Month: July 2004

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.