Look, I left Canada, OK? So you can fairly assume I'm not a fan. On the other hand, the rhetoric that circulates in the US and other quarters is the kind of thing that gets my blood boiling. And no, I am not going to discuss Michael Moore's views. What I am going to say is that the system works, albeit not perfectly. I am also going to say that many people are missing the real danger of replicating Canada's system in the United States.
The Canadian system is fully socialized. It is operated and entirely funded by one source, the government. Well, not to be a nit-picker, by ten sources, since provincial jurisdictions are mandated to run the system. Each province collects business and personal taxes for the express purpose of funding a health system for all.
The principle of universality is near and dear to the Canadian heart. It assures that all citizens have access to any program ostensibly intended to improve quality of life for the poor. This means that even milk money (my nickname for a national nutritional subsidy) means that checks were delivered monthly to the wealthiest households in the country. It also means that if you're wealthy enough to skip it, you are not forced to use the system.
The system works well for the majority. Most Canadians prefer the access provided by the Medicare to nothing at all. Of course the system could be improved and there is no place on earth where we don't enjoy complaining about the government.
Physicians are underpaid in Canada and some areas have caps on earnings, so there are not many incentives to work harder or see more patients. Thus there is a shortage and there are queues. When I worked there, my practice was full within six months and I was sometimes tempted to run patients out of the office. I'm a good doctor, but not that good. When demand exceeded what my quarterly cap would be, I would just go on vacation. So it really wasn't all that bad from a lifestyle perspective.
Physicians and hospitals represent a cost, pure and simple. Canada does not look to its health care system to produce innovation, since Canada is not as business oriented as other countries.
Obviously, as any business man knows, systems only have to be good enough to achieve your goals. Canada's health system is good enough to fulfill it's primary public health function. It is good enough to maintain a reasonable supply of physicians. It is good enough that constraints on the supply of physicians and technology serve to keep costs down. It is good enough to raise the tax burden to a level that is apparently tolerable to the various stakeholders.
Yes, Canadians sometimes die wating for care. Americans die due to a total lack of access. Overrall the US ranks worse than Canada.
The American system is cleaner, more luxurious, sexier and more exciting. There was a time there were more CT scanners in San Francisco than the entire country of Canada. It makes practicing medicine more fun, but this is unlikely to be a deciding factor for most physicians who might consider crossing the border. It certainly makes medicine more profitable, which is a factor for some. Readers may be interested in what convinced me to leave Canada.
My opinion about the risks of a Canadian style medical system is related to the general American fear that the government may abuse the rights of individuals. In an all-out political battle between different interest groups, there are fewer checks and balances in Canada than in the United States. The health system is a weapon in such circumstances.
In 1995 the government of Quebec decided to close 11 hospitals in the province. Five were acute care hospitals, three of which were located in the English-speaking part of Montreal, not likely to vote in support of the ruling party's separatist agenda. One of the other acute care-hospitals was a bilingual hospital near the almost universally French capital, Quebec City, and was converted to a long-term care facility.
There is no way to avoid the conclusion that hospitals were closed as a form of political punishment. And it seemed to me that nobody else in the country cared.
The real lessons for Americans is to ensure that health care stays out of government hands, because politics here are more ruthless than in Canada. Can you imagine what would happen to a Democratic-designed health system when Republicans came to power? Just think Medicare Part D; dollars for those best able to amnipulate the political winds.
Universal health coverage can and should be mandated, because it represents a social good. A health system should be funded by all stakeholders, especially those most able to profit from it, hospitals and pharmaceutical companies included. It should be regulated only to the extent necessary to assure a free and competitive market. It should never be left to any government to administer.
Tuesday, September 18, 2007
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12 comments:
A few years back I recall reading an report about an elderly man accosting his representative on the steps of a capital of some sort with complaints related to health care. In front of reporters the representative turned on him angrily and made remarks about the man's health care record. The old man was shocked, and asked how the representative had that information, that his health records were by law private. The representative sneered to him that he could access any personal records he liked. I saw two reports of this incident, but nothing further after the initial reports. That MIGHT happen in the U.S., but I really doubt a public servant would feel free to do such a thing publicly and with such contempt.
In the U.S., I do not believe the poor ever lack medical care. The ones who might not get ALL the medical services they wish are the lower-middle class with health insurance.
The old man and his representative that I described were Canadians. Sorry I didn't make that clear.
We don't have to have a government run system for that to happen here if we let them con us into building a national health information network like they want. How many people know that the government gave itself the right to look at all medical records (even if not medicare/medicaid) in the HIPAA "Privacy Regulation"?
Contempt for the poor is not an ethnic phenomenon, it is a socio-economic one.
But forgive them, they are so clueless, once they start travelling in the 'right' circles.
I can tell you how many patients I have who cannot get badly needed treatments becasue they are uninsured. People die in this country because they are waiting for charity or because they have to make choices between paying for medication or food.
A universally mandated free market system is in the broadest sense the way of threading the needle to allow the benefits of the free market while avoiding government administration.
However, the question of regulation cannot be brushed over here. What kind of care should be mandated as universal? Who determines the minimum standard, and where is the minimum contribution?
Personally I like Oregon's above the line/below the line principle. It is based on cost versus expected impact, tempered by societal values. At least on paper. No system is going to be perfect.
But you raised an excellent point: the proper response to poor government regulation should be better regulation, not no regulation.
I know this will come across as very naive but I am not sure that Health care is something that should be for profit. Yes health care professionals need to be paid, and well, but the money made by HMOs because they deny so many claims is unethical, especially when so many do without the care they need.
Canada’s system is not perfect, I know that too well, but I think it starts with the right premise- everyone has a right to health care here. What we need to address is how we spend the money we do have. So much of it is wasted.
Nadine,
I believe in markets more than government. It is a question of choosing between the lesser of two evils. Without the profit motive, there is no incentive to come up with new technologies, treatments and tools to better our lives. But without regulation and some government involvement, market players can become unconscionably mercantilistic.
It is a delicate balance in my opinion.
This was a very interesting post. Thank you for the insights. And your comment today is spot on: finding the right role for government in an American system key to creating a better health care system. The impact of completely politicizing the system is frightening given the country's politics.
As I've posted on my blog (thanks for posting your comment today, by the way) we've already got plenty of examples of how this might play out. One of the most recent: in California they cut about $60 million in funds designated for enrolling 100,000 children in the state's SCHIP program (called Healthy Families), but they kept a tax deduction for folks who buy yachts.
We need to find the delicate balance between the government participating in the system and regulating it. Perhaps one model would be the Securities and Exchange Commission. The stock exchanges are independent, private entities, but the SEC's oversight is (usually) thorough and, at least when I worked there, strongly enforced.
Everyone here keeps talking about our "free market". The only folks who have a free market are the insurance carriers. They have a free market to approach any life that they care to cover. The majority of Doctors haven't seen a free market in years. Once the insurance companies make the doctors sign the anti-free trade, exclusive agreements which level out the price of all providers the free market evaporates..Poof!
I believe that participating with any carrier should be seen as anti-free trade in and of itself. Now we all cost the same; "$25 co-pay please". Right? The choice in healthcare plans is the choice of the employer usually, not the patients or their families. The free choice for your employer to pick your health plan for you.
The FTC has wrongly ruled that doctors are not allowed to act collectively because each provider or practice is a separate business ID. But what is an insurance company but millions of tax ID's, social security numbers, combined under the heading of another tax ID, the employers TIN, which then gets combined again, under the TIN of the insurance carrier. So why can't the provider band together in similar fashion and numbers to have equal leverage back?
Medicine is the only business where a super small business is basically forced to sign a self defeating contract, just to have access to the end retail customer; the patient. No other business that I know of has to do such once you get away from greedy insurance companies.
I have two really great analogies I want everyone to know and think of. The First one is Food Stamps:
We as a society feel that it is the right thing to do, to provide basic nutrition to those who can't afford it. But we don't ask the end retailer to finance the system for us. If we as a society want to buy milk and formula for these folks then we still have to pay the full price of whatever the free market will allow. So this end retailer does not care if you are food stamps or not, because he gets paid the same for products whether it's cash and carry or food stamps? But in medicine we have cut reimbursement especially to primary care docs to below what it costs to run the office and provide the care. Tonight if two different people go into the same supermarket to buy a gallon of milk, they will both be charged, and that merchant will receive the same price for that gallon of milk whether it be the cash customer or the Food Stamps one. Why can not doctors be protected and be allowed to return to some amount of real free market forces? Yes I take Food Stamps (medicare or medicaid) but I don't get raided every other day and I don't get asked to be the one picking up the majority of the tab to cover the under and un-insured.
Sesond: Is the Vet. I recently had a very sick and dehydrated family pet, our wonderful fluffy Black cat, Pepe Lemuiex. Twice in six months I have had to take him in just to find out he has a very upset tummy and is dehydrated. I knew I was going to get Banged for this and at the end of the visit, out comes my Visa card. We all expect to pay in full at time of service for our pets. Even people of limited means seem to find ways to pay for food and medicine for beloved family pets.
Now I don't rank on folks who love their pets we do too, very much. And I am certainly not ranking on Vets. Just like the single species doctors most of these folks studied long and hard, know their stuff and deserve their just compensation for their, time, knowledge and expertise. But if the Vet down the road from our solo family practice can be treated with such basic economic respect and dignity for attending to Fido and Whiskers, then why not the my wife, the hard working family doc that I represent as her practice manager?
The problem with modern primary care is that nobody wants to pay PCP's nearly enough to slow down and do the job they already know how to do just fine. Most PCP's went into medicine with better intentions than most. We need to get rid of the managed care paperwork, that like everything else is not paid for, get all of the parasitic loses out of the system billing and fighting with insurance carriers, using for profit clearinghouses and billing companies just to try and get paid for services already rendered. We need to finally pay PCP's for what they do and what they do best, educating, advicing, managing and caring for people and there health. But office visit, 99213's and 4's which are the life's blood of any primaries office just doesn't pay the rent or keep the lights on. We can't even afford to really buy health insurance for ourselves or those who would work for us. Now where is the fairness or justice in that? Doctors who can not afford their own health insurance or care, because the gov't and the carriers pay them so poorly.
My wife sends me to the driveway on the weekends to fix our rusting out old '98 Jeep with 183K miles on it, because we really can't afford to pay someone else to do it, no less buy a new one to replace it. I think in a hundred years from now, such stories will sound to those then, like we think about pre union coal mines do to us today.
The insurance carriers are modern day Robber Barrons, syphoning all the cream off the top of healthcare financing for themselves. Many of the provider Reps from the carriers that come in here, drive better cars, live in nicer homes (really!) and probably get paid better by BC/BS and the other majors than my wife and she is the one with the MD who went to Medical School and all that goes with that.
People want many things but few of them are really willing to pay for it. We tend to pay for what we value and we tend to not pay for what we do not. It is fairly clear to me then, that most people no longer value primary care physicians. People will pay dearly to a specialist, go out of network, if and when they get really sick. But to do the same for your PCP who keeps you well, manages your DM, cholesterol, BP, they are not willing to pay a slightly higher co-pay or deductable for that. Shame on them, shame on us all.
Doctors are now just about the only ones who are expected to NOT make money on healthcare. Big Pharma certainly does, insurance carries too, Medical suppliers and vendors of devices we need and use like Whelch Allyn and GE (when was the last time GE lost money on a CAT scan or MRI machine?), MidMark Ritter, the software vendors of both EMR's and the practice management, billing programs like Medisoft and NextGen all of these folks make their money. And my favorite is the growing profits of the collection agencies because more and more people try to stick their docs with what the insurance carriers ever increasingly won't cover. But docs are supposed to pick up the slack and provide more and more care for less and at a loss. Only docs should be altruistic in healthcare. My wife took an oath to do no harm and to do what is in the best interest of her paitent. But I don't remember that oath being an oath of real poverty. This is so wrong.
"Beware of the Medical Industrial Complex"
I apologize for posting my comments so long after the original blog, but I just discovered it while Googling The Truth About Canada, the title of a book by Mel Hurtig. Anyway, I wanted to add my two cents worth as a Canadian.
TPE claims that "the principle of universality is near and dear to the Canadian heart." If by the Canadian heart, he is referring to Parliament Hill, the seat of the Canadian government, then I might agree. However, not every Canadian agrees with universal (i.e. free) access to kidney transplants for practicing alcoholics, free lung transplants for chain smokers, or free abortions.
TPE also claims that the system works well for the majority. This is only true in the sense that the majority are healthy and rarely require medical attention. I don't consider waiting 17 weeks (the Canadian average) for treatment by a specialist as 'working well.' It is reported that over one million Canadians can’t find a family doctor. Emergency rooms are crowded with patients on gurneys waiting to be admitted in hospitals were entire floors have been closed in order to contain the cost of health care. Meanwhile paramedics and their ambulances must wait hours with patients waiting to be seen in the emergency room. This is working well? Would anyone voluntarily pay for this kind of service?
Universal Health Care is unsustainable. Government health care costs have been growing faster than total government revenue in all ten provinces in Canada. If these trends continue in my province, Ontario, health care will consume 100% of government revenues by 2026. This is in spite of government restrictions on the number of doctors and hospital beds in Ontario, and a “Health Care Premium” introduced shortly after the Premier promised not to increase taxes during the 2003 election campaign.
It is worth noting that Canada does not allow private insurance for any procedures covered by the government. North Korea and Cuba are the only other countries that have this restriction.
We are fortunate that our politicians haven't decided to provide universal nutrition as a way to get elected. (Surely good nutrition is a prerequisite to good health.) Too bad Canadian politicians didn’t decide that the Food Stamps approach would be a better way to ensure all citizens received good health care.
i belive the canadain's are suffering cause of the differnt ways you have to treat diffrent people accrording to there incom. And how Ouw own govermnet can sit here and watch below advergae income people waitse away and worry about third wolrd counties wehn we have our own country to think about first
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