Blame Canada!

Last week a little post of mine on frustration with US health care made some noise here and here. I have to admit I was taken by suprise that my complaining got so much attention.

Much of that attention demanded that I give proof for my accusations! Well, if you read the post closely you'd see I wasn't making any claims except the simple fact that our health system has its problems, waiting being one of them. But today I'm going to give all those naysayers some satisfaction by debunking another huge myth about the perils of Canadian medicine: that many thousands of desperate Canadians cross the border every year seeking medical care because of unsatisfactory care at home, be it long waits, lack of new technology, or [insert appropriate false claim about Canadian care here.]

Three years ago, long before this blog came into existence, Health Affairs ran an article on Canadians seeking care in the US. The authors used some nifty methodology, including surveying numerous US hospitals along the border, as well as institutions generally regarded as "America's Best Hospitals". On the Canadian side, they used the National Population Health Survey (which literally asks, "In the past twelve months did you receive any health care services in the United States?" and "Did you go there primarily to get these services?"), as well as querying insurance companies on the Canadian side about the popularity of policies that cover US institutions.

Before I pull back the curtain to reveal their astounding findings, let's make a couple things clear. Many Canadians travel in the US every year. It is expected that this fact will show up in statistics. Further, I assume there are some very wealthy Canadians who will always say "No thanks" to waiting lists, and hop over to the US. I believe that is a reasonable assumption, and a fact of life that I'm comfortable with.

So what did the authors find?

In terms of hospitals along the border offering advanced treatments or special diagnostic technology (i.e. CT scans and MRIs), about 640 Canadians were seen, along with 270 for procedures like cataract surgery. They compare this to about 375,000 and 44,000 similar procedures in the region of Quebec alone during the same period. If you divide the total number of Canadians seeking those treatments in the US, divided by the number in Quebec alone that's about 0.09%. Not even a tenth of a percent.

But the most striking stats come from the Canadian National Population Health Survey (NPHS). From the article:

Only 90 of 18,000 respondents to the 1996 Canadian NPHS indicated that they had received care in the United States during the previous twelve months, and only twenty had indicated that they had gone to the United States expressly for the purpose of getting that care.

Only 20 of 18,000 sought care in the United States. I can't believe how many people are coming over here! Their system but be truly awful.

But let's give this number some context. We've all heard about seniors getting their prescriptions from Canada. (Hell, even driving to visit my sister at college in rural Kansas, I saw a billboard for "Canada Drug of Topeka!") But how many seniors really do that? Is it exaggerated, like the claims of Canadians coming stateside?

Polling data from 2003 (approximately a year after the Health Affairs article) indicates that 8% answered YES to the following question:

"Have you ever bought prescription drugs from Canada or other countries outside the United States in order to pay a lower price?"

If 8% of the 18,000 Canadians polled in NPHS had expressly sought care in the United States, that would be 1,440. Not 20, as the survey showed.

In other words, we have 72 times the number of Canadians seeking care in the US going to Canada (or at least calling there) to get prescriptions.

Honestly, what's really wrong with this picture?

[Source: Katz, Steven J et al. "Phantoms in the Snow: Canadians' Use Of Health Care Services In The United States." Health Affairs May/June 2002.

Comments

[Stephen]

I attend grad school in Kansas City. It has a distance-learning program where people from all over the US and Canada come to the school for two weeks each fall and spring, spend 8+ hours/day in lectures and then go back to their jobs and lives and finish the papers and reasearch and stuff at home. Out of about 50 people involved at any one time (it's a small school), there's usually at least 10 Canadians participating. To a person, they have expressed in classes and conversations their fear that they might get sick while in the US. They are afraid that getting a cold will bankrupt them.

Nowadays when people start using the Canadian health system as a defense of our present system I start talking about giant alligators in the New York sewer system and how there's this video, if you watch it, you'll die in like a week or something.

[parsec]

During the '88 primary Sen. Paul Tsongas repeated the claim that if he'd been a Canadian when his cancer appeared he would have been dead by then. It turned out that his treatment had been pioneered in Canada.
Americans have never let reality get in the way of a good anecdote, especially on the subject of health care.

[David Andersen]

Your context is poorly selected. Comparing the # of Americans who go to Canada for drugs to the # of Canadians who go to the US for medical care is meaningless. It's two completely different things for different reasons.

Medicine is cheaper in Canada because it's subsidized. If the price difference is significant enough, people in the US will make the trip. This has nothing to do with quality of care in either country.

How many Americans go to Canada for healthcare? I'm guessing it is less than 0.09% in an equivalent sampling. What would that mean? Nothing necessarily, but that's the proper comparison, if you're going to make one.

Finally, the notion of Canadians not going to the US for care as evidence of the suitability (or superiority) of the Canadian system is misleading.

People will put up with a lot if it means avoiding spending out of pocket money on healthcare. I bet most of us know one or more people like this. I knew a Canadian who needed his knee replaced after a rugby injury. He was working in the US at the time. It clearly was painful and he walked with a limp, but rather than pay for expedient treatment somewhere he waited 5 months for replacement in Canada. Why? Because he didn't want to spend the money out of pocket and he was already paying for his government insurance. His choice, but not necessarily the best one for his health or comfort. I know of an American who made the same sort of choice, waiting to treat a hernia until Medicare kicked in, even though she could have afforded to take care of the problem immediately. People will put up with a lot to avoid spending money on their health. It seems like mostly men do this in my experience.

I'd like to see a study that asks people something like this:

"If you could have your painful and uncomfortable non-emergency problem "X" treated now for $2000, in 3 weeks for $1000, or in 3 months for free, which would you prefer?"

That may not be the ideal wording, but something along those lines would reveal the magnitude of our tendency to tolerate discomfort in order to minimize out of pocket medical spending.

Put another way, if people are forced to pay for a service there is some percentage of these people who will use the service no matter its quality because it’s already been paid for and they either don’t want to spend additional money for better service or they can’t afford to. I think the same problem exists in the American public school system. People think they are being helpful by mandating taxation for universal service when in fact they very well may be causing more harm than good.

[A Canadian]

Telemedicine is the solution to saving the health care system. See the Canadian Society of Telehealth