One of the thorniest domestic issues I have is with health care. American health care is truly amazing — for those who can afford it, are insured against its costs, etc.
Canada’s system is often touted as an intelligent alternative to the American partially-socialized system. But it has problems, too,
A study recently released by the Fraser Institute in Vancouver, B.C., compared industrialized countries in the Organization for Economic Cooperation and Development (OECD) that strive to provide universal health-care access. Among those countries, Canada spends most on its system while ranking among the lowest in such indicators as access to physicians, quality of medical equipment and key health outcomes.
One of the major reasons for this discrepancy is that, unlike other countries in the study that outperformed Canada — such as Sweden, Japan, Australia and France — Canada outlaws most private health care. If the government says it provides a medical service, it’s illegal for a Canadian citizen to pay for and get the service privately.
At the same time, to try to keep spending down, the government chips away at the number and variety of covered services. According to another Fraser Institute survey, this means that on average a patient must wait in line 17.7 weeks for hospital treatment.
In 1999, Dr. Richard F. Davies described how delays affected Ontario heart patients scheduled for coronary artery bypass graft (CABG) surgery. In a single year, just for this one operation, 71 Ontario patients died before surgery, “121 were removed from the list permanently because they had become medically unfit for surgery” and 44 left the province to have their CABG surgery elsewhere, often in the U.S.
In other words, 192 people either died or were too sick to have surgery before they worked their way to the front of the waiting line. Yet, the Ontario population of about 12 million is only 4 percent of the population of the United States.
In an article in the journal Health Affairs, Robert Blendon describes an international survey of hospital administrators in Australia, New Zealand, Great Britain, the U.S. and Canada. When asked for the average waiting time for biopsy of a possible breast cancer in a 50-year-old woman, 21 percent of administrators of Canadian hospitals said more than three weeks; only 1 percent of American hospital administrators gave the same answer.
Fifty percent of the Canadian hospital administrators said the average waiting time for a 65-year-old man who requires a routine hip replacement was more than six months; in contrast, not one American hospital administrator reported waiting periods that long. Eighty-six percent of American hospital administrators said the average waiting time was shorter than three weeks; only 3 percent of Canadian hospital administrators said their patients have this brief a wait.
Canadian physicians’ frustration with their inability to provide quality and timely care is resulting in a brain drain. A doctor shortage looms as the nation falls 500 doctors a year short of the 2,500 new physicians it needs, according to Sally C. Pipes, president of the San Francisco-based Pacific Research Institute.
Now, certainly, it’s fine to say that Person X, presenting need Y, gets treatment in C time in Canada, U time in the US. One thing that doesn’t take into account is that it assumes that if X is in the US, they have insurance coverage to pay for the treatment. Short of being independently wealthy, that’s a very big caveat.
Not that I think that necessarily balances the results (it’s impossible to say, to be sure). The primary question, though, in any health care debate, is what level of need are you prepared to have the individual pay for, vs. society pay for? And that’s not an abstract question — every dollar that goes into a unviersal health-care system has to be allocated from taxpayers through their representatives (assuming a democratic society). It goes without saying that society is not willing to pay enough to cover everything from brain cancer surgery to botox treatments. But it’s also not just a matter of what treatments, but the quality of the treatments, and the lag time to get to them (whether discretionary or not).
Simply throwing money at the problem is a simplistic way of looking at the problem. Because you’ll never throw enough money at it to allow every person to get every treatment with the most expensive drugs and devices and talent possible. Anything short of that, though, is going to incur suffering, possibly death.
Who makes those decisions, both in the micro (politicians and plan adminsitrators) and in the macro (taxpayers)? And are politicians and government boards and bureaucrats really any better at it or more compassionate than, say, HMO review boards and corporate suits?
And does the insertion of the taxpayers, voting (indirectly) on what to fund more compassionate and just and fair than, say, employers deciding what insurance to offer to their employees (or, taking it a step further back, consumers deciding whether it’s worth going to someplace other than Wal-Mart that charges them more in order to provide decent insurance)?
Another direction to tackle the problem from is, if we assume we cannot pay for everything we want, is how we spend our dollars the most efficiently. In general, competition (and capitalism) seems to be more efficient — more empirical in determining how to maximize effort for cost — than setting a government policy and then defining how to meet its mandates. Survival of the fittest solutions. The profit motive (personal or corporate), while jarring in considering something like medical care, does seem to motivate some people to do things better and/or less-expensively.
But competition and capitalism, while working pretty well (again, in the macro), leaves a lot of folks in the dust (the micro). That’s fine when we’re talking about, say, automobiles or stereo systems, but when we’re talking about the health of people, both individually and societally, that’s a cost I don’t think we can afford. At least, not beyond some point.
But then that gets us back on the other end, trying to manage things like the Soviets did with their economy, and doubtless with the same short- and long-term results.
It seems to me that any solution (and I don’t pretend that there’s only one, or even an obviousl one) is going to be mixed. There’s going to have to be some government/societal oversight to make sure that some level of care is available to all, regardless of their means to pay, but there needs to be some sort of private profit built into the system, to keep some sort of efficiency, and innovation.
And there has to be something that keeps folks from “abusing” the system — which is another way of saying, again, that we societally recognize that not everyone can get everything, and so some folks are not going to get some things they want, unless they’re willing (and, to be sure, able) to pay for it themselves. And that might mean some pain and suffering, yes, though different folks might disagree on what pain and suffering deserves public support and what doesn’t. One person’s frivolous face-lift is another person’s necessary facial reconstruction. One person’s only chance at a possible cure is another person’s boondoggle that will cost what would pay for three other folks to live a better a life.
There’s never going to be a perfect system. The American system certainly isn’t. Nor is Britain’s NHS, or Canada’s system, either, in their own ways. What level of imperfection we’re willing to tolerate (or sacrifice ourselves/societally to correct) is, perhaps, the bottom line, the definition of what society itself means.
Which is probably way too long and confused a rant for a Tuesday morning. Time for lunch.
We’re debating these issues again in Canada as treatment costs soar partly due to very expensive drugs such as the statins (think Lipitor), the newest generation of antibiotics, and some of the newer cancer drugs which have begun push health care costs through the ceiling.
In Canada we are committed to keeping everyone under the umbrella, but there is talk of rewarding the folks who make the lifestyle choices that keep them from being sick and posing a drain on the system. A tax credit is a possibility for this.
Another possibility being considered is to make health care benefits a taxable benefit–if you put an especially heavy drain on the system and your income is higher, you might chip in extra for your use. A user fee for every time you walk in the doctor’s door is a possibility, too.
Everyone agrees, though, that no matter what your income, if something catastrophic happens then you’re covered.
The ramifications of this have rippled through my life. My mother committed suicide when I was a child, just a few years before Canada instituted universal health care. She was in intensive care three days before she succumbed to her wounds. My father had Blue Cross, but because my mother’s wounds were self-inflicted, his health insurance would not cover her hospital stay.
My father and my stepmother spent the first 20 years of their married life paying off my mother’s hospital bill in tiny increments because it was all they could afford. There was never any extra money when I was growing up.
Fast forward to about 15 years ago. My mother-in-law suddenly had a heart attack. They rushed her into the hospital and found that four arteries were blocked. She was rushed in to Montreal for by-pass surgery. Every red cent covered by the government.
They give you an itemized bill here in Quebec, just to let you know what it all ran. For my mom-in-law, the surgery and three week hospital stay ran over $100,000. Aye carumba. Would normal health insurance have covered all of this? I’m grateful that we didn’t ever have to seek an answer to that question.
At my gym in Vermont I hear people talking about the health trade-offs they have to make because either they can’t afford health insurance, or their insurance won’t cover what they need. One man has had by-pass surgery and is not considered insurable. He can’t find a company to take him on even though he’s made many lifestyle changes that should lower his risk substantially.
One woman told a friend the other day her kid was growing like a weed and needed new shoes so she was cancelling her annual exam and pap smear.
Yikes.
Does the system need tweaking in Canada? Yep, that’s why it’s under discussion. Am I grateful it exists? Oh, man, yes. I’m just old enough that I can remember the time before universal health care existed. I have experienced what that can mean.
Which brings us to the second huge social benefit Canada gives its citizens.
I think we can all agree that a higher education opens crucial doors for a person both in terms of job opportunities and personal growth.
The only reason I ever got a university education is that I earned scholarships, worked part time, and the Canadian government committed itself to making higher education as affordable as possible–I got a mix of very low interest student loans and outright bursaries from the government to keep the wolf from the door.
The spousal unit and I helped our daughter out, she worked, and there were scholarships but again, without government help she would never, ever have been able to afford that degree.
I think these two committments–that every Canadian has the right to health care and that the government will heavily underwrite higher education for its people–are the two smartest investments my country has made. But then, I’m biased and I’ll freely admit that.
I agree with the idea of trying to provide some sort of “catastrophic” care — though that’s still going to get one into debates about what’s catastrophic, why this person at this income level gets X in case of Y, but that person over there gets A in case of B.
I also agree with helping those who can’t afford basic health care (while recognizing that gets into the same sort of debates).
But, as you note, there’s always a new treatment, a new “most expensive device that goes ‘ping,'” and the question of who should get access to it, is it the most cost-effective way of allocating limited resources (“you can have one person live five years longer on the expensive device, or you can provide basic chemo for two dozen cancer patients, or you can immunize 500,000 kids against polio”). Certainly Americans, I think, expect the best, most expensive, most extreme, no holds barred, finest treatment available, and consider it a cruelty if that’s not available for any reason; I don’t think that’s a rational judgment, but, then, I’m not the one whose mom is suffering from Horrid Disease X that might be curable on this $500,000/yr treatment …
I can speak from personal experience with the finance-crippling cost of medical care, and with battling Unfeeling and Impersonal Insurance Companies, sometimes with (sometimes without) the help of doctors and hospital staff. Not as extreme as your own case, but traumatic enough in its own way. So on the one hand, I can relate to wanting to make it affordable to all who need it.
On the other hand, defining “it” and “affordable” and “need” seem to be the devilish details. And, assuming the stats given in the article are accurate, it’s something that Canada’s struggling with, too.
And I get a different perspective being married to someone who works for a medical group/insurance firm, albeit a non-profit one.
I worry a little (well, a lot) as well over the “healthy lifestyles” idea mentioned above — and I’ve heard it floated here in the US, too (some health insurance companies offer a rate reduction for non-smokers, for example). My worry here is who gets to decide, and at what point it stops being a “reward the folks making healthy choices” (is a financial incentive enough when the obvious health incentive is not?) and it becomes a “punish the folks making choices we think are unhealthy, like dairy, or red meat, or alcohol, or whatever the Health Busybodies are busy warring against this year.”
I wish I had an easy answer for this — or even a difficult but clear one. 🙂
Hmmm, interesting to see the comparison to the Australian system. Which isn’t perfect, but has it’s good points.
Just reminded me of something I overheard between the other household folks today:
The Silly Pudding likes to say, “Eh,” a lot, so his mother remarked, “I think he’s Canadian.”
The LintKing turned around and noted what the boy was “Eh”ing at, and offhandedly said, “Good thing. He’ll need to have universal healthcare if he’s going to slay dragons.”