Canadians' Common-Sense Discussion of U.S. Medical Care - Up-Dated Views

One Landed Immigrants Experiences Plus Washington Post Input

Published on Sunday, August 23, 2009 by The Washington Post
Socialized Medicine? Not Quite
5 Myths About Health Care Around the World
by T.R. Reid

As Americans search for the cure to what ails our health-care system, we've overlooked an invaluable source of ideas and solutions: the rest of the world. All the other industrialized democracies have faced problems like ours, yet they've found ways to cover everybody -- and still spend far less than we do.

I've traveled the world from Oslo to Osaka to see how other developed democracies provide health care. Instead of dismissing these models as "socialist," we could adapt their solutions to fix our problems. To do that, we first have to dispel a few myths about health care abroad:

1. It's all socialized medicine out there.

Not so. Some countries, such as Britain, New Zealand and Cuba, do provide health care in government hospitals, with the government paying the bills. Others -- for instance, Canada and Taiwan -- rely on private-sector providers, paid for by government-run insurance. But many wealthy countries -- including Germany, the Netherlands, Japan and Switzerland -- provide universal coverage using private doctors, private hospitals and private insurance plans.

In some ways, health care is less "socialized" overseas than in the United States. Almost all Americans sign up for government insurance (Medicare) at age 65. In Germany, Switzerland and the Netherlands, seniors stick with private insurance plans for life. Meanwhile, the U.S. Department of Veterans Affairs is one of the planet's purest examples of government-run health care.

2. Overseas, care is rationed through limited choices or long lines.

Generally, no. Germans can sign up for any of the nation's 200 private health insurance plans -- a broader choice than any American has. If a German doesn't like her insurance company, she can switch to another, with no increase in premium. The Swiss, too, can choose any insurance plan in the country.

In France and Japan, you don't get a choice of insurance provider; you have to use the one designated for your company or your industry. But patients can go to any doctor, any hospital, any traditional healer. There are no U.S.-style limits such as "in-network" lists of doctors or "pre-authorization" for surgery. You pick any doctor, you get treatment -- and insurance has to pay.

Canadians have their choice of providers. In Austria and Germany, if a doctor diagnoses a person as "stressed," medical insurance pays for weekends at a health spa.

As for those notorious waiting lists, some countries are indeed plagued by them. Canada makes patients wait weeks or months for nonemergency care, as a way to keep costs down. But studies by the Commonwealth Fund and others report that many nations -- Germany, Britain, Austria -- outperform the United States on measures such as waiting times for appointments and for elective surgeries.

In Japan, waiting times are so short that most patients don't bother to make an appointment. One Thursday morning in Tokyo, I called the prestigious orthopedic clinic at Keio University Hospital to schedule a consultation about my aching shoulder. "Why don't you just drop by?" the receptionist said. That same afternoon, I was in the surgeon's office. Dr. Nakamichi recommended an operation. "When could we do it?" I asked. The doctor checked his computer and said, "Tomorrow would be pretty difficult. Perhaps some day next week?"

3. Foreign health-care systems are inefficient, bloated bureaucracies.

Much less so than here. It may seem to Americans that U.S.-style free enterprise -- private-sector, for-profit health insurance -- is naturally the most cost-effective way to pay for health care. But in fact, all the other payment systems are more efficient than ours.

U.S. health insurance companies have the highest administrative costs in the world; they spend roughly 20 cents of every dollar for nonmedical costs, such as paperwork, reviewing claims and marketing. France's health insurance industry, in contrast, covers everybody and spends about 4 percent on administration. Canada's universal insurance system, run by government bureaucrats, spends 6 percent on administration. In Taiwan, a leaner version of the Canadian model has administrative costs of 1.5 percent; one year, this figure ballooned to 2 percent, and the opposition parties savaged the government for wasting money.

The world champion at controlling medical costs is Japan, even though its aging population is a profligate consumer of medical care. On average, the Japanese go to the doctor 15 times a year, three times the U.S. rate. They have twice as many MRI scans and X-rays. Quality is high; life expectancy and recovery rates for major diseases are better than in the United States. And yet Japan spends about $3,400 per person annually on health care; the United States spends more than $7,000.

4. Cost controls stifle innovation.

False. The United States is home to groundbreaking medical research, but so are other countries with much lower cost structures. Any American who's had a hip or knee replacement is standing on French innovation. Deep-brain stimulation to treat depression is a Canadian breakthrough. Many of the wonder drugs promoted endlessly on American television, including Viagra, come from British, Swiss or Japanese labs.

Overseas, strict cost controls actually drive innovation. In the United States, an MRI scan of the neck region costs about $1,500. In Japan, the identical scan costs $98. Under the pressure of cost controls, Japanese researchers found ways to perform the same diagnostic technique for one-fifteenth the American price. (And Japanese labs still make a profit.)

5. Health insurance has to be cruel.

Not really. American health insurance companies routinely reject applicants with a "preexisting condition" -- precisely the people most likely to need the insurers' service. They employ armies of adjusters to deny claims. If a customer is hit by a truck and faces big medical bills, the insurer's "rescission department" digs through the records looking for grounds to cancel the policy, often while the victim is still in the hospital. The companies say they have to do this stuff to survive in a tough business.

Foreign health insurance companies, in contrast, must accept all applicants, and they can't cancel as long as you pay your premiums. The plans are required to pay any claim submitted by a doctor or hospital (or health spa), usually within tight time limits. The big Swiss insurer Groupe Mutuel promises to pay all claims within five days. "Our customers love it," the group's chief executive told me. The corollary is that everyone is mandated to buy insurance, to give the plans an adequate pool of rate-payers.

The key difference is that foreign health insurance plans exist only to pay people's medical bills, not to make a profit. The United States is the only developed country that lets insurance companies profit from basic health coverage.

In many ways, foreign health-care models are not really "foreign" to America, because our crazy-quilt health-care system uses elements of all of them. For Native Americans or veterans, we're Britain: The government provides health care, funding it through general taxes, and patients get no bills. For people who get insurance through their jobs, we're Germany: Premiums are split between workers and employers, and private insurance plans pay private doctors and hospitals. For people over 65, we're Canada: Everyone pays premiums for an insurance plan run by the government, and the public plan pays private doctors and hospitals according to a set fee schedule. And for the tens of millions without insurance coverage, we're Burundi or Burma: In the world's poor nations, sick people pay out of pocket for medical care; those who can't pay stay sick or die.

This fragmentation is another reason that we spend more than anybody else and still leave millions without coverage. All the other developed countries have settled on one model for health-care delivery and finance; we've blended them all into a costly, confusing bureaucratic mess.

Which, in turn, punctures the most persistent myth of all: that America has "the finest health care" in the world. We don't. In terms of results, almost all advanced countries have better national health statistics than the United States does. In terms of finance, we force 700,000 Americans into bankruptcy each year because of medical bills. In France, the number of medical bankruptcies is zero. Britain: zero. Japan: zero. Germany: zero.

Given our remarkable medical assets -- the best-educated doctors and nurses, the most advanced hospitals, world-class research -- the United States could be, and should be, the best in the world. To get there, though, we have to be willing to learn some lessons about health-care administration from the other industrialized democracies.

© 2009 The Washington Post T.R. Reid, a former Washington Post reporter, is the author of "The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care," to be published Monday.

This is long — but it presents the truth. I hope you will take time to read it.

I. Introduction

I am not a Canadian, but I did live in Canada as a “landed immigrant” for 21 years. My three daughters were born in Canada.

The following letter is my response to many of the false comments, interpretations, and general misinformation about the Canadian health care system (often cited as either a positive or a negative during the ongoing U.S. struggle with medical-care reform).

Although this is not my main point, I do relay that many Canadians are more-than-irritated at the mangled representations of their medicine. (And, the “cool” Canadians are not easily irritated, I might add.) Their system is so often misrepresented that the truth seems not to matter – no doubt because the truth would not be beneficial to our greedy insurance and pharmaceutical companies, among others.

II. My Personal Experience

I moved back to the United States for family business reasons and although I, a native of the United States, treasure much about this country, I also am certainly cognizant of its flaws – flaws that need to be discussed rationally and truthfully.

One of the flaws of which I have been keenly aware since my return is still the lack of adequate access to health care. Yes, I have had the comfortable employer umbrella plans that make many complacent. But, I have also been a mother with sick children and have had to make difficult decisions about, for example, groceries so that my daughters could get to a doctor. Even now, as a senior, I am on Medicare (with a supplement), which serves me quite well.

However, my younger husband — a private, small-business owner — is in that never-never land of being self-employed and too young for Medicare. His monthly premium for a $5,000 deductible is $500! It essentially does us no good. Its only possible value would be some catastrophic event, but by then, how many thousands of dollars would we have wasted on the just-in-cases? Meanwhile, no prescriptions, no doctor’s annual physicals, no lab tests are covered. This is NOT preventative medicine; it’s a waste of money.

And, before I go any further, I want to add that I have been a conservative (or an independent) for decades. I am the farthest thing from a “socialist.” Further, the people I cite below are well-educated, conservative citizens of Canada. One is the daughter, sister, and mother of doctors. The other is a doctor of anesthesiology and intensive care medicine who practices in Canada.

Although there are other countries with which we might compare our medical care, it does seem that Canada (with so many similarities to the United States) is most often cited re: their medical system. Unfortunately, too many times they have been cited incorrectly.

I present some Canadian opinions, given at my request, — and the truth

III. Several Responses from a Well-Educated Canadian Woman — the Daughter, Mother, and Sister of Canadian Doctors

Response #1:
As most Canadians, I feel our system, while not perfect, is nevertheless one of the great advantages of living here. And …, bureaucrats do NOT make medical decisions; doctors and patients do.

I know about that commercial the anti-reformers are running that features the Canadian woman with a brain tumour who said she had to go to the United States for treatment. Kinda have my doubts about her and think there must be a serious back story they're not mentioned. For one thing, I've never heard of the town she's supposedly from. Maybe it has a population of half a dozen, no doctor and/or no hospital. Anyway, many of us Canucks are pretty angry about our health care system being so wrongly portrayed.

I pay $162 every three months for B.C. health care: That covers all the basics. No problems. No waiting. No deductible. No refusing payment. No coverage lapses or “stops.” And, I have opted to pay another couple of hundred each month for supplemental Blue Cross, that covers dental, optometric, all prescriptions, things like ambulances, etc. (And I'm bitching about it: In Alberta, it's all free. No premiums, no sales tax, no cancelled coverage.)

The wait times get somewhat problematic for non-urgent or optional stuff, like hip replacements. But, when you need the system, it most certainly works. . . and fast. And, not just because my brother, daughter and son-in-law are all “in the system.”

Most doctors here want to be like [names her relatives]; they're on salary associated with one or more hospitals (and they're certainly high salaries, but nothing like what they tell me some of the American docs earn, especially in Texas, they tell me), but they also have some fee-for-service patients outside the hospital. Plus, they have paid holidays, lots of 'em, and a very, very good benefits and pension plan. In other words, as [one doctor] says, they can have a very nice life while delivering the best possible service to their patients.

They don't have the fear of lawsuits, either, along with the accompanying need for astronomical malpractice insurance. In fact, as an emergency and anesthesia combo specialist, [her brother] deliberately chose NOT to practice in the U.S. — said the insurance premiums for his specialty would be intolerable.

Here's the scoop: I have five doctors keeping an eye on me. I see the skin doctor for a full body exam once a month, the cancer clinic doc every six months, and my general practitioner as often as I want. Also, I have two other specialists watching my test results, and called in as “consults” whenever necessary. Can't get much better care than that! (And I'm not even counting [her relatives]!)

My advice? Lobby your senators and congressional reps for a health care plan as close to Canada's as possible. In this day and age, it's a bloody disgrace that there are 45 million Americans with no insurance, and God knows how many whose insurance coverage seems to vanish when it's needed most.

Response #2:
Just got the real story behind about that commercial the anti-health care reform people are running in the United States, the one I wrote about the other day.

As you'll recall, it features a young woman from Nowheresville, Ontario, who claimed to have a brain tumour and couldn't get medical attention promptly here in Canada. She said she had to go to the U.S., paid over $100,000 but was operated on immediately.

Here's what really happened: She had a congenital (i.e., she was born with it) cyst on her pituitary or adrenal gland (I can't remember which) but most definitely NOT a brain tumour. The cyst would eventually have to be removed, as on rare occasions, they can grow and eventually press on the optic nerve, but any such growth takes place over years and years.

Her reason for allowing herself to be “used” as a poster girl against Canadian-style health care? She's trying to “persuade” the Ontario health care insurance program into covering the cost of her unnecessary U.S. surgery.

But, because of the strict patient confidentiality rules under which our medical information is protected, Ontario Health cannot make any public statement about this woman and her “brain tumour.”

Not sure how the story got out — probably someone who knows her well, and is thoroughly offended off by her deliberately misleading portrayal of the Canadian system. It's amazing how upset Canadians are by this campaign, and any inference that bureaucrats — not doctors and their patients — make the medical decisions here.

I KNEW there was something not right about that woman and her situation.

Response #3:
As we discussed, I asked my brother [Canadian doctor] … for more comparative data re: the Canadian and American health care systems, info you could use to help convince some 'Mericans to get on board with reform.

These points might help: 1. [He] says that, in all head-to-head, system-wide comparisons — infant mortality, life expectancy, outcomes from coronary artery disease, etc. — the Canadian system always ranks higher than the American. Probably because —

2. The Canadian system provides much more uniform quality of care than the American. Private centres like the Mayo, Lehey (spelling?) or Cleveland clinics or the DeBakey (sp?) Heart Institute provide superb care, with all the high-tech bells and whistles, [brother] says, but many of the county / public hospitals are dreadful.

3. Because there is no deductible and no “co-pay” charged here, Canadians seek medical help much earlier in their illness. This means treatment begins much earlier — before the illness “gets away on us” — and the outcomes are better, simpler, and less expensive.

He says a young Canadian kid suffering an asthma attack, for example, is brought in earlier, and treated immediately in emergency by putting him / her on a ventilator and/or giving a shot of adrenalin. A couple of hours later, the child is able to go home, breathing normally.

Because 'Mericans have to pay a hefty deductible, parents are more likely to hope they get over it at home; when they do come into emergency, they are often so bad, they have to be admitted to hospital and put on IV for a few days. Thus, the outcomes are more serious, and so, of course, is the cost.

4. Interesting: that woman who claimed to have a “brain tumour,” said she couldn't get treatment in Canada so she had to go to the United States and pay a “kadzillion dollars,” is no longer appearing on television as a spokesperson for the anti-public pay health care lobby. Guess they finally got the real story, and yanked her off the air.

Does this help? I'm sure [brother] would be happy to answer any other questions you may have.

P.S. He's a conservative too!

IV. Letter I Recently Received (which I later forwarded to the Canadians, asking for their reaction): Subject: THE 64,000.00 DOLLAR QUESTION ANSWERED!

37 Million people lived under the poverty line in 2008. According to the US Health and Human Services, the poverty threshold for a family of 5 is $25,790. Private health insurance for a family of 5 would run over $1000 per month, plus deductibles of $500 per person leaving the family with $11,290 per year to live on. Most people who have jobs that don’t pay insurance can’t afford private healthcare so I think it’s an ethical and moral obligation for a government to provide basic human health services….

With that said, I have “Gold Plated” health care for my wife and I and I wouldn’t give it up for a general healthcare plan. What most people don’t know is that Canadian and British citizens, although they have public healthcare still choose to receive private healthcare coverage from their employer because there are no restrictions on their choice of Dr. or strict limitations of benefits. In the UK birthing a child is completely free for everyone as it should be in the US but seeing a physiatrist, physical therapist, chiropractor, etc. is not. With private healthcare I can get professional help for whatever I want with no restrictions, no lines, and no worries, why would I give that up?

If it were a basic human right to own a gun, most people would get a cheap .22 and the people who are better off would have a .44, it’s the way of the world.

V. Reaction (Requested) to the Letter Above:

Response #4:
Frankly, it makes my blood boil.
For one thing, the only restriction on what doctor you see is the size of his / her practice. If he / she has room for another patient, no problem. If not, they'll usually refer you to someone who does have room. Even if his practice is full, a doctor will always take other members of the same family.

And, most cities also have a network of round-the-clock family medical centres, staffed in rotation by groups of general practitioners, nurses, lab staff, etc. Instead of going to the emergency at a hospital, it makes more sense to go to one of these clinics: I had one in Calgary just a few blocks from me, and that's where I went for small things, like having my infected leg dressed, (happened after a bad fall, not when I had the septicemia originating in the lymph gland), ear aches dealt with, etc. Again, just give them your health care insurance number, and that's all it takes. You never see a bill.

We do have a shortage of doctors, like practically everywhere else in the world, but …, the system works very well.

You might also tell [the letter writer] that having a baby is completely free here: all pre- and post-natal care, the delivery itself, and of course, if the newborn needs medical treatment, it's completely covered. When [the letter writer] talks about Canadians getting add-on health benefits from their employers — or, like me, by purchasing additional Blue Cross coverage — that's for things like full dental coverage, full prescriptions, etc. And, we don't pay a deductible.

As I said, my basic BC Health Care coverage is $162 every three months. I personally believe there should be a public-insurance option available in the United States, but I have no right to an opinion, since I'm a Canucklehead!

Must say, though, I'm appalled at some of the so-called “town hall” meetings re: health care that apparently are happening around the U.S. And, to my Canadian way of thinking, [names a radio talk-show host] should be institutionalized. The guy's nuts, certifiably nuts!

Response #6 —Resentment Expressed:
Please excuse my ranting last night about the “town brawls,” crazy [names the radio show host again], and some of those ultra right-wing politicians, paid for by the HMOs and “big medicine.”

As so many Canadians, I really resent the way these people are misrepresenting our health care system: Without any apparent conscience, they are making it appear as if some faceless civil servant with a rubber stamp decides our fate — that cancer patients are dying in the streets outside the hospital doors, waiting for a bed. And, that given a choice, most Canadians would opt for American-style health care.

My god, these people are suggesting that “living wills” are a form of euthanasia!!!!! Appalling. As David Gergen said on CNN, these organized, highly financed rabble rousers are making a mockery of the principles upon which the United States was founded. (As you know, he's probably the most calm, dispassionate and experienced presidential advisor alive today — he was an advisor to four presidents, representing both parties. I give a whole lotta credence to what he says!)

Having dinner with my “big medicine” brother … and his wife tonight, so no doubt this will be the number-one topic of conversation. … he does a lot of work in Vancouver — although most of the time he works in the O.R. in a hospital in Victoria.

He got some of his training in Seattle and Long Beach: he has a double specialty, anaesthesiology and intensive care medicine. (In Long Beach, he said he got really proficient at sewing up knife wound victims!) He always says the United States offers both the best — and the worst —of health care. When he was ready to set up his practice, he insisted on coming back to Canada: didn't want any part of what he called the lawsuit-happy, “politicized” health care industry in the U.S.

Interestingly enough, he says even the American Medical Association is firmly now on board with health care reform. So who are the holdouts? Seems to me it's the insurance industry and the politicians they've bought. MSNBC had a fascinating report the other night on how much that industry has donated to the campaigns of the key senators and congressmen/women. It ran into the millions. Even more interesting, the politicians didn't dispute the report.

And, all those lobby groups?! … they're doing a disservice to the country.

VI. A Canadian Doctor Speaks Out:

Two further points of debate about health care are the "queues" for care, and the cost of bringing in universal coverage.

No health care system can exist without some form of rationing — the expectations of people and medical capabilities are limitless! In Canada, the rationing is by limiting resources, so-called secondary rationing. No politician or bureaucrat tells anyone what they can or cannot have done, but only that they have to wait their turn.

Presumably, the system triages it such that emergent and urgent things are addressed first, then elective things are considered. That is reflected in what we see in the press: anger over waiting months for a hip replacement ("I was overweight for 40 years before it began to hurt"), but very rapid care for things like cancer, trauma, and cardiac issues.

In the U.S. the rationing is primary, and provided to those who have insurance, and/or [are] able to handle the co-payment. The insurance companies vary with their willingness to pay even when one does have basic coverages, rather than deciding based upon the medical necessity or justification.

Case in point: the remarkably low rates of immunization (less than 50 percent) of American children because it is not considered "medically necessary" by some insurance providers! No intervention has been shown to have as profound an influence on the health of its people! (And we are denying this simple, proven protection to more than half the American population.)

The second point argued by opponents … is the cost of health care systems. In the USA. the administrative (non-direct care components) cost of their "non-system" is currently at least 10 percent of the total. This is largely due to determining eligibility, collecting premiums, etc. (I ignore the issue of shareholder profit). What a waste! But, it keeps a whole industry employed.

In contrast, since we in Canada have no need to determine eligibility and revenue is handled by the tax system, the overhead is under 1 percent. What we do spend goes to services, perhaps not distributed optimally, but nonetheless without being skimmed off the top!

Undoubtedly, the U.S. will pay more if the 10 percent of their population currently without adequate coverage is to be protected. However, the pundits have to factor in the enormous financial cost paid by those who are bankrupt by medical illness. Shouldn't we include these legal fees and social costs that will not be included in calculating the fiscal cost of universal coverage?

I certainly don't think our Canadian system is perfect — far from it. We need to keep the politicians' hands off it, and need to establish a boundary definition of what is "health care." We also need to stop viewing any change as undesirable, and a start down a "slippery slope." But, at least we are not wasting money on inappropriate care for the few while ignoring the legitimate needs of the unfortunate amongst us!

Food for thought!

V11. A U.S. University Professor Offers Resources:

Here are some links from npr.org that you may find useful for facts and comparisons:
A. About health care in France: http://www.npr.org/templates/story/story.php?storyId=92419273
B. A comparison of costs, systems, taxes, etc. in industrialized countries (including Canada and the UK):
http://www.npr.org/templates/story/story.php?storyId=110997469

I have lived recently in France, and have found their health care to be excellent, efficient, and accessible — both as someone who was inside (while I was living there) and outside (when I was researching there) the system. [As the letter writer in IV. Above], I have excellent insurance here in the States, and have few complaints personally. However, I watch my students (many of whom come from depressed areas of Michigan) without insurance, and find it horrific that — in a country that is better off than many — there are many with no access. In Canada (where I was born, and well taken care of) and in France, this would never be the case.

VIII. Conclusion:

If you have read to this point, thank you. Whatever your viewpoint, I hope we’ll stop “shouting at each other” and THINK. We need to discuss, input sensibly, treasure the truth, and come to a satisfactory conclusion for ALL Americans’ health care.

I sincerely thank the Canadians who have taken the time to give their detailed, knowledgeable, and caring input to my original question.

My intention is to forward this to everyone in my e-mail book and to my state representatives and senators. Perhaps you’ll do the same?

cla

P.S. Two other thoughts I’ve had since I originally compiled this:
1. We should all ACTUALLY READ (slow-going as it may be) the relevant House bill; I think many are reacting emotionally without having studied it at all.

2. Interestingly, some of the people and friends who are most opposed to health-care reform are teachers (who must have had some sort of “government” behind their health care, city or otherwise) and seniors who have government Medicare now.









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