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A little common sense about health care - will the morons get a clue?

August 7 2009 at 7:49 PM


Universal health insurance is on the American policy agenda for the fifth time since World War II. In the 1960s, the U.S. chose public coverage for only the elderly and the very poor, while Canada opted for a universal program for hospitals and physicians services.

As a policy analyst, I know there are lessons to be learned from studying the effect of different approaches in similar jurisdictions. But, as a Canadian with lots of American friends and relatives, I am saddened that Americans seem incapable of learning them.

Our countries are joined at the hip. We peacefully share a continent, a British heritage of representative government and now ownership of GM. And, until 50 years ago, we had similar health systems, health-care costs and vital statistics.

The U.S. and Canadas different health insurance decisions make up the worlds largest health policy experiment. And the results?

On coverage, all Canadians have insurance for hospital and physician services. There are no deductibles or co-pays. Most provinces also provide coverage of programs for home care, long-term care, pharmaceuticals and durable medical equipment, although there are co-pays.

On the U.S. side, 46 million people have no insurance, millions are underinsured and health-care bills bankrupt more than 1 million Americans every year.

Lesson No. 1: A single-payer system would eliminate most U.S. coverage problems.

On costs, Canada spends 10 percent of its economy on health care; the U.S. spends 16 percent. The extra 6 percentage points of GDP amounts to more than $800 billion per year. The spending gap between the two nations is almost entirely because of higher overhead.

Canadians dont need thousands of actuaries to set premiums or thousands of lawyers to deny care. Even the U.S. Medicare program has 80 percent to 90 percent lower administrative costs than private Medicare Advantage policies. And providers and suppliers cant charge as much when they have to deal with a single payer.

Lessons No. 2 and 3: Single-payer systems reduce duplicative administrative costs and can negotiate lower prices.

Because most of the difference in spending is for nonpatient care, Canadians actually get more of most services. We see the doctor more often and take more drugs. We even have more lung-transplant surgery. We do get less heart surgery, but not so much less that we are any more likely to die of heart attacks. And we now live nearly three years longer, and our infant mortality is 20 percent lower.

Lesson No. 4: Single-payer plans can deliver the goods because their funding goes to services, not overhead.

The Canadian system does have its problems, and these also provide important lessons. Notwithstanding a few well-publicized and misleading cases, Canadians needing urgent care get immediate treatment. But we do wait too long for much elective care, including appointments with family doctors and specialists and selected surgical procedures. We also do a poor job managing chronic disease.

However, according to the New York-based Commonwealth Fund, both the American and the Canadian systems fare badly in these areas. In fact, an April U.S. Government Accountability Office report noted that U.S. emergency room wait times have increased, and patients who should be seen immediately are now waiting an average of 28 minutes. The GAO has also raised concerns about two- to four-month waiting times for mammograms.

On closer examination, most of these problems have little to do with public insurance or even overall resources. Despite the delays, the GAO said there is enough mammogram capacity.

These problems are largely caused by our shared politico-cultural barriers to quality of care. In 19th-century North America, doctors waged a campaign against quacks and snake-oil salesmen and attained a legislative monopoly on medical practice. In return, they promised to set and enforce standards of practice. By and large, it didnt happen. And perverse incentives like fee-for-service make things even worse.

Using techniques like those championed by the Boston-based Institute for Healthcare Improvement, providers can eliminate most delays. In Hamilton, Ontario, 17 psychiatrists have linked up with 100 family doctors and 80 social workers to offer some of the worlds best access to mental-health services. And in Toronto, simple process improvements mean you can now get your hip assessed in one week and get a new one, if you need it, within a month.

Lesson No. 5: Canadian health-care delivery problems have nothing to do with our single-payer system and can be fixed by re-engineering for quality.

U.S. health policy would be miles ahead if policy-makers could learn these lessons. But they seem less interested in Canadas, or any other nations, experience than ever. Why?

American democracy runs on money. Pharmaceutical and insurance companies have the fuel. Analysts see hundreds of billions of premiums wasted on overhead that could fund care for the uninsured. But industry executives and shareholders see bonuses and dividends.

Compounding the confusion is traditional American ignorance of what happens north of the border, which makes it easy to mislead people. Boilerplate anti-government rhetoric does the same. The U.S. media, legislators and even presidents have claimed that our socialized system doesnt let us choose our own doctors. In fact, Canadians have free choice of physicians. Its Americans these days who are restricted to in-plan doctors.

Unfortunately, many Americans wont get to hear the straight goods because vested interests are promoting a caricature of the Canadian experience.

By Dr. Michael Rachlis

Dr. Michael Rachlis is a physician, health policy analyst and author

 Respond to this message   

  1. We have a few new prospects - Anonymous on Aug 7, 2009, 10:14 PM
  3. So you posted an article from one doctor, and anyone who disagrees is a moron?? - Anonymous on Aug 8, 2009, 9:20 AM
  5. Ice Age economics - Anonymous on Aug 8, 2009, 12:25 PM
  7. Outright Lie - Anonymous on Aug 8, 2009, 10:37 PM
    1. Why let the facts get in the way of a good story? - Anonymous on Aug 9, 2009, 8:37 AM
  8. Re: A little common sense about health care - will the morons get a clue? - anonymous on Aug 9, 2009, 11:28 AM
    1. Re: A little common sense about health care - will the morons get a clue? - Anonymous on Aug 9, 2009, 12:45 PM
    2. Not sure we should iew him as an expert, rather a part of the Canadian system - Anonymous on Aug 9, 2009, 9:27 PM
      1. Is this an application (w/ resume) or - Anonymous on Aug 10, 2009, 9:24 PM
    3. and look at the nonsense that Pelosi and Hoyer spew: - Anonymous on Aug 10, 2009, 10:32 AM
      1. How should this work? - Anonymous on Aug 10, 2009, 10:46 AM
        1. here's the Obama answer - Anonymous on Aug 10, 2009, 11:11 AM
          1. equal premiums =/= equal treatment - Anonymous on Aug 10, 2009, 11:45 AM
      2. CBO: Preventive Care Raises Health-Care Costs - Anonymous on Aug 10, 2009, 1:12 PM
        1. I think they plan to save money - Anonymous on Aug 10, 2009, 1:57 PM
        2. Earth to Pelosi: - Anonymous on Aug 10, 2009, 2:01 PM
  9. Defensive Medicine - Anonymous on Aug 10, 2009, 1:03 PM
  11. ha ha ha - Obama just said the Canadian approach wouldn't work in US - Anonymous on Aug 10, 2009, 2:44 PM
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