn’t it at least give you pause to champion the US system as better than Canada’s, when we still have such acute health-care professional shortages even with our vigorous efforts to “brain-drain” care providers away from Canada and other countries?
If the market system was really so good at providing universal health care, surely we in the US ought all to be fat ‘n’ happy about it, getting great service for everyone at easily affordable rates, right? Sorry, but that ain’t how it is on our side of the fence.
Sam, I’m sympathetic to the suggestion that there are problems with the Canadian system, and that the labour migration and such that you point to are indicative of something. What they’re indicative, though, I believe is just that we’ve cut too deeply into funding. Remember, we’re spending something like half of what the US is in terms of percentage of GDP, and our GDP per capita is 25% (or whatever) lower to begin with. Push our funding up by 25-30% from where it is now, so we’re spending 75% of what the US is in terms of percentage of GDP and there would be a massive change in the situation. Most of the disparity you’re pointing to would vanish, and the advantages we currently have would increase, and we’d still be paying far less for universal coverage than Americans are for a half-ass patchwork.
I think the problem with thinking that the market is the solution to medical resource allocation is that the demand for medical resources is nothing like the demand for most other things. It just doesn’t work the same way as the market for consumer electronics. The whole field is beset with collective action problems and externalities and whatnot. I lived in the States for 4 years, and I had what I presume was very good coverage - grad students at UM-Ann Arbor got the same deal as faculty there, and given the nature of that institution, you can bet that the faculty package wasn’t substandard, given the way top colleges there compete for personel. I can tell you, my experience there in terms of doctor visits and the like was absolutely no better than my experience here, though I never did have to see a gastroenterologist there. Thankfully my UC was quiescent the whole time I was there. My coverage was slightly more expansive than basic coverage here in that it included prescriptions (though there were hefty co-pays on absolutely everything, and they kept increasing at a rate about 10x higher than inflation), but even the most meagre of supplementary benefits packages one might get here from an employer far surpassed it in terms of dental/optometry etc. Plus the HMO dictated far more details of my routine care there than the government ever has here, which isn’t much fun.
Whatever problems we have are pretty directly traceable to underfunding. Their problems are far more intractable, since the ultimate arbiters of medical care, the insurers, have perverse incentives, namely, it’s in their best interests to collect premiums from healthy people, and finding ways not to insure people who will cost them money. The people who actually dole out the health care there aren’t interested in your health at all. Here, whatever other problems we might have, that is not the case. Health adminstrators want you to be healthy, cuz there’s no way they can get off the hook for paying your medical bills. “Pre-existing condition” isn’t in our medical vocabulary, thankfully.
Don’t get me wrong - I’m not opposed to changes in health care. I was pointing out the flaws specific to a single-payer system such that we have in Canada, and which I bellieve both Kerry and Edwards support.
Rather, my position would be that any attempts to improve access to health care must retain the fundamental market-driven nature of the industry. So I could be talked into expanded insurance for the working poor, or medical liability reform, or other plans to correct some of the worst problems.
But single-payer is not the way to go. Because once the government sets the fee schedules, all the rules change. All of the problems, excesses, and shortages in our system can be traced back to that one simple fact.
No, but rationing is. I’m sorry, but you have to provide far more extraordinary evidence that a burocrat in a far off capital is more caring of your health than a buerocrat in a corporate office (whome I can fire at will) is of mine. You said it yourself, the insurers are interested in having healthy subscribers. I think if you look at the recent moves toward preventitive care in the US, you’ll find that insurance companies are behind much of it.
The problem of third party payer does not magically disapear when you establish a one tier system such as Canada’s. If anything it has to get worse.
As an American, I also know about house calls. They’re like party lines, where there’s one phone number for the whole block, and you have to say which house you’re calling, right? 
But rationing is part of your system as well. Not only do your insurance companies refuse to cover pre-existing conditions, they tell you how many days you can stay in the hospital after surgery, and how often you can receive your prescription drugs. That’s every bit as much rationing as queuing people up for scarce resources is.
I have no idea why you think a profit-driven corporate person would be more interested in your health than a re-election driven elected official would be. And I think you have to present some extraordinary evidence as well. Insurance companies can and do find way to ditch people who develop chronic conditions. It’s in their interest to do so. Their incentive isn’t so much to keep the people they insure healthy as it is to only insure healthy people. This should be obvious from the widespread refusal to cover pre-existing conditions. The government has no such incentive, as it cannot ditch people, ever, and cannot pick and choose what to cover. The government bureaucrat’s incentive is not to maximize the profit of his company, but to avoid being canned (or, in the case of unionized management, to avoid being transferred to Iqaluit, compared to which being canned might look like a good deal) by elected officials responsive to complaints registered by voters. They have no incentive to screw over the consumers of medical services, whereas insurers do have such an incentive. And you can’t fire your insurer any more readily than I can fire bureaucrats, since you, by and large, are stuck with whatever insurer your employer provides, unless you’re independently wealthy. What are you going to do? Quit your job and declare bankruptcy so you qualify for Medicaid?
Well, to be fair, I thought I simply interpreted what you said. I don’t think I made that claim.
Look at the two parts of this sentence. They are not exclusive.
I have to call bullshit on this one. Can you point to the Canadian law which requires the government to pay for each and every medical procedure undertaken in every circumstance? Or is it possible that availability (or the lack thereof) performs this same function?
Quite right. Complaints like high taxes. Can you point to a single government official who has ever been fired for denying service? I can point to many instances of people changing insurance coverages because they were inadequate.
And this is where the hyperbole leaves the realm of planet Earth. I’m sorry, but insurance companies do not have an incentive to “screw over” their subscribers. That’s who pays them.
If necessary yes. But I don’t have to do that. I could simply pay for medical expenses out of pocket. I could simply buy private insurance. I could simply go to the emergency room. I could talk to my doctor and negotiate an equitable payment schedule for whatever I needed done. Can you do any of these things without also travelling to the US?
Seriously, I don’t know what bug has crawled into an uncomfortable position with regards to profit for you. But profit is not the devil’s handy work. It may not be God’s gift to man either, but it does not magically induce honest people to become evil. It can easily have the opposite effect.
I composed a more rational post to this thread but the hamsters ate it. I’m, begining to sound more vitriolic than I like. I’ll leave this for a while and see if I can’t do better tommorrow.
A few notes on the U.S. system:
Saying that healthcare in the United States is an example of a “market system” is not quite true. The US federal government now spends 60% of all healthcare dollars in the country. This is less than most countries, of course, but it’s closer to being socialized than being pure laissez faire. Also, HMO’s were originally created by an act of Congress, and thus it is misleading to think of them as the fruit of a market-driven economy.
The health insurance industry is not really a free market in the U.S. either. As an unemployed 35yo, healthy, monogamous, non-smoking, vegan male with all my grandparents still alive, I consider my primary health risk to be driving my car, followed by riding my bike. Think I could find a policy to cover me only for trauma? Not a chance. The industry is required by federal law to also cover me for almost all diseases and conditions, including ones I’m very, very unlikely to get. Thus, I find health insurance to be overpriced by law, and a waste of money.
I also think the cost of medical malpractice suits affects the U.S. system more than other countries because the U.S. is unique in not having a “loser-pays” civil court system. (That is, most countries require the loser of a civil suit to pay the court costs and legal expenses of the winning side. In the US, each side pays its own expenses regardless of outcome.) I have no statistics, but I would bet the U.S. has more malpractice lawsuits per capita than other countries. Many cases here are frivolous, but they cost doctors tens of thousands of dollars to defend against each one. Since 85% of malpractice cases that go to trial are found in favor of the doctor, I think this problem would be greatly controlled by going to a loser-pays system. Chance of this happening: zero. 
The FDA and AMA are also driving up prices in the U.S., but that will have to wait for a future post.
It’s called the Canada Health Act. If a medical service isn’t available in Rankin Inlet, the gov’t is obliged to airlift the patient who requires it to Winnipeg. Availability only limits things in the form of too little funding resulting in queues. This factor, admittedly, has become significant, but the solution to it is simple.
Sure, but if you’re too sick to work, none of these are an option, unless you’re independently wealthy.
I have no issues with the profit motive per se. It’s just that in the case of the medical insurance industry, the profit motive results in perverse incentives. Given the difficulty of switching insurance in the US, there is relatively little incentive to provide better service than the next guy to prevent losing customers. And worse, the more a customer needs your services, the less valuable he is to you (and to the competition), to the point of becoming a liability instead of an asset, so the less incentive you have to provide quality service. It needn’t be this way, but that’s currently the way market pressures are acting on medical insurance in the US. The profit motive pushes them in an entirely different way than it does, say, the manufacturers of consumer electronics, or the construction industry, or virtually any other segment of the economy.
There is completely a different mindset between the US and Canada with regards to healthcare. In Canada, healthcare is regarded as a public service, like roads & bridges, police, etc. In the US, healthcare is regarded as something that is a benefit from having a good job (or a lot of money). I’ve lived under both systems, and I can tell you, if you have good insurance and live in a place well-endowed with medical facilities, the US wins hands down. However, there are costs, and not all of them are obvious.
Last year I had a pinched nerve. My doctor (who is a Canadian in exile, like me) figured that out using a hammer and testing my reflexes, then backed that up (30 minutes later) with nerve conduction testing (which in itself isn’t cheap). However, my doctor wanted an MRI to be certain. His secretary called the MRI clinic, and after a few seconds of talking to the clinic, the secretary turned to me and asked “would you like tomorrow morning or afternoon”? When I told family members back in Canada, they asked me when I became a sports star. In Ottawa, the wait for a non-emergency MRI is 5 months, in Toronto 3 months. The cost here is twofold: overdiagnosis and overcapacity.
If there was a long wait for MRI, my doc most likely would have been satisfied with his initial diagnosis without the need for “toys”. Even the nerve conduction testing was probably superfluous. I have a number of friends who are foreign trained doctors, from places like Japan, South Africa, and Russia. Like all foreign trained doctors (except Canadians!), to work in the US they had to do a residency in the US, on top of the one they did in their home country. They all say that training in the US places an emphasis on “toys” rather than simpler, low tech diagnosis.
If the MRI was available both tomorrow morning and afternoon, want to make a guess as to the utilization of the MRI? When I was in the office (morning, btw), there was nobody in the waiting room when I left, so presumably the MRI sat unused for a time. If California has 400 MRIs at 50% utilization, and Canada has 171 MRIs at 100% utilization, you can still say there is a shortage in Canada (which there is), but the extent of the shortage isn’t so bad as the raw number of machines would indicate. The wait time in Canada is for non-emergency – if it is an emergency, you’ll get your MRI as quick a I did.
Another cost, as many people have pointed out, is lawsuits, which manifest themselves in the medical industry as malpractice insurance. A friend of mine is a oncologist, but she chooses to do other things than practice medicine. One reason is that malpractice insurance would cost $80,000. Another local doctor (a gerontologist, not a high-paying specialty) has seen his malpractice insurance jump from $5,000 to $10,000 to $30,000 in the past 3 years. Insurance for neurosurgeons can cost $250,000. Radiologists have very high insurance rates, too, because evidence that they screwed up is right there on film. I know a high-risk ObGyn who specialized in things such as pregnant teens (and occasionally pre-teens). One of his patients, a young adult, was poor, pregnant, and had a medical condition where pregnancy could be fatal, for her. The only option in this condition is termination (abortion). This Ob-gyn doesn’t usually do abortions, but voluntereed his time and asked others involved to do the same. Everything went fine. A few months later, he was sued by this young lady.
Billing and administration are another cost. I’ve only live in two places in the 8 years I’ve been in Cleveland. I’ve had the same insurance for the past 5 years, from the 2nd largest health insurer in the country. In the time that I’ve been here, I’ve had 7 bills go to collection, simply because the hospital or doctor group was incapable of billing my health insurance properly, or incapable of fixing a billing issue. Sending a bill to collection costs the hospital a lot of money (typically 50% of the amount owed). Part of the problem is that hospitals try to save money by outsourcing their billing, which is then handled by high school dropouts in West Virgina (or other low-wage states). If they did billing in-house, their percentage of collection would go up, but the increased cost of hiring people with adequate experience would wipe out any gain. I found this out by talking to the head of billing at one of the local 1000 bed “world class” hospitals (yes, there are two of these here, within walking distance of each other – another overcapacity nightmare).
Research, as others have pointed out, hardly matters in health care costs. Research budgets generally come from government or industry grants, and are a tiny percentage of overall health costs. However, health research is a large industry in the US. In Cleveland alone, there are 3 major research centers (Case medical school, University Hospitals, Cleveland Clinic), and a few other hospitals have smaller research programs (VA Hospital, MetroHealth). Total annual NIH (National Institutes of Health) research grants to Case medical school is in the ballpark of $170 Million. Cleveland Clinic spends about $80 million a year in research (with about 90% of that coming from external grants). Many of the foreign doctors I know were attracted here by the research funding. Even with all that money, Cleveland is only in the top 10 in terms of health research funding.
Gorsnak: You seem to think that the problems with the Canadian system can be fixed by simply pumping more money into it. This is simply not the case. To see that, have a look at Alberta - we spend significantly more on health care than most other provinces, but we still have a waiting list problem.
Your assumption is that ‘full’ health care with no waiting lists would cost X, and we currently fund health care at a level of X-y. Pump up the funding to X, and voila, no more waiting lists.
But there is NO level of health care funding that would meet everyone’s demand (at least, not if we are talking about reasonable funding levels). If you doubled our health care funding, you’d still have waiting lists. Why? Two reasons. First, because people will consume every health care dollar available, and then some. The ‘and then some’ is what causes scarcity and means that people have to compete for services. Economics is all about how to deal with the problem of scarcity. You can use prices to control supply and demand, or you can go to a government system where supply is rationed. Doesn’t matter how much you spend, you can’t possible spend enough that everyone in the country gets as much health care as they want - this is especially true as the population ages.
The other reason why mere funding won’t do it is because one of our big problems is that there is a shortage of doctors and nurses. Again, when you regulate something and put price ceilings on salaries, you will cause shortages. The history of wage and price controls is quite clear on that. Plus, doctors and nurses don’t like our egalitarian system - they want the opportunity to excel, and they don’t really get it here. That’s why 42% of the people who are in the top 10% of their class wind up in the United States - there, you are free to rise to the level of your ability. In Canada, you are not.
So the only way you are going to solve the problem of waiting lists is to replace that particular form of rationing with something else. And while you’re at it, you’ll have to reform the way doctors and nurses are paid and treated.